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pdfAPPENDIX E
COBRA SUBSIDY STUDY SURVEY
Reference No.: 06859
Impact of the ARRA
Subsidy on COBRA
Take-Up
COBRA Subsidy Study
Survey
July 2011
Prepared by:
Mathematica Policy Research
CONTENTS
Section
Page
A.
CASE MANAGEMENT ................................................................................................. 1
B.
SCREENER CONFIRMATION, SAMPLE MEMBER VERIFICATION,
AND HOUSEHOLD CHARACTERISTICS ................................................................. 18
C.
EMPLOYMENT AND WORK SEARCH ACTIVITIES ................................................. 27
D.
HEALTH INSURANCE ............................................................................................... 44
E.
COBRA KNOWLEDGE AND TAKE UP ..................................................................... 63
F.
COBRA SUBSIDY KNOWLEDGE AND TAKE UP..................................................... 68
G.
HEALTH ..................................................................................................................... 76
H.
INCOME AND PARTICIPATION IN OTHER TRANSFER PROGRAMS ................... 89
I.
FINANCIAL WELL-BEING........................................................................................ 106
J.
BACKGROUND ........................................................................................................ 113
K.
CLOSING AND CONTACT INFORMATION ............................................................ 115
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SECTION A: CASE MANAGEMENT
NOTE TO REVIEWERS: IN GENERAL, TEXT IN UPPERCASE IS NOT READ TO THE RESPONDENT.
PROGRAMMER: PRELOAD JOB SEPARATION MONTH, YEAR, UI CLAIM DATE, AND EMPLOYER
NAME.
CLAIM DATES BETWEEN FEBRUARY 17, 2009 AND MAY 31, 2010 ARE IN THE
SUBSIDY ELIGIBLE GROUP (ARRA PERIOD)—MPRID BEGINS WITH “1”
CLAIM DATES BETWEEN JUNE 1, 2010 THROUGH MARCH 31, 2011 (POST-ARRA)
ARE IN THE SUBSIDY COMPARISON GROUP—MPRID BEGINS WITH “2”
[Call Type]
A0.
INTERVIEWER: WHICH OF THE FOLLOWING BEST DESCRIBES THIS CALL?
CODE ONE ONLY
IMMEDIATE IVR TRANSFER .................................................. 01 (A31)
CALLBACK TO AN IVR COMPLETER .................................... 02 (A1a)
CALLBACK FROM AN IVR COMPLETER .............................. 03 (A31)
INITIAL CALL-IN TO THE SOC LINE ...................................... 04 (A32)
CALL OUT BY AN INTERVIEWER .......................................... 05 (A1)
(Call Type=Call out by an interviewer (A0=05)
[Hello (Q1)]
A1.
Hello, my name is [fill IntvName]. I am calling on behalf of the U.S. Department of Labor. May I
please speak to [fill FullName]?
SPEAKING TO SAMPLE MEMBER ........................................
SAMPLE MEMBER COMES TO THE PHONE .......................
PERSON ASKS WHAT CALL IS ABOUT ................................
NEED TO CALLBACK..............................................................
SAMPLE MEMBER HAS A HEALTH PROBLEM/
DECEASED...........................................................................
SAMPLE MEMBER] IS IN AN INSTITUTION ..........................
SAMPLE MEMBER HAS MOVED ...........................................
SAMPLE MEMBER HAS BEEN DEPLOYED BY MILITARY ..
SAMPLE MEMBER DOES NOT SPEAK ENGLISH ................
NEVER HEARD OF SAMPLE MEMBER/
WRONG NUMBER................................................................
HUNG UP DURING INTRODUCTION .....................................
REFUSED ................................................................................
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01
02
03
04
SampMemb (A23)
SampMemb (A23)
WhatAbout (A2)
Callback
05
06
07
08
09
HealthProb (A3)
Institution (A10)
KnowWhere (A11)
(A15)
Lang (A17)
10 Thanks (A38) Status 530
11 Status 640
r Status 220
(Call Type=Callback to IVR completer—A0=02)
A1a.
[Hello (Q1a)]
Hello, my name is [fill IntvName]. I am calling on behalf of the U.S. Department of Labor. May I
please speak to [fill FullName]? I am returning (his/her) call.
SPEAKING TO SAMPLE MEMBER ........................................
SAMPLE MEMBER COMES TO THE PHONE .......................
PERSON ASKS WHAT CALL IS ABOUT ................................
NEED TO CALLBACK..............................................................
SAMPLE MEMBER HAS A HEALTH PROBLEM/
DECEASED...........................................................................
SAMPLE MEMBER IS IN AN INSTITUTION ...........................
SAMPLE MEMBER HAS MOVED ...........................................
SAMPLE MEMBER HAS BEEN DEPLOYED BY MILITARY ..
SAMPLE MEMBER DOES NOT SPEAK ENGLISH ................
NEVER HEARD OF SAMPLE MEMBER/
WRONG NUMBER................................................................
REFUSED ................................................................................
01
02
03
04
SampMemb (A30)
SampMemb (A30)
WhatAbout (A2)
Callback
05
06
07
08
09
HealthProb (A3)
Institution (A10)
KnowWhere (A11)
(A15)
Lang (A17)
10 Thanks (A38) Status 530
r Status 200
(A1=03; A1a=03)
[WhatAbout (Q2)]
A2.
The U.S. Department of Labor recently sent [fill NAME] a letter inviting (him/her) to call in to see if
(he/she) would be eligible to participate in a special study they are sponsoring. Mathematica
Policy Research is a nationally recognized research company based in Princeton, New Jersey.
We are conducting the study on behalf of the U.S. Department of Labor. We are not selling
anything or asking for contributions.
PROGRAMMER: ALLOW INTERVIEWER TO ACCESS FAQs FROM THIS SCREEN.
SAMPLE MEMBER COMES TO THE PHONE .......................
NEED TO CALLBACK..............................................................
SAMPLE MEMBER HAS A HEALTH PROBLEM/
DECEASED...........................................................................
SAMPLE MEMBER IS IN AN INSTITUTION ...........................
SAMPLE MEMBER MOVED ....................................................
SAMPLE MEMBER DOES NOT SPEAK ENGLISH ................
SAMPLE MEMBER DIDN'T RECEIVE LETTER .....................
SAMPLE MEMBER HAS BEEN DEPLOYED
BY MILITARY ........................................................................
HUNG UP DURING INTRODUCTION .....................................
SUPERVISOR REVIEW...........................................................
NEVER HEARD OF SAMPLE MEMBER/
WRONG NUMBER................................................................
REFUSED ................................................................................
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01 SampMemb (A23)
02 Callback
03
04
05
06
07
HealthProb (A3)
Institution (A10)
KnowWhere (A11)
Lang (A17)
NoLetter (A24)
08 (A15)
09 Status 640
10 Status 380
11 Thanks (A38) Status 530
r Status 220
(A1 OR A1a=05)
[HealthProb (Q3)]
A3.
ENTER TYPE OF HEALTH PROBLEM.
HEARING PROBLEM ..............................................................
SPEECH PROBLEM ................................................................
PHYSICAL PROBLEM .............................................................
COGNITIVE PROBLEM ...........................................................
IN A COMA...............................................................................
DECEASED..............................................................................
REFUSED ................................................................................
01
02
03
04
05
06
r
AmpTTY (A4)
AmpTTY (A4)
CallLater (A8)
Thanks (A38) Status 410
Thanks (A38) Status 410
Deceased (A9)
Status 220
(A3=01 OR 02)
[AmpTTY (Q4)]
A4.
I was calling to conduct an interview with [fill FirstName] for the U.S. Department of Labor. I can
get on a phone that will amplify my voice or [fill FirstName]’s voice, or we could use a TTY
service. Would either of these enable (him/her) to complete the interview?
YES – USE AMPLIFIER PHONE ............................................. 01 RespAvail (A5)
YES – USE TTY CAPABILITY ................................................. 02 RespAvail (A5)
NO ........................................................................................... 00 Thanks (A38) Status 410
DON’T KNOW .......................................................................... d Callback
REFUSED ................................................................................ r Status 220
(A4=01 OR 02)
[RespAvail (Q5)]
A5.
Is [fill FirstName] available now?
YES .......................................................................................... 01 if AmpTTY (A4) = 1 then
AmpPhone (A6) else
CallTTY (A7)
NO ............................................................................................ 00 Callback
(A4=01 AND A5=01)
[AmpPhone (Q6)]
A6.
Please hold while I get the amplifier phone.
INTERVIEWER: SET UP AMPLIFIER/WEAK SPEECH EQUIPMENT AND ASK
GATEKEEPER TO CALL [fill FirstName] TO THE PHONE.
SAMPLE MEMBER COMES TO THE PHONE ....................... 01 SampMemb (A23)
CALLBACK............................................................................... 02 Callback
(A5=01 AND A4 NE 1)
[CallTTY (Q7)]
A7.
I will call back in a few minutes after I have the help of the TTY operator.
ARRANGE CALL WITH OPERATOR ...................................... 01 SampMemb (A23)
IF UNSUCCESSFUL SET CALLBACK .................................... 02 Callback
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(A3=03)
[CallLater (Q8)]
A8.
Will [fill FirstName] be able to talk on the telephone if I call back next week?
YES/MAYBE – CALLBACK...................................................... 01 Callback
NO ............................................................................................ 00 Thanks (A38) Status 380
DON’T KNOW .......................................................................... d Callback
REFUSED ................................................................................ r Status 220
(A3=06)
[Deceased (Q9)]
A9.
I am sorry to hear that [fill NAME] has passed away. I was calling about a study we are
conducting for the U.S. Department of Labor. You might have seen a letter we recently sent
[fill NAME] explaining the study. When did (he/she) pass away?
| |/| | |/| 2 | 0 | |
MO
DAY
YEAR
DATE: |
(01-12)
(01-31)
|
(2008-2012)
DON’T KNOW ..........................................................................
REFUSED ................................................................................
Status 440—DECEASED
d
r
Thank you. Please accept my condolences. Good-bye.
(A1 OR A1a=06 OR A2=04)
[Institution (Q10)]
A10.
ENTER TYPE OF INSTITUTION.
HOSPITAL ................................................................................
NURSING HOME .....................................................................
ASSISTED LIVING FACILITY ..................................................
GROUP HOME ........................................................................
JAIL OR PRISON .....................................................................
01
02
03
04
05
HomeSoon (A14)
HomeSoon (A14)
HomeSoon (A14)
HomeSoon (A14)
Thanks (A38) Status 421
(A1 OR A1a=07, A2=05)
[KnowWhere (Q17)]
A11.
Do you or anyone there know how we can reach [fill NAME]?
YES .......................................................................................... 01 (A12)
NO ............................................................................................ 00 (A27)
DON’T KNOW .......................................................................... d (A27)
REFUSED ................................................................................ r (A27)
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[NewPhone (Q18)]
A12.
May I please have [fill his/her] telephone number?
[Phone Number]
Please give me the telephone number, area code first.
[Have Exten]
Is there an extension number?
TELEPHONE: |
EXT. |
|
|
|
|
|
|-|
|
|
|-|
|
|
|
|
|
DON’T KNOW ..........................................................................
REFUSED ................................................................................
NewAddr (A12c)
d
r
[Phone Type]
A12a. Is this a home phone, business phone, or a cell phone?
HOME PHONE .........................................................................
OFFICE PHONE ......................................................................
HOME AND OFFICE PHONE ..................................................
CELL PHONE...........................................................................
PAGER .....................................................................................
COMPUTER/FAX LINE ............................................................
OTHER .....................................................................................
01
02
03
04
05
06
07
[Time of Day]
A12b. Should this number be used at only certain times?
ANYTIME ................................................................................. 01
DAYTIME ONLY (SPECIFY) _______________________ .... 02
EVENING ONLY (SPECIFY) _______________________ .... 03
[NewAddr (Q19)]
A13.
May I please have [fill his/her] address?
ADDRESS:
DON’T KNOW .......................................................................... d
REFUSED ................................................................................ r
Thanks (A38) if NewPhone eq DK/RF then Status 530 else Status 899
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A14.
PROGRAMMER: CHECK A13: IS STATE OUTSIDE THE UNITED STATES AND DC?
YES (OUTSIDE USA) .............................................................. 01 (A15)
NO (INSIDE USA) .................................................................... 00 Callback
(A1, A1a, OR A2=08 OR A14=01)
A15.
When do you expect [fill NAME] to return (home/to live in the U.S.)?
| | |/| 2 | 0 | |
MONTH
YEAR
(01-12)
|
(2011-2020)
NEVER ..................................................................................... 00 Thanks (A38) Status 450
DON’T KNOW .......................................................................... d (A38) Status 380
REFUSED ................................................................................ r (A38) Status 380
A16.
INTERVIEWER: IS DATE DURING FIELD PERIOD?
YES .......................................................................................... 01 Callback
NO, AFTER MARCH 2012 ....................................................... 00 Thanks (A38) Status 450
(A1 OR A1a=09 OR A2=06)
[Lang (Q20)]
A17.
CODE LANGUAGE NEEDED TO COMPLETE INTERVIEW IF KNOWN.
ARABIC ....................................................................................
BOSNIAN .................................................................................
CAMBODIAN............................................................................
CHINESE .................................................................................
CREOLE ...................................................................................
ENGLISH ..................................................................................
HINDI ........................................................................................
ITALIAN ....................................................................................
LAOTIAN ..................................................................................
POLISH ....................................................................................
PORTUGUESE ........................................................................
RUSSIAN .................................................................................
SPANISH ..................................................................................
TAGALOG ................................................................................
VIETNAMESE ..........................................................................
OTHER (SPECIFY) [specify] ....................................................
DON’T KNOW ..........................................................................
REFUSED ................................................................................
01
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
(A19)
(A19)
(A19)
(A19)
(A19)
(A19)
(A19)
(A19)
(A19)
(A19)
(A19)
(A19)
(A17)
(A19)
(A19)
(A19)
d Thanks (Q38) Status 400
r Thanks (Q38) Status 400
(A17=14)
A18.
(IF SPANISH NEEDED, SAY: A Spanish speaking interviewer will call you.) Thank you very much
for your time. [Status 401]
ENTER 1 TO CONTINUE
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(A16 NE 14, d, OR r)
[NeedAsst (Q22)]
A19.
(The U.S. Department of Labor recently sent [fill NAME] a letter saying that someone from
Mathematica would be calling to see if (he/she) would be eligible to participate in a study they are
conducting. Mathematica is a nationally recognized research company based in Princeton,
New Jersey. We are conducting the study for the U.S. Department of Labor. We are not selling
anything or asking for contributions.) We are looking for someone who is 18 years or older to help
[fill NAME] by interpreting the interview for us. Are you 18 years of age or older?
IF YES: Would you be able to help [fill NAME] by interpreting the interview?
IF NO:
Is there someone else 18 years or older who could come to the phone and help with the
interview?
SPEAKING TO FAMILY MEMBER/FRIEND WHO
WILL ACT AS INTERPRETER .............................................
NO INTERPRETER AVAILABLE AT THIS TIME ....................
NO INTERPRETER AVAILABLE .............................................
SUPERVISOR REVIEW...........................................................
DON’T KNOW ..........................................................................
REFUSED ................................................................................
01
02
03
04
d
r
Asst Name (A20)
Asst Name (A20)
Callback
Status 380
Callback
Status 210
(A19-01 OR 02)
[Asst/ProxyName (Q23)]
A20.
(Before we begin), can you please tell me (your name/the name of the person who may be able
to interpret the interview for [fill NAME])?
INTERPRETER NAME
DON’T KNOW ..........................................................................
REFUSED ................................................................................
AsstRel (A21)
d
r
[AsstRel (Q24)]
A21.
And how (are you/is [fill NAME FROM A20]) related to [fill FirstName]?
SPOUSE ..................................................................................
CHILD .......................................................................................
SIBLING ...................................................................................
PARENT ...................................................................................
NIECE/NEPHEW......................................................................
FRIEND/NEIGHBOR/OTHER RELATIVE................................
GROUP/FOSTER HOME/ASSISTED LIVING
FACILITY ADMINISTRATOR/CAREGIVER .........................
OTHER RELATIVE ..................................................................
NOT RELATED ........................................................................
DON’T KNOW ..........................................................................
REFUSED ................................................................................
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01
02
03
04
05
06
07
08
09
d
r
[INTERPRETER INSTRUCTION (Q25a)]
A22.
Thank you for agreeing to interpret the interview for (him/her). Please repeat the questions to
[fill NAME] exactly as I read them to you.
Screener/Survey *** GO TO A33
(A1=01 OR 02, A2=01, A6 OR A7=01)
[if Hello (Q1) eq <2> or WhatAbout (Q2) eq <1> then] Hello, my name is [fill IntvName]. I am calling on behalf of ... [endif]
A23.
[Hello, my name is [fill NAME], calling on behalf of the U.S. Department of Labor.] Recently the
U.S. Department of Labor sent you a letter saying that someone from Mathematica would be
calling to see if you would be eligible to participate in a study they are conducting about people
who became unemployed and how being unemployed affected their health insurance situation.
To see if you are eligible, I need to ask a few questions which will take about 2 minutes. If you are
eligible, for the study, I will ask you to complete a survey with me over the phone. After you
complete the survey, Mathematica will send you $40 for your participation. The survey questions
will take between 40 and 45 minutes to complete, depending on your situation. All of your
answers will be private and used for research purposes only. Let’s start now.
PROGRAMMER: ALLOW INTERVIEWER TO ACCESS FAQs FROM THIS SCREEN.
BEGIN INTERVIEW ................................................................. 01
DID NOT RECEIVE OR DOES NOT RECALL LETTER ......... 02
NOT A GOOD TIME ................................................................. 03
HUNG UP DURING INTRODUCTION ..................................... 04
SUPERVISOR REVIEW........................................................... 05
[fill NAME] WILL CALL MPR BACK ......................................... 06
WANTS MORE INFORMATION ..............................................FAQ
REFUSED ................................................................................ r
Screener/Survey (A33)
NoLetter (A24)
Callback
Status 640
Status 380
(A39)
Status 200
(A2=07 OR A23=02
[NoLetter (Q32)]
A24.
The letter was from the U.S. Department of Labor and said that someone from Mathematica
would be calling to see if you would be eligible to participate in a study they are conducting about
people who became unemployed and how being unemployed affected people’s health insurance
situation. We are not selling anything or asking for contributions. If you like, I can read the letter to
you now and we can start the interview. To see if you are eligible, we need to ask a few questions
which will take about 2 minutes. If you are eligible, for the study, we will ask you to complete a
survey with me over the phone. After you complete the survey, we will send you ($50/$40) for
your participation. The questions I have will take between 40 and 45 minutes to complete,
depending on your situation. All of your answers will be private and used for research purposes
only. Should I read the letter?
(IF NEEDED: I can also mail (you/him/her) another copy. (You/He/She) should receive the letter
in about a week.)
BEGIN INTERVIEW ................................................................. 01
WANTS ANOTHER LETTER/WANTS LETTER
READ TO THEM ................................................................... 02
NOT A GOOD TIME ................................................................. 03
WANTS MORE INFORMATION ..............................................FAQ
REFUSED ................................................................................ r
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Screener/Survey (A33)
ReadLetter (A25)
Callback
Status 200
(A24=02)
[ReadLetter (Q34)]
A25.
May I read the letter to you and then we can begin?
LOAD TEXT OF LETTER HERE
YES, READ THE LETTER ....................................................... 01 (A33)
NO, WANTS ANOTHER LETTER FIRST ................................ 02 SendLetter (A26)
REFUSED ................................................................................ r Status 200
(A25=02)
[SendLetter (Q35)]
A26.
Okay, I'll mail another letter and will call back in a few days. To what address should we mail the
letter?
ADDRESS:
DON’T KNOW ..........................................................................
REFUSED ................................................................................
Thanks (A38) Status 831—LETTER REQUESTED
d
r
(A11=00, d, OR r)
A27.
Is there someone else who might know how to reach [fill NAME]?
YES .......................................................................................... 01
NO ............................................................................................ 00 (A39a)
DON’T KNOW .......................................................................... d (A39a)
REFUSED ................................................................................ r (A39a)
(A27=01)
A28.
What’s that person’s name and phone number?
PROBE: If you don’t have all the information, please tell me what you can.
NAME
FIRST, MIDDLE, LAST
Please give me the telephone number, starting with the area code first.
TELEPHONE: |
|
|
|-|
|
|
|-|
|
|
|
|
DON’T KNOW ..........................................................................
REFUSED ................................................................................
(A38) Status 530
d (A38) Status 530
r (A38) Status 530
PROGRAMMER: THIS INFORMATION NEEDS TO BE SENT TO
LOCATING AS A LEAD
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NO A29 THIS VERSION.
(Call Type=Callback to IVR completer—A1a=01 OR 02)
[Confirm]
A30.
Thank you for calling in to see if you would be eligible to participate in the study being sponsored
by the U.S. Department of Labor. I am calling you back to complete the screening process with
you. The study is about people who became unemployed and how being unemployed affected
their health insurance situation. I will need to confirm your answers with you and ask you a few
more questions to see if you are eligible. These questions will take about 2 minutes. If you are
eligible for the study, I will ask you to complete a survey with me over the phone. After you
complete the survey, Mathematica will send you $50 for your participation. The full survey will
take between 40 and 45 minutes to complete, depending on your situation. All of your answers
will be private and used for research purposes only. Let’s start now.
BEGIN INTERVIEW ................................................................. 01
NOT A GOOD TIME ................................................................. 02
HUNG UP DURING INTRODUCTION ..................................... 03
SUPERVISOR REVIEW........................................................... 04
SAMPLE MEMBER WILL CALL MATHEMATICA BACK ........ 05
WANTS MORE INFORMATION ..............................................FAQ
REFUSED ................................................................................ r
Screener/Survey (A33)
Callback
Status 640
Status 380
(A39)
Status 200
(Call Type=IVR transfer or callback—A0=01 OR 03)
A31.
Thank you for calling in to see if you would be eligible to participate in the study being sponsored
by the U.S. Department of Labor. The study is about people who became unemployed and how
being unemployed affected their health insurance situation. Based on the answers you entered
on your telephone keypad, you have been transferred to continue the screening process for the
study. I will need to confirm your answers with you and ask you a few more questions to see if
you are eligible. These questions will take about 2 minutes. If you are eligible for the study, I will
ask you to complete a survey with me over the phone. After you complete the survey,
Mathematica will send you $50 for your participation. The full survey will take between 40 and
45 minutes to complete, depending on your situation. All of your answers will be private and used
for research purposes only. Let’s start now.
BEGIN INTERVIEW ................................................................. 01
NOT A GOOD TIME ................................................................. 02
HUNG UP DURING INTRODUCTION ..................................... 03
SUPERVISOR REVIEW........................................................... 04
SAMPLE MEMBER WILL CALL MATHEMATICA BACK ........ 05
WANTS MORE INFORMATION ..............................................FAQ
REFUSED ................................................................................ r
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Screener/Survey (A33)
Callback
Status 640
Status 380
(A39)
Status 200
(Call Type=Initial call-in to SOC line—A0=04)
A32.
Thank you for calling in to see if you would be eligible to participate in the study being sponsored
by the U.S. Department of Labor. The study is about people who became unemployed and how
being unemployed affected their health insurance situation. To see if you are eligible for the
study, I need to ask you a few questions. These questions will take about 2 minutes. If you are
eligible for the study, I will ask you to complete a survey with me over the phone. After you
complete the survey, Mathematica will send you $40 for your participation. The full survey will
take between 40 and 45 minutes to complete, depending on your situation. All of your answers
will be private and used for research purposes only. Let’s start now.
BEGIN INTERVIEW ................................................................. 01
NOT A GOOD TIME ................................................................. 02
HUNG UP DURING INTRODUCTION ..................................... 03
SUPERVISOR REVIEW........................................................... 04
SAMPLE MEMBER WILL CALL MATHEMATICA BACK ........ 05
WANTS MORE INFORMATION ..............................................FAQ
REFUSED ................................................................................ r
Screener/Survey (A33)
Callback
Status 640
Status 380
(A39)
Status 200
(A23, A24, A25, A30, A31, OR A32=01)
A33.
To get started, I need to confirm that I am speaking with the correct person. Is your full name
[fill FROM PRELOADS]?
YES .......................................................................................... 01 (A34)
NAME CHANGED .................................................................... 02
NO ............................................................................................ 00
DON’T KNOW .......................................................................... d Thanks (A38) Status 380
REFUSED ................................................................................ r Thanks (A38) Status 380
(A33=00 OR 02)
[NewName]
A33a. For the record, what is your (new) name?
NAME
IDENTITY CONFIRMED .......................................................... 01
IDENTITY NOT CONFIRMED ................................................. 02 (A40)
DON’T KNOW .......................................................................... d Thanks (A38) Status 380
REFUSED ................................................................................ r Thanks (A38) Status 380
PROGRAMMER: STORE NAME CHANGE IN NAME UPDATE BLOCK
[State_Ask]
A34.
(Are you/Is [he/she]) now living in (STATE FROM PRELOAD)?
YES .......................................................................................... 01 (A35)
NO ............................................................................................ 00 (A34a)
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(A34=00)
[State]
A34a. In what state (are you/is [he/she]) now living?
STATE |
|
| TWO LETTER CODE
DON’T KNOW ..........................................................................
REFUSED ................................................................................
d
r
PROGRAMMER: STORE STATE CHANGE FOR USE IN FUTURE
QUESTIONS AT STATE UPDATE BLOCK
(All)
A35.
What is (your/his/her) date of birth?
| | |/| | |/| 1 | 9 | |
MONTH DAY
YEAR
(01–12)
(01-31)
|
(A36)
(1937–1994)
DON’T KNOW ..........................................................................
REFUSED ................................................................................
d
r
(A35=d OR r)
[Age]
A35a. How old (are you/is [he/she])?
RECORD AGE |
|
| YEARS (18-65)
DON’T KNOW ..........................................................................
REFUSED ................................................................................
A36.
d (A37)
r (A37)
PROGRAMMER: CHECK BIRTHDATE OR AGE: IS MONTH, DAY, YEAR OF BIRTH AT
A35=MONTH, DAY, AND YEAR OF BIRTH ON RECORD OR DOES AGE
CONVERT TO DOB ON RECORD?
NO MATCH ..............................................................................
1 MATCHES .............................................................................
2 MATCH ..................................................................................
3 MATCH ..................................................................................
00
01
02
03
PROGRAMMER: NOTE: 2 OF 3=VERIFIED
(All)
A37.
What are the last four digits of your social security number?
|
|
|
|
| LAST FOUR SSN DIGITS
DON’T KNOW ..........................................................................
REFUSED ................................................................................
Prepared by Mathematica Policy Research
E.12
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
d
r
A37a. PROGRAMMER: IS [fill NAME]’s IDENTITY VERIFIED—NAME, BIRTHDATE, AND/OR LAST
FOUR SSN VERIFIED? NOTE: 2 OF 3 NEEDED.
YES (VERIFIED) ...................................................................... 01
NO (FAILED VERIFICATION ................................................... 00 (A40)
(A37a=01)
A37b. CODE WITHOUT ASKING IF KNOWN, OTHERWISE, ASK: Are you male or female?
MALE ........................................................................................ 01
FEMALE ................................................................................... 02
DON’T KNOW ......................................................................... d
REFUSED ................................................................................ r
(A37a=01)
[Whom]
A37c.
INTERVIEWER: WHO ARE YOU SPEAKING WITH?
NAME ....................................................................................... 01 (B1)
INTERPRETER ........................................................................ 02 (B1)
(A1 OR A1a=10, A2=11, A3=04 OR 05, A4=00, A8=00, A10=05, A12c=d OR r,
A14=00, d, OR r, A15=00, A16=d OR r, A28=d OR r, A33 OR A33a=d OR r)
[Thanks (Q36)]
A38.
Thank you very much for your time.
ENTER 1 TO CONTINUE
(A23=06)
A39.
Thanks for offering to call back. Please write down our toll-free number. It is XXX-XXX-XXXX. We
are available days, evenings, and weekends. Please ask for Carla Smith when you call. If you call
after hours, please leave a message and we will get back to you the next day.
(STATUS 830—RESPONDENT WILL CALL MATHEMATICA)
(A27=00, d, OR r)
A39a. Please write down my toll free number and give it to [fill SAMPLE MEMBER NAME] or someone
who might know how to reach (him/her). The toll free number is XXX-XXX-XXXX.
(A33a=02 OR A37a=00)
A40.
Thanks for your patience. There seems to be a problem with my information. I need to check with
my supervisor about what to do next. Someone from Mathematica will get back to you. Thanks
again. Good-bye. STATUS 380—SUPERVISOR REVIEW
Prepared by Mathematica Policy Research
E.13
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
REFUSAL MODULE: THIS WILL DISPLAY WHEN BREAKOFF IS INDICATED IN CATI.
NOTE: A REFUSAL CAN OCCUR AT ANY POINT IN THE INTERVIEW.
[WHO REFUSED]
INTERVIEWER: INDICATE WHO REFUSED.
SAMPLE MEMBER .................................................................. 01
GATEKEEPER ......................................................................... 02
UNKNOWN PERSON .............................................................. 03
[REFUSAL REASON]
INTERVIEWER: INDICATE REFUSAL REASON TO BEST OF KNOWLEDGE.
CODE BEST
UNHAPPY WITH UI BENEFITS/UI BENEFITS ENDED ......... 01
NO HEALTH CARE BENEFITS/LOST BENEFITS .................. 02
COULD NOT AFFORD COBRA PREMIUM ............................ 03
NO TIME .................................................................................. 04
SAID NEVER COLLECTED BENEFITS .................................. 05
NO INTEREST ......................................................................... 06
DON’T TRUST GOVERNMENT/DOL ...................................... 07
CONFIDENTIALITY ................................................................. 08
NONE GIVEN ........................................................................... 09
OTHER (SPECIFY) .................................................................. 10
Prepared by Mathematica Policy Research
E.14
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
IMPACT OF THE ARRA SUBSIDIES ON COBRA HEALTH INSURANCE
FREQUENTLY ASKED QUESTIONS (FAQs)
PROGRAMMER: ALLOW INTERVIEWER TO VIEW FAQS AT ANY TIME.
WHO/WHICH AGENCY IS SPONSORING THE STUDY?
This study is being sponsored by the U.S. Department of Labor.
WHO IS CONDUCTING THE STUDY?
Mathematica, an independent research company, is conducting the study on behalf of the
U.S. Department of Labor. Mathematica has more than 40 years of policy research and program
evaluation experience. You can learn more about Mathematica by visiting our website at
www.mathematica-mpr.com.
WHAT IS THE PURPOSE OF THE STUDY?
This study is about the health insurance needs and use among workers and their families after
they become unemployed.
WHO IS ELIGIBLE TO PARTICIPATE IN THE STUDY?
Some people who became unemployed between February 17, 2009 and March 31, 2011.
WHAT IS COBRA?
COBRA is the Consolidated Omnibus Budget Reconciliation Act of 1985. COBRA was intended
to help prevent loss of health insurance coverage for workers and their families when
employees change or lose their jobs. COBRA benefits are available for a limited time after an
employee separates from a job.
WHAT IS THE ARRA SUBSIDY?
To help workers maintain their coverage, the American Recovery and Reinvestment Act (ARRA)
provided money to help pay insurance premium costs to most COBRA-eligible people who lost
their jobs between September 1, 2008 and May 31, 2010.
I DON’T COLLECT UNEMPLOYMENT BENEFITS ANYMORE/I COLLECTED THEM FOR A
VERY SHORT TIME.
We are calling people who filed for unemployment insurance benefits between February 2009
and March 2011. Even if you no longer receive or never collected unemployment benefits, your
experience and input is very important to the study. Hearing from people with different
experiences helps us learn more about how being unemployed affects health insurance
coverage for different groups.
Prepared by Mathematica Policy Research
E.15
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
FAQS – (continued)
I’M DISSATISFIED WITH MY UNEMPLOYMENT BENEFITS/LOCAL AGENCIES.
I understand. Your comments will be especially important to the research. The U.S. Department
of Labor needs to hear from people who were satisfied and people who were dissatisfied with
their experiences.
HOW DID YOU GET MY NAME?
Your name was scientifically selected from among persons in your state who filed for
unemployment insurance benefits between February 17, 2009 and March 31, 2011.
IS THE SURVEY PRIVATE?
Yes. All of the information we collect in the survey will be kept private and will be used for
research purposes only. Your answers will be combined with the answers of other survey
participants. Your name will never be used in any reports. Only members of the study team will
have information about you.
HOW LONG WILL THIS TAKE?
The length of the interview is different for different people, but it usually takes between 40 and
45 minutes.
I DON’T HAVE THE TIME.
We can schedule a call to do the survey at your convenience. Our interviewers are available to
speak with you seven days a week as follows: on Mondays through Thursdays from 9:00 A.M. to
12:00 midnight, on Fridays from 9:00 A.M. to 8:00 P.M., Saturdays from 9:00 A.M.-5:00 P.M. and
Sundays from 1:00 P.M. to 9:00 P.M. Eastern Standard Time. We can also complete the survey
in more than one call, if necessary.
WHAT HAPPENS IF I DON’T PARTICIPATE IN THE SURVEY?
Your participation is voluntary and will not affect your eligibility to receive any services or
benefits. Your selection for the survey was done scientifically. You were chosen to represent
other people who received unemployment insurance benefits in your area. Your answers will
help the U.S. Department of Labor improve services to people who become unemployed. There
are no right or wrong answers. We’re interested in your experiences and opinions.
I’M NOT INTERESTED.
Let me reassure you that we are not selling anything. The questions we ask will help the
U.S. Department of Labor improve services to people who are unemployed. There are no right
or wrong answers. We’re interested in your experiences and opinions. Your answers will be
combined with those of others and reported in summary form. Your name will never be included
in any report. If you qualify and complete the survey, we will pay you ($40/$50) as a token of our
appreciation.
Prepared by Mathematica Policy Research
E.16
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
FAQS – (continued)
WHO GAVE YOU THE AUTHORITY TO CONDUCT THE STUDY?
This study is being sponsored by the U.S. Department of Labor and has been approved by the
U.S. Office of Management and Budget under OMB Control Number XXXX-XXXX. Without this
approval we would not be able to conduct this survey.
WILL I BE PAID?
Yes, we will mail you a check in the amount of ($40/$50) within 2 weeks of completing the
survey.
WHAT ARE YOU GOING TO DO FOR ME NOW? ARE YOU GOING TO HELP ME FIND A
JOB OR HELP ME WITH HEALTH CARE COVERAGE?
Mathematica is a private, independent research firm. Our company is conducting this study for
the U.S. Department of Labor, and this survey is part of the study. We cannot provide
assistance finding jobs or health care. You will, however, receive ($50/$40) for completing the
survey.
I’M ON THE NATIONAL “DO NOT CALL LIST/REGISTRY.” WHY ARE YOU CALLING ME?
The do not call list or registry applies to telemarketing calls, not to calls like this one that are
approved by the government. Lawmakers recognize the need for the public to participate in
studies like this to learn how government programs are working and how to improve them. We
will not sell you anything, nor will we ask for money. Your privacy will be respected, and your
cooperation is appreciated. For more information on who is included and excluded on the do not
call list, you can visit the website at www.donotcall.gov.
DOES THE MONEY I RECEIVE FOR COMPLETING THIS SURVEY COUNT TOWARDS MY
INCOME FOR THIS YEAR?
No, the money received for completing this survey is not considered employment income.
Employment income is generated from an employment contract. This is a one-time payment for
volunteering to take part in the survey.
WHO CAN I CONTACT FOR MORE INFORMATION?
For more information about the study, you can visit the U.S. Department of Labor (DOL) website
at http://www.dol.gov/. You can also call the study’s project officer, Dr. Kristin Lantz of DOL at
202-693-4812 or Mathematica’s Project Director, Dr. Anu Rangarajan at 609-936-2765. For
questions about the survey you can call Mathematica’s Survey Director, Julita Milliner-Waddell
at 609-275-2206.
Prepared by Mathematica Policy Research
E.17
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
SECTION B: SCREENER CONFIRMATION, SAMPLE MEMBER VERIFICATION,
AND HOUSEHOLD CHARACTERISTICS
(All)
B1.
(FOR IVR CALLERS, SAY: I have just a bit more information to verify with you.) ALL OTHERS,
START HERE: For these next questions, please think about the job you had in [fill JOB
SEPARATION MONTH, YEAR]. My computer shows that the name of the company you worked
for at that time was [fill EMPLOYER NAME FROM UI RECORDS]. Is that correct?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(B1ck)
(B1 NE 01)
B1a.
What is the correct name of the company you worked for just before you filed for unemployment
benefits in [fill UI CLAIM DATE]?
PROBE IF NEEDED: Having the name of your company will help the interview to flow more
smoothly and go more quickly.
RECORD VERBATIM
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(All)
B1ck.
INTERVIEWER: IS THIS CALL AN IVR CALL-IN OR A CATI CALL-IN?
IVR CALL- IN ......................................................................... 01
CATI CALL-IN ........................................................................ 02
(B2)
(B3)
(B1ck=01–IVR CALLERS ONLY)
B2.
And, you were covered by health insurance through your job at [fill EMPLOYER NAME FROM
UI RECORDS OR B1a IF UPDATED] when that job ended. Is that correct?
INTERVIEWER: IF THE RESPONDENT ANSWERS DON’T KNOW OR REFUSED TO B2,
SAY: I’m sorry, but I will need the answer to this question to continue the
interview.
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
Prepared by Mathematica Policy Research
E.18
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(B4)
(B3a)
(End, Status 380)
(End, Status 200)
(B1ck=02–CATI CALL-INS ONLY
B3.
Did you have health insurance through your job with [fill EMPLOYER NAME FROM UI
RECORDS OR B1a IF UPDATED] when that job ended in [fill JOB SEPARATION MONTH,
YEAR]?
INTERVIEWER: IF THE RESPONDENT ANSWERS DON’T KNOW OR REFUSED TO B3,
SAY: I’m sorry, but I will need the answer to this question to continue the
interview.
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(B4)
(B3a)
(End) (Status 380)
(End) (Status 200)
(B2 or B3=00)
B3a.
(IF AN IVR CALLER, SAY: OK, I will correct my information.) Even though you did not have
health insurance through your job when it ended, did your employer offer health insurance to
any of its employees at the time your job ended in [fill JOB SEPARATION MONTH, YEAR]?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(B3c)
(B3c)
(B3c)
(B3a=00)
B3b.
Even though you did not have health insurance through your job when it ended, were you eligible
to enroll in your employer’s health insurance plan at that time?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(B3a=00, d OR r, OR B3b=01, 00, d OR r)
B3c.
Thank you for calling in to see if you would be eligible for the study. You have not been selected
to participate in the study. Thanks again and best wishes to you.
END SURVEY – STATUS 460—COBRA INELIGIBLE
(B2 OR B3=01)
B4.
At the time your job ended in [fill JOB SEPARATION MONTH, YEAR], what was your marital
status—were you married, living with a partner, separated, divorced, widowed, or had you never
been married?
CODE ONE
MARRIED............................................................................... 01
LIVING WITH A PARTNER ................................................... 02
SEPARATED ......................................................................... 03
DIVORCED ............................................................................ 04
WIDOWED ............................................................................. 05
NEVER MARRIED ................................................................. 06
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
Prepared by Mathematica Policy Research
E.19
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(B2 or B3=01)
B5.
Were you eligible to participate in any of the following types of group health insurance plans at
the time your job ended in [fill JOB SEPARATION MONTH, YEAR]? Please do not include
individual health plans or health insurance provided by an employer from a new job that began
after [fill JOB SEPARATION MONTH, YEAR] here.
PROBE: Were you eligible to participate in… [fill a-d]
INTERVIEWER: CODE “YES” IF ELIGIBLE, BUT NOT USED.
INTERVIEWER: IF NOT APPLICABLE, FOR EXAMPLE NO SPOUSE OR PARTNER,
CODE NO.
a. Medicare? ...........................................................................
(B4=01, 02 OR 03)
b. Your spouse’s or partner’s health insurance plan? ............
c. A health insurance plan sponsored by a union? ................
d. PROGRAMMER: ASK “d” ONLY FOR
RESPONDENTS AGE 29 OR YOUNGER
A parent’s health insurance plan? ......................................
YES
01
NO
00
DON’T
KNOW
d
REFUSED
r
01
00
d
r
01
00
d
r
01
00
d
r
(All, except not selected subset of Group 3—subsidy ineligibles)
B6.
Thank you. Based on your responses you are eligible to participate in the study and will receive
[fill $50/$40] when you complete the survey. Let’s get started.
GO TO B8
(Not selected subset of Group 3—subsidy ineligibles)
B7.
Thank you for calling in to see if you would be eligible for the study. You have not been selected
to participate in the study. Thanks again and best wishes to you.
END SURVEY – STATUS 461—SUBSIDY INELIGIBLE
Prepared by Mathematica Policy Research
E.20
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(All)
B8.
Now, I‘d like you to think about who was living in your household at that time—when your job with
[fill EMPLOYER FROM UI RECORDS OR B1a IF UPDATED] ended in [fill JOB SEPARATION
MONTH, YEAR]. How many people, including yourself, lived or stayed in your household then?
Please include babies, small children, people who are not related to you, and people who were
temporarily away, for example, away at school.
ENTER NUMBER OF PEOPLE IN HOUSEHOLD INCLUDING SAMPLE MEMBER
|
|
| NUMBER OF PEOPLE IN HOUSEHOLD
(01-10)
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(All)
B8a.
INTERVIEWER: DID SAMPLE MEMBER LIVE ALONE—DOES B8=01?
YES ........................................................................................ 01
NO .......................................................................................... 00
Prepared by Mathematica Policy Research
E.21
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(B16)
(B9)
INTERVIEWER: TOTAL PERSONS LISTED AT B9 MUST EQUAL NUMBER IN B8 MINUS 1.
PERSON | 01 |
PERSON | 02 |
PERSON | 03 |
__________________________
NAME #01
__________________________
NAME #02
__________________________
NAME #03
SPOUSE ................................ . 01
SPOUSE ................................ . 01
SPOUSE ................................ . 01
PARTNER ............................. 02
PARTNER.............................. 02
PARTNER .............................. 02
BOYFRIEND, GIRLFRIEND .. 03
BOYFRIEND, GIRLFRIEND .. 03
BOYFRIEND, GIRLFRIEND .. 03
SON/DAUGHTER.................. 04
SON/DAUGHTER .................. 04
SON/DAUGHTER .................. 04
STEPCHILD OR
ADOPTED CHILD ................. 05
STEPCHILD OR
ADOPTED CHILD.................. 05
STEPCHILD OR
ADOPTED CHILD .................. 05
OTHER CUSTODIAL OR
FOSTER CHILD .................... 06
OTHER CUSTODIAL OR
FOSTER CHILD .................... 06
OTHER CUSTODIAL OR
FOSTER CHILD..................... 06
PARENT/STEPPARENT ....... 07
PARENT/STEPPARENT ....... 07
PARENT/STEPPARENT ....... 07
GRANDPARENT OR
GREAT-GRANDPARENT ..... 08
GRANDPARENT OR
GREAT-GRANDPARENT...... 08
GRANDPARENT OR
GREAT-GRANDPARENT ...... 08
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE .............. 09
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE............... 09
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE ............... 09
SIBLING (BROTHER OR
SISTER) ................................ 10
SIBLING (BROTHER OR
SISTER)................................. 10
SIBLING (BROTHER OR
SISTER) ................................. 10
NEPHEW OR NIECE ............ 11
NEPHEW OR NIECE............. 11
NEPHEW OR NIECE ............. 11
COUSIN ................................. 12
COUSIN ................................. 12
COUSIN ................................. 12
GRANDCHILD ....................... 13
GRANDCHILD ....................... 13
GRANDCHILD ....................... 13
OTHER RELATIVE
OR IN-LAW ............................ 14
OTHER RELATIVE
OR IN-LAW ............................ 14
OTHER RELATIVE
OR IN-LAW ............................ 14
NON-RELATIVE
(INCLUDING ROOMER
OR BOARDER) ..................... 15
NON-RELATIVE
(INCLUDING ROOMER
OR BOARDER) ..................... 15
NON-RELATIVE
(INCLUDING ROOMER
OR BOARDER)...................... 15
OTHER (SPECIFY) [specify] ..... 00
OTHER (SPECIFY) [specify] ..... 00
OTHER (SPECIFY) [specify] ..... 00
DON’T KNOW ....................... d
DON’T KNOW ........................ d
DON’T KNOW ........................ d
REFUSED ............................. r
REFUSED.............................. r
REFUSED .............................. r
MALE ..................................... 01
MALE ..................................... 01
MALE ..................................... 01
FEMALE ................................ 02
FEMALE ................................ 02
FEMALE................................. 02
A.
YEARS. ............ |
|
|
A.
YEARS. ............ |
|
|
A.
YEARS. ............ |
|
|
B.
MONTHS .......... |
|
|
B.
MONTHS .......... |
|
|
B.
MONTHS .......... |
|
|
(All)
B9.
Please tell me the first name
of everyone who lived with
you in [fill JOB
SEPARATION MONTH,
YEAR].
PROBE: Who else lived with
you at that time?
RECORD ALL NAMES ACROSS
FIRST, THEN ASK B10
THROUGH B15 FOR EACH
PERSON.
PROGRAMMER: STORE
NAMES BY PERSON NUMBER
FOR USE IN REMAINDER OF
SURVEY.
B10. What is [fill NAME]'s
relationship to you?
CODE ONE ONLY
B11. CODE GENDER WITHOUT
ASKING IF KNOWN, OR
ASK: Is [fill NAME] male or
female?
(All)
B12 How old is [fill NAME]?
PROBE: Your best
estimate is fine.
ZERO FILL BOXES TO
THE LEFT.
B13. INTERVIEWER: CHECK
B12. IS [fill NAME] 18 OR
OLDER?
(B13=01)
B14. Was [fill NAME] employed
for pay at the time your job
ended?
B15. PROGRAMMER: CHECK
B9. IS THERE ANOTHER
PERSON TO ASK ABOUT?
YES .......................
01 (B14)
YES ........................
01 (B14)
YES ........................
01 (B14)
NO .........................
00 (B15)
NO .........................
00 (B15)
NO..........................
00 (B15)
YES ....................................... 01
YES ........................................ 01
YES ........................................ 01
NO ......................................... 00
NO ......................................... 00
NO.......................................... 00
YES .......................
NAME 02)
01 (B9
YES ........................
NAME 03)
01 (B9
YES ........................
NAME 04)
01 (B9
NO .........................
00 (B16)
NO .........................
00 (B16)
NO..........................
00 (B16)
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.22
PERSON | 04 |
PERSON | 05 |
PERSON | 06 |
PERSON | 07 |
__________________________
NAME #04
__________________________
NAME #05
__________________________
NAME #06
__________________________
NAME #07
SPOUSE ............................... . 01
SPOUSE ................................ . 01
SPOUSE ................................ . 01
SPOUSE ................................ . 01
PARTNER ............................. 02
PARTNER ............................. 02
PARTNER.............................. 02
PARTNER .............................. 02
BOYFRIEND, GIRLFRIEND.. 03
BOYFRIEND, GIRLFRIEND .. 03
BOYFRIEND, GIRLFRIEND .. 03
BOYFRIEND, GIRLFRIEND .. 03
SON/DAUGHTER ................. 04
SON/DAUGHTER.................. 04
SON/DAUGHTER .................. 04
SON/DAUGHTER .................. 04
STEPCHILD OR
ADOPTED CHILD ................. 05
STEPCHILD OR
ADOPTED CHILD ................. 05
STEPCHILD OR
ADOPTED CHILD.................. 05
STEPCHILD OR
ADOPTED CHILD .................. 05
OTHER CUSTODIAL OR
FOSTER CHILD .................... 06
OTHER CUSTODIAL OR
FOSTER CHILD .................... 06
OTHER CUSTODIAL OR
FOSTER CHILD .................... 06
OTHER CUSTODIAL OR
FOSTER CHILD..................... 06
PARENT/STEPPARENT ....... 07
PARENT/STEPPARENT ....... 07
PARENT/STEPPARENT ....... 07
PARENT/STEPPARENT ....... 07
GRANDPARENT OR
GREAT-GRANDPARENT ..... 08
GRANDPARENT OR
GREAT-GRANDPARENT ..... 08
GRANDPARENT OR
GREAT-GRANDPARENT...... 08
GRANDPARENT OR
GREAT-GRANDPARENT ...... 08
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE .............. 09
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE .............. 09
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE............... 09
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE ............... 09
SIBLING (BROTHER OR
SISTER) ................................ 10
SIBLING (BROTHER OR
SISTER) ................................ 10
SIBLING (BROTHER OR
SISTER)................................. 10
SIBLING (BROTHER OR
SISTER) ................................. 10
NEPHEW OR NIECE ............ 11
NEPHEW OR NIECE ............ 11
NEPHEW OR NIECE............. 11
NEPHEW OR NIECE ............. 11
COUSIN ................................ 12
COUSIN ................................. 12
COUSIN ................................. 12
COUSIN ................................. 12
GRANDCHILD ....................... 13
GRANDCHILD ....................... 13
GRANDCHILD ....................... 13
GRANDCHILD ....................... 13
OTHER RELATIVE
OR IN-LAW ........................... 14
OTHER RELATIVE
OR IN-LAW ............................ 14
OTHER RELATIVE
OR IN-LAW ............................ 14
OTHER RELATIVE
OR IN-LAW ............................ 14
NON-RELATIVE
(INCLUDING ROOMER
OR BOARDER) ..................... 15
NON-RELATIVE
(INCLUDING ROOMER
OR BOARDER) ..................... 15
NON-RELATIVE
(INCLUDING ROOMER
OR BOARDER) ..................... 15
NON-RELATIVE
(INCLUDING ROOMER
OR BOARDER)...................... 15
OTHER (SPECIFY) [specify] ..... 00
OTHER (SPECIFY) [specify] ..... 00
OTHER (SPECIFY) [specify] ..... 00
OTHER (SPECIFY) [specify] ..... 00
DON’T KNOW ....................... d
DON’T KNOW ....................... d
DON’T KNOW........................ d
DON’T KNOW ........................ d
REFUSED ............................. r
REFUSED ............................. r
REFUSED.............................. r
REFUSED .............................. r
MALE ..................................... 01
MALE ..................................... 01
MALE ..................................... 01
MALE ..................................... 01
FEMALE ................................ 02
FEMALE ................................ 02
FEMALE ................................ 02
FEMALE................................. 02
A.
YEARS. ............ |
|
|
A.
YEARS. ............ |
|
|
A.
YEARS. ............ |
|
|
A.
YEARS. ............ |
|
|
B.
MONTHS.......... |
|
|
B.
MONTHS .......... |
|
|
B.
MONTHS .......... |
|
|
B.
MONTHS .......... |
|
|
YES .......................
01 (B14)
YES .......................
01 (B14)
YES........................
01 (B14)
YES ........................
01 (B14)
NO .........................
00 (B15)
NO .........................
00 (B15)
NO .........................
00 (B15)
NO..........................
00 (B15)
YES ....................................... 01
YES ....................................... 01
YES........................................ 01
YES ........................................ 01
NO ......................................... 00
NO ......................................... 00
NO ......................................... 00
NO.......................................... 00
YES .......................
NAME 05)
01 (B9
YES .......................
NAME 06)
01 (B9
YES........................
NAME 07)
01 (B9
YES ........................
NAME 08)
01 (B9
NO .........................
00 (B16)
NO .........................
00 (B16)
NO .........................
00 (B16)
NO..........................
00 (B16)
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.23
PERSON | 08 |
PERSON | 09 |
PERSON | 10 |
__________________________
NAME #08
__________________________
NAME #09
__________________________
NAME #10
SPOUSE ................................ . 01
SPOUSE ................................ . 01
SPOUSE ............................... . 01
PARTNER .............................. 02
PARTNER .............................. 02
PARTNER ............................. 02
BOYFRIEND, GIRLFRIEND .. 03
BOYFRIEND, GIRLFRIEND .. 03
BOYFRIEND, GIRLFRIEND.. 03
SON/DAUGHTER .................. 04
SON/DAUGHTER .................. 04
SON/DAUGHTER ................. 04
STEPCHILD OR
ADOPTED CHILD .................. 05
STEPCHILD OR
ADOPTED CHILD .................. 05
STEPCHILD OR
ADOPTED CHILD ................. 05
OTHER CUSTODIAL OR
FOSTER CHILD ..................... 06
OTHER CUSTODIAL OR
FOSTER CHILD ..................... 06
OTHER CUSTODIAL OR
FOSTER CHILD .................... 06
PARENT/STEPPARENT ....... 07
PARENT/STEPPARENT........ 07
PARENT/STEPPARENT ....... 07
GRANDPARENT OR
GREAT-GRANDPARENT ...... 08
GRANDPARENT OR
GREAT-GRANDPARENT ...... 08
GRANDPARENT OR
GREAT-GRANDPARENT ..... 08
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE ............... 09
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE ............... 09
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE .............. 09
SIBLING (BROTHER OR
SISTER) ................................. 10
SIBLING (BROTHER OR
SISTER) ................................. 10
SIBLING (BROTHER OR
SISTER) ................................ 10
NEPHEW OR NIECE ............. 11
NEPHEW OR NIECE ............. 11
NEPHEW OR NIECE ............ 11
COUSIN ................................. 12
COUSIN ................................. 12
COUSIN ................................ 12
GRANDCHILD ....................... 13
GRANDCHILD ....................... 13
GRANDCHILD....................... 13
OTHER RELATIVE
OR IN-LAW ............................ 14
OTHER RELATIVE
OR IN-LAW ............................ 14
OTHER RELATIVE
OR IN-LAW ........................... 14
NON-RELATIVE
(INCLUDING ROOMER
OR BOARDER) ...................... 15
NON-RELATIVE
(INCLUDING ROOMER
OR BOARDER) ...................... 15
NON-RELATIVE
(INCLUDING ROOMER
OR BOARDER) ..................... 15
OTHER (SPECIFY) [specify] ..... 00
OTHER (SPECIFY) [specify]...... 00
OTHER (SPECIFY) [specify] ..... 00
DON’T KNOW ........................ d
DON’T KNOW ........................ d
DON’T KNOW ....................... d
REFUSED .............................. r
REFUSED .............................. r
REFUSED ............................. r
MALE ..................................... 01
MALE ..................................... 01
MALE..................................... 01
FEMALE ................................. 02
FEMALE ................................. 02
FEMALE ................................ 02
A.
YEARS.............. |
|
|
A.
YEARS. ............ |
|
|
A.
YEARS. ............ |
|
|
B.
MONTHS .......... |
|
|
B.
MONTHS ......... |
|
|
B.
MONTHS ......... |
|
|
YES ........................
01 (B14)
YES .......................
01 (B14)
YES .......................
01 (B14)
NO ..........................
00 (B15)
NO .........................
00 (B15)
NO .........................
00 (B15)
YES ........................................ 01
YES ........................................ 01
YES ....................................... 01
NO .......................................... 00
NO .......................................... 00
NO ......................................... 00
YES ........................
NAME 09)
01 (B9
YES .......................
NAME 10)
01 (B9
YES .......................
NAME 11)
01 (B9
NO ..........................
00 (B16)
NO .........................
00 (B16)
NO .........................
00 (B16)
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.24
(All)
B16.
[PROGRAMMER: IF B10=04, 05 OR 06, START HERE: Besides your (child/children) who lived
with you), at the time your job ended], did you have any (IF B10=04, 05 OR 06, SAY: other)
children for whom you were financially responsible who did not live with you at that time?
YES ........................................................................................ 01
NO .......................................................................................... 00
DOES NOT KNOW ................................................................ d
REFUSED ..............................................................................
r
Prepared by Mathematica Policy Research
E.25
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(B17)
(C1)
(C1)
(C1)
INTERVIEWER: ONLY INCLUDE SAMPLE MEMBER’S CHILDREN WHO ARE NOT LISTED AT B9.
CHILD | 01 |
CHILD | 02 |
CHILD | 03 |
_________________________
CHILD | 01 |
_________________________
CHILD | 02 |
_________________________
CHILD | 03 |
MALE ..................................... 01
MALE ..................................... 01
MALE ..................................... 01
FEMALE ................................ 02
FEMALE ................................ 02
FEMALE................................. 02
A.
YEARS. ............ |
|
|
A.
YEARS. ............ |
|
|
A.
YEARS. ............ |
|
|
B.
MONTHS .......... |
|
|
B.
MONTHS .......... |
|
|
B.
MONTHS .......... |
|
|
(B16=01)
B17. Please tell me the first
name(s) of your children
who did not live with you at
that time.
RECORD FIRST NAMES
ACROSS AT B17, THEN
ASK B18 THROUGH B20
FOR EACH CHILD.
B18. CODE GENDER WITHOUT
ASKING IF KNOWN, OR
ASK: Is [fill NAME] male or
female?
(B16=01)
B19. How old is [fill NAME]?
PROBE: Your best
estimate is fine.
ZERO FILL BOXES TO
THE LEFT.
(B16=01)
B20. In [fill JOB SEPARATION
MONTH, YEAR] when your
job ended, was [fill NAME] in
school, in the military,
working, or doing something
else?
CODE ONE
IN SCHOOL ........................... 01
IN SCHOOL ........................... 01
IN SCHOOL ........................... 01
IN THE MILITARY ................. . 02
IN THE MILITARY ................. . 02
IN THE MILITARY.................. . 02
WORKING ............................. 03
WORKING ............................. 03
WORKING ............................. 03
OTHER (SPECIFY) ............... 04
OTHER (SPECIFY) ............... 04
OTHER (SPECIFY)................ 04
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
DON’T KNOW ....................... d
DON’T KNOW ........................ d
DON’T KNOW ........................ d
REFUSED ............................. r
REFUSED.............................. r
REFUSED .............................. r
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.26
SECTION C: EMPLOYMENT AND WORK SEARCH ACTIVITIES
(All)
C1.
Now I’d like to ask some questions about your job with [fill EMPLOYER FROM UI RECORDS OR
B1a IF UPDATED] and other jobs you may have had since then. Since that time, have you
worked at a job for pay?
PROGRAMMER: SHOW PROBE IF NO: Include both part-time and full-time jobs, as well as any
self-employment jobs held for pay or profit, even if you held them for only a short time.
YES ................................................................................... 01
NO ..................................................................................... 00 (C6, JOB 1)
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r
(C1=01, d OR r)
C2.
Are you currently working at a job for pay?
PROGRAMMER: SHOW PROBE IF NO: Include both part-time and full-time jobs, as well as any
self-employment jobs held for pay or profit.
YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r
PROGRAMMER: IF C1 AND C2 = DON’T KNOW OR REFUSED, GO TO C6, JOB 1.
(C1 NE 00 OR C1 AND C2 NE d OR r)
C3.
(Including your current job) how many different jobs have you had since [fill JOB SEPARATION
MONTH, YEAR]? Include both part time and full-time jobs, as well as any self-employment jobs
or business ventures held for pay or profit .
INTERVIEWER:
IF A JOB THAT WAS INTERRUPTED BY TWO OR MORE UNPAID
WEEKS, COUNT AS SEPARATE JOBS, EVEN IF IT IS WITH THE SAME
EMPLOYER. IF THE SEPARATION WAS LESS THAN TWO WEEKS,
COUNT IT AS ONE JOB.
INTERVIEWER:
TREAT JOBS WITH TEMPORARY AGENCIES AS ONE JOB,
REGARDLESS OF THE NUMBER OF ASSIGNMENTS.
|
| NUMBER OF JOBS
(1-5)
DON’T KNOW ...................................................................
REFUSED .........................................................................
Prepared by Mathematica Policy Research
E.27
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
d
r
FIRST JOB AFTER UI CLAIM
JOB | 02 |
UI CLAIM TRIGGER JOB
JOB | 01 |
(C1 NE 00, OR C1 AND C2 NE d OR r)
[JOB 2]:
C4. In addition to your job with [fill
EMPLOYER NAME FROM UI
RECORDS OR B1a], please tell
me the name of the other places
where you have worked since [fill
JOB SEPARATION MONTH,
YEAR]. What was the name of the
first job you had after your job with
[fill NAME FROM UI RECORDS
OR B1a]? RECORD AS JOB 2.
PROGRAMMER: PRE-FILL
EMPLOYER NAME FROM UI
RECORDS OR B1a, IF UPDATED
[PRE-FILLED]
SECOND JOB AFTER UI CLAIM
JOB | 03 |
(SPECIFY) [specify] ..................... 01
(SPECIFY) [specify] ..................... 01
DON’T KNOW ..............................
d
DON’T KNOW ..............................
d
REFUSED ....................................
r
REFUSED ....................................
r
PROBE JOBS [3], [4], [5]: What was
the name of the company you worked for
after that?
RECORD ALL JOBS ACROSS FIRST
AND VERIFY AT C5. THEN ASK C6 TO
C18a FOR JOB 1. ASK ONLY C6 TO
C10 AND C12 TO C18 FOR
SUBSEQUENT JOBS.
(C3 > 1)
C5. Let me verify. Since [fill JOB
SEPARATION MONTH, YEAR]
you worked at [fill C4 NAMES FOR
JOBS 2-5]. Is this correct, or
[START HERE IF C4=d OR r] are
there any other jobs you may have
had?
YES/CORRECT .......................
01
NO/NOT CORRECT-ADD
JOBS........................................
00
DON’T KNOW ..........................
d
REFUSED ................................
r
IF CORRECT, ENTER “1” AND
CONTINUE TO C6. IF NOT CORRECT.
GO BACK TO C3 AND C4 TO ENTER
CORRECT NUMBER AND NAMES OF
JOBS HELD.
(All)
C6. (Was/Is) your job with [fill
EMPLOYER NAME] a seasonal or
temporary job?
YES .............................................. 01
YES .............................................. 01
YES .............................................. 01
NO................................................ 00
NO ................................................ 00
NO ................................................ 00
DON’T KNOW ..............................
d
DON’T KNOW ..............................
d
DON’T KNOW ..............................
d
PROBE: (Was/Is) this a job that you
knew from the beginning would only last
a few weeks or months.
(All)
C7. In what month and year did you
start working there?
REFUSED ....................................
r
REFUSED ....................................
r
REFUSED ....................................
r
IF DON’T KNOW OR REFUSED,
PROBE: What year was it? What time of
year was it—early in the year, in the
middle of year, or late in the year? Your
best estimate is fine.
| | |/|
MONTH
(1-12)
| | | |
YEAR
(1968-2010)
(C9)
| | |/|
MONTH
(1-12)
| | | |
YEAR
(1968-2010)
(C9)
| | |/|
MONTH
(1-12)
| | | |
YEAR
(1968-2010)
(C9)
DON’T KNOW ..............................
d
DON’T KNOW ..............................
d
DON’T KNOW ..............................
d
REFUSED ....................................
r
REFUSED ....................................
r
REFUSED ....................................
r
PROBE FOR JOBS 2-6: Since [fill JOB
SEPARATION MONTH, YEAR]
(C7=d OR r)
C8. How many years and/or months
did you work at [fill EMPLOYER]?
PROBE: Your best estimate is fine.
|
|
| YEARS |
|
| MONTHS
DON’T KNOW ..............................
REFUSED ....................................
d
r
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
|
|
| YEARS |
|
| MONTHS
DON’T KNOW ..............................
REFUSED ....................................
E.28
d
r
|
|
| YEARS |
|
| MONTHS
DON’T KNOW ..............................
REFUSED ....................................
d
r
FIFTH JOB AFTER UI CLAIM
JOB | 06 |
THIRD JOB AFTER UI CLAIM
JOB | 04 |
FOURTH JOB AFTER UI CLAIM
JOB | 05 |
(SPECIFY) [specify] ..................... 01
(SPECIFY) [specify] ..................... 01
(SPECIFY) [specify] ..................... 01
DON’T KNOW ..............................
d
DON’T KNOW ..............................
d
DON’T KNOW ..............................
d
REFUSED ....................................
r
REFUSED ....................................
r
REFUSED ....................................
r
YES............................................... 01
YES .............................................. 01
YES .............................................. 01
NO ................................................ 00
NO................................................ 00
NO ................................................ 00
DON’T KNOW ..............................
d
DON’T KNOW ..............................
d
DON’T KNOW ..............................
d
REFUSED ....................................
r
REFUSED ....................................
r
REFUSED ....................................
r
| | |/|
MONTH
(1-12)
| | | |
YEAR
(1968-2010)
(C9)
| | |/|
MONTH
(1-12)
| | | |
YEAR
(1968-2010)
(C9)
| | |/|
MONTH
(1-12)
| | | |
YEAR
(1968-2010)
(C9)
DON’T KNOW ..............................
d
DON’T KNOW ..............................
d
DON’T KNOW ..............................
d
REFUSED ....................................
r
REFUSED ....................................
r
REFUSED ....................................
r
|
|
| YEARS |
|
| MONTHS
DON’T KNOW ..............................
REFUSED ....................................
d
r
|
|
| YEARS |
|
| MONTHS
DON’T KNOW ..............................
REFUSED ....................................
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
d
r
E.29
|
|
| YEARS |
|
| MONTHS
DON’T KNOW ..............................
REFUSED ....................................
d
r
FIRST JOB AFTER UI CLAIM
JOB | 02 |
UI CLAIM TRIGGER JOB
JOB | 01 |
(All)
C9.
JOB [1]: According to our
records, your job at
[fill EMPLOYER FROM UI
RECORDS OR B1a IF
UPDATED] ended in [fill JOB
SEPARATION MONTH, YEAR].
Is that correct?
JOBS [2], [3], [4], [5]: In what month
and year did your job at [fill EMPLOYER]
end?
IF DON’T KNOW OR REFUSED,
PROBE: What year was it? What time of
year was it—early in the year, in the
middle of year, or late in the year? Your
best estimate is fine.
YES .......................... 01
NO............................ 00
| | |/|
MONTH
(1-12)
(CORRECT
BELOW)
| | | |
YEAR
(2008-2012)
DON’T KNOW ..........
REFUSED ................
| | |/|
MONTH
(1-12)
| | | |
YEAR
(2008-2012)
SECOND JOB AFTER UI CLAIM
JOB | 03 |
(C10)
| | |/|
MONTH
(1-12)
(C10)
(C10)
STILL AT JOB .................
n
STILL AT JOB .................
n
DON’T KNOW .................
d
DON’T KNOW .................
d
REFUSED .......................
r
REFUSED .......................
r
(C10)
d
r
GO TO C10
INTERVIEWER: FOR JOB 1, IF
SAMPLE MEMBER HAS RETURNED
TO JOB 1, RECORD THE DATE THE
JOB ENDED PRIOR TO FILING THE UI
CLAIM.
(C9, JOBS 2-5=d OR r)
JOBS [2], [3], [4], [5]:
C9a. Would you say your job at [fill
JOBS 2, 3, 4, 5,] ended…
PROBE: Your best estimate is fine.
Within the past month ..................... 01
Within the past month ..................... 01
Between 1 and 3 months ago ......... 02
Between 1 and 3 months ago ......... 02
Between 3 and 6 months ago ......... 03
Between 3 and 6 months ago ......... 03
Between 6 and 12 months ago, or .. 04
Between 6 and 12 months ago, or .. 04
More than 12 months ago ............... 05
More than 12 months ago ............... 05
DON’T KNOW ................................. d
DON’T KNOW ................................. d
REFUSED .......................................
REFUSED ....................................... r
r
(All)
C10. What kind of work (did/do) you do
at [fill EMPLOYER]?
RECORD VERBATIM
PROBE: That is, what (was/is) your
occupation?
DON’T KNOW ................................. d
DON’T KNOW ................................. d
PROBE: What were your duties?
(All)
C11. What kind of company is this—
what do they make, sell, or do?
REFUSED .......................................
REFUSED .......................................
PROBE: What was the major product or
service of [fill COMPANY NAME]
DON’T KNOW ................................. d
DON’T KNOW ................................. d
REFUSED .......................................
REFUSED .......................................
(All)
JOB [1] ONLY:
C12. Counting all locations where
[fill EMPLOYER FROM UI
RECORDS OR B1a IF
UPDATED] operates, would
you say that there were 20 or
more employees or fewer than 20
employees who worked for [fill
EMPLOYER]?
(All)
ALL JOBS:
C13. Were you represented by a union
at this job?
| | | |
YEAR
(2008-2012)
RECORD VERBATIM
r
r
RECORD VERBATIM
RECORD VERBATIM
r
20 OR MORE EMPLOYEES .......... 01
FEWER THAN 20 EMPLOYEES.... 00
DON’T KNOW ................................. d
REFUSED .......................................
r
YES ................................................. 01
NO................................................... 00
DON’T KNOW ................................. d
REFUSED ....................................... r
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.30
r
| | |/|
MONTH
(1-12)
| | | | ......................(C10)
YEAR
(2008-2012)
STILL AT JOB .......................................
n
DON’T KNOW .......................................
REFUSED .............................................
FIFTH JOB AFTER UI CLAIM
JOB | 06 |
FOURTH JOB AFTER UI CLAIM
JOB | 05 |
THIRD JOB AFTER UI CLAIM
JOB | 04 |
| | |/|
MONTH
(1-12)
(C10)
| | | | ..................... (C10)
YEAR
(2008-2012)
STILL AT JOB .......................................
n
d
DON’T KNOW .......................................
r
REFUSED .............................................
| | |/|
MONTH
(1-12)
(C10)
| | | | ...................... (C10)
YEAR
(2008-2012)
STILL AT JOB .......................................
n
d
DON’T KNOW .......................................
d
r
REFUSED .............................................
r
Within the past month..................... 01
Within the past month ..................... 01
Within the past month ..................... 01
Between 1 and 3 months ago......... 02
Between 1 and 3 months ago ......... 02
Between 1 and 3 months ago ......... 02
Between 3 and 6 months ago......... 03
Between 3 and 6 months ago ......... 03
Between 3 and 6 months ago ......... 03
Between 6 and 12 months ago, or . 04
Between 6 and 12 months ago, or.. 04
Between 6 and 12 months ago, or .. 04
More than 12 months ago .............. 05
More than 12 months ago ............... 05
More than 12 months ago ............... 05
DON’T KNOW ................................ d
DON’T KNOW ................................. d
DON’T KNOW ................................. d
REFUSED ......................................
REFUSED .......................................
REFUSED .......................................
r
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.31
r
r
(C10)
FIRST JOB AFTER UI CLAIM
JOB | 02 |
UI CLAIM TRIGGER JOB
JOB | 01 |
(All)
ALL JOBS:
C14.
How many hours per week,
including regular overtime
hours (did/do) you usually
work at [fill EMPLOYER]?
(C14=v, d OR r)
C14a.
Would you say you work(ed)
less than 20 hours per week,
between 20 and 29 hours per
week, between 30 and 39
hours per week, or 40 or more
hours per week?
(All)
ALL JOBS:
C15a.
What (was/is) your usual pay,
including tips, bonuses and
commissions at this job
before taxes or other
deductions (were/are) taken?
PROBE: Your best estimate is
fine.
INTERVIEWER: ACCEPT
MOST CONVENIENT PAY
PERIOD. IF NECESSARY,
CONFIRM PAY PERIOD.
(C15a=d OR r)
C15b.
I’ll read some ranges. Please
try to estimate your annual
pay at [fill EMPLOYER].
Would you say your annual
earnings (are/were)…
PROBE: (Did/Does) this
include tips and commissions?
| | |
(1-80)
(C15a)
VARIES ......................................
DON’T KNOW ...............................
REFUSED .....................................
LESS THAN 20 HOURS
PER WEEK ...................................
BETWEEN 20 AND
29 HOURS PER WEEK ................
BETWEEN 30 AND
39 HOURS PER WEEK ................
40 OR MORE HOURS
PER WEEK ...................................
DON’T KNOW ...............................
REFUSED .....................................
$|
| | |,| | |
(5.00 – 300,000.00)
|.|
v
d
r
01
02
03
04
d
r
| |
(C15c)
| | |
(1-80)
(C15a)
VARIES ......................................
DON’T KNOW ...............................
REFUSED .....................................
LESS THAN 20 HOURS
PER WEEK ...................................
BETWEEN 20 AND
29 HOURS PER WEEK ................
BETWEEN 30 AND
39 HOURS PER WEEK ................
40 OR MORE HOURS
PER WEEK ...................................
| | |,| | |
(5.00 – 300,000.00)
|.|
v
d
r
| | |
(1-80)
(C15a)
VARIES ......................................
DON’T KNOW ..............................
REFUSED ....................................
04
LESS THAN 20 HOURS
PER WEEK ..................................
BETWEEN 20 AND
29 HOURS PER WEEK ...............
BETWEEN 30 AND
39 HOURS PER WEEK ...............
40 OR MORE HOURS
PER WEEK ..................................
d
r
DON’T KNOW ..............................
REFUSED ....................................
01
02
03
DON’T KNOW ...............................
REFUSED .....................................
$|
SECOND JOB AFTER UI CLAIM
JOB | 03 |
| |
(C15c)
$|
| | |,| | |
(5.00 – 300,000.00)
|.|
v
d
r
01
02
03
04
d
r
| |
(C15c)
PER HOUR ................................... 01
PER HOUR ................................... 01
PER HOUR .................................. 01
PER WEEK ................................... 02
ONCE EVERY TWO WEEKS ....... 03
PER WEEK ................................... 02
ONCE EVERY TWO WEEKS ....... 03
PER WEEK .................................. 02
ONCE EVERY TWO WEEKS ...... 03
TWICE A MONTH......................... 04
PER MONTH ................................ 05
TWICE A MONTH ......................... 04
PER MONTH................................. 05
TWICE A MONTH ........................ 04
PER MONTH ................................ 05
PER YEAR .................................... 06
OTHER (SPECIFY) [specify] ........ 07
PER YEAR .................................... 06
OTHER (SPECIFY) [specify] ........ 07
PER YEAR ................................... 06
OTHER (SPECIFY) [specify]........ 07
DON’T KNOW ...............................
REFUSED .....................................
DON’T KNOW ...............................
REFUSED .....................................
DON’T KNOW ..............................
REFUSED ....................................
d
r
d
r
Less than $10,000
per year, .............................. 01
Less than $10,000
per year, .............................. 01
Less than $10,000
per year, .............................. 01
$10,000 or more, but less
than $20,000 per year,........ 02
$10,000 or more, but less
than $20,000 per year, ........ 02
$10,000 or more, but less
than $20,000 per year, ........ 02
$20,000 or more but less
$20,000 or more but less
$20,000 or more but less
than $30,000 per year,........ 03
than $30,000 per year, ........ 03
than $30,000 per year, ........ 03
$30,000 or more but less
than $40,000 per year,........ 04
$30,000 or more but less
than $40,000 per year, ........ 04
$30,000 or more but less
than $40,000 per year, ........ 04
$40,000 or more but less
than $50,000 per year,........ 05
$40,000 or more but less
than $50,000 per year, ........ 05
$40,000 or more but less
than $50,000 per year, ........ 05
$50,000 or more but less
than $75,000 per year,........ 06
$50,000 or more but less
than $75,000 per year, ........ 06
$50,000 or more but less
than $75,000 per year, ........ 06
$75,000 or more but
less than $100,000
per year, or ......................... 07
$75,000 or more but
less than $100,000
per year, or .......................... 07
$75,000 or more but
less than $100,000
per year, or .......................... 07
more than $100,000
per year? ............................. 08
more than $100,000
per year? ............................. 08
more than $100,000
per year? ............................. 08
d
r
DON’T KNOW ..................... d
(C16)
DON’T KNOW ..................... d
(C16)
DON’T KNOW ..................... d
(C16)
REFUSED ........................... r
(C16)
REFUSED ........................... r
(C16)
REFUSED ........................... r
(C16)
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.32
| | |
(1-80)
(C15a)
| | |
(1-80)
VARIES ..........................................................
DON’T KNOW ................................................
REFUSED ......................................................
v
d
r
LESS THAN 20 HOURS
PER WEEK.....................................................
BETWEEN 20 AND
29 HOURS PER WEEK .................................
BETWEEN 30 AND
39 HOURS PER WEEK .................................
40 OR MORE HOURS
PER WEEK.....................................................
DON’T KNOW ................................................
| | |,| | |
(5.00 – 300,000.00)
|.|
|
|
(C15a)
| | |
(1-80)
VARIES ...........................................................
DON’T KNOW .................................................
REFUSED .......................................................
04
d
LESS THAN 20 HOURS
PER WEEK .....................................................
BETWEEN 20 AND
29 HOURS PER WEEK ..................................
BETWEEN 30 AND
39 HOURS PER WEEK ..................................
40 OR MORE HOURS
PER WEEK .....................................................
DON’T KNOW .................................................
r
REFUSED .......................................................
01
02
03
REFUSED ......................................................
$|
FIFTH JOB AFTER UI CLAIM
JOB | 06 |
FOURTH JOB AFTER UI CLAIM
JOB | 05 |
THIRD JOB AFTER UI CLAIM
JOB | 04 |
(C15c)
$|
| | |,| | |
(5.00 – 300,000.00)
|.|
|
|
v
d
r
(C15a)
VARIES ..........................................................
DON’T KNOW ................................................
REFUSED ......................................................
v
d
r
LESS THAN 20 HOURS
PER WEEK ....................................................
BETWEEN 20 AND
29 HOURS PER WEEK .................................
BETWEEN 30 AND
39 HOURS PER WEEK .................................
40 OR MORE HOURS
PER WEEK ....................................................
DON’T KNOW ................................................
REFUSED ......................................................
01
02
03
04
d
r
(C15c)
$|
| | |,| | |
(5.00 – 300,000.00)
|.|
|
|
01
02
03
04
d
r
(C15c)
PER HOUR.....................................................
PER WEEK.....................................................
ONCE EVERY TWO WEEKS ........................
TWICE A MONTH ..........................................
PER MONTH ..................................................
PER YEAR .....................................................
OTHER (SPECIFY) [specify] ..........................
01
02
03
04
05
06
07
PER HOUR .....................................................
PER WEEK .....................................................
ONCE EVERY TWO WEEKS .........................
TWICE A MONTH ...........................................
PER MONTH ..................................................
PER YEAR ......................................................
OTHER (SPECIFY) [specify] ..........................
01
02
03
04
05
06
07
PER HOUR ....................................................
PER WEEK ....................................................
ONCE EVERY TWO WEEKS ........................
TWICE A MONTH ..........................................
PER MONTH ..................................................
PER YEAR .....................................................
OTHER (SPECIFY) [specify] .........................
01
02
03
04
05
06
07
DON’T KNOW ................................................
d
DON’T KNOW .................................................
d
DON’T KNOW ................................................
d
REFUSED ......................................................
r
REFUSED .......................................................
r
REFUSED ......................................................
r
Less than $10,000
per year, ....................................................... 01
Less than $10,000
per year, ....................................................... 01
Less than $10,000
per year, ....................................................... 01
$10,000 or more, but less
than $20,000 per year, ................................. 02
$10,000 or more, but less
than $20,000 per year,................................. 02
$10,000 or more, but less
than $20,000 per year, ................................. 02
$20,000 or more but less
than $30,000 per year, ................................. 03
$20,000 or more but less
than $30,000 per year,................................. 03
$20,000 or more but less
than $30,000 per year, ................................. 03
$30,000 or more but less
than $40,000 per year, ................................. 04
$30,000 or more but less
than $40,000 per year,................................. 04
$30,000 or more but less
than $40,000 per year, ................................. 04
$40,000 or more but less
than $50,000 per year, ................................. 05
$40,000 or more but less
than $50,000 per year,................................. 05
$40,000 or more but less
than $50,000 per year, ................................. 05
$50,000 or more but less
than $75,000 per year, ................................. 06
$50,000 or more but less
than $75,000 per year,................................. 06
$50,000 or more but less
than $75,000 per year, ................................. 06
$75,000 or more but
less than $100,000
per year, or ................................................... 07
$75,000 or more but
less than $100,000
per year, or................................................... 07
$75,000 or more but
less than $100,000
per year, or ................................................... 07
more than $100,000
per year? ...................................................... 08
more than $100,000
per year? ...................................................... 08
more than $100,000
per year? ...................................................... 08
DON’T KNOW .............................................. d
(C16)
DON’T KNOW .............................................. d
(C16)
DON’T KNOW .............................................. d
(C16)
REFUSED .................................................... r
(C16)
REFUSED .................................................... r
(C16)
REFUSED .................................................... r
(C16)
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.33
FIRST JOB AFTER UI CLAIM
JOB | 02 |
UI CLAIM TRIGGER JOB
JOB | 01 |
(All)
ALL JOBS:
C16. (Was/Is) [fill a-c]) available to
you at [fill EMPLOYER]?
PROGRAMMER: FOR JOB [1] ONLY,
IF B2 OR B3=01, START AT C16b.
INTERVIEWER: IF BENEFITS WERE
OR WILL BE AVAILABLE TO SAMPLE
MEMBER AFTER A STANDARD
PROBATIONARY PERIOD, CODE
YES, EVEN IF NOT USED.
(All)
JOBS [1] AND [2] ONLY:
C17. What was the main reason this
job ended? Was it because…
CODE ONE RESPONSE
YES NO DK RF
b. Paid vacation ............ 1
c. Participation in a
retirement or
pension plan.............. 1
0
0
d
d
YES NO DK RF
a. Health insurance or
membership in an
HMO or PPO plan ..... 1
0
d
r
b. Paid vacation ............. 1
0
d
r
c. Participation in a
retirement or
pension plan .............. 1
a. NOT APPLICABLE
UI RECORDS OR B1a IF
UPDATED], did you expect the
layoff to be temporary – that is did
you think you would be recalled?
(All)
JOB [1] ONLY:
C18. At the time your job ended, did
the company, plant, or facility
you worked for move or close?
PROGRAMMER: CHECK C4. IF NO
OTHER JOBS, GO TO C19.
PROGRAMMER: BEFORE GOING TO
JOB 2, SHOW THIS: These are all the
questions I have about [fill JOB 1
NAME]. Now I’m going to ask you just a
few questions about the other jobs you
had since [fill JOB SEPARATION
MONTH, YEAR].
0
d
r
0
d
r
r
b. Paid vacation ............ 1
0
d
r
r
c. Participation in a
retirement or
pension plan ............. 1
0
d
r
GO TO C19
you were laid off................ 01 (C17a)
you were laid off ................ 01 (C17a)
you retired, .................................... 02
you were discharged or fired, ....... 03
you quit, ........................................ 04
Or was there some other reason?
(SPECIFY) [specify] ...................... 05
__________________________
YOU GOT A BETTER JOB .......... 06
YOU MOVED ................................ 07
YOU HAD HEALTH PROBLEMS . 08
YOU RETURNED TO SCHOOL... 09
YOU NEEDED TO TAKE CARE OF
A FAMILY MEMBER..................... 10
you retired, .................................... 02
you were discharged or fired,........ 03
you quit,......................................... 04
Or was there some other reason?
(SPECIFY) [specify] ...................... 05
__________________________
YOU GOT A BETTER JOB ........... 06
YOU MOVED ................................ 07
YOU HAD HEALTH PROBLEMS . 08
YOU RETURNED TO SCHOOL ... 09
YOU NEEDED TO TAKE CARE OF
A FAMILY MEMBER ..................... 10
JOB COMPLETED/
TEMP. WORK/SEASONAL WORK/
WORK PERIOD ENDED ... 11 (C17a)
JOB COMPLETED/
TEMP. WORK/SEASONAL WORK/
WORK PERIOD ENDED ...... 11 (C17a)
DON’T KNOW ...............................
REFUSED .....................................
DON’T KNOW ...............................
REFUSED .....................................
(INCLUDE REORGANIZATION/
DOWNSIZING/ COMPANY SOLD/
COMPANY MOVED/ COMPANY WENT
OUT OF BUSINESS/PLANT OR FACILITY
MOVED OR CLOSED/ END OF TERM IN
SERVICE/ENLISTMENT UP/REDUCTION
IN FORCE OR RIF’ED/ JOB/POSITION
ELIMINATED)
d
r
(INCLUDE REORGANIZATION/
DOWNSIZING/ COMPANY SOLD/
COMPANY MOVED/ COMPANY WENT
OUT OF BUSINESS/PLANT OR FACILITY
MOVED OR CLOSED/ END OF TERM IN
SERVICE/ENLISTMENT UP/REDUCTION
IN FORCE OR RIF’ED/ JOB/POSITION
ELIMINATED)
GO TO C19
YES ............................................... 01
NO................................................. 00
DON’T KNOW ...............................
d
REFUSED .....................................
r
YES ............................................... 01
NO................................................. 00
DON’T KNOW ...............................
d
REFUSED .....................................
r
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.34
YES NO DK RF
a. Health insurance or
membership in an
HMO or PPO plan..... 1
IF STILL AT JOB, GO TO C19
GO TO C19
[JOB [1] ONLY
(C17=01)
C17a. At the time that you were laid off
from [fill EMPLOYER FROM
SECOND JOB AFTER UI CLAIM
JOB | 03 |
d
r
THIRD JOB AFTER UI CLAIM
JOB | 04 |
YES NO DK RF
a. Health insurance or
membership in an
HMO or PPO plan ..... 1
0
d
b. Paid vacation ............ 1
0
d
c. Participation in a
retirement or
pension plan ............. 1
0
d
FOURTH JOB AFTER UI CLAIM
JOB | 05 |
YES NO DK RF
r
a. Health insurance or
membership in an
HMO or PPO plan ..... 1
0
d
r
b. Paid vacation............. 1
0
d
r
c. Participation in a
retirement or
pension plan .............. 1
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
0
E.35
d
FIFTH JOB AFTER UI CLAIM
JOB | 06 |
YES NO DK RF
r
a. Health insurance or
membership in an
HMO or PPO plan .....1
0
d
r
r
b. Paid vacation .............1
0
d
r
r
c. Participation in a
retirement or
pension plan ..............1
0
d
r
(All)
C19.
Think back to when your job ended in [fill JOB SEPARATION MONTH, YEAR]. At that time, how
long did you think it would take to find a job? Did you think it would take less than three months,
three to six months, seven to nine months, ten to twelve months, or longer than twelve months?
CODE ONE ONLY
LESS THAN THREE MONTHS .............................................
THREE TO SIX MONTHS .....................................................
SEVEN TO NINE MONTHS ...................................................
TEN TO TWELVE MONTHS .................................................
LONGER THAN 12 MONTHS ...............................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
01
02
03
04
05
d
r
(All)
C20.
In reality, how difficult (IF WORKED SINCE JOB LOSS (C1=01), SAY: was it/IF NEVER
WORKED SINCE JOB LOSS (C1=00, d, or r), SAY: has it been) to find a job? (Was it/Has it
been) more difficult than you expected, less difficult than you expected, or just about as difficult
as you expected?
CODE ONE ONLY
MORE DIFFICULT THAN EXPECTED.................................. 01
LESS DIFFICULT THAN EXPECTED ................................... 02
AS DIFFICULT AS EXPECTED............................................. 03
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(All)
C21.
After your job with [fill EMPLOYER NAME FROM UI RECORDS OR B1a] ended, about how
many hours did you spend each week, on average, looking for work during the first three months?
PROBE: Your best estimate is fine.
|
|
| HOURS (IF WORKED SINCE JOB LOSS, GO TO C26, OTHERWISE GO TO C22)
(01-80)
ZERO/DID NOT LOOK FOR WORK .....................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
Prepared by Mathematica Policy Research
E.36
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
n
d
r
(C24)
(C21=D OR R)
C21a. Would you say you spent between…
CODE ONE ONLY
1 and 5 hours per week, ........................................................ 01
6 and 10 hours per week, ...................................................... 02
11 and 20 hours per week, .................................................... 03
21 and 30 hours per week, .................................................... 04
31 and 40 hours per week, or ................................................ 05
more than 40 hours per week? .............................................. 06
DON’T KNOW ........................................................................
d
REFUSED ..............................................................................
r
(All)
C22.
Since that time have you received any job offers that you turned down?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
Prepared by Mathematica Policy Research
E.37
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(C26)
(C26)
(C26)
(C22=01)
C23.
There are many reasons why people sometimes do not accept a job offer. What was the main
reason why you did not accept a job that you were offered? Was it because…
CODE ONE ONLY
It did not pay enough, ............................................................ 01
It did not offer health benefits,................................................ 02
You expected to be called back to your former job,............... 03
Or some other reason? (SPECIFY) ....................................... 04
_______________________________________________
IT DID NOT OFFER OTHER BENEFITS............................... 05
THE JOB WAS NOT IN MY USUAL OCCUPATION ............. 06
STARTED OWN BUSINESS/SELF-EMPLOYED .................. 07
COMMUTE WAS TOO LONG ............................................... 08
FAMILY RESPONSIBILITIES ................................................ 09
IN SCHOOL OR OTHER TRAINING ..................................... 10
ILL HEALTH OR PHYSICAL DISABILITY ............................. 11
DON’T KNOW ........................................................................
d
REFUSED ..............................................................................
r
(C22=01)
C23a. Were there any other reasons?
YES ........................................................................................ 01
NO .......................................................................................... 00
(C26)
DON’T KNOW ........................................................................
d
(C26)
REFUSED ..............................................................................
r
(C26)
Prepared by Mathematica Policy Research
E.38
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(C23a=01)
C23b. What were the other reasons why you did not accept a job that you were offered?
CODE ALL THAT APPLY
IT DID NOT PAY ENOUGH ................................................... 01
IT DID NOT OFFER HEALTH BENEFITS ............................. 02
EXPECTED TO BE CALLED BACK TO FORMER JOB ....... 03
IT DID NOT OFFER OTHER BENEFITS............................... 04
THE JOB WAS NOT IN MY USUAL OCCUPATION ............. 05
STARTED OWN BUSINESS/SELF-EMPLOYED .................. 06
COMMUTE WAS TOO LONG ............................................... 07
FAMILY RESPONSIBILITIES ................................................ 08
IN SCHOOL OR OTHER TRAINING ..................................... 09
ILL HEALTH OR PHYSICAL DISABILITY ............................. 10
SOME OTHER REASON (SPECIFY) [SPECIFY) ................. 11
_______________________________________________
DON’T KNOW ........................................................................
d
REFUSED ..............................................................................
r
GO TO C26
Prepared by Mathematica Policy Research
E.39
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(C21=n)
C24.
What is the main reason you did not look for work in the first three months after your job with
[fill EMPLOYER FROM PRELOADS OR B1a] ended?
CODE ONE ONLY
EXPECTED NEW JOB TO START ........................................... 01
DID NOT WANT TO WORK/DID NOT WANT TO LOOK
FOR WORK........................................................................... 02
BELIEVES NO WORK AVAILABLE IN LINE OF WORK
OR AREA .............................................................................. 03
COULDN’T FIND ANY WORK ................................................... 04
EXPECTED TO BE CALLED BACK TO JOB (NO
SPECIFIC DATE) .................................................................. 05
ON STANDBY WITH EMPLOYER—HAS A SPECIFIC
CALLBACK DATE ................................................................. 06
EXPECTED UNION TO PROVIDE JOB .................................... 07
MOVED OR MOVING ................................................................ 08
STARTED OWN BUSINESS/SELF-EMPLOYED ...................... 09
LACKS NECESSARY SCHOOLING, TRAINING, SKILLS
OR EXPERIENCE................................................................. 10
RETIRED ................................................................................... 11
EMPLOYERS THINK TOO YOUNG OR TOO OLD .................. 12
OTHER TYPES OF DISCRIMINATION ..................................... 13
CAN’T ARRANGE CHILD CARE ............................................... 14
FAMILY RESPONSIBILITIES .................................................... 15
IN SCHOOL OR OTHER TRAINING ......................................... 16
ILL HEALTH OR PHYSICAL DISABILITY ................................. 17
PREGNANCY ............................................................................ 18
TRANSPORTATION PROBLEMS ............................................. 19
STILL WORKING PART-TIME/WORKING PART-TIME
WHILE COLLECTING UI BENEFITS ................................... 20
OTHER (SPECIFY) [specify] ..................................................... 21
_______________________________________________
DON’T KNOW ........................................................................
d
(C26)
REFUSED ..............................................................................
r
(C26)
Prepared by Mathematica Policy Research
E.40
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(C21=n)
C25.
Were there any other reasons why you did not look for work in the three months after that job
ended?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(C26)
(C26)
(C26)
(C25=01)
C25a. What were the other reasons why you did not look for work in the three months after that job
ended?
PROBE: Any other reasons?
CODE ALL THAT APPLY
EXPECTED NEW JOB TO START ........................................... 01
DID NOT WANT TO WORK/DID NOT WANT TO LOOK
FOR WORK........................................................................... 02
BELIEVES NO WORK AVAILABLE IN LINE OF WORK
OR AREA .............................................................................. 03
COULDN’T FIND ANY WORK ................................................... 04
EXPECTED TO BE CALLED BACK TO JOB (NO
SPECIFIC DATE) .................................................................. 05
ON STANDBY WITH EMPLOYER—HAS A SPECIFIC
CALLBACK DATE ................................................................. 06
EXPECTED UNION TO PROVIDE JOB .................................... 07
MOVED OR MOVING ................................................................ 08
STARTED OWN BUSINESS/SELF-EMPLOYED ...................... 09
LACKS NECESSARY SCHOOLING, TRAINING, SKILLS
OR EXPERIENCE................................................................. 10
RETIRED ................................................................................... 11
EMPLOYERS THINK TOO YOUNG OR TOO OLD .................. 12
OTHER TYPES OF DISCRIMINATION ..................................... 13
CAN’T ARRANGE CHILD CARE ............................................... 14
FAMILY RESPONSIBILITIES .................................................... 15
IN SCHOOL OR OTHER TRAINING ......................................... 16
ILL HEALTH, PHYSICAL DISABILITY....................................... 17
PREGNANCY ............................................................................ 18
TRANSPORTATION PROBLEMS ............................................. 19
STILL WORKING PART-TIME/WORKING PART-TIME
WHILE COLLECTING UI BENEFITS ................................... 20
OTHER (SPECIFY) [specify] ..................................................... 21
_______________________________________________
DON’T KNOW ........................................................................
d
REFUSED ..............................................................................
r
Prepared by Mathematica Policy Research
E.41
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(All)
C26.
Are you currently looking for work?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(D1)
(D1)
(C26=01 OR 00)
C26ck. PROGRAMMER: IF C2 AND C26=01 - CURRENTLY WORKING AND LOOKING FOR WORK,
GO TO C26a.
IF C2 AND C26=00 - NOT CURRENTLY WORKING AND NOT LOOKING FOR WORK, GO TO
C26b.
EVERYONE ELSE, GO TO D1.
(C26ck=01)
C26a. Although you are currently working, why are you looking for work?
PROBE: Any other reasons?
CODE ALL THAT APPLY
BETTER PAY ......................................................................... 01
MORE HOURS ...................................................................... 02
BETTER WORK SCHEDULE ................................................ 03
BETTER HEALTH INSURANCE ........................................... 04
MORE AFFORDABLE HEALTH INSURANCE...................... 05
BETTER OTHER BENEFITS (NOT HEALTH) ...................... 06
SHORTER COMMUTE .......................................................... 07
BETTER FIT WITH EDUCATION OR TRAINING ................. 08
OTHER (SPECIFY) [specify] ................................................. 09
_______________________________________________
DON’T KNOW ........................................................................
REFUSED ..............................................................................
GO TO D1
Prepared by Mathematica Policy Research
E.42
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
d
r
(C26=00)
C26b. People have different reasons for not looking for work. What is the main reason you are not
currently looking for work?
CODE ONE RESPONSE
BELIEVES NO WORK AVAILABLE IN LINE OF WORK
OR AREA .................................................................................. 01
COULDN’T FIND ANY WORK ....................................................... 02
EXPECTED TO BE CALLED BACK TO JOB ................................ 03
MOVED OR MOVING .................................................................... 04
STARTED OWN BUSINESS/SELF-EMPLOYED .......................... 05
LACKS NECESSARY SCHOOLING, TRAINING, SKILLS
OR EXPERIENCE..................................................................... 06
RETIRED ....................................................................................... 07
EMPLOYERS THINK TOO YOUNG OR TOO OLD ...................... 08
OTHER TYPES OF DISCRIMINATION ......................................... 09
CAN’T ARRANGE CHILD CARE ................................................... 10
FAMILY RESPONSIBILITIES ........................................................ 11
IN SCHOOL OR OTHER TRAINING ............................................. 12
ILL HEALTH OR PHYSICAL DISABILITY ..................................... 13
TRANSPORTATION PROBLEMS ................................................. 14
WORKING PART TIME WHILE COLLECTING UI BENEFITS ..... 15
OTHER (SPECIFY) [SPECIFY] ..................................................... 16
_________________________________________________
DON’T KNOW ................................................................................
REFUSED ......................................................................................
Prepared by Mathematica Policy Research
E.43
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
d
r
SECTION D: HEALTH INSURANCE
(All)
D1.
These next questions are about health insurance. Please think back to [fill JOB SEPARATION
MONTH, YEAR] just before your job with [fill EMPLOYER NAME FROM PRELOADS OR B1a]
ended and about your employer’s health plan that you were enrolled in at that time.
How good was that plan at meeting your (and your family’s) medical needs? Would you say it
was excellent, very good, good, fair, or poor?
EXCELLENT .............................................................................
VERY GOOD ............................................................................
GOOD .......................................................................................
FAIR ..........................................................................................
POOR ........................................................................................
DON’T KNOW ...........................................................................
REFUSED .................................................................................
01
02
03
04
05
d
r
(All)
D1a.
In general, did that plan cover the doctors you wanted to see?
YES ........................................................................................... 01
NO ............................................................................................. 00
DON’T KNOW ........................................................................... d
REFUSED .................................................................................
r
(All)
D2.
Were any of your family members covered by that same plan while you were still working at that
job? By family we mean your spouse or partner, and children for whom you were financially
responsible, even if they did not live with you.
YES ........................................................................................... 01
NO ............................................................................................. 00 (D3a)
DON’T KNOW ........................................................................... d (D3a)
REFUSED .................................................................................
r (D3a)
(D2=01)
D2a.
Were all of your family members covered by that same plan at that time?
PROBE, IF NEEDED: Again, by family we mean your spouse or partner, and children for whom
you were financially responsible, even if they did not live with you.
YES ........................................................................................... 01 (D4)
NO ............................................................................................. 00 (D3)
DON’T KNOW ........................................................................... d (D3)
REFUSED .................................................................................
r (D3)
Prepared by Mathematica Policy Research
E.44
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
ASK D3 FOR SPOUSE AND
DEPENDENT CHILDREN ONLY
(B10=01, 02, 04, 05, 06) AND CHILDREN
NAMED AT B17.
(D2=01 AND D2a =00, d OR r)
D3.
Was [fill NAME] covered by your
employer-sponsored health plan
while you were still working at that
job?
PROGRAMMER: IF D3=00, d, OR r, GO
DIRECTLY TO D3a, SAME PERSON.
PROGRAMMER: IF D3=00, d, or r, GO
DIRECTLY TO D3a, SAME PERSON.
(D3=00, d OR r OR D2=00, d OR r)
D3a. Was [fill NAME] covered by another
health insurance plan in [fill JOB
SEPARATION MONTH, YEAR]
before your job ended?
PROGRAMMER: IF D3a=01, GO DIRECTLY
TO D3b, SAME PERSON. ELSE STAY AT
D3a, NEXT PERSON BEFORE MOVING TO
D4.
(D3a=01)
D3b. What type of plan was [fill NAME]
covered by at that time?
PROBES: Medicaid is a program
that pays for the health care of
persons in need. In your state, you
may also hear it called
[STATEMED FROM (NAME’s)
CURRENT STATE].
Medicare is the health insurance
plan for people 65 years old and
older or for people with certain
disabilities. The Medicare card is
red, white and blue and says
“Medicare Health Insurance” in the
white section across the top.
INTERVIEWER: IF RESPONDENT HAS
MULTIPLE PLANS, ASK HIM/HER TO
CHOOSE THE PRIMARY PLAN.
RESPONDENT
PERSON | 01 |
PERSON | 02 |
YES .......................................... 01 (D3,
NEXT PERSON OR D4)
YES .......................................... 01 (D3,
NEXT PERSON OR D4)
NO ............................................ 00
NO............................................ 00
DON’T KNOW .......................... d
DON’T KNOW.......................... d
REFUSED ................................ r
REFUSED................................ r
YES .......................................... 01
YES .......................................... 01
NO ............................................ 00 (D3
NEXT PERSON OR D4)
NO............................................ 00 (D3
NEXT PERSON OR D4)
DON’T KNOW .......................... d
NEXT PERSON OR D4)
(D3
DON’T KNOW.......................... d
NEXT PERSON OR D4)
(D3
REFUSED ................................ r
NEXT PERSON OR D4)
(D3
REFUSED................................ r
NEXT PERSON OR D4)
(D3
CODE ONE ONLY
(HIS/HER) EMPLOYER’S
SPONSORED HEALTH PLAN ................. 00
A FAMILY MEMBER’S EMPLOYER
SPONSORED HEALTH PLAN ................ 01
A FAMILY MEMBER’S EMPLOYER
SPONSORED HEALTH PLAN ................. 01
MEDICAID ................................................ 02
MEDICAID ................................................ 02
MEDICARE .............................................. 03
MEDICARE ............................................... 03
THE CHILDREN’S HEALTH INSURANCE
PROGRAM OR CHIP............................... 04
THE CHILDREN’S HEALTH INSURANCE
PROGRAM OR CHIP ............................... 04
A STATE GOVERNMENT PROGRAM
OTHER THAN MEDICAID OR CHIP ....... 05
A STATE GOVERNMENT PROGRAM
OTHER THAN MEDICAID OR CHIP ....... 05
MILITARY HEALTH CARE THROUGH
ARMED FORCES RETIREMENT BENEFITS,
THE VA, TRICARE, CHAMPUS, OR
CHAMP-VA .............................................. 06
MILITARY HEALTH CARE THROUGH
ARMED FORCES RETIREMENT BENEFITS,
THE VA, TRICARE, CHAMPUS, OR
CHAMP-VA ............................................... 06
A PLAN FROM THE INDIAN
HEALTH SERVICE .................................. 07
A PLAN FROM THE INDIAN
HEALTH SERVICE................................... 07
GROUP COVERAGE THROUGH A
UNION ...................................................... 08
GROUP COVERAGE THROUGH A
UNION ...................................................... 08
GROUP COVERAGE THROUGH SOME
OTHER ASSOCIATION ........................... 09
GROUP COVERAGE THROUGH SOME
OTHER ASSOCIATION ........................... 09
INSURANCE PURCHASED DIRECTLY
FROM AN INSURER, OR ....................... . 10
INSURANCE PURCHASED DIRECTLY
FROM AN INSURER, OR ........................ 10
SOME OTHER TYPE OF HEALTH
INSURANCE? (SPECIFY) [SPECIFY] .... 11
SOME OTHER TYPE OF HEALTH
INSURANCE? (SPECIFY) [SPECIFY] ..... 11
________________________________
________________________________
COBRA (DO NOT READ) ............ 12 (D3c)
COBRA (DO NOT READ) ........... 12 (D3c)
DON’T KNOW .......................................... d
DON’T KNOW........................................... d
REFUSED ................................................ r
REFUSED................................................. r
GO TO D3, NEXT PERSON OR D4
(D3b=12)
D3c.
Was this COBRA plan through a
family member’s employer?
INTERVIEWER: CORRECT D3b IF
NEEDED. COBRA INSURANCE
THROUGH A FAMILY MEMBER
SHOULD BE CODED “01.”
CODE ONE ONLY
(HIS/HER) EMPLOYER’S
SPONSORED HEALTH PLAN ................ 00
GO TO D3, NEXT PERSON OR D4
YES ...............................................
01
YES ...............................................
01
NO .................................................
00
NO.................................................
00
DON’T KNOW ...............................
d
DON’T KNOW...............................
d
REFUSED .....................................
r
REFUSED.....................................
r
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.45
PERSON | 03 |
PERSON | 04 |
PERSON | 05 |
PERSON | 06 |
YES .......................................... 01 (D3,
NEXT PERSON OR D4)
YES .......................................... 01 (D3,
NEXT PERSON OR D4)
YES .......................................... 01 (D3,
NEXT PERSON OR D4)
YES.......................................... 01 (D3,
NEXT PERSON OR D4)
NO ............................................ 00
NO ............................................ 00
NO............................................ 00
NO ........................................... 00
DON’T KNOW .......................... d
DON’T KNOW .......................... d
DON’T KNOW.......................... d
DON’T KNOW ......................... d
REFUSED ................................ r
REFUSED ................................ r
REFUSED ................................ r
REFUSED................................ r
YES .......................................... 01
YES .......................................... 01
YES .......................................... 01
YES.......................................... 01
NO ............................................ 00 (D3
NEXT PERSON OR D4)
NO ............................................ 00 (D3
NEXT PERSON OR D4)
NO............................................ 00 (D3
NEXT PERSON OR D4)
NO ........................................... 00 (D3
NEXT PERSON OR D4)
DON’T KNOW .......................... d
NEXT PERSON OR D4)
(D3
DON’T KNOW .......................... d
NEXT PERSON OR D4)
(D3
DON’T KNOW.......................... d
NEXT PERSON OR D4)
(D3
DON’T KNOW ......................... d
NEXT PERSON OR D4)
(D3
REFUSED ................................ r
NEXT PERSON OR D4)
(D3
REFUSED ................................ r
NEXT PERSON OR D4)
(D3
REFUSED ................................ r
NEXT PERSON OR D4)
(D3
REFUSED................................ r
NEXT PERSON OR D4)
(D3
CODE ONE ONLY
CODE ONE ONLY
CODE ONE ONLY
CODE ONE ONLY
(HIS/HER) EMPLOYER’S
SPONSORED HEALTH PLAN ................ 00
(HIS/HER) EMPLOYER’S
SPONSORED HEALTH PLAN ................ 00
(HIS/HER) EMPLOYER’S
SPONSORED HEALTH PLAN ................ 00
(HIS/HER) EMPLOYER’S
SPONSORED HEALTH PLAN ................. 00
A FAMILY MEMBER’S EMPLOYER
SPONSORED HEALTH PLAN ................ 01
A FAMILY MEMBER’S EMPLOYER
SPONSORED HEALTH PLAN ................ 01
A FAMILY MEMBER’S EMPLOYER
SPONSORED HEALTH PLAN ................ 01
A FAMILY MEMBER’S EMPLOYER
SPONSORED HEALTH PLAN ................. 01
MEDICAID ................................................ 02
MEDICAID................................................ 02
MEDICAID ............................................... 02
MEDICAID ................................................ 02
MEDICARE .............................................. 03
MEDICARE .............................................. 03
MEDICARE .............................................. 03
MEDICARE ............................................... 03
THE CHILDREN’S HEALTH INSURANCE
PROGRAM OR CHIP .............................. 04
THE CHILDREN’S HEALTH INSURANCE
PROGRAM OR CHIP .............................. 04
THE CHILDREN’S HEALTH INSURANCE
PROGRAM OR CHIP .............................. 04
THE CHILDREN’S HEALTH INSURANCE
PROGRAM OR CHIP ............................... 04
A STATE GOVERNMENT PROGRAM
OTHER THAN MEDICAID OR CHIP ....... 05
A STATE GOVERNMENT PROGRAM
OTHER THAN MEDICAID OR CHIP ....... 05
A STATE GOVERNMENT PROGRAM
OTHER THAN MEDICAID OR CHIP ...... 05
A STATE GOVERNMENT PROGRAM
OTHER THAN MEDICAID OR CHIP ....... 05
MILITARY HEALTH CARE THROUGH
ARMED FORCES RETIREMENT
BENEFITS,
THE VA, TRICARE, CHAMPUS, OR
CHAMP-VA .............................................. 06
MILITARY HEALTH CARE THROUGH
ARMED FORCES RETIREMENT
BENEFITS,
THE VA, TRICARE, CHAMPUS, OR
CHAMP-VA .............................................. 06
MILITARY HEALTH CARE THROUGH
ARMED FORCES RETIREMENT
BENEFITS,
THE VA, TRICARE, CHAMPUS, OR
CHAMP-VA .............................................. 06
MILITARY HEALTH CARE THROUGH
ARMED FORCES RETIREMENT
BENEFITS,
THE VA, TRICARE, CHAMPUS, OR
CHAMP-VA ............................................... 06
A PLAN FROM THE INDIAN
HEALTH SERVICE .................................. 07
A PLAN FROM THE INDIAN
HEALTH SERVICE .................................. 07
A PLAN FROM THE INDIAN
HEALTH SERVICE .................................. 07
A PLAN FROM THE INDIAN
HEALTH SERVICE................................... 07
GROUP COVERAGE THROUGH A
UNION ...................................................... 08
GROUP COVERAGE THROUGH A
UNION...................................................... 08
GROUP COVERAGE THROUGH A
UNION ..................................................... 08
GROUP COVERAGE THROUGH A
UNION ...................................................... 08
GROUP COVERAGE THROUGH SOME
OTHER ASSOCIATION ........................... 09
GROUP COVERAGE THROUGH SOME
OTHER ASSOCIATION........................... 09
GROUP COVERAGE THROUGH SOME
OTHER ASSOCIATION .......................... 09
GROUP COVERAGE THROUGH SOME
OTHER ASSOCIATION ........................... 09
INSURANCE PURCHASED DIRECTLY
FROM AN INSURER, OR ....................... . 10
INSURANCE PURCHASED DIRECTLY
FROM AN INSURER, OR ....................... . 10
INSURANCE PURCHASED DIRECTLY
FROM AN INSURER, OR ...................... . 10
INSURANCE PURCHASED DIRECTLY
FROM AN INSURER, OR ........................ 10
SOME OTHER TYPE OF HEALTH
INSURANCE? (SPECIFY) [SPECIFY] .... 11
SOME OTHER TYPE OF HEALTH
INSURANCE? (SPECIFY) [SPECIFY] .... 11
SOME OTHER TYPE OF HEALTH
INSURANCE? (SPECIFY) [SPECIFY] .... 11
SOME OTHER TYPE OF HEALTH
INSURANCE? (SPECIFY) [SPECIFY] ..... 11
________________________________
________________________________
________________________________
_______________________________
COBRA (DO NOT READ) ............ 12 (D3c)
COBRA (DO NOT READ)............ 12 (D3c)
COBRA (DO NOT READ) ........... 12 (D3c)
COBRA (DO NOT READ) ........... 12 (D3c)
DON’T KNOW .......................................... d
DON’T KNOW .......................................... d
DON’T KNOW.......................................... d
DON’T KNOW .......................................... d
REFUSED ................................................ r
REFUSED ................................................
REFUSED ................................................
REFUSED................................................. r
GO TO D3, NEXT PERSON OR D4
GO TO D3, NEXT PERSON OR D4
r
GO TO D3, NEXT PERSON OR D4
r
GO TO D3, NEXT PERSON OR D4
YES ...............................................
01
YES ...............................................
01
YES ...............................................
01
YES...............................................
01
NO .................................................
00
NO .................................................
00
NO.................................................
00
NO ................................................
00
DON’T KNOW ...............................
d
DON’T KNOW ...............................
d
DON’T KNOW...............................
d
DON’T KNOW ..............................
d
REFUSED .....................................
r
REFUSED .....................................
r
REFUSED .....................................
r
REFUSED.....................................
r
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.46
PERSON | 07 |
PERSON | 08 |
PERSON | 09 |
PERSON | 10 |
YES .......................................... 01 (D3,
NEXT PERSON OR D4)
YES .......................................... 01 (D3,
NEXT PERSON OR D4)
YES .......................................... 01 (D3,
NEXT PERSON OR D4)
YES.......................................... 01 (D3,
NEXT PERSON OR D4)
NO ............................................ 00
NO ............................................ 00
NO............................................ 00
NO ........................................... 00
DON’T KNOW .......................... d
DON’T KNOW .......................... d
DON’T KNOW.......................... d
DON’T KNOW ......................... d
REFUSED ................................ r
REFUSED ................................ r
REFUSED ................................ r
REFUSED................................ r
YES ................................. 01
YES ................................ 01
YES................................. 01
YES ................................. 01
NO ................................... 00 (D4)
NO .................................. 00 (D4)
NO .................................. 00 (D4)
NO................................... 00 (D4)
DON’T KNOW ................. d
(D4)
DON’T KNOW ................ d
(D4)
DON’T KNOW................. d
(D4)
DON’T KNOW ................. d
(D4)
REFUSED ....................... r
(D4)
REFUSED ...................... r
(D4)
REFUSED....................... r
(D4)
REFUSED ....................... r
(D4)
CODE ONE ONLY
CODE ONE ONLY
CODE ONE ONLY
CODE ONE ONLY
(HIS/HER) EMPLOYER’S
SPONSORED HEALTH PLAN ................ 00
(HIS/HER) EMPLOYER’S
SPONSORED HEALTH PLAN ................ 00
(HIS/HER) EMPLOYER’S
SPONSORED HEALTH PLAN ................ 00
(HIS/HER) EMPLOYER’S
SPONSORED HEALTH PLAN ................. 00
A FAMILY MEMBER’S EMPLOYER
SPONSORED HEALTH PLAN ................ 01
A FAMILY MEMBER’S EMPLOYER
SPONSORED HEALTH PLAN ................ 01
A FAMILY MEMBER’S EMPLOYER
SPONSORED HEALTH PLAN ................ 01
A FAMILY MEMBER’S EMPLOYER
SPONSORED HEALTH PLAN ................. 01
MEDICAID ................................................ 02
MEDICAID................................................ 02
MEDICAID ............................................... 02
MEDICAID ................................................ 02
MEDICARE .............................................. 03
MEDICARE .............................................. 03
MEDICARE .............................................. 03
MEDICARE ............................................... 03
THE CHILDREN’S HEALTH INSURANCE
PROGRAM OR CHIP .............................. 04
THE CHILDREN’S HEALTH INSURANCE
PROGRAM OR CHIP .............................. 04
THE CHILDREN’S HEALTH INSURANCE
PROGRAM OR CHIP .............................. 04
THE CHILDREN’S HEALTH INSURANCE
PROGRAM OR CHIP ............................... 04
A STATE GOVERNMENT PROGRAM
OTHER THAN MEDICAID OR CHIP ....... 05
A STATE GOVERNMENT PROGRAM
OTHER THAN MEDICAID OR CHIP ....... 05
A STATE GOVERNMENT PROGRAM
OTHER THAN MEDICAID OR CHIP ...... 05
A STATE GOVERNMENT PROGRAM
OTHER THAN MEDICAID OR CHIP ....... 05
MILITARY HEALTH CARE THROUGH
ARMED FORCES RETIREMENT
BENEFITS,
THE VA, TRICARE, CHAMPUS, OR
CHAMP-VA .............................................. 06
MILITARY HEALTH CARE THROUGH
ARMED FORCES RETIREMENT
BENEFITS,
THE VA, TRICARE, CHAMPUS, OR
CHAMP-VA .............................................. 06
MILITARY HEALTH CARE THROUGH
ARMED FORCES RETIREMENT
BENEFITS,
THE VA, TRICARE, CHAMPUS, OR
CHAMP-VA .............................................. 06
MILITARY HEALTH CARE THROUGH
ARMED FORCES RETIREMENT
BENEFITS,
THE VA, TRICARE, CHAMPUS, OR
CHAMP-VA ............................................... 06
A PLAN FROM THE INDIAN
HEALTH SERVICE .................................. 07
A PLAN FROM THE INDIAN
HEALTH SERVICE .................................. 07
A PLAN FROM THE INDIAN
HEALTH SERVICE .................................. 07
A PLAN FROM THE INDIAN
HEALTH SERVICE................................... 07
GROUP COVERAGE THROUGH A
UNION ...................................................... 08
GROUP COVERAGE THROUGH A
UNION...................................................... 08
GROUP COVERAGE THROUGH A
UNION ..................................................... 08
GROUP COVERAGE THROUGH A
UNION ...................................................... 08
GROUP COVERAGE THROUGH SOME
OTHER ASSOCIATION ........................... 09
GROUP COVERAGE THROUGH SOME
OTHER ASSOCIATION........................... 09
GROUP COVERAGE THROUGH SOME
OTHER ASSOCIATION .......................... 09
GROUP COVERAGE THROUGH SOME
OTHER ASSOCIATION ........................... 09
INSURANCE PURCHASED DIRECTLY
FROM AN INSURER, OR ....................... . 10
INSURANCE PURCHASED DIRECTLY
FROM AN INSURER, OR ....................... . 10
INSURANCE PURCHASED DIRECTLY
FROM AN INSURER, OR ...................... . 10
INSURANCE PURCHASED DIRECTLY
FROM AN INSURER, OR ........................ 10
SOME OTHER TYPE OF HEALTH
INSURANCE? (SPECIFY) [SPECIFY] .... 11
SOME OTHER TYPE OF HEALTH
INSURANCE? (SPECIFY) [SPECIFY] .... 11
SOME OTHER TYPE OF HEALTH
INSURANCE? (SPECIFY) [SPECIFY] .... 11
SOME OTHER TYPE OF HEALTH
INSURANCE? (SPECIFY) [SPECIFY] ..... 11
________________________________
________________________________
________________________________
_______________________________
COBRA (DO NOT READ) ............ 12 (D3c)
COBRA (DO NOT READ)............ 12 (D3c)
COBRA (DO NOT READ) ........... 12 (D3c)
COBRA (DO NOT READ) ........... 12 (D3c)
DON’T KNOW .......................................... d
DON’T KNOW .......................................... d
DON’T KNOW.......................................... d
DON’T KNOW .......................................... d
REFUSED ................................................ r
REFUSED ................................................
REFUSED ................................................
REFUSED................................................. r
GO TO D3, NEXT PERSON OR D4
GO TO D3, NEXT PERSON OR D4
r
GO TO D3, NEXT PERSON OR D4
r
GO TO D3, NEXT PERSON OR D4
YES ...............................................
01
YES ...............................................
01
YES ...............................................
01
YES...............................................
01
NO .................................................
00
NO .................................................
00
NO.................................................
00
NO ................................................
00
DON’T KNOW ...............................
d
DON’T KNOW ...............................
d
DON’T KNOW...............................
d
DON’T KNOW ..............................
d
REFUSED .....................................
r
REFUSED .....................................
r
REFUSED .....................................
r
REFUSED.....................................
r
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.47
RESPONDENT
PERSON | 01 |
(All)
D4.
How much was your portion
of the monthly premium; that
is, how much did you have
to pay for health insurance
coverage before your job
with [fill EMPLOYER FROM
UI RECORDS OR B1a IF
UPDATED] ended]?
$ |___|,|___|___|___|
PROBE: The premium is the
amount you pay to maintain
health insurance coverage.
Your best estimate is fine.
DON’T KNOW ........................... d
(D5)
CODE ONE
PER MONTH ............................. 01
PER WEEK ............................... 02
EVERY TWO WEEKS ............... 03
TWICE PER MONTH…… ......... 04
REFUSED ................................. r
(D4=d OR r)
D4a. Would you say you paid less
than $100 per month,
between $100 and $200 per
month, between $200 and
$400 per month, between
$400 and $600 per month,
or more than $600 per
month?
LESS THAN $100 .....................
$100 TO $200 PER MONTH .....
$200 TO $400 PER MONTH .....
$400 TO $600 PER MONTH .....
MORE THAN $600 ....................
DON’T KNOW ...........................
REFUSED .................................
(All)
YES .............................
D5.
Did you continue with the
same plan that you had with
your employer after your
job ended in [fill JOB
SEPARATION MONTH,
YEAR]?
PROBE: If there was a gap
in coverage of two months or
less, please answer yes.
01
02
03
04
05
d
r
01 (D5a)
YES, MENTIONED
COBRA .......................... 02 (D5a)
NO ...............................
00 (D7)
DON’T KNOW .............
d (D7)
REFUSED ...................
r (D7)
PROBE; Please do not
include retiree health
insurance plans.
INTERVIEWER: IF
RESPONDENT SAYS THEY
ENROLLED IN COBRA, CODE
AS YES, CODE 02. DO NOT
MENTION COBRA UNLESS
RESPONDENT ASKS ABOUT IT.
(D5 =01 OR 02)
D5a. How much did you have to
pay to continue this health
insurance coverage after
your job ended?
PROBE: The premium is the
amount you pay to maintain
health insurance coverage.
Your best estimate is fine.
PROBE, IF ASKED: Please
tell me the amount after the
subsidy.
(D5a=d OR r)
D5b. Would you say you paid less
than $100 per month,
between $100 and $200 per
month, between $200 and
$400 per month, between
$400 and $600 per month,
or more than $600 per
month?
$ |___|,|___|___|___| (D5c)
CODE ONE
PER MONTH ............................. 01
PER WEEK ............................... 02
EVERY TWO WEEKS ............... 03
TWICE PER MONTH ................ 04
DON’T KNOW ........................... d
REFUSED ................................. r
LESS THAN $100 ..................... 01
$100 TO $200 PER MONTH ..... 02
$200 TO $400 PER MONTH ..... 03
$400 TO $600 PER MONTH ..... 04
MORE THAN $600 .................... 05
DON’T KNOW ........................... d
REFUSED ................................. r
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.48
PERSON | 02 |
PERSON | 01 |
NAME:______________________
RESPONDENT
(D5=01 or 02 AND D2=01)
D5c. Did you continue coverage
with that same plan for all of
your family members who
were covered by that plan
before that job ended?
YES .............................
01 (D8)
NO ...............................
00 (D5d)
DON’T KNOW .............
d (D5d)
REFUSED ...................
r (D5d)
PERSON | 02 |
NAME:______________________
(D5c=00, d OR r)
YES..............................
01
YES .............................
01
D5d. Did you continue coverage
with that same plan for [fill
NAME] after your job ended?
NO ...............................
00 (D6)
NO ...............................
00 (D6)
DON’T KNOW..............
d (D6)
DON’T KNOW .............
d (D6)
REFUSED....................
r (D6)
REFUSED ...................
r (D6)
(D5d = 00, d OR r)
D6.
Was [fill NAME] covered by
another health insurance plan
within two months of when
your job with [fill EMPLOYER
FROM UI RECORDS OR
FROM B1a] ended?
(D6=01)
D6a. What type of plan was [fill
NAME] covered by at that
time? Was it…
PROBES: Medicaid is a
program that pays for the
health care of persons in
need. In your state, you may
also hear it called
[STATEMED FROM
(NAME’s) CURRENT
STATE].
Medicare is the health
insurance plan for people
65 years old and older or for
people with certain
disabilities. The Medicare
card is red, white and blue
and says “Medicare Health
Insurance” in the white
section across the top.
INTERVIEWER: IF RESPONDENT
HAS MULTIPLE PLANS, ASK
HIM/HER TO CHOOSE THE
PRIMARY PLAN.
(D6a=12)
D6b. Was this COBRA plan
through your employer or
through a family member’s
employer?
INTERVIEWER: CORRECT D5 OR
D6a IF NEEDED. COBRA
INSURANCE THROUGH
RESPONDENT’S EMPLOYER
SHOULD BE CODED D5=01.
COBRA INSURANCE THROUGH
A FAMILY MEMBER SHOULD BE
CODED D6a=01.
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
IF YES, GO TO D5d, NEXT PERSON
OR IF NO OTHERS, GO TO D8
IF YES, GO TO D5d, NEXT PERSON
OR IF NO OTHERS, GO TO D8
YES.............................. 01 (D6a)
NO ............................... 00 (D5d,
NEXT PERSON OR D8)
DON’T KNOW..............
d (D5d,
NEXT PERSON OR D8)
REFUSED....................
r (D5d,
NEXT PERSON OR D8)
YES ............................. 01 (D6a)
NO ............................... 00 (D5d,
NEXT PERSON OR D8)
DON’T KNOW .............
d (D5d,
NEXT PERSON OR D8)
REFUSED ...................
r (D5d,
NEXT PERSON OR D8)
CODE ONE ONLY
Your new employer’s plan ........ 01
Your spouse’s employer’s plan. 02
A plan you purchased
directly, or ................................. 03
Another type of plan?
(SPECIFY) [specify] .................. 04
CODE ONE ONLY
Your new employer’s plan ........ 01
Your spouse’s employer’s plan. 02
A plan you purchased
directly, or ................................. 03
Another type of plan?
(SPECIFY) [specify] ................. 04
MEDICAID ................................ 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] .......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS, THE
VA, TRICARE, CHAMPUS, OR
CHAMP-VA .............................. 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION................ 11
COBRA (DO NOT READ) ..... 12 (D6b)
DON’T KNOW.......................... d
REFUSED................................. r
MEDICAID ................................ 05
MEDICARE .............................. 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ...... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] ......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS, THE
VA, TRICARE, CHAMPUS, OR
CHAMP-VA .............................. 09
A PLAN FROM THE INDIAN
HEALTH SERVICE .................. 10
GROUP COVERAGE
THROUGH A UNION ............... 11
COBRA (DO NOT READ) ..... 12 (D6b)
DON’T KNOW .......................... d
REFUSED ................................ r
GO TO D5d, NEXT PERSON OR D8
GO TO D5d, NEXT PERSON OR D8
YOUR EMPLOYER ............... 01
YOUR EMPLOYER ................ 01
FAMILY MEMBER’S
EMPLOYER ........................... 00
FAMILY MEMBER’S
EMPLOYER ........................... 00
DON’T KNOW........................ d
DON’T KNOW ........................ d
REFUSED.............................. r
REFUSED .............................. r
GO TO D5d, NEXT PERSON OR D8
E.49
GO TO D5d, NEXT PERSON OR D8
PERSON | 03 |
PERSON | 04 |
PERSON | 05 |
NAME:______________________
NAME:______________________
NAME:______________________
(D5=01 or 02 AND D2=01)
D5c. Did you continue coverage
with that same plan for all of
your family members who
were covered by that plan
before that job ended?
(D5c=00, d OR r)
YES .............................
01
YES..............................
01
YES ..............................
01
D5d. Did you continue coverage
with that same plan for [fill
NAME] after your job ended?
NO ...............................
00 (D6)
NO ...............................
00 (D6)
NO................................
00 (D6)
DON’T KNOW .............
d (D6)
DON’T KNOW..............
d (D6)
DON’T KNOW ..............
d (D6)
REFUSED ...................
r (D6)
REFUSED....................
r (D6)
REFUSED ....................
r (D6)
(D5d = 00, d OR r)
D6.
Was [fill NAME] covered by
another health insurance plan
within two months of when
your job with [fill EMPLOYER
FROM UI RECORDS OR
FROM B1a] ended?
(D6=01)
D6a. What type of plan was [fill
NAME] covered by at that
time? Was it…
PROBES: Medicaid is a
program that pays for the
health care of persons in
need. In your state, you may
also hear it called
[STATEMED FROM
(NAME’s) CURRENT
STATE].
Medicare is the health
insurance plan for people
65 years old and older or for
people with certain
disabilities. The Medicare
card is red, white and blue
and says “Medicare Health
Insurance” in the white
section across the top.
INTERVIEWER: IF RESPONDENT
HAS MULTIPLE PLANS, ASK
HIM/HER TO CHOOSE THE
PRIMARY PLAN.
(D6a=12)
D6b. Was this COBRA plan
through your employer or
through a family member’s
employer?
INTERVIEWER: CORRECT D5 OR
D6a IF NEEDED. COBRA
INSURANCE THROUGH
RESPONDENT’S EMPLOYER
SHOULD BE CODED D5=01.
COBRA INSURANCE THROUGH
A FAMILY MEMBER SHOULD BE
CODED D6a=01.
IF YES, GO TO D5d, NEXT PERSON
OR IF NO OTHERS, GO TO D8
IF YES, GO TO D5d, NEXT PERSON
OR IF NO OTHERS, GO TO D8
YES ............................. 01 (D6a)
NO ............................... 00 (D5d,
NEXT PERSON OR D8)
DON’T KNOW .............
d (D5d,
NEXT PERSON OR D8)
REFUSED ...................
r (D5d,
NEXT PERSON OR D8)
YES.............................. 01 (D6a)
NO ............................... 00 (D5d,
NEXT PERSON OR D8)
DON’T KNOW..............
d (D5d,
NEXT PERSON OR D8)
REFUSED....................
r (D5d,
NEXT PERSON OR D8)
YES .............................. 01 (D6a)
NO................................ 00 (D5d,
NEXT PERSON OR D8)
DON’T KNOW ..............
d (D5d,
NEXT PERSON OR D8)
REFUSED ....................
r (D5d,
NEXT PERSON OR D8)
CODE ONE ONLY
Your new employer’s plan ........ 01
Your spouse’s employer’s plan. 02
A plan you purchased
directly, or ................................. 03
Another type of plan?
(SPECIFY) [specify] .................. 04
CODE ONE ONLY
Your new employer’s plan ........ 01
Your spouse’s employer’s plan. 02
A plan you purchased
directly, or ................................. 03
Another type of plan?
(SPECIFY) [specify] .................. 04
CODE ONE ONLY
Your new employer’s plan ........ 01
Your spouse’s employer’s plan. 02
A plan you purchased
directly, or ................................. 03
Another type of plan? (SPECIFY)
[specify] ..................................... 04
MEDICAID ................................ 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] .......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS, THE
VA, TRICARE, CHAMPUS, OR
CHAMP-VA .............................. 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION ............... 11
COBRA (DO NOT READ) ..... 12 (D6b)
DON’T KNOW ......................... d
REFUSED ................................ r
MEDICAID ................................ 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] .......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS, THE
VA, TRICARE, CHAMPUS, OR
CHAMP-VA .............................. 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION................ 11
COBRA (DO NOT READ) ..... 12 (D6b)
DON’T KNOW.......................... d
REFUSED................................. r
MEDICAID ................................ 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR CHIP
[FILL STATE NAME] ................. 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL STATE
NAME]....................................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS, THE
VA, TRICARE, CHAMPUS, OR
CHAMP-VA .............................. 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION ................ 11
COBRA (DO NOT READ)...... 12 (D6b)
DON’T KNOW .......................... d
REFUSED ................................. r
GO TO D5d, NEXT PERSON OR D8
GO TO D5d, NEXT PERSON OR D8
GO TO D5d, NEXT PERSON OR D8
YOUR EMPLOYER ............... 01
YOUR EMPLOYER ............... 01
YOUR EMPLOYER ............... 01
FAMILY MEMBER’S
EMPLOYER ........................... 00
FAMILY MEMBER’S
EMPLOYER ........................... 00
FAMILY MEMBER’S
EMPLOYER ........................... 00
DON’T KNOW ....................... d
DON’T KNOW........................ d
DON’T KNOW ........................ d
REFUSED ............................. r
REFUSED.............................. r
REFUSED .............................. r
GO TO D5d, NEXT PERSON OR D8
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.50
GO TO D5d, NEXT PERSON OR D8
IF YES, GO TO D5d, NEXT PERSON OR
IF NO OTHERS, GO TO D8
GO TO D5d, NEXT PERSON OR D8
PERSON | 06 |
PERSON | 07 |
PERSON | 08 |
NAME:______________________
NAME:______________________
NAME:______________________
(D5=01 or 02 AND D2=01)
D5c. Did you continue coverage
with that same plan for all of
your family members who
were covered by that plan
before that job ended?
(D5c=00, d OR r)
YES .............................
01
YES..............................
01
YES ..............................
01
D5d. Did you continue coverage
with that same plan for [fill
NAME] after your job ended?
NO ...............................
00 (D6)
NO ...............................
00 (D6)
NO................................
00 (D6)
DON’T KNOW .............
d (D6)
DON’T KNOW..............
d (D6)
DON’T KNOW ..............
d (D6)
REFUSED ...................
r (D6)
REFUSED....................
r (D6)
REFUSED ....................
r (D6)
(D5d = 00, d OR r)
D6.
Was [fill NAME] covered by
another health insurance plan
within two months of when
your job with [fill EMPLOYER
FROM UI RECORDS OR
FROM B1a] ended?
(D6=01)
D6a. What type of plan was [fill
NAME] covered by at that
time? Was it…
PROBES: Medicaid is a
program that pays for the
health care of persons in
need. In your state, you may
also hear it called
[STATEMED FROM
(NAME’s) CURRENT
STATE].
Medicare is the health
insurance plan for people
65 years old and older or for
people with certain
disabilities. The Medicare
card is red, white and blue
and says “Medicare Health
Insurance” in the white
section across the top.
INTERVIEWER: IF RESPONDENT
HAS MULTIPLE PLANS, ASK
HIM/HER TO CHOOSE THE
PRIMARY PLAN.
(D6a=12)
D6b. Was this COBRA plan
through your employer or
through a family member’s
employer?
INTERVIEWER: CORRECT D5 OR
D6a IF NEEDED. COBRA
INSURANCE THROUGH
RESPONDENT’S EMPLOYER
SHOULD BE CODED D5=01.
COBRA INSURANCE THROUGH
A FAMILY MEMBER SHOULD BE
CODED D6a=01.
IF YES, GO TO D5d, NEXT PERSON
OR IF NO OTHERS, GO TO D8
IF YES, GO TO D5d, NEXT PERSON
OR IF NO OTHERS, GO TO D8
YES ............................. 01 (D6a)
NO ............................... 00 (D5d,
NEXT PERSON OR D8)
DON’T KNOW .............
d (D5d,
NEXT PERSON OR D8)
REFUSED ...................
r (D5d,
NEXT PERSON OR D8)
YES.............................. 01 (D6a)
NO ............................... 00 (D5d,
NEXT PERSON OR D8)
DON’T KNOW..............
d (D5d,
NEXT PERSON OR D8)
REFUSED....................
r (D5d,
NEXT PERSON OR D8)
YES .............................. 01 (D6a)
NO................................ 00 (D5d,
NEXT PERSON OR D8)
DON’T KNOW ..............
d (D5d,
NEXT PERSON OR D8)
REFUSED ....................
r (D5d,
NEXT PERSON OR D8)
CODE ONE ONLY
Your new employer’s plan ........ 01
Your spouse’s employer’s plan. 02
A plan you purchased
directly, or ................................. 03
Another type of plan?
(SPECIFY) [specify] .................. 04
CODE ONE ONLY
Your new employer’s plan ........ 01
Your spouse’s employer’s plan. 02
A plan you purchased
directly, or ................................. 03
Another type of plan?
(SPECIFY) [specify] .................. 04
CODE ONE ONLY
Your new employer’s plan ........ 01
Your spouse’s employer’s plan. 02
A plan you purchased
directly, or ................................. 03
Another type of plan? (SPECIFY)
[specify] ..................................... 04
MEDICAID ................................ 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] .......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS, THE
VA, TRICARE, CHAMPUS, OR
CHAMP-VA .............................. 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION ............... 11
COBRA (DO NOT READ) ..... 12 (D6b)
DON’T KNOW ......................... d
REFUSED ................................ r
MEDICAID ................................ 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] .......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS, THE
VA, TRICARE, CHAMPUS, OR
CHAMP-VA .............................. 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION................ 11
COBRA (DO NOT READ) ..... 12 (D6b)
DON’T KNOW.......................... d
REFUSED................................. r
MEDICAID ................................ 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR CHIP
[FILL STATE NAME] ................. 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL STATE
NAME]....................................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS, THE
VA, TRICARE, CHAMPUS, OR
CHAMP-VA .............................. 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION ................ 11
COBRA (DO NOT READ)...... 12 (D6b)
DON’T KNOW .......................... d
REFUSED ................................. r
GO TO D5d, NEXT PERSON OR D8
GO TO D5d, NEXT PERSON OR D8
GO TO D5d, NEXT PERSON OR D8
YOUR EMPLOYER ............... 01
YOUR EMPLOYER ............... 01
YOUR EMPLOYER ............... 01
FAMILY MEMBER’S
EMPLOYER ........................... 00
FAMILY MEMBER’S
EMPLOYER ........................... 00
FAMILY MEMBER’S
EMPLOYER ........................... 00
DON’T KNOW ....................... d
DON’T KNOW........................ d
DON’T KNOW ........................ d
REFUSED ............................. r
REFUSED.............................. r
REFUSED .............................. r
GO TO D5d, NEXT PERSON OR D8
Prepared by Mathematica Policy Research
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E.51
GO TO D5d, NEXT PERSON OR D8
IF YES, GO TO D5d, NEXT PERSON OR
IF NO OTHERS, GO TO D8
GO TO D5d, NEXT PERSON OR D8
RESPONDENT
(D5=00, d, OR r)
D7.
Were you covered by
another health insurance
plan within two months of
the time your job with [fill
EMPLOYER FROM UI
RECORDS OR B1a]
ended?
(D7=01)
D7a. What type of plan were you
covered by at that time?
Was it…
PROBES: Medicaid is a
program that pays for the
health care of persons in
need. In your state, you may
also hear it called
[STATEMED FROM
(NAME’s) CURRENT
STATE].
Medicare is the health
insurance plan for people
65 years old and older or for
people with certain
disabilities. The Medicare
card is red, white and blue
and says “Medicare Health
Insurance” in the white
section across the top.
INTERVIEWER: IF
RESPONDENT HAS MULTIPLE
PLANS, ASK HIM/HER TO
CHOOSE THE PRIMARY PLAN.
YES .............................. 01
NO ................................ 00 (D7f or D9)
DON’T KNOW .............. d
(D7f or D9)
REFUSED ....................
(D7f or D9)
r
CODE ONE ONLY
Your new employer’s plan ............ 01
Your spouse’s employer’s plan. ... 02
A plan you purchased directly, or . 03
Another type of plan? (SPECIFY)
[specify] ........................................ 04
MEDICAID .................................... 05
MEDICARE .................................. 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] .......... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL STATE
NAME] .......................................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS, THE
VA, TRICARE, CHAMPUS, OR
CHAMP-VA .................................. 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ...................... 10
GROUP COVERAGE THROUGH
A UNION ...................................... 11
COBRA (DO NOT READ) ............. 12 (D7b)
DON’T KNOW .............................. d
REFUSED .................................... r
GO TO D7c
(D7a=12)
D7b. Was this COBRA plan
through a family member’s
employer?
YES ..............................................
NO ................................................
DON’T KNOW ..............................
REFUSED ....................................
01
00
d
r
(D7=01)
D7c. How much was your portion
of the premium; that is, how
much did you have to pay
each month for this health
insurance coverage?
PROBE: The premium is
the amount you pay—the
amount deducted from your
paycheck—to maintain
health insurance coverage.
Your best estimate is fine.
(D7c=d OR r)
D7d. Would you say you paid
less than $100 per month,
between $100 and $200 per
month, between $200 and
$400 per month, between
$400 and $600 per month,
or more than $600 per
month?
$ |___|,|___|___|___|
(D7e)
CODE ONE
PER MONTH ................................
01
PER WEEK ..................................
02
EVERY TWO WEEKS..................
03
TWICE PER MONTH ...................
04
DON’T KNOW ..............................
d
REFUSED ....................................
r
LESS THAN $100 ........................
01
$100 TO $200 PER MONTH........
02
$200 TO $400 PER MONTH........
03
$400 TO $600 PER MONTH........
04
MORE THAN $600 .......................
05
DON’T KNOW ..............................
d
REFUSED ....................................
r
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.52
PERSON | 01 |
PERSON | 02 |
NAME:_________________
NAME:_________________
RESPONDENT
(D7=01and D3=01 or D2a=01)
D7e. Was [fill NAME] also covered
by your plan at that time?
PROGRAMMER: ASK
ONLY FOR THOSE
COVERED BY EMPLOYER
SPONSORED PLAN PRIOR
TO JOB LOSS – D2 OR
D3a=01)
(D7 OR D7e=00, d OR r)
D7f. Was [fill NAME]) covered by
another health insurance
plan within two months of
when your job with [fill
EMPLOYER FROM UI
RECORDS OR B1a] ended?
ASK D7f FOR PERSONS 1
THROUGH 9, FIRST THEN
CONTINUE.
(D7f=01)
D7g. What type of plan was [fill
NAME] covered by at that
time? Was it…
PROBES: Medicaid is a
program that pays for the
health care of persons in
need. In your state, you may
also hear it called
[STATEMED FROM
(NAME’s) CURRENT
STATE].
Medicare is the health
insurance plan for people
65 years old and older or for
people with certain
disabilities. The Medicare
card is red, white and blue
and says “Medicare Health
Insurance” in the white
section across the top.
INTERVIEWER: IF
RESPONDENT HAS
MULTIPLE PLANS, ASK
HIM/HER TO CHOOSE THE
PRIMARY PLAN.
PERSON | 01 |
PERSON | 02 |
NAME:______________________
NAME:______________________
YES ................................
01
(D7e, NEXT PERSON OR D8)
YES ................................
01
(D7e, NEXT PERSON OR D8)
NO ..................................
00
NO .................................
00
DON’T KNOW ................
d
DON’T KNOW ................
d
REFUSED ......................
r
REFUSED ......................
r
01
YES ................................
YES ................................
01
NO ..................................
NEXT PERSON OR D8)
00 (D7f,
NO .................................
NEXT PERSON OR D8)
00 (D7f,
DON’T KNOW ................
NEXT PERSON OR D8)
d (D7f,
DON’T KNOW ................
NEXT PERSON OR D8)
d (D7f,
REFUSED ......................
NEXT PERSON OR D8)
r
REFUSED ......................
NEXT PERSON OR D8)
r
(D7f,
(D7f,
CODE ONE ONLY
Your new employer’s plan ......... 01
Your spouse’s employer’s plan. 02
A plan you purchased directly,
or ............................................... 03
Another type of plan?
(SPECIFY) [specify] .................. 04
CODE ONE ONLY
Your new employer’s plan ........ 01
Your spouse’s employer’s plan. 02
A plan you purchased directly,
or ............................................... 03
Another type of plan?
(SPECIFY) [specify] .................. 04
MEDICAID................................. 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] .......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS,
THE VA, TRICARE,
CHAMPUS, OR CHAMP-VA ..... 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION ................ 11
COBRA (DO NOT READ) ...... 12 (D7h)
DON’T KNOW ........................... d
REFUSED ................................. r
MEDICAID ................................ 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] .......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS,
THE VA, TRICARE,
CHAMPUS, OR CHAMP-VA .... 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION ................ 11
COBRA (DO NOT READ)...... 12 (D7h)
DON’T KNOW ........................... d
REFUSED ................................. r
GO TO D7f, NEXT PERSON OR D8
GO TO D7f, NEXT PERSON OR D8
(D7g=12)
YES .....................................
01
YES .....................................
01
D7h. Was this COBRA Plan
through your employer or
through a family member’s
employer?
NO .......................................
00
NO ......................................
00
DON’T KNOW .....................
d
DON’T KNOW .....................
d
REFUSED ...........................
r
REFUSED ...........................
r
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.53
(D7=01and D3=01 or D2a=01)
D7e. Was [fill NAME] also covered
by your plan at that time?
PROGRAMMER: ASK
ONLY FOR THOSE
COVERED BY EMPLOYER
SPONSORED PLAN PRIOR
TO JOB LOSS – D2 OR
D3a=01)
(D7 OR D7e=00, d OR r)
D7f. Was [fill NAME]) covered by
another health insurance
plan within two months of
when your job with [fill
EMPLOYER FROM UI
RECORDS OR B1a] ended?
ASK D7f FOR PERSONS 1
THROUGH 9, FIRST THEN
CONTINUE.
(D7f=01)
D7g. What type of plan was [fill
NAME] covered by at that
time? Was it…
PROBES: Medicaid is a
program that pays for the
health care of persons in
need. In your state, you may
also hear it called
[STATEMED FROM
(NAME’s) CURRENT
STATE].
Medicare is the health
insurance plan for people
65 years old and older or for
people with certain
disabilities. The Medicare
card is red, white and blue
and says “Medicare Health
Insurance” in the white
section across the top.
INTERVIEWER: IF
RESPONDENT HAS
MULTIPLE PLANS, ASK
HIM/HER TO CHOOSE THE
PRIMARY PLAN.
PERSON | 03 |
PERSON | 04 |
PERSON | 05 |
NAME:______________________
NAME:______________________
NAME:______________________
YES ................................
01
(D7e, NEXT PERSON OR D8)
YES ................................
01
(D7e, NEXT PERSON OR D8)
YES ................................
01
(D7e, NEXT PERSON OR D8)
NO ..................................
00
NO ..................................
00
NO .................................
00
DON’T KNOW ................
d
DON’T KNOW ................
d
DON’T KNOW ................
d
REFUSED ......................
r
REFUSED ......................
r
REFUSED ......................
r
01
YES ................................
01
YES ................................
YES ................................
01
NO ..................................
NEXT PERSON OR D8)
00 (D7f,
NO ..................................
NEXT PERSON OR D8)
00 (D7f,
NO .................................
NEXT PERSON OR D8)
00 (D7f,
DON’T KNOW ................
NEXT PERSON OR D8)
d (D7f,
DON’T KNOW ................
NEXT PERSON OR D8)
d (D7f,
DON’T KNOW ................
NEXT PERSON OR D8)
d (D7f,
REFUSED ......................
NEXT PERSON OR D8)
r
REFUSED ......................
NEXT PERSON OR D8)
r
REFUSED ......................
NEXT PERSON OR D8)
r
(D7f,
(D7f,
(D7f,
CODE ONE ONLY
Your new employer’s plan ........ 01
Your spouse’s employer’s plan. 02
A plan you purchased directly,
or .............................................. 03
Another type of plan?
(SPECIFY) [specify] ................. 04
CODE ONE ONLY
Your new employer’s plan ......... 01
Your spouse’s employer’s plan. 02
A plan you purchased directly,
or ............................................... 03
Another type of plan?
(SPECIFY) [specify] .................. 04
CODE ONE ONLY
Your new employer’s plan ........ 01
Your spouse’s employer’s plan. 02
A plan you purchased directly,
or ............................................... 03
Another type of plan?
(SPECIFY) [specify] .................. 04
MEDICAID ................................ 05
MEDICARE .............................. 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME]....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] ......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS,
THE VA, TRICARE,
CHAMPUS, OR CHAMP-VA .... 09
A PLAN FROM THE INDIAN
HEALTH SERVICE .................. 10
GROUP COVERAGE
THROUGH A UNION ............... 11
COBRA (DO NOT READ) ..... 12 (D7h)
DON’T KNOW .......................... d
REFUSED ................................ r
MEDICAID................................. 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] .......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS,
THE VA, TRICARE,
CHAMPUS, OR CHAMP-VA ..... 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION ................ 11
COBRA (DO NOT READ) ...... 12 (D7h)
DON’T KNOW ........................... d
REFUSED ................................. r
MEDICAID ................................ 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] .......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS,
THE VA, TRICARE,
CHAMPUS, OR CHAMP-VA .... 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION ................ 11
COBRA (DO NOT READ)...... 12 (D7h)
DON’T KNOW ........................... d
REFUSED ................................. r
GO TO D7f, NEXT PERSON OR D8
GO TO D7f, NEXT PERSON OR D8
GO TO D7f, NEXT PERSON OR D8
(D7g=12)
YES ....................................
01
YES .....................................
01
YES .....................................
01
D7h. Was this COBRA Plan
through your employer or
through a family member’s
employer?
NO ......................................
00
NO .......................................
00
NO ......................................
00
DON’T KNOW ....................
d
DON’T KNOW .....................
d
DON’T KNOW .....................
d
REFUSED ..........................
r
REFUSED ...........................
r
REFUSED ...........................
r
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E.54
(D7=01and D3=01 or D2a=01)
D7e. Was [fill NAME] also covered
by your plan at that time?
PROGRAMMER: ASK
ONLY FOR THOSE
COVERED BY EMPLOYER
SPONSORED PLAN PRIOR
TO JOB LOSS – D2 OR
D3a=01)
(D7 OR D7e=00, d OR r)
D7f. Was [fill NAME]) covered by
another health insurance
plan within two months of
when your job with [fill
EMPLOYER FROM UI
RECORDS OR B1a] ended?
ASK D7f FOR PERSONS 1
THROUGH 9, FIRST THEN
CONTINUE.
PERSON | 06 |
PERSON | 07 |
PERSON | 08 |
NAME:______________________
NAME:______________________
NAME:______________________
YES ................................
01
(D7e, NEXT PERSON OR D8)
YES ................................
01
(D7e, NEXT PERSON OR D8)
YES ................................
01
(D7e, NEXT PERSON OR D8)
NO ..................................
00
NO ..................................
00
NO .................................
00
DON’T KNOW ................
d
DON’T KNOW ................
d
DON’T KNOW ................
d
REFUSED ......................
r
REFUSED ......................
r
REFUSED ......................
r
01
YES ................................
01
YES ................................
YES ................................
01
NO ..................................
NEXT PERSON OR D8)
00 (D7f,
NO ..................................
NEXT PERSON OR D8)
00 (D7f,
NO .................................
NEXT PERSON OR D8)
00 (D7f,
DON’T KNOW ................
NEXT PERSON OR D8)
d (D7f,
DON’T KNOW ................
NEXT PERSON OR D8)
d (D7f,
DON’T KNOW ................
NEXT PERSON OR D8)
d (D7f,
REFUSED ......................
NEXT PERSON OR D8)
r
REFUSED ......................
NEXT PERSON OR D8)
r
REFUSED ......................
NEXT PERSON OR D8)
r
(D7f,
(D7f,
(D7f,
CODE ONE ONLY
Your new employer’s plan ........ 01
Your spouse’s employer’s plan. 02
A plan you purchased directly,
or .............................................. 03
Another type of plan?
(SPECIFY) [specify] ................. 04
CODE ONE ONLY
Your new employer’s plan ......... 01
Your spouse’s employer’s plan. 02
A plan you purchased directly,
or ............................................... 03
Another type of plan?
(SPECIFY) [specify] .................. 04
CODE ONE ONLY
Your new employer’s plan ........ 01
Your spouse’s employer’s plan. 02
A plan you purchased directly,
or ............................................... 03
Another type of plan?
(SPECIFY) [specify] .................. 04
MEDICAID ................................ 05
MEDICARE .............................. 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME]....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] ......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS,
THE VA, TRICARE,
CHAMPUS, OR CHAMP-VA .... 09
A PLAN FROM THE INDIAN
HEALTH SERVICE .................. 10
GROUP COVERAGE
THROUGH A UNION ............... 11
COBRA (DO NOT READ) ..... 12 (D7h)
DON’T KNOW .......................... d
REFUSED ................................ r
MEDICAID................................. 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] .......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS,
THE VA, TRICARE,
CHAMPUS, OR CHAMP-VA ..... 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION ................ 11
COBRA (DO NOT READ) ...... 12 (D7h)
DON’T KNOW ........................... d
REFUSED ................................. r
MEDICAID ................................ 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] .......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS,
THE VA, TRICARE,
CHAMPUS, OR CHAMP-VA .... 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION ................ 11
COBRA (DO NOT READ)...... 12 (D7h)
DON’T KNOW ........................... d
REFUSED ................................. r
GO TO D7f, NEXT PERSON OR D8
GO TO D7f, NEXT PERSON OR D8
GO TO D7f, NEXT PERSON OR D8
(D7g=12)
YES ....................................
01
YES .....................................
01
YES .....................................
01
D7h. Was this COBRA Plan
through your employer or
through a family member’s
employer?
NO ......................................
00
NO .......................................
00
NO ......................................
00
DON’T KNOW ....................
d
DON’T KNOW .....................
d
DON’T KNOW .....................
d
REFUSED ..........................
r
REFUSED ...........................
r
REFUSED ...........................
r
(D7f=01)
D7g. What type of plan was [fill
NAME] covered by at that
time? Was it…
PROBES: Medicaid is a
program that pays for the
health care of persons in
need. In your state, you may
also hear it called
[STATEMED FROM
(NAME’s) CURRENT
STATE].
Medicare is the health
insurance plan for people
65 years old and older or for
people with certain
disabilities. The Medicare
card is red, white and blue
and says “Medicare Health
Insurance” in the white
section across the top.
INTERVIEWER: IF
RESPONDENT HAS
MULTIPLE PLANS, ASK
HIM/HER TO CHOOSE THE
PRIMARY PLAN.
Prepared by Mathematica Policy Research
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E.55
PLAN 1
PLAN 2
(D5c OR D7=01)
YES ............................................. 01 (D12)
D8.
NO............................................... 00
(IF D5=01. SAY: Now I’d like
to ask more about your
continuation of coverage
through [fill EMPLOYER.) (If
D7=01, SAY: Now I’d like to
ask more about the coverage
you had just after you left [fill
EMPLOYER].) Are you still
covered by that plan?
(D8=00)
D8a. When did your coverage in
that health plan end?
DON’T KNOW.............................
d (D12)
REFUSED...................................
r (D12)
| | |/ | | | |
MONTH
YEAR
(1-12)
(2008-2012)
|
DON’T KNOW ....................
REFUSED ..........................
(D8=00)
D8b. What was the main reason
that your coverage ended?
d
r
HAD OTHER INSURANCE
HAD COVERAGE FROM A SPOUSE/
PARTNER/PARENTS PLAN ........... 01
HAD LESS EXPENSIVE
COVERAGE AVAILABLE .................02
HAD BETTER COVERAGE
AVAILABLE.......................................03
FOUND A JOB WITH BENEFITS .....04
STATE SUBSIDY AVAILABLE .........05
HAD NO OTHER COVERAGE
TOO EXPENSIVE.............................06
JOB ENDED .....................................07
COBRA RAN OUT ............................08
COBRA SUBSIDY RAN OUT ...........09
DIDN’T UNDERSTAND HOW TO
ENROLL/ TOO COMPLICATED ......10
IN GOOD HEALTH ...........................11
USING A 60-DAY PERIOD TO
DECIDE ............................................12
EXPECT TO FIND NEW JOB
SOON ............................................... 13
NON-PAYMENT OF PREMIUM/
POLICY CANCELLED ......................14
OTHER (SPECIFY) [specify] ............15
____________________________
DON’T KNOW ................................... d
REFUSED ......................................... r
(D7f=00, d OR r or D8=00)
YES ........................................
D9.
NO..........................................
00 (D11)
DON’T KNOW........................
d (D11)
REFUSED..............................
r (D11)
(IF D7=00, SAY: Now I would
like to ask about other health
insurance coverage that you
may have had for yourself at
any time after your job at [fill
EMPLOYER] ended). Were
you covered by another
health insurance plan after
that time?
01
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E.56
PLAN 3
PLAN 1
(D9=01)
D9a. What type of health
insurance coverage did you
have next? Were you
covered by…
PROBES: Medicaid is a
program that pays for the
health care of persons in
need. In your state, you may
also hear it called
[STATEMED FROM
(NAME’s) CURRENT
STATE].
Medicare is the health
insurance plan for people
65 years old and older or for
people with certain
disabilities. The Medicare
card is red, white and blue
and says “Medicare Health
Insurance” in the white
section across the top.
INTERVIEWER: IF RESPONDENT
HAS MULTIPLE PLANS, ASK
HIM/HER TO CHOOSE THE
PRIMARY PLAN.
PLAN 2
CODE ONE ONLY
Your new employer’s plan ........
Your spouse’s employer’s plan.
A plan you purchased directly,
or ..............................................
Another type of plan?
(SPECIFY) [specify] .................
01
02
03
04
MEDICAID ................................ 05
MEDICARE .............................. 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME]....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] ......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS,
THE VA, TRICARE,
CHAMPUS, OR CHAMP-VA .... 09
A PLAN FROM THE INDIAN
HEALTH SERVICE .................. 10
GROUP COVERAGE
THROUGH A UNION ............... 11
COBRA (DO NOT READ) ..... 12 (D9b)
DON’T KNOW .......................... d
REFUSED ................................ r
D9b. Was this COBRA plan
through your employer or
through a family member’s
employer?
01
02
03
04
CODE ONE ONLY
Your new employer’s plan ........
Your spouse’s employer’s plan.
A plan you purchased directly,
or ...............................................
Another type of plan?
(SPECIFY) [specify] ..................
01
02
03
04
MEDICAID................................. 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] .......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS,
THE VA, TRICARE,
CHAMPUS, OR CHAMP-VA ..... 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION ................ 11
COBRA (DO NOT READ) ..... 12 (D9b)
DON’T KNOW ........................... d
REFUSED ................................. r
MEDICAID ................................ 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] .......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS,
THE VA, TRICARE,
CHAMPUS, OR CHAMP-VA .... 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION ................ 11
COBRA (DO NOT READ)...... 12 (D9b)
DON’T KNOW ........................... d
REFUSED ................................. r
GO TO D9c
GO TO D9c
GO TO D9c
(D9a=12)
PLAN 3
CODE ONE ONLY
Your new employer’s plan .........
Your spouse’s employer’s plan.
A plan you purchased directly,
or ...............................................
Another type of plan?
(SPECIFY) [specify] ..................
YOUR EMPLOYER ............... 01
YOUR EMPLOYER ................ 01
YOUR EMPLOYER ............... 01
FAMILY MEMBER’S
EMPLOYER .......................... 00
FAMILY MEMBER’S
EMPLOYER ........................... 00
FAMILY MEMBER’S
EMPLOYER ........................... 00
DON’T KNOW ....................... d
DON’T KNOW ........................ d
DON’T KNOW ........................ d
REFUSED ......................
REFUSED .............................. r
REFUSED .............................. r
r
(D9=01)
D9c. When did your coverage in
that health plan begin?
|__|__| /|__|__|__|__| MONTH/YEAR
|__|__| /|__|__|__|__| MONTH/YEAR
|__|__| /|__|__|__|__| MONTH/YEAR
DON’T KNOW .................... d
DON’T KNOW ..................... d
DON’T KNOW ..................... d
REFUSED ......................
r
REFUSED ......................
r
REFUSED .......................
r
(D9=01)
YES ................................
01 (D11)
YES ................................
01 (D12)
YES .................................
01 (D12)
D9d. Are you still covered as part
of that plan?
NO ..................................
00
NO ..................................
00
NO...................................
00
DON’T KNOW ................
d
DON’T KNOW ................
d
DON’T KNOW .................
d
REFUSED ......................
r
REFUSED ......................
r
REFUSED .......................
r
(D9d=00, d, OR r)
D9e. When did your coverage in
that health plan end?
|__|__| /|__|__|__|__| MONTH/YEAR
|__|__| /|__|__|__|__| MONTH/YEAR
|__|__| /|__|__|__|__| MONTH/YEAR
DON’T KNOW .................... d
DON’T KNOW ..................... d
DON’T KNOW ..................... d
REFUSED ......................
r
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REFUSED ......................
E.57
r
REFUSED .......................
r
(D9=01)
D9a. What type of health
insurance coverage did you
have next? Were you
covered by…
PROBES: Medicaid is a
program that pays for the
health care of persons in
need. In your state, you may
also hear it called
[STATEMED FROM
(NAME’s) CURRENT
STATE].
Medicare is the health
insurance plan for people
65 years old and older or for
people with certain
disabilities. The Medicare
card is red, white and blue
and says “Medicare Health
Insurance” in the white
section across the top.
INTERVIEWER: IF RESPONDENT
HAS MULTIPLE PLANS, ASK
HIM/HER TO CHOOSE THE
PRIMARY PLAN.
PLAN 4
Your new employer’s plan ........
Your spouse’s employer’s plan.
A plan you purchased directly,
or ..............................................
Another type of plan?
(SPECIFY) [specify] .................
01
02
03
04
MEDICAID ................................ 05
MEDICARE .............................. 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME]....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] ......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS,
THE VA, TRICARE,
CHAMPUS, OR CHAMP-VA .... 09
A PLAN FROM THE INDIAN
HEALTH SERVICE .................. 10
GROUP COVERAGE
THROUGH A UNION ............... 11
COBRA (DO NOT READ) ..... 12 (D9b)
DON’T KNOW .......................... d
REFUSED ................................ r
PLAN 5
Your new employer’s plan .........
Your spouse’s employer’s plan.
A plan you purchased directly,
or ...............................................
Another type of plan?
(SPECIFY) [specify] ..................
D9b. Was this COBRA plan
through your employer or
through a family member’s
employer?
03
04
PLAN 6
Your new employer’s plan ........
Your spouse’s employer’s plan.
A plan you purchased directly,
or ...............................................
Another type of plan?
(SPECIFY) [specify] ..................
01
02
03
04
MEDICAID................................. 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] .......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS,
THE VA, TRICARE,
CHAMPUS, OR CHAMP-VA ..... 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION ................ 11
COBRA (DO NOT READ) ..... 12 (D9b)
DON’T KNOW ........................... d
REFUSED ................................. r
MEDICAID ................................ 05
MEDICARE ............................... 06
THE CHILDREN’S HEALTH
INSURANCE PROGRAM OR
CHIP [FILL STATE NAME] ....... 07
A STATE GOVERNMENT
PROGRAM OTHER THAN
MEDICAID OR CHIP [FILL
STATE NAME] .......................... 08
MILITARY HEALTH CARE,
THROUGH ARMED FORCES
RETIREMENT BENEFITS,
THE VA, TRICARE,
CHAMPUS, OR CHAMP-VA .... 09
A PLAN FROM THE INDIAN
HEALTH SERVICE ................... 10
GROUP COVERAGE
THROUGH A UNION ................ 11
COBRA (DO NOT READ)...... 12 (D9b)
DON’T KNOW ........................... d
REFUSED ................................. r
GO TO D9c
GO TO D9c
GO TO D9c
(D9a=12)
01
02
YOUR EMPLOYER ............... 01
YOUR EMPLOYER ................ 01
YOUR EMPLOYER ............... 01
FAMILY MEMBER’S
EMPLOYER .......................... 00
FAMILY MEMBER’S
EMPLOYER ........................... 00
FAMILY MEMBER’S
EMPLOYER ........................... 00
DON’T KNOW ....................... d
DON’T KNOW ........................ d
DON’T KNOW ........................ d
REFUSED ......................
REFUSED .............................. r
REFUSED .............................. r
r
(D9=01)
D9c. When did your coverage in
that health plan begin?
|__|__| /|__|__|__|__| MONTH/YEAR
|__|__| /|__|__|__|__| MONTH/YEAR
|__|__| /|__|__|__|__| MONTH/YEAR
DON’T KNOW .................... d
DON’T KNOW ..................... d
DON’T KNOW ..................... d
(D9=01)
YES ................................
01 (D12)
YES ................................
01 (D12)
YES .................................
01 (D12)
D9d. Are you still covered as part
of that plan?
NO ..................................
00
NO ..................................
00
NO...................................
00
DON’T KNOW ................
d
DON’T KNOW ................
d
DON’T KNOW .................
d
REFUSED ......................
r
REFUSED ......................
r
REFUSED .......................
r
REFUSED ......................
r
REFUSED ......................
r
REFUSED .......................
r
(D9d=00, d, OR r)
D9e. When did your coverage in
that health plan end?
|__|__| /|__|__|__|__| MONTH/YEAR
|__|__| /|__|__|__|__| MONTH/YEAR
|__|__| /|__|__|__|__| MONTH/YEAR
DON’T KNOW .................... d
DON’T KNOW ..................... d
DON’T KNOW ..................... d
REFUSED ......................
r
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PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
REFUSED ......................
E.58
r
REFUSED .......................
r
PLAN 1
(D9d=00, d OR r)
D9f. What was the main reason
that your coverage ended?
D10. Did you have any other
health plan coverage after
your [fill D9a PLAN TYPE]
coverage ended?
PLAN 3
HAD OTHER INSURANCE
HAD COVERAGE FROM A
SPOUSE/ PARTNER/
PARENTS PLAN .......................01
HAD LESS EXPENSIVE
COVERAGE AVAILABLE .........02
HAD BETTER COVERAGE
AVAILABLE ...............................03
FOUND A JOB WITH
BENEFITS ................................04
STATE SUBSIDY AVAILABLE .05
HAD OTHER INSURANCE
HAD COVERAGE FROM A
SPOUSE/ PARTNER/
PARENTS PLAN ...................... 01
HAD LESS EXPENSIVE
COVERAGE AVAILABLE ......... 02
HAD BETTER COVERAGE
AVAILABLE .............................. 03
FOUND A JOB WITH
BENEFITS ................................ 04
STATE SUBSIDY AVAILABLE . 05
HAD NO OTHER COVERAGE
TOO EXPENSIVE .................... 06
JOB ENDED ............................. 07
COBRA RAN OUT .................... 08
COBRA SUBSIDY RAN OUT ... 09
DIDN’T UNDERSTAND HOW
TO ENROLL/ TOO
COMPLICATED ........................ 10
IN GOOD HEALTH ................... 11
USING A 60-DAY PERIOD TO
DECIDE .................................... 12
EXPECT TO FIND NEW JOB
SOON ....................................... 13
NON-PAYMENT OF
PREMIUM/POLICY
CANCELLED ............................ 14
OTHER (SPECIFY) [specify] .... 15
_________________________
DON’T KNOW........................... d
REFUSED................................. r
HAD NO OTHER COVERAGE
TOO EXPENSIVE .....................06
JOB ENDED .............................07
COBRA RAN OUT ....................08
COBRA SUBSIDY RAN OUT ...09
DIDN’T UNDERSTAND HOW
TO ENROLL/ TOO
COMPLICATED ........................10
IN GOOD HEALTH ...................11
USING A 60-DAY PERIOD TO
DECIDE ....................................12
EXPECT TO FIND NEW JOB
SOON .......................................13
NON-PAYMENT OF
PREMIUM/ POLICY
CANCELLED ............................14
OTHER (SPECIFY) [specify] ....15
________________________
DON’T KNOW ........................... d
REFUSED ................................. r
HAD NO OTHER COVERAGE
TOO EXPENSIVE ..................... 06
JOB ENDED ............................. 07
COBRA RAN OUT .................... 08
COBRA SUBSIDY RAN OUT ... 09
DIDN’T UNDERSTAND HOW
TO ENROLL/ TOO
COMPLICATED ........................ 10
IN GOOD HEALTH ................... 11
USING A 60-DAY PERIOD TO
DECIDE .................................... 12
EXPECT TO FIND NEW JOB
SOON ....................................... 13
NON-PAYMENT OF
PREMIUM/ POLICY
CANCELLED ............................ 14
OTHER (SPECIFY) [specify] .... 15
_________________________
DON’T KNOW ........................... d
REFUSED ................................. r
YES..............................
NEXT PLAN)
01 (D9a,
YES .............................
NEXT PLAN)
01 (D9a,
YES ..............................
NEXT PLAN)
01 (D9a,
NO ...............................
00 (D11)
NO ...............................
00 (D12)
NO ...............................
00 (D12)
DON’T KNOW.................
REFUSED....................
D11. Between [fill JOB
SEPARATION MONTH,
YEAR] and now, for
approximately how many
months were you without
health insurance coverage?
PLAN 2
HAD OTHER INSURANCE
HAD COVERAGE FROM A
SPOUSE/ PARTNER/
PARENTS PLAN ...................... 01
HAD LESS EXPENSIVE
COVERAGE AVAILABLE ......... 02
HAD BETTER COVERAGE
AVAILABLE .............................. 03
FOUND A JOB WITH
BENEFITS ................................ 04
STATE SUBSIDY AVAILABLE . 05
d (D11)
r (D11)
DON’T KNOW ................. d (D12)
DON’T KNOW .................
d (D12)
REFUSED ....................... r (D12)
REFUSED .......................
r (D12)
|___|___| MONTHS
(01-48)
ZERO/NONE ............................. 00
DON’T KNOW............................ d
REFUSED...............................
r
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E.59
PLAN 4
(D9d=00, d OR r)
D9f. What was the main reason
that your coverage ended?
D10. Did you have any other
health plan coverage after
your [fill D9a PLAN TYPE]
coverage ended?
PLAN 5
PLAN 6
HAD OTHER INSURANCE
HAD COVERAGE FROM A
SPOUSE/ PARTNER/
PARENTS PLAN ...................... 01
HAD LESS EXPENSIVE
COVERAGE AVAILABLE ......... 02
HAD BETTER COVERAGE
AVAILABLE .............................. 03
FOUND A JOB WITH
BENEFITS ................................ 04
STATE SUBSIDY AVAILABLE . 05
HAD OTHER INSURANCE
HAD COVERAGE FROM A
SPOUSE/ PARTNER/
PARENTS PLAN .......................01
HAD LESS EXPENSIVE
COVERAGE AVAILABLE .........02
HAD BETTER COVERAGE
AVAILABLE ...............................03
FOUND A JOB WITH
BENEFITS ................................04
STATE SUBSIDY AVAILABLE .05
HAD OTHER INSURANCE
HAD COVERAGE FROM A
SPOUSE/ PARTNER/
PARENTS PLAN ...................... 01
HAD LESS EXPENSIVE
COVERAGE AVAILABLE ......... 02
HAD BETTER COVERAGE
AVAILABLE .............................. 03
FOUND A JOB WITH
BENEFITS ................................ 04
STATE SUBSIDY AVAILABLE . 05
HAD NO OTHER COVERAGE
TOO EXPENSIVE .................... 06
JOB ENDED ............................. 07
COBRA RAN OUT .................... 08
COBRA SUBSIDY RAN OUT ... 09
DIDN’T UNDERSTAND HOW
TO ENROLL/ TOO
COMPLICATED ........................ 10
IN GOOD HEALTH ................... 11
USING A 60-DAY PERIOD TO
DECIDE .................................... 12
EXPECT TO FIND NEW JOB
SOON ....................................... 13
NON-PAYMENT OF
PREMIUM/POLICY
CANCELLED ............................ 14
OTHER (SPECIFY) [specify] .... 15
_________________________
DON’T KNOW........................... d
REFUSED................................. r
HAD NO OTHER COVERAGE
TOO EXPENSIVE .....................06
JOB ENDED .............................07
COBRA RAN OUT ....................08
COBRA SUBSIDY RAN OUT ...09
DIDN’T UNDERSTAND HOW
TO ENROLL/ TOO
COMPLICATED ........................10
IN GOOD HEALTH ...................11
USING A 60-DAY PERIOD TO
DECIDE ....................................12
EXPECT TO FIND NEW JOB
SOON .......................................13
NON-PAYMENT OF
PREMIUM/ POLICY
CANCELLED ............................14
OTHER (SPECIFY) [specify] ....15
________________________
DON’T KNOW ........................... d
REFUSED ................................. r
HAD NO OTHER COVERAGE
TOO EXPENSIVE ..................... 06
JOB ENDED ............................. 07
COBRA RAN OUT .................... 08
COBRA SUBSIDY RAN OUT ... 09
DIDN’T UNDERSTAND HOW
TO ENROLL/ TOO
COMPLICATED ........................ 10
IN GOOD HEALTH ................... 11
USING A 60-DAY PERIOD TO
DECIDE .................................... 12
EXPECT TO FIND NEW JOB
SOON ....................................... 13
NON-PAYMENT OF
PREMIUM/ POLICY
CANCELLED ............................ 14
OTHER (SPECIFY) [specify] .... 15
_________________________
DON’T KNOW ........................... d
REFUSED ................................. r
YES..............................
NEXT PLAN)
01 (D9a,
YES .............................
NEXT PLAN)
01 (D9a,
YES ..............................
NEXT PLAN)
01 (D9a,
NO ...............................
00 (D12)
NO ...............................
00 (D12)
NO ...............................
00 (D12)
DON’T KNOW.................
d (D12)
DON’T KNOW ................. d (D12)
DON’T KNOW .................
d (D12)
REFUSED.......................
r (D12)
REFUSED ....................... r (D12)
REFUSED .......................
r (D12)
D11. Between [fill JOB
SEPARATION MONTH,
YEAR] and now, for
approximately how many
months were you without
health insurance coverage?
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E.60
(All)
D12.
Now, please think about the six months after your job with [fill EMPLOYER FROM UI
RECORDS OR B1a] ended. During that time, did you (or a family member) have any medical
needs and expenses that you needed to postpone or delay?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(D13)
(D13)
(D13)
(D12=01 AND D11=01)
D12a. Was it because you did not have health insurance?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(D12 =01)
D12b. Was it because your income was lower and you could not afford to visit a doctor?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(All)
D13.
During that time, did you (or a family member) ever visit an emergency room?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(D14)
(D14)
(D14)
(D13=01 AND D11=01)
D13a. Was it because you did not have health insurance?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(D14)
(D14)
(D14)
(D13=01)
D13b. Was it because your income was lower and you could not afford to visit a doctor?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
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E.61
(E1)
(E1)
(E1)
(All)
D14.
During that time, did you (or a family member) delay getting preventive medical care?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(E1)
(E1)
(E1)
(D14=01 AND D11=01)
D14a. Was it because you did not have health insurance?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(E1)
(E1)
(E1)
(D14=01)
D14b. Was it because your income was lower and you could not afford to visit a doctor?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
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E.62
SECTION E: COBRA KNOWLEDGE AND TAKE UP
(D5=02—MENTIONED COBRA)
E1.
Now I’d like to ask a few general questions about COBRA health insurance continuation. As you
know, COBRA allows some workers and their families who lose their job and health benefits the
right to continue health benefits provided by their former employer’s group plan for a limited
period of time.
GO TO E2
(D5= 01, 00, d OR r—DID NOT MENTION COBRA)
E1a.
Now I’d like to ask a few general questions about COBRA health insurance continuation. COBRA
allows some workers and their families who lose their job and health benefits the right to continue
health benefits provided by their former employer’s group plan for a limited period of time. Does
that sound familiar?
IF ASKED: COBRA stands for the Consolidated Omnibus Budget Reconciliation Act.
YES ........................................................................................... 01
NO ............................................................................................. 00 (F1)
DON’T KNOW ........................................................................... d (F1)
REFUSED .................................................................................
r (F1)
(D5= 02, OR E1a=01)
E2.
Please tell me your best guess in response to these questions about COBRA health insurance.
Don’t worry if you don’t know the exact answer.
Compared to what you pay while you are employed, does your premium increase, decrease, or
stay the same under COBRA?
PROBE: The premium is the amount you pay to maintain health insurance coverage.
INCREASE ................................................................................ 01
DECREASE .............................................................................. 02
STAY THE SAME ..................................................................... 03
DON’T KNOW ........................................................................... d
REFUSED .................................................................................
r
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E.63
(D5= 02, OR E1a=01)
E3.
Compared to what you pay while you are employed, does your deductible or co-pay increase,
decrease, or stay the same under COBRA?
PROBES: A deductible is the amount of money which the insured person must pay before the
insurance company's coverage begins.
A co-pay is a specified amount of out-of-pocket expenses for health-care services
such as doctor visits and prescriptions drugs that must be paid at the time of service.
CODE ONE ONLY
INCREASE ................................................................................ 01
DECREASE .............................................................................. 02
STAY THE SAME ..................................................................... 03
DON’T KNOW ........................................................................... d
REFUSED .................................................................................
r
(D5 NE 01 OR 02)
E4.
Were you eligible to continue participation in your employer’s sponsored health plan through
COBRA at the time your job ended?
YES ........................................................................................... 01
NO ............................................................................................. 00 (F1)
DON’T KNOW ........................................................................... d (F1)
REFUSED .................................................................................
r (F1)
(D5=01 or 02, OR E4=01)
E5.
Did you first learn that you were eligible to continue participating in your health plan through
written notification from your employer, verbal notification from your employer, in a meeting at
your job site, or in some other way?
CODE ALL THAT APPLY
RECEIVED WRITTEN NOTIFICATION FROM EMPLOYER ...
RECEIVED VERBAL NOTIFICATION FROM EMPLOYER .....
IN A JOB-SITE MEETING ........................................................
SOME OTHER WAY (SPECIFY) [specify] ...............................
01
02
03
04
DON’T KNOW ...........................................................................
REFUSED .................................................................................
d
r
(D5=01 or 02, OR E4=01)
E6.
When you were notified that you were eligible for COBRA coverage, were you provided with
information about the cost of participating in COBRA?
YES ........................................................................................... 01
NO ............................................................................................. 00 (E11)
DON’T KNOW ........................................................................... d (E11)
REFUSED .................................................................................
r (E11)
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(E6=01)
E7.
Were you provided with an exact dollar amount that you would be required to pay?
YES ........................................................................................... 01
NO ............................................................................................. 00 (E9)
DON’T KNOW ........................................................................... d (E9)
REFUSED .................................................................................
r (E9)
(E7=01)
E8.
What was the dollar amount that you would be required to pay each month to keep your health
insurance coverage through COBRA?
|,|
$|
|
DOLLARS
|
|.|
|
|
CENTS
CODE ONE ONLY
PER WEEK ............................................................................... 01
PER MONTH............................................................................. 02
PER QUARTER ........................................................................ 03
OTHER (SPECIFY) [specify] .................................................... 04
DON’T KNOW ...........................................................................
REFUSED .................................................................................
d
r
GO TO E10
(E7=00, d OR r or E8=d OR r)
E9.
Were you given a percentage of your previous premium that you would be required to pay?
YES ........................................................................................... 01
NO ............................................................................................. 00 (E10)
DON’T KNOW ........................................................................... d (E10)
REFUSED .................................................................................
r (E10)
(E9=01)
E9a.
What was the percentage that you would be required to pay to keep your health insurance
coverage through COBRA?
|
|
|
|%
DON’T KNOW ...........................................................................
REFUSED .................................................................................
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E.65
d
r
(E6=01)
E10.
How easy or difficult was the information about costs to understand? Would you say it was very
easy, somewhat easy, somewhat difficult, or very difficult?
CODE ONE ONLY
VERY EASY ..............................................................................
SOMEWHAT EASY ..................................................................
SOMEWHAT DIFFICULT .........................................................
VERY DIFFICULT .....................................................................
DON’T KNOW ...........................................................................
REFUSED .................................................................................
PROGRAMMER:
01
02
03
04
d
r
IF E4=01 AND D5=00, d, OR r—ELIGIBLE, BUT DID NOT CONTINUE
COVERAGE—GO TO E12. OTHERWISE, GO TO E11.
(E4 AND D5=01 OR 02)
E11.
If COBRA had not been available to you (and your family) at the time your job ended, would you
have looked for some other health insurance option or would you have gone without insurance?
CODE ONE ONLY
LOOKED FOR OTHER OPTIONS............................................ 01
GONE WITHOUT INSURANCE ............................................... 02 (F1)
DON’T KNOW ........................................................................... d (F1)
REFUSED .................................................................................
r (F1)
(E11=01)
E11a. What is the option you would have most likely pursued?
CODE ONE ONLY
ENROLLED IN A FAMILY MEMBER’S
INSURANCE PLAN................................................................ 01
PURCHASED AN INDIVIDUAL OR FAMILY PLAN
DIRECTLY FROM AN INSURANCE COMPANY .................. 02
ENROLLED IN A PUBLIC HEALTH CARE
OPTION SUCH AS MEDICAID .............................................. 03
SOMETHING ELSE (SPECIFY) [specify] ................................. 04
DON’T KNOW ...........................................................................
REFUSED .................................................................................
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PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.66
d
r
(E11=01)
E11b. What was the main reason you chose to enroll in COBRA instead of [fill E11a ANSWER]?
CODE ONE ONLY
COBRA WAS READILY AVAILABLE/EASY TO ENROLL .......
COBRA WAS CONVENIENT ...................................................
COBRA WAS CHEAPER THAN OTHER OPTIONS ................
WAS NOT AWARE OF/DIDN’T KNOW OTHER OPTIONS .....
WAS NOT ELIGIBLE FOR OTHER OPTIONS .........................
OTHER (SPECIFY) [specify] ....................................................
01
02
03
04
05
06
DON’T KNOW ...........................................................................
REFUSED .................................................................................
d
r
GO TO F1
(E8=01 AND D5=00, d, OR r)
E12.
At the time your coverage with [fill EMPLOYER FROM UI RECORDS OR B1a] ended, what was
the main reason you did not enroll in COBRA?
CODE ONE ONLY
HAD OTHER INSURANCE
HAD COVERAGE FROM A SPOUSE/
PARTNER/PARENTS PLAN ................................................. 01
HAD LESS EXPENSIVE COVERAGE AVAILABLE ................. 02
HAD BETTER COVERAGE AVAILABLE ................................. 03
HAD COVERAGE FROM A JOB OTHER
THAN UI CLAIM JOB ............................................................. 04
STATE SUBSIDY AVAILABLE ................................................. 05
HAD NO OTHER COVERAGE
TOO EXPENSIVE .....................................................................
DIDN’T UNDERSTAND HOW TO ENROLL/
TOO COMPLICATED ............................................................
IN GOOD HEALTH ...................................................................
USING A 60-DAY PERIOD TO DECIDE ..................................
EXPECTS TO FIND NEW JOB SOON .....................................
OTHER (SPECIFY) [specify] ....................................................
07
08
09
10
11
DON’T KNOW ...........................................................................
REFUSED .................................................................................
d
r
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E.67
06
SECTION F: COBRA SUBSIDY KNOWLEDGE AND TAKE UP
(All)
F1.
The stimulus bill or the Recovery Act helped some groups of unemployed workers pay part of
COBRA health insurance costs. This is sometimes called the COBRA subsidy. Does this sound
familiar?
IF NEEDED: The Recovery Act is also known as ARRA—the American Recovery and
Reinvestment Act of 2009.
CODE ONE ONLY
YES ........................................................................................ 01 (F2)
NO .......................................................................................... 00
NO, BUT WOULD LIKE TO KNOW ....................................... 02
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(F1 NE 01)
F1a.
This program was intended to help people who were laid off as a result of the recession with
some support in continuing health insurance coverage through COBRA. Are you aware of
anything like this?
CODE ONE ONLY
YES ........................................................................................ 01
NO .......................................................................................... 00 (F17)
NO, BUT WOULD LIKE TO KNOW ....................................... 02 (F17)
DON’T KNOW ........................................................................ d (F17)
REFUSED ..............................................................................
r (F17)
(F1 or F1a=01)
F2.
How did you hear about the COBRA subsidy?
PROBE: Any other ways?
CODE ALL THAT APPLY
FRIENDS ............................................................................... 01
TELEVISION .......................................................................... 02
NEWSPAPER ........................................................................ 03
OTHER MEDIA ...................................................................... 04
FORMER EMPLOYER........................................................... 05
UNEMPLOYMENT AGENCY ................................................ 06
OTHER GOVERNMENT AGENCY ....................................... 07
OTHER (SPECIFY) [specify] ................................................. 08
DON’T KNOW ........................................................................
REFUSED ..............................................................................
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E.68
d
r
(F1 OR F1a=01)
F3.
Now I would like to ask you a couple of general questions about the rules for receiving the
COBRA subsidy. Please tell me your best guess in response to these questions. Don’t worry if
you don’t know the exact answer.
ADD IF NECESSARY: The U.S. Department of Labor would like to know how well people
understand the health insurance aspects of ARRA rules and regulations.
First, with the COBRA subsidy, would your COBRA premium be the same, higher, or lower than
what you would have paid without the program?
PROBE: The premium is the amount you pay—the amount deducted from your paycheck—to
maintain health insurance coverage.
CODE ONE ONLY
THE SAME ............................................................................. 01
HIGHER ................................................................................. 02
LOWER .................................................................................. 03
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(F4a)
(F4a)
(F4a)
(F3=02 OR 03)
F4.
How much (higher/lower) would your premium amount be with the COBRA subsidy?
PROBE: Your best estimate is fine.
|
|
|
| % OR $ |
|,|
|
|
|.|
DOLLARS
|
|
CENTS
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(F1 OR F1a=01)
F4a.
With the COBRA subsidy, would your deductible or co-pay be higher, lower, or the same as what
you would have paid without the program?
PROBES: A deductible is the amount of money which the insured person must pay before the
insurance company's coverage begins.
A co-pay is a specified amount of out-of-pocket expenses for health-care services
such as doctor visits and prescriptions drugs that must be paid at the time of service.
CODE ONE ONLY
HIGHER .................................................................................... 01
LOWER ..................................................................................... 02
THE SAME ................................................................................ 03
DON’T KNOW ........................................................................... d
REFUSED .................................................................................
r
(F1 OR F1a=01)
F5.
Were you eligible for the COBRA subsidy?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
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E.69
(F16)
(F16)
(F16)
(F2 NE 05)
F5a.
Did you receive any information from [fill EMPLOYER FROM UI RECORDS OR B1a] about your
health insurance and your eligibility for any assistance with paying your premiums?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(F10)
(F10)
(F10)
(F2 NE 05 OR F5a=01)
F6.
Did your employer notify you about the COBRA subsidy through written notification, verbal
notification, in a meeting at your job site, or in some other way?
CODE ALL THAT APPLY
RECEIVED WRITTEN NOTIFICATION ................................
RECEIVED VERBAL NOTIFICATION ...................................
IN A JOB-SITE MEETING .....................................................
SOME OTHER WAY (SPECIFY) [specify] ............................
01
02
03
04
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(F5a=01)
F7.
Were you notified about the COBRA subsidy at the same time that you were notified about your
eligibility to participate in COBRA or was it at a different time?
SAME TIME ........................................................................... 01
DIFFERENT TIME ................................................................. 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(F5a=01)
F8.
When you were notified that you were eligible for the COBRA subsidy, were you told the monthly
amount that you would have to pay?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(F10)
(F10)
(F10)
(F8=01)
F8a.
How easy or difficult was the information about the amount you would have to pay to understand?
Would you say it was very easy, somewhat easy, somewhat difficult, or very difficult?
CODE ONE ONLY
VERY EASY ...........................................................................
SOMEWHAT EASY ...............................................................
SOMEWHAT DIFFICULT ......................................................
VERY DIFFICULT ..................................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
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E.70
01
02
03
04
d
r
(F8=01 AND D5 NE 01 OR 02)
F9.
What were you told your monthly cost would be?
PROBE: Your best estimate is fine.
|,|
$|
|
|
DOLLARS
|.|
|
|
CENTS
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(F5=01)
F10.
Did you use the COBRA subsidy?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(F15)
(F15)
(F15)
(F10=01)
F11.
In what month and year did you start using the COBRA subsidy?
|
|
| MONTH
(01-12)
| 2 | 0 |
|
| YEAR
(2008-2012)
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(F10=01)
F12.
Are you still receiving the COBRA subsidy?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(F12=00)
F13.
When did you stop receiving the COBRA subsidy?
PROBE: Your best estimate is fine.
|
|
(01-12)
| MONTH
| 2 | 0 |
|
| YEAR (F14)
(2008-2012)
DON’T KNOW ........................................................................
REFUSED ..............................................................................
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E.71
d
r
(F14)
(F14)
(F14)
(F13=d OR r)
F13a.
Would you say (you received/have been receiving) the COBRA subsidy for…
CODE ONE ONLY
1 to 3 months, ........................................................................
4 to 6 months, ........................................................................
7 to 9 months, ........................................................................
10 to 12 months, ....................................................................
13 to 15 months, ....................................................................
16 to 18 months, or ................................................................
More than 18 months? ...........................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
01
02
03
04
05
06
07
d
r
(F10=01)
F14.
How important was the COBRA subsidy in allowing you to enroll in COBRA? Would you say it
was very important, somewhat important, somewhat unimportant, or very unimportant?
VERY IMPORTANT ...............................................................
SOMEWHAT IMPORTANT ....................................................
SOMEWHAT UNIMPORTANT ..............................................
VERY UNIMPORTANT ..........................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
01
02
03
04
d
r
GO TO F16
(F10=00)
F15.
Why did you decide not to take advantage of the COBRA subsidy?
CODE ONE ONLY
HAD OTHER INSURANCE
HAD COVERAGE FROM A SPOUSE/PARTNER/
PARENTS PLAN ................................................................. 01
HAD LESS EXPENSIVE COVERAGE AVAILABLE .............. 02
HAD BETTER COVERAGE AVAILABLE .............................. 03
STATE SUBSIDY AVAILABLE .............................................. 04
FOUND A JOB WITH BENEFITS .......................................... 05
HAD NO OTHER COVERAGE
TOO EXPENSIVE ..................................................................
DIDN’T UNDERSTAND HOW TO ENROLL/
TOO COMPLICATED .........................................................
IN GOOD HEALTH ................................................................
USING A 60-DAY PERIOD TO DECIDE ...............................
EXPECTED TO FIND NEW JOB ...........................................
OTHER (SPECIFY) [specify] .................................................
07
08
09
10
11
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
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E.72
06
F16.
PROGRAMMER CHECK:
ENROLLED IN COBRA SUBSIDY (F10=01)......................... 01
(F16a)
NOT FAMILIAR WITH COBRA AND NOT
ENROLLED, NOT ELIGIBLE, OR DO NOT KNOW
OF SUBSIDY (E4=0, d, OR r; AND [F2=0, d OR r;
OR F5=0, d OR r; OR F10=0, d, OR r]) .............................. 02
(F17)
FAMILIAR WITH COBRA (D5=02 OR E1a=01) BUT
DON’T KNOW WHETHER ENROLLED OR NOT
ENROLLED, NOT ELIGIBLE, OR DO NOT KNOW
OF SUBSIDY (E4=00, d OR r; AND F1=00, d OR r;
OR F5=00, d OR r) ............................................................. 03
(F17)
ENROLLED IN COBRA, DO NOT KNOW WHETHER
ENROLLED IN SUBSIDY (D5=01 OR 02 AND
F10=d OR r) ........................................................................ 04
(F17)
NOT ENROLLED BUT FAMILIAR WITH COBRA
(D5=00, d OR r, OR E1a=01) AND NOT FAMILIAR
WITH, NOT ELIGIBLE FOR, OR DON’T KNOW
WHETHER ENROLLED IN SUBSIDY
(F1=00, 02, d OR r; OR F5=00, d OR r; OR
F10=d OR r]) ....................................................................... 05
(F17)
NOT ENROLLED BUT FAMILIAR WITH COBRA AND
NOT ELIGIBLE FOR SUBSIDY (D5=00 AND
E1a=01AND F5=00) ........................................................... 06
(F19)
ENROLLED IN COBRA (F5=01 OR 02) AND NOT
ENROLLED, NOT ELIGIBLE, OR NOT FAMILIAR WITH
SUBSIDY (D5=01 OR 02 AND F1 OR F1a=00, 02, d OR r;
OR F10=00, d OR r) ........................................................... 07
(F17)
(F16=01)
F16a.
Now I’m going to ask a few questions about health insurance choices you would have made if
the costs were different. Do you think you would have enrolled in COBRA health insurance, even
if you did not get the COBRA subsidy?
(IF FAMILY MEMBERS WERE ENROLLED (D2=01), SAY: Without the subsidy, the average
family plan would have cost about $1,000 per month.)
(IF ONLY SAMPLE MEMBER WAS ENROLLED (D2=00, d, OR r), SAY: Without the subsidy,
the average individual plan would have cost about $400 per month.)
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
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E.73
(G1)
(F18)
(F18)
(F18)
(F16=02, 03, OR 04)
F17.
Now I’m going to ask a few questions about health insurance choices you would have made if
the costs were different. When your job with [fill EMPLOYER FROM UI RECORDS OR B1a]
ended, suppose you had the option to continue the same health insurance coverage.
(IF FAMILY MEMBERS WERE ENROLLED (D2=01), SAY: Without the subsidy, the average
family plan would have cost about $1,000 per month.) Would you have enrolled?
(IF ONLY SAMPLE MEMBER WAS ENROLLED (D2=00, d, OR r), SAY: Without the subsidy,
the average individual plan would have cost about $400 per month.) Would you have enrolled?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(G1)
(F16=05 OR F17=0, d, OR r)—65 PERCENT
F17a.
(Now I’m going to ask a few questions about health insurance choices you would have made if
the costs were different.) When your job from [fill EMPLOYER FROM UI RECORDS OR B1a]
ended, suppose you had the option to continue your same health insurance coverage and receive
a COBRA subsidy to cover 65 percent of the cost of your monthly premiums.
(IF FAMILY MEMBERS WERE ENROLLED (D2=01), SAY: After this subsidy, the average family
plan would have cost about $350 per month instead of $1,000.) Do you think you would have
continued your coverage through COBRA?
(IF ONLY SAMPLE MEMBER WAS ENROLLED (D2=00, d, OR r), SAY: After this subsidy, the
average individual plan would have cost about $150 per month instead of $400.) Do you think you
would have continued your coverage through COBRA?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(F19)
(F19)
(F19)
(F15a=00 OR F17a=01)—35 PERCENT
F18.
Suppose you had been offered a COBRA subsidy to cover 35 percent of the cost of your monthly
premiums.
(IF FAMILY MEMBERS WERE ENROLLED (D2=01), SAY: After this subsidy, the average family
plan would have cost about $650 per month instead of $1,000.) Do you think you would have
continued your coverage through COBRA?
(IF ONLY SAMPLE MEMBER WAS ENROLLED (D2=00, d, OR r), SAY: After this subsidy, the
average individual plan would have cost about $250 per month instead of $400.) Do you think you
would have continued your coverage through COBRA?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
GO TO G1
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E.74
(F17a=00, d OR r; OR F16=06)—80 PERCENT
F19.
(Now I’m going to ask a few questions about health insurance choices you would have made if
the costs were different.) When your job from [fill EMPLOYER FROM UI RECORDS OR B1a]
ended, suppose you had the option to continue the same health insurance coverage and receive
a COBRA subsidy to cover 80 percent of the cost of your monthly premiums.
(IF FAMILY MEMBERS WERE ENROLLED (D2=01), SAY: After this subsidy, the average family
plan would have cost about $200 per month instead of $1,000.) Do you think you would have
continued your coverage through COBRA?
(IF ONLY SAMPLE MEMBER WAS ENROLLED (D2=00, d, OR r), SAY: After this subsidy, the
average individual plan would have cost about $80 per month instead of $400.) Do you think you
would have continued your coverage through COBRA?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(G1)
(F19=00, d, OR r)—90 PERCENT
F20.
Suppose you had been offered a COBRA subsidy to cover 90 percent of the cost of your monthly
premiums.
(IF FAMILY MEMBERS WERE ENROLLED (D2=01), SAY: After this subsidy, the average family
plan would have cost about $100 per month instead of $1,000.) Do you think you would have
continued your coverage through COBRA?
(IF ONLY SAMPLE MEMBER WAS ENROLLED (D2=00, d, OR r), SAY: After this subsidy, the
average individual plan would have cost about $40 per month instead of $400.) Do you think you
would have continued your coverage through COBRA?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
Prepared by Mathematica Policy Research
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E.75
SECTION G: HEALTH
(All)
G1.
Now I have some questions about your health [IF D2=01, SAY: and the health of your family members who were
enrolled in your health insurance plan].
RESPONDENT
(All)
G1. Thinking about [fill JOB
SEPARATION MONTH,
YEAR] when your job
ended; in general, how
would you say (your/fill
NAME]’s health was at that
time? Would you say it
was…
PROBE: And how was
[fill NAME]’s health at that
time? Was it….?
PERSON | 01 |
PERSON | 02 |
NAME:______________________
NAME:______________________
excellent, .......................... 01
excellent, .......................... 01
excellent, .......................... 01
very good, ........................ 02
very good, ........................ 02
very good, ........................ 02
good, ................................ 03
good, ................................ 03
good, ................................ 03
fair, or ............................... 04
fair, or ............................... 04
fair, or ............................... 04
poor? ................................ 05
poor? ................................ 05
poor? ................................ 05
DON’T KNOW ..................
d
DON’T KNOW ..................
d
DON’T KNOW ..................
d
REFUSED ........................
r
REFUSED ........................
r
REFUSED ........................
r
ASK G1 ACROSS,
THEN ASK G2.
ASK SERIES ONLY FOR
FAMILY MEMBERS FOR
WHOM D3=01 (COVERED BY
SAMPLE MEMBER’S PLAN AT
JOB LOSS)
(All)
G2. At that time, did you have a
physical, emotional, or
other health condition that
limited the amount or type
of work you could do?
YES .................................. 01
NO .................................... 00
DON’T KNOW ..................
d
REFUSED ........................
r
(A37b OR B11 =02 AND A35, A35a
OR B12 = 15 to 45 YEARS OLD)
YES .................................. 01
G2a. Was anyone in your family
pregnant at that time]?
NO .................................... 00
DON’T KNOW ..................
d
REFUSED ........................
r
FROM THIS POINT ON, ASK QUESTIONS BY PERSON—GO DOWN EACH COLUMN
(All)
G3. Prior to the time your job
ended, (were you/was [fill
NAME]) diagnosed with a
chronic health condition or
other health condition
needing ongoing medical
care?
YES .................................. 01 (G4)
YES .................................. 01 (G4)
YES ..................................01 (G4)
NO .................................... 00 (G6)
NO .................................... 00 (G6)
NO ....................................00 (G6)
DON’T KNOW .................. d (G6)
DON’T KNOW .................. d (G6)
DON’T KNOW ..................d (G6)
REFUSED ........................
(G6)
REFUSED ........................ r (G6)
REFUSED ........................r
r
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E.76
(G6)
(All)
G1. Thinking about [fill JOB
SEPARATION MONTH,
YEAR] when your job
ended; in general, how
would you say (your/fill
NAME]’s health was at that
time? Would you say it
was…
PROBE: And how was
[fill NAME]’s health at that
time? Was it….?
PERSON | 03 |
PERSON | 04 |
PERSON | 05 |
NAME:______________________
NAME:______________________
NAME:______________________
excellent, .......................... 01
excellent, .......................... 01
excellent, .......................... 01
very good, ........................ 02
very good, ........................ 02
very good,......................... 02
good, ................................ 03
good, ................................ 03
good, ................................ 03
fair, or ............................... 04
fair, or ............................... 04
fair, or ............................... 04
poor? ................................ 05
poor? ................................ 05
poor? ................................ 05
DON’T KNOW ..................
d
DON’T KNOW ..................
d
DON’T KNOW ..................
d
REFUSED ........................
r
REFUSED ........................
r
REFUSED ........................
r
ASK G1 ACROSS,
THEN ASK G2.
ASK SERIES ONLY FOR
FAMILY MEMBERS FOR
WHOM D3=01 (COVERED BY
SAMPLE MEMBER’S PLAN AT
JOB LOSS)
(All)
G2. At that time, did you have a
physical, emotional, or
other health condition that
limited the amount or type
of work you could do?
(A37b OR B11 =02 AND A35,
A35a OR B12 = 15 to 45 YEARS
OLD)
G2a. Was anyone in your family
pregnant at that time]?
(All)
G3. Prior to the time your job
ended, (were you/was [fill
NAME]) diagnosed with a
chronic health condition or
other health condition
needing ongoing medical
care?
YES .................................. 01 (G4)
YES ................................01 (G4)
YES ............................... 01 (G4)
NO.................................... 00 (G6)
NO ..................................00 (G6)
NO ................................. 00 (G6)
DON’T KNOW .................. d (G6)
DON’T KNOW ................d (G6)
DON’T KNOW ............... d (G6)
REFUSED ........................ r
REFUSED ......................r
REFUSED ..................... r
(G6)
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E.77
(G6)
(G6)
(All)
G1. Thinking about [fill JOB
SEPARATION MONTH,
YEAR] when your job
ended; in general, how
would you say (your/fill
NAME]’s health was at that
time? Would you say it
was…
PROBE: And how was
[fill NAME]’s health at that
time? Was it….?
PERSON | 06 |
PERSON | 07 |
PERSON | 08 |
NAME:______________________
NAME:______________________
NAME:______________________
excellent, .......................... 01
excellent, .......................... 01
excellent, .......................... 01
very good, ........................ 02
very good, ........................ 02
very good,......................... 02
good, ................................ 03
good, ................................ 03
good, ................................ 03
fair, or ............................... 04
fair, or ............................... 04
fair, or ............................... 04
poor? ................................ 05
poor? ................................ 05
poor? ................................ 05
DON’T KNOW ..................
d
DON’T KNOW ..................
d
DON’T KNOW ..................
d
REFUSED ........................
r
REFUSED ........................
r
REFUSED ........................
r
ASK G1 ACROSS,
THEN ASK G2.
ASK SERIES ONLY FOR
FAMILY MEMBERS FOR
WHOM D3=01 (COVERED BY
SAMPLE MEMBER’S PLAN AT
JOB LOSS)
(All)
G2. At that time, did you have a
physical, emotional, or
other health condition that
limited the amount or type
of work you could do?
(A37b OR B11 =02 AND A35,
A35a OR B12 = 15 to 45 YEARS
OLD)
G2a. Was anyone in your family
pregnant at that time]?
(All)
G3. Prior to the time your job
ended, (were you/was [fill
NAME]) diagnosed with a
chronic health condition or
other health condition
needing ongoing medical
care?
YES .................................. 01 (G4)
YES ................................01 (G4)
YES ............................... 01 (G4)
NO.................................... 00 (G6)
NO..................................00 (G6)
NO ................................. 00 (G6)
DON’T KNOW .................. d (G6)
DON’T KNOW ................d (G6)
DON’T KNOW ............... d (G6)
REFUSED ........................ r (G6)
REFUSED ......................r (G6)
REFUSED ..................... r (G6)
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E.78
RESPONDENT
(G3=01)
G4. What type of chronic or
ongoing health conditions did
(you/[fill NAME]) have?
INTERVIEWER: RECORD
VERBATIM AND CODE AT
END OF INTERVIEW.
PROBE: Were there any
other conditions?
PERSON | 01 |
PERSON | 02 |
NAME:______________________
NAME:______________________
RECORD VERBATIM
RECORD VERBATIM
RECORD VERBATIM
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
CODE ALL THAT APPLY
CODE ALL THAT APPLY
CODE ALL THAT APPLY
ARTHRITIS, INCLUDING
RHEUMATOID ARTHRITIS .... 01
ARTHRITIS, INCLUDING
RHEUMATOID ARTHRITIS .... 01
ARTHRITIS, INCLUDING
RHEUMATOID ARTHRITIS.... 01
CANCER, MALIGNANCY,
OR TUMOR, EXCEPT SKIN
CANCER ................................. 02
CANCER, MALIGNANCY,
OR TUMOR, EXCEPT SKIN
CANCER ................................. 02
CANCER, MALIGNANCY,
OR TUMOR, EXCEPT SKIN
CANCER ................................. 02
DIABETES, HIGH BLOOD
SUGAR, OR SUGAR IN
YOUR URINE ......................... 03
DIABETES, HIGH BLOOD
SUGAR, OR SUGAR IN
YOUR URINE ......................... 03
DIABETES, HIGH BLOOD
SUGAR, OR SUGAR IN
YOUR URINE ......................... 03
EMPHYSEMA, ASTHMA, OR
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
(COPD) ................................... 04
EMPHYSEMA, ASTHMA, OR
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
(COPD) ................................... 04
EMPHYSEMA, ASTHMA, OR
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
(COPD) ................................... 04
HEARING LOSS OR
OTHER HEARING
PROBLEM .............................. 05
HEARING LOSS OR
OTHER HEARING
PROBLEM .............................. 05
HEARING LOSS OR
OTHER HEARING
PROBLEM .............................. 05
HEART DISEASE/HEART
PROBLEMS ............................ 06
HEART DISEASE/HEART
PROBLEMS ............................ 06
HEART DISEASE/HEART
PROBLEMS ............................ 06
HYPERTENSION OR
HIGH BLOOD PRESSURE ..... 07
HYPERTENSION OR
HIGH BLOOD PRESSURE .... 07
HYPERTENSION OR
HIGH BLOOD PRESSURE .... 07
MENTAL OR
PSYCHIATRIC DISORDER .... 08
MENTAL OR
PSYCHIATRIC DISORDER .... 08
MENTAL OR
PSYCHIATRIC DISORDER.... 08
MULTIPLE SCLEROSIS OR
MS ........................................... 09
MULTIPLE SCLEROSIS OR
MS........................................... 09
MULTIPLE SCLEROSIS OR
MS .......................................... 09
PARKINSON’S DISEASE ....... 10
PARKINSON’S DISEASE ....... 10
PARKINSON’S DISEASE ....... 10
STROKE OR PARTIAL OR
COMPLETE PARALYSIS ....... 11
STROKE OR PARTIAL OR
COMPLETE PARALYSIS ....... 11
STROKE OR PARTIAL OR
COMPLETE PARALYSIS ....... 11
VISION PROBLEMS ............... 12
VISION PROBLEMS ............... 12
VISION PROBLEMS............... 12
OTHER (SPECIFY) [specify] .. 13
OTHER (SPECIFY) [specify] .. 13
OTHER (SPECIFY) [specify] .. 13
DON’T KNOW ......................... d
DON’T KNOW ......................... d
DON’T KNOW ......................... d
REFUSED ............................... r
REFUSED ............................... r
REFUSED............................... r
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E.79
(G3=01)
G4. What type of chronic or
ongoing health conditions did
(you/[fill NAME]) have?
INTERVIEWER: RECORD
VERBATIM AND CODE AT
END OF INTERVIEW.
PROBE: Were there any
other conditions?
PERSON | 03 |
PERSON | 04 |
PERSON | 05 |
NAME:______________________
NAME:______________________
NAME:______________________
RECORD VERBATIM
RECORD VERBATIM
RECORD VERBATIM
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
CODE ALL THAT APPLY
CODE ALL THAT APPLY
CODE ALL THAT APPLY
ARTHRITIS, INCLUDING
RHEUMATOID ARTHRITIS .... 01
ARTHRITIS, INCLUDING
RHEUMATOID ARTHRITIS .... 01
ARTHRITIS, INCLUDING
RHEUMATOID ARTHRITIS .... 01
CANCER, MALIGNANCY,
OR TUMOR, EXCEPT
SKIN CANCER ....................... 02
CANCER, MALIGNANCY,
OR TUMOR, EXCEPT
SKIN CANCER ....................... 02
CANCER, MALIGNANCY,
OR TUMOR, EXCEPT
SKIN CANCER ........................ 02
DIABETES, HIGH BLOOD
SUGAR, OR SUGAR IN
YOUR URINE ......................... 03
DIABETES, HIGH BLOOD
SUGAR, OR SUGAR IN
YOUR URINE ......................... 03
DIABETES, HIGH BLOOD
SUGAR, OR SUGAR IN
YOUR URINE .......................... 03
EMPHYSEMA, ASTHMA,
OR CHRONIC
OBSTRUCTIVE
PULMONARY DISEASE
(COPD) ................................... 04
EMPHYSEMA, ASTHMA,
OR CHRONIC
OBSTRUCTIVE
PULMONARY DISEASE
(COPD) ................................... 04
EMPHYSEMA, ASTHMA,
OR CHRONIC
OBSTRUCTIVE
PULMONARY DISEASE
(COPD) .................................... 04
HEARING LOSS OR
OTHER HEARING
PROBLEM .............................. 05
HEARING LOSS OR
OTHER HEARING
PROBLEM .............................. 05
HEARING LOSS OR
OTHER HEARING
PROBLEM ............................... 05
HEART DISEASE/HEART
PROBLEMS ............................ 06
HEART DISEASE/HEART
PROBLEMS ............................ 06
HEART DISEASE/HEART
PROBLEMS............................. 06
HYPERTENSION OR
HIGH BLOOD PRESSURE ..... 07
HYPERTENSION OR
HIGH BLOOD PRESSURE .... 07
HYPERTENSION OR
HIGH BLOOD PRESSURE ..... 07
MENTAL OR
PSYCHIATRIC DISORDER .... 08
MENTAL OR
PSYCHIATRIC DISORDER.... 08
MENTAL OR
PSYCHIATRIC DISORDER .... 08
MULTIPLE SCLEROSIS
OR MS .................................... 09
MULTIPLE SCLEROSIS
OR MS .................................... 09
MULTIPLE SCLEROSIS
OR MS ..................................... 09
PARKINSON’S DISEASE ....... 10
PARKINSON’S DISEASE ....... 10
PARKINSON’S DISEASE........ 10
STROKE OR PARTIAL OR
COMPLETE PARALYSIS ....... 11
STROKE OR PARTIAL OR
COMPLETE PARALYSIS ....... 11
STROKE OR PARTIAL OR
COMPLETE PARALYSIS ........ 11
VISION PROBLEMS ............... 12
VISION PROBLEMS............... 12
VISION PROBLEMS ............... 12
OTHER (SPECIFY) [specify] .. 13
OTHER (SPECIFY) [specify] .. 13
OTHER (SPECIFY) [specify] ... 13
DON’T KNOW ......................... d
DON’T KNOW ......................... d
DON’T KNOW ......................... d
REFUSED ............................... r
REFUSED ............................... r
REFUSED ............................... r
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E.80
(G3=01)
G4. What type of chronic or
ongoing health conditions did
(you/[fill NAME]) have?
INTERVIEWER: RECORD
VERBATIM AND CODE AT
END OF INTERVIEW.
PROBE: Were there any
other conditions?
PERSON | 06 |
PERSON | 07 |
PERSON | 08 |
NAME:______________________
NAME:______________________
NAME:______________________
RECORD VERBATIM
RECORD VERBATIM
RECORD VERBATIM
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
CODE ALL THAT APPLY
CODE ALL THAT APPLY
CODE ALL THAT APPLY
ARTHRITIS, INCLUDING
RHEUMATOID ARTHRITIS .... 01
ARTHRITIS, INCLUDING
RHEUMATOID ARTHRITIS..... 01
ARTHRITIS, INCLUDING
RHEUMATOID ARTHRITIS .... 01
CANCER, MALIGNANCY,
OR TUMOR, EXCEPT SKIN
CANCER ................................. 02
CANCER, MALIGNANCY,
OR TUMOR, EXCEPT SKIN
CANCER.................................. 02
CANCER, MALIGNANCY,
OR TUMOR, EXCEPT SKIN
CANCER ................................. 02
DIABETES, HIGH BLOOD
SUGAR, OR SUGAR IN
YOUR URINE ......................... 03
DIABETES, HIGH BLOOD
SUGAR, OR SUGAR IN
YOUR URINE .......................... 03
DIABETES, HIGH BLOOD
SUGAR, OR SUGAR IN
YOUR URINE .......................... 03
EMPHYSEMA, ASTHMA, OR
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
(COPD) ................................... 04
EMPHYSEMA, ASTHMA, OR
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
(COPD) .................................... 04
EMPHYSEMA, ASTHMA, OR
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
(COPD) .................................... 04
HEARING LOSS OR
OTHER HEARING
PROBLEM .............................. 05
HEARING LOSS OR
OTHER HEARING
PROBLEM ............................... 05
HEARING LOSS OR
OTHER HEARING
PROBLEM ............................... 05
HEART DISEASE/HEART
PROBLEMS ............................ 06
HEART DISEASE/HEART
PROBLEMS ............................. 06
HEART DISEASE/HEART
PROBLEMS ............................ 06
HYPERTENSION OR
HIGH BLOOD PRESSURE ..... 07
HYPERTENSION OR
HIGH BLOOD PRESSURE ..... 07
HYPERTENSION OR
HIGH BLOOD PRESSURE ..... 07
MENTAL OR
PSYCHIATRIC DISORDER .... 08
MENTAL OR
PSYCHIATRIC DISORDER..... 08
MENTAL OR PSYCHIATRIC
DISORDER ............................. 08
MULTIPLE SCLEROSIS OR
MS ........................................... 09
MULTIPLE SCLEROSIS OR
MS ........................................... 09
MULTIPLE SCLEROSIS OR
MS ........................................... 09
PARKINSON’S DISEASE ....... 10
PARKINSON’S DISEASE ........ 10
PARKINSON’S DISEASE ....... 10
STROKE OR PARTIAL OR
COMPLETE PARALYSIS ....... 11
STROKE OR PARTIAL OR
COMPLETE PARALYSIS ........ 11
STROKE OR PARTIAL OR
COMPLETE PARALYSIS ........ 11
VISION PROBLEMS ............... 12
VISION PROBLEMS................ 12
VISION PROBLEMS ............... 12
OTHER (SPECIFY) [specify] .. 13
OTHER (SPECIFY) [specify] ... 13
OTHER (SPECIFY) [specify] ... 13
DON’T KNOW ......................... d
DON’T KNOW.......................... d
DON’T KNOW ......................... d
REFUSED ............................... r
REFUSED................................ r
REFUSED ............................... r
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.81
PERSON | 01 |
PERSON | 02 |
NAME:______________________
NAME:______________________
YES ....................... 01
NO ......................... 00 (G5b)
DON’T KNOW ....... d (G5b)
YES ....................... 01
NO......................... 00 (G5b)
DON’T KNOW....... d (G5b)
YES ....................... 01
NO ......................... 00 (G5b)
DON’T KNOW ....... d (G5b)
REFUSED .............
REFUSED .............
REFUSED .............
RESPONDENT
(G3=01)
G5. (Were you/Was [fill
NAME]) regularly seeing
a doctor for (this condition/
these conditions)?
(G5=01)
G5a. While you were still
working at [fill EMPLOYER
FROM UI RECORDS OR
B1a], about how many
times a year did (you/[fill
NAME]) see a doctor or go
in for medical tests for (this
condition/these
conditions)? Would you
say once a year, two to
three times per year, four
to five times per year, or
more than five times per
year?
(G5=01)
G5b. Did (you/[fill NAME]) see a
doctor or go in for medical
tests for (this condition/
these conditions) more
often, less often, or about
the same in the six months
after your job ended?
(G3=01)
G5c. (Were you/Was [fill
NAME]) taking prescription
medication for (this
condition/these conditions)
while you were still
working at [fill EMPLOYER
FROM UI RECORDS OR
B1a]?
(G5c=01)
G5d. In the six months after your
job ended, did
(you/NAME) increase,
decrease or continue
taking the same number of
prescription medicines for
(your/his/her) chronic
condition(s)?
(G3=01)
G5e. Did (this condition/these
conditions) improve,
worsen, or stay the same
in the six months after
your job with [fill
EMPLOYER FROM UI
RECORDS OR B1a]
ended?
r (G5b)
r (G5b)
CODE ONE
CODE ONE
r (G5b)
CODE ONE
ONCE PER YEAR .............. 01
ONCE PER YEAR .............. 01
ONCE PER YEAR.............. 01
2-3 TIMES PER YEAR ....... 02
2-3 TIMES PER YEAR ....... 02
2-3 TIMES PER YEAR ....... 02
4-5 TIMES PER YEAR ....... 03
4-5 TIMES PER YEAR ....... 03
4-5 TIMES PER YEAR ....... 03
MORE THAN FIVE TIMES
PER YEAR ......................... 04
MORE THAN FIVE TIMES
PER YEAR .......................... 04
MORE THAN FIVE TIMES
PER YEAR ......................... 04
NEVER ...............................
n
NEVER ...............................
n
NEVER ...............................
n
DON’T KNOW ....................
d
DON’T KNOW.....................
d
DON’T KNOW ....................
d
REFUSED ..........................
r
REFUSED ...........................
r
REFUSED ..........................
r
MORE OFTEN ................... 01
MORE OFTEN .................... 01
MORE OFTEN ................... 01
LESS OFTEN ..................... 02
LESS OFTEN ..................... 02
LESS OFTEN ..................... 02
ABOUT THE SAME ........... 03
ABOUT THE SAME ............ 03
ABOUT THE SAME ........... 03
DON’T KNOW ....................
d
DON’T KNOW.....................
d
DON’T KNOW ....................
d
REFUSED ..........................
r
REFUSED ...........................
r
REFUSED ..........................
r
YES ....................... 01
YES ....................... 01
YES ....................... 01
NO ......................... 00 (G5e)
NO......................... 00 (G5e)
NO ......................... 00 (G5e)
DON’T KNOW .......
d (G5e)
DON’T KNOW.......
d (G5e)
DON’T KNOW .......
d (G5e)
REFUSED .............
r (G5e)
REFUSED .............
r (G5e)
REFUSED .............
r (G5e)
INCREASE ......................... 01
INCREASE ......................... 01
INCREASE ......................... 01
DECREASE........................ 02
DECREASE ........................ 02
DECREASE ....................... 02
SAME AMOUNT ................ 03
SAME AMOUNT ................. 03
SAME AMOUNT ................ 03
DON’T KNOW ....................
d
DON’T KNOW.....................
d
DON’T KNOW ....................
d
REFUSED ..........................
r
REFUSED ...........................
r
REFUSED ..........................
r
IMPROVE ........................... 01
IMPROVE ........................... 01
IMPROVE ........................... 01
WORSEN ........................... 02
WORSEN ............................ 02
WORSEN ........................... 02
STAY THE SAME .............. 03
STAY THE SAME ............... 03
STAY THE SAME .............. 03
DON’T KNOW ....................
d
DON’T KNOW.....................
d
DON’T KNOW ....................
d
REFUSED ..........................
r
REFUSED ...........................
r
REFUSED ..........................
r
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.82
PERSON | 03 |
NAME:______________________
(G3=01)
G5. (Were you/Was [fill NAME])
regularly seeing a doctor for
(this condition/ these
conditions)?
(G5=01)
G5b. Did (you/[fill NAME]) see a
doctor or go in for medical
tests for (this condition/
these conditions) more
often, less often, or about
the same in the six months
after your job ended?
(G3=01)
G5c. (Were you/Was [fill NAME])
taking prescription
medication for (this
condition/these conditions)
while you were still working
at [fill EMPLOYER FROM
UI RECORDS OR B1a]?
(G5c=01)
G5d. In the six months after your
job ended, did (you/NAME)
increase, decrease or
continue taking the same
number of prescription
medicines for (your/his/her)
chronic condition(s)?
(G3=01)
G5e. Did (this condition/these
conditions) improve,
worsen, or stay the same in
the six months after your
job with [fill EMPLOYER
FROM UI RECORDS OR
B1a] ended?
PERSON | 05 |
NAME:______________________
YES ....................... 01
YES ....................... 01
YES ....................... 01
NO......................... 00 (G5b)
NO......................... 00 (G5b)
NO......................... 00 (G5b)
DON’T KNOW .......
d (G5b)
DON’T KNOW.......
d (G5b)
DON’T KNOW.......
d (G5b)
REFUSED .............
r (G5b)
REFUSED.............
r (G5b)
REFUSED .............
r (G5b)
(G5=01)
G5a. While you were still working
at [fill EMPLOYER FROM
UI RECORDS OR B1a],
about how many times a
year did (you/[fill NAME])
see a doctor or go in for
medical tests for (this
condition/these conditions)?
Would you say once a year,
two to three times per year,
four to five times per year,
or more than five times per
year?
PERSON | 04 |
NAME:______________________
CODE ONE
CODE ONE
CODE ONE
ONCE PER YEAR .............. 01
ONCE PER YEAR .............. 01
ONCE PER YEAR .............. 01
2-3 TIMES PER YEAR ....... 02
2-3 TIMES PER YEAR ....... 02
2-3 TIMES PER YEAR ....... 02
4-5 TIMES PER YEAR ....... 03
4-5 TIMES PER YEAR ....... 03
4-5 TIMES PER YEAR ....... 03
MORE THAN FIVE TIMES
PER YEAR .......................... 04
MORE THAN FIVE TIMES
PER YEAR.......................... 04
MORE THAN FIVE TIMES
PER YEAR .......................... 04
NEVER................................
n
NEVER ...............................
n
NEVER ...............................
n
DON’T KNOW .....................
d
DON’T KNOW.....................
d
DON’T KNOW.....................
d
REFUSED ...........................
r
REFUSED...........................
r
REFUSED ...........................
r
MORE OFTEN .................... 01
MORE OFTEN .................... 01
MORE OFTEN .................... 01
LESS OFTEN ..................... 02
LESS OFTEN ..................... 02
LESS OFTEN ..................... 02
ABOUT THE SAME ............ 03
ABOUT THE SAME ............ 03
ABOUT THE SAME ............ 03
DON’T KNOW .....................
d
DON’T KNOW.....................
d
DON’T KNOW.....................
d
REFUSED ...........................
r
REFUSED...........................
r
REFUSED ...........................
r
YES ....................... 01
YES ....................... 01
YES ....................... 01
NO......................... 00 (G5e)
NO......................... 00 (G5e)
NO......................... 00 (G5e)
DON’T KNOW .......
d (G5e)
DON’T KNOW.......
d (G5e)
DON’T KNOW.......
d (G5e)
REFUSED .............
r (G5e)
REFUSED.............
r (G5e)
REFUSED .............
r (G5e)
INCREASE ......................... 01
INCREASE ......................... 01
INCREASE ......................... 01
DECREASE ........................ 02
DECREASE ........................ 02
DECREASE ........................ 02
SAME AMOUNT ................. 03
SAME AMOUNT ................. 03
SAME AMOUNT ................. 03
DON’T KNOW .....................
d
DON’T KNOW.....................
d
DON’T KNOW.....................
d
REFUSED ...........................
r
REFUSED...........................
r
REFUSED ...........................
r
IMPROVE ........................... 01
IMPROVE ........................... 01
IMPROVE ........................... 01
WORSEN ............................ 02
WORSEN ............................ 02
WORSEN ............................ 02
STAY THE SAME ............... 03
STAY THE SAME ............... 03
STAY THE SAME ............... 03
DON’T KNOW .....................
d
DON’T KNOW.....................
d
DON’T KNOW.....................
d
REFUSED ...........................
r
REFUSED...........................
r
REFUSED ...........................
r
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.83
(G3=01)
G5. (Were you/Was [fill NAME])
regularly seeing a doctor for
(this condition/ these
conditions)?
PERSON | 06 |
PERSON | 07 |
PERSON | 08 |
NAME:______________________
NAME:______________________
NAME:______________________
YES ....................... 01
YES ....................... 01
YES ....................... 01
NO......................... 00 (G5b)
NO......................... 00 (G5b)
NO ........................ 00 (G5b)
DON’T KNOW .......
d (G5b)
DON’T KNOW.......
d (G5b)
DON’T KNOW.......
d (G5b)
REFUSED .............
r (G5b)
REFUSED.............
r (G5b)
REFUSED.............
r (G5b)
(G5=01)
G5a. While you were still working
at [fill EMPLOYER FROM
UI RECORDS OR B1a],
about how many times a
year did (you/[fill NAME])
see a doctor or go in for
medical tests for (this
condition/these conditions)?
Would you say once a year,
two to three times per year,
four to five times per year,
or more than five times per
year?
(G5=01)
G5b. Did (you/[fill NAME]) see a
doctor or go in for medical
tests for (this condition/
these conditions) more
often, less often, or about
the same in the six months
after your job ended?
(G3=01)
G5c. (Were you/Was [fill NAME])
taking prescription
medication for (this
condition/these conditions)
while you were still working
at [fill EMPLOYER FROM
UI RECORDS OR B1a]?
(G5c=01)
G5d. In the six months after your
job ended, did (you/NAME)
increase, decrease or
continue taking the same
number of prescription
medicines for (your/his/her)
chronic condition(s)?
(G3=01)
G5e. Did (this condition/these
conditions) improve,
worsen, or stay the same in
the six months after your
job with [fill EMPLOYER
FROM UI RECORDS OR
B1a] ended?
CODE ONE
CODE ONE
CODE ONE
ONCE PER YEAR .............. 01
ONCE PER YEAR .............. 01
ONCE PER YEAR .............. 01
2-3 TIMES PER YEAR ....... 02
2-3 TIMES PER YEAR ....... 02
2-3 TIMES PER YEAR ....... 02
4-5 TIMES PER YEAR ....... 03
4-5 TIMES PER YEAR ....... 03
4-5 TIMES PER YEAR ....... 03
MORE THAN FIVE TIMES
PER YEAR .......................... 04
MORE THAN FIVE TIMES
PER YEAR.......................... 04
MORE THAN FIVE TIMES
PER YEAR.......................... 04
NEVER................................
n
NEVER ...............................
n
NEVER ...............................
n
DON’T KNOW .....................
d
DON’T KNOW.....................
d
DON’T KNOW.....................
d
REFUSED ...........................
r
REFUSED...........................
r
REFUSED...........................
r
MORE OFTEN .................... 01
MORE OFTEN .................... 01
MORE OFTEN .................... 01
LESS OFTEN ..................... 02
LESS OFTEN ..................... 02
LESS OFTEN ..................... 02
ABOUT THE SAME ............ 03
ABOUT THE SAME ............ 03
ABOUT THE SAME ............ 03
DON’T KNOW .....................
d
DON’T KNOW.....................
d
DON’T KNOW.....................
d
REFUSED ...........................
r
REFUSED...........................
r
REFUSED...........................
r
YES ....................... 01
YES ....................... 01
YES ....................... 01
NO......................... 00 (G5e)
NO......................... 00 (G5e)
NO ........................ 00 (G5e)
DON’T KNOW .......
d (G5e)
DON’T KNOW.......
d (G5e)
DON’T KNOW.......
d (G5e)
REFUSED .............
r (G5e)
REFUSED.............
r (G5e)
REFUSED.............
r (G5e)
INCREASE ......................... 01
INCREASE ......................... 01
INCREASE ......................... 01
DECREASE ........................ 02
DECREASE ........................ 02
DECREASE ........................ 02
SAME AMOUNT ................. 03
SAME AMOUNT ................. 03
SAME AMOUNT ................. 03
DON’T KNOW .....................
d
DON’T KNOW.....................
d
DON’T KNOW.....................
d
REFUSED ...........................
r
REFUSED...........................
r
REFUSED...........................
r
IMPROVE ........................... 01
IMPROVE ........................... 01
IMPROVE ........................... 01
WORSEN ............................ 02
WORSEN ............................ 02
WORSEN............................ 02
STAY THE SAME ............... 03
STAY THE SAME ............... 03
STAY THE SAME ............... 03
DON’T KNOW .....................
d
DON’T KNOW.....................
d
DON’T KNOW.....................
d
REFUSED ...........................
r
REFUSED...........................
r
REFUSED...........................
r
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.84
RESPONDENT
(All)
G6. (Other than doctor visits
made for chronic health
conditions), how often did
(you/[fill NAME]) visit a
doctor for preventive care,
general checkups, or sick
visits when you were
still working at [fill
EMPLOYER FROM UI
RECORDS OR B1a]?
Would you say never,
once a year, two to three
times per year, four to five
times per year, or more
than five times per year?
(All)
G7. (Other than prescriptions
for chronic conditions),
(were you/was [fill NAME])
regularly taking any (IF
G5b=01, SAY, other)
prescription medication at
that time?
(G7=01)
G7a. In the six months after
your job with [fill
EMPLOYER FROM UI
RECORDS OR B1a]
ended, did (you/[fill
NAME]) increase,
decrease or continue
taking the same number of
these prescription
medicines?
G7ck. INTERVIEWER: IS
THERE SOMEONE
ELSE TO ASK ABOUT?
PERSON | 01 |
PERSON | 02 |
NAME:______________________
NAME:______________________
CODE ONE
CODE ONE
CODE ONE
NEVER ............................... 01
NEVER ............................... 01
NEVER ............................... 01
ONCE PER YEAR .............. 02
ONCE PER YEAR .............. 02
ONCE PER YEAR.............. 02
2-3 TIMES PER YEAR ....... 03
2-3 TIMES PER YEAR ....... 03
2-3 TIMES PER YEAR ....... 03
4-5 TIMES PER YEAR ....... 04
4-5 TIMES PER YEAR ....... 04
4-5 TIMES PER YEAR ....... 04
MORE THAN FIVE TIMES
PER YEAR ......................... 05
MORE THAN FIVE TIMES
PER YEAR .......................... 05
MORE THAN FIVE TIMES
PER YEAR ......................... 05
DON’T KNOW ....................
d
DON’T KNOW.....................
d
DON’T KNOW ....................
d
REFUSED ..........................
r
REFUSED ...........................
r
REFUSED ..........................
r
YES .................... 01 (G7a)
YES ..................... 01 (G7a)
YES .................... 01 (G7a)
NO ...................... 00 (G7ck)
NO....................... 00 (G7ck)
NO ...................... 00 (G7ck)
DON’T KNOW .... d
(G7ck)
DON’T KNOW..... d
(G7ck)
DON’T KNOW .... d
(G7ck)
REFUSED .......... r
(G7ck)
REFUSED ........... r
(G7ck)
REFUSED .......... r
(G7ck)
INCREASE ......................... 01
INCREASE ......................... 01
INCREASE ......................... 01
DECREASE........................ 02
DECREASE ........................ 02
DECREASE ....................... 02
SAME AMOUNT ................ 03
SAME AMOUNT ................. 03
SAME AMOUNT ................ 03
DON’T KNOW ....................
d
DON’T KNOW.....................
d
DON’T KNOW ....................
d
REFUSED ..........................
r
REFUSED ...........................
r
REFUSED ..........................
r
YES ............. 01 (G3, NEXT
PERSON)
NO ......................
00
YES ............. 01 (G3, NEXT
PERSON)
(G8)
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
NO.......................
E.85
00
YES ............. 01 (G3, NEXT
PERSON)
(G8)
NO ......................
00
(G8)
PERSON | 03 |
PERSON | 04 |
PERSON | 05 |
NAME:______________________
NAME:______________________
NAME:______________________
(All)
G6. (Other than doctor visits
made for chronic health
conditions), how often did
(you/[fill NAME]) visit a
doctor for preventive care,
general checkups, or sick
visits when you were
still working at [fill
EMPLOYER FROM UI
RECORDS OR B1a]?
Would you say never, once
a year, two to three times
per year, four to five times
per year, or more than five
times per year?
(All)
G7. (Other than prescriptions
for chronic conditions),
(were you/was [fill NAME])
regularly taking any (IF
G5b=01, SAY, other)
prescription medication at
that time?
(G7=01)
G7a. In the six months after your
job with [fill EMPLOYER
FROM UI RECORDS OR
B1a] ended, did (you/[fill
NAME]) increase, decrease
or continue taking the same
number of these
prescription medicines?
G7ck. INTERVIEWER: IS
THERE SOMEONE
ELSE TO ASK ABOUT?
CODE ONE
CODE ONE
CODE ONE
NEVER................................ 01
NEVER................................ 01
NEVER ............................... 01
ONCE PER YEAR .............. 02
ONCE PER YEAR .............. 02
ONCE PER YEAR .............. 02
2-3 TIMES PER YEAR ....... 03
2-3 TIMES PER YEAR ....... 03
2-3 TIMES PER YEAR ....... 03
4-5 TIMES PER YEAR ....... 04
4-5 TIMES PER YEAR ....... 04
4-5 TIMES PER YEAR ....... 04
MORE THAN FIVE TIMES
PER YEAR .......................... 05
MORE THAN FIVE TIMES
PER YEAR .......................... 05
MORE THAN FIVE TIMES
PER YEAR .......................... 05
DON’T KNOW .....................
d
DON’T KNOW .....................
d
DON’T KNOW.....................
d
REFUSED ...........................
r
REFUSED ...........................
r
REFUSED ...........................
r
YES ..................... 01 (G7a)
YES ..................... 01 (G7a)
YES ..................... 01 (G7a)
NO....................... 00 (G7ck)
NO....................... 00 (G7ck)
NO....................... 00 (G7ck)
DON’T KNOW ..... d
(G7ck)
DON’T KNOW ..... d
(G7ck)
DON’T KNOW..... d
(G7ck)
REFUSED ........... r
(G7ck)
REFUSED ........... r
(G7ck)
REFUSED ........... r
(G7ck)
INCREASE.......................... 01
INCREASE ......................... 01
INCREASE ......................... 01
DECREASE ........................ 02
DECREASE ........................ 02
DECREASE ........................ 02
SAME AMOUNT ................. 03
SAME AMOUNT ................. 03
SAME AMOUNT ................. 03
DON’T KNOW .....................
d
DON’T KNOW .....................
d
DON’T KNOW.....................
d
REFUSED ...........................
r
REFUSED ...........................
r
REFUSED ...........................
r
YES ............. 01 (G3, NEXT
PERSON)
NO.......................
00
YES ............. 01 (G3, NEXT
PERSON)
(G8)
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
NO.......................
E.86
00
YES ............. 01 (G3, NEXT
PERSON)
(G8)
NO.......................
00
(G8)
PERSON | 06 |
PERSON | 07 |
PERSON | 08 |
NAME:______________________
NAME:______________________
NAME:______________________
(All)
G6. (Other than doctor visits
made for chronic health
conditions), how often did
(you/[fill NAME]) visit a
doctor for preventive care,
general checkups, or sick
visits when you were
still working at [fill
EMPLOYER FROM UI
RECORDS OR B1a]?
Would you say never, once
a year, two to three times
per year, four to five times
per year, or more than five
times per year?
(All)
G7. (Other than prescriptions
for chronic conditions),
(were you/was [fill NAME])
regularly taking any (IF
G5b=01, SAY, other)
prescription medication at
that time?
(G7=01)
G7a. In the six months after your
job with [fill EMPLOYER
FROM UI RECORDS OR
B1a] ended, did (you/[fill
NAME]) increase, decrease
or continue taking the same
number of these
prescription medicines?
G7ck. INTERVIEWER: IS
THERE SOMEONE
ELSE TO ASK ABOUT?
CODE ONE
CODE ONE
CODE ONE
NEVER................................ 01
NEVER ............................... 01
NEVER ............................... 01
ONCE PER YEAR .............. 02
ONCE PER YEAR .............. 02
ONCE PER YEAR .............. 02
2-3 TIMES PER YEAR ....... 03
2-3 TIMES PER YEAR ....... 03
2-3 TIMES PER YEAR ....... 03
4-5 TIMES PER YEAR ....... 04
4-5 TIMES PER YEAR ....... 04
4-5 TIMES PER YEAR ....... 04
MORE THAN FIVE TIMES
PER YEAR .......................... 05
MORE THAN FIVE TIMES
PER YEAR.......................... 05
MORE THAN FIVE TIMES
PER YEAR.......................... 05
DON’T KNOW .....................
d
DON’T KNOW.....................
d
DON’T KNOW.....................
d
REFUSED ...........................
r
REFUSED...........................
r
REFUSED...........................
r
YES ..................... 01 (G7a)
YES ..................... 01 (G7a)
YES ..................... 01 (G7a)
NO....................... 00 (G7ck)
NO....................... 00 (G7ck)
NO ...................... 00 (G7ck)
DON’T KNOW ..... d
(G7ck)
DON’T KNOW..... d
(G7ck)
DON’T KNOW..... d
(G7ck)
REFUSED ........... r
(G7ck)
REFUSED........... r
(G7ck)
REFUSED........... r
(G7ck)
INCREASE ......................... 01
INCREASE ......................... 01
INCREASE ......................... 01
DECREASE ........................ 02
DECREASE ........................ 02
DECREASE ........................ 02
SAME AMOUNT ................. 03
SAME AMOUNT ................. 03
SAME AMOUNT ................. 03
DON’T KNOW .....................
d
DON’T KNOW.....................
d
DON’T KNOW.....................
d
REFUSED ...........................
r
REFUSED...........................
r
REFUSED...........................
r
YES ............. 01 (G3, NEXT
PERSON)
NO.......................
00
YES ............. 01 (G3, NEXT
PERSON)
(G8)
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NO.......................
E.87
00
YES ............. 01 (G3, NEXT
PERSON)
(G8)
NO ......................
00
(G8)
(All)
G8.
Now please think about after your job ended in [fill JOB SEPARATION MONTH, YEAR].
Compared to before your job ended, did the number of times you or your family members went to
a medical doctor for any reason increase, decrease, or stay the same?
PROBE:
Please think about all of your family members, even if they were not covered by your
employer’s health plan.
CODE ONE ONLY
INCREASE ............................................................................. 01
DECREASE ........................................................................... 02
STAY THE SAME .................................................................. 03
DON’T KNOW ........................................................................ d
(REFUSED .............................................................................
r
(All)
G9.
Overall, since your job ended, do you feel that access to health care for you and your family is
better, worse, or about the same?
CODE ONE ONLY
BETTER ................................................................................. 01
WORSE .................................................................................. 02
ABOUT THE SAME ............................................................... 03
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(All)
G10.
Earlier you said that your health was [fill G1 ANSWER] when your job ended, how would you say
your health is now, in general. Would you say it is…
CODE ONE ONLY
excellent, ................................................................................ 01
very good, .............................................................................. 02
good, ...................................................................................... 03
fair, or ..................................................................................... 04
poor? ...................................................................................... 05
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(All)
G11.
Do you now have a physical, emotional, or other health condition that limits the amount or type of
work you can do?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
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E.88
SECTION H: INCOME AND PARTICIPATION IN OTHER TRANSFER PROGRAMS
PROGRAMMER: CHECK B12. IF ANY HOUSEHOLD MEMBER IS 16 OR OLDER, ASK H1.
OTHERWISE, GO TO H2ck1.
(B12 GE 16)
H1.
The next questions are about sources of income and other support that you (and other members
of your family) may have been receiving at the time your job ended in [fill JOB SEPARATION
MONTH, YEAR].
Besides your unemployment insurance claim filed in [fill UI CLAIM MONTH, YEAR] was anyone
else in your family receiving unemployment compensation benefits at that time?
MANDATORY PROBE: By family we mean your spouse or partner and any children for whom
you are financially responsible, even if they don’t live with you.
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(H2ck1)
(H2ck1)
(H2ck1)
(H1=01)
H1a.
What was the total monthly amount that other members of your family received in unemployment
insurance benefits in [fill JOB SEPARATION MONTH, YEAR]?
PROBE: Your best estimate is fine.
$ |___|,|
|
DOLLARS
|
|.|
|
| PER MONTH
CENTS
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(REF)
PROGRAMMER:
REF. THIS ITEM SHOULD BE PROGRAMMED AS AN INFO SCREEN.
INTERVIEWER: IF AMOUNTS RECEIVED ARE REFUSED FOR ANY SOURCE, SAY: Your
answers to these questions will help the researchers better understand the problems people face
when they are unemployed. Neither your name nor any other information that would identify you
is kept with your answers. Please tell me your best estimate.
H2ck1. PROGRAMMER: CHECK B7. WAS SAMPLE MEMBER MARRIED OR WITH A PARTNER
WHEN JOB ENDED?
YES ........................................................................................ 01
NO .......................................................................................... 00
(H2ck2)
(H3)
H2ck2. PROGRAMMER: CHECK B10 AND B14. WAS THE SPOUSE/PARTNER WORKING AT JOB
LOSS?
YES ........................................................................................ 01
NO .......................................................................................... 00
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E.89
(H2)
(H3)
(H2ck2=01)
H2.
You said that your (spouse/partner) was working when your job ended in [fill JOB SEPARATION
MONTH, YEAR]. What were your (spouse’s/partner’s) earnings at the time your job ended?
$|
|
|
| ,|
DOLLARS
|
|
|.|
|
|
CENTS
PER MONTH.......................................................................... 01
PER YEAR ............................................................................. 02
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(All)
H3.
Prior to losing your job at [fill EMPLOYER FROM UI RECORDS OR B1a], were you (or anyone
else in your family) receiving any benefits or income from the following sources…
PROGRAMMER: INSERT STATE TANF NAME AT H3b.
PROBE IF NEEDED: Please think about [fill JOB SEPARATION MONTH, YEAR MINUS 1 MONTH].
CODE ONE FOR EACH
YES
NO
DON’T
KNOW
REFUSED
a. Food Stamp or SNAP benefits? .....................................
01
00
d
r
b. Welfare programs such as [fill STATE TANF NAME]?...
01
00
d
r
c.
General Assistance? ......................................................
01
00
d
r
d. SSI, SSDI, or other disability benefits? ..........................
01
00
d
r
e. Social Security or Pension benefits? ..............................
01
00
d
r
f.
Workers Compensation benefits? ..................................
01
00
d
r
g. Alimony, child support, or rent payments? .....................
01
00
d
r
h. Interest and/or dividends? ..............................................
01
00
d
r
01
00
d
r
PROGRAMS
i.
Any other income sources?
PROBE: Please do not include unemployment
benefits. SPECIFY ........................................................
___________________________________________
IF ALL ANSWERS TO H3=00, D OR R, GO TO H4.
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E.90
(H3a=01)
H3a-1. What was the total monthly amount that you (and other members of your family) were receiving in
food stamp or SNAP benefits at that time?
PROBE: Your best estimate is fine.
$|
|,|
|
|
DOLLARS
|.|
|
| PER MONTH
CENTS
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(REF)
IF NO OTHER BENEFITS, GO TO H4.
(H3b=01)
H3b-1. What was the total monthly amount that you (and other members of your family) were receiving
in [fill STATE TANF PROGRAM NAME]benefits at that time?
PROBE: Your best estimate is fine.
$|
|,|
|
|
DOLLARS
|.|
|
| PER MONTH
CENTS
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(REF)
IF NO OTHER BENEFITS, GO TO H4.
(H3c=01)
H3c-1. What was the total monthly amount that you (and other members of your family) were receiving in
general assistance benefits at that time?
PROBE: Your best estimate is fine.
$|
|,|
|
|
DOLLARS
|.|
|
| PER MONTH
CENTS
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(REF)
IF NO OTHER BENEFITS, GO TO H4.
(H3d=01)
H3d-1. What was the total monthly amount that you (and other members of your family) were receiving in
SSI, SSDI, or other disability benefits at that time?
PROBE: Your best estimate is fine.
$|
|,|
|
|
DOLLARS
|.|
|
| PER MONTH
CENTS
DON’T KNOW ........................................................................
REFUSED ..............................................................................
IF NO OTHER BENEFITS, GO TO H4.
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E.91
d
r
(REF)
(H3e=01)
H3e-1. What was the total monthly amount that you (and other members of your family) were receiving in
Social Security or pension benefits at that time?
PROBE: Your best estimate is fine.
$|
|,|
|
|
DOLLARS
|.|
|
| PER MONTH
CENTS
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(REF)
IF NO OTHER BENEFITS, GO TO H4.
(H3f=01)
H3f-1. What was the total monthly amount that you (and other members of your family) were receiving in
Workers’ Compensation benefits at that time?
PROBE: Your best estimate is fine.
$|
|,|
|
|
DOLLARS
|.|
|
| PER MONTH
CENTS
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(REF)
IF NO OTHER BENEFITS, GO TO H4.
(H3g=01)
H3g-1. What was the total monthly amount that you (and other members of your family) were receiving in
alimony, child support, or rent payments at that time?
PROBE: Your best estimate is fine.
$|
|,|
|
|
DOLLARS
|.|
|
| PER MONTH
CENTS
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(REF)
IF NO OTHER BENEFITS, GO TO H4.
(H3h=01)
H3h-1. What was the total monthly amount that you (and other members of your family) were receiving in
interest and/or dividends at that time?
PROBE: Your best estimate is fine.
$|
|,|
|
|
DOLLARS
|.|
|
| PER MONTH
CENTS
DON’T KNOW ........................................................................
REFUSED ..............................................................................
IF NO OTHER BENEFITS, GO TO H4.
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E.92
d
r
(REF)
(H3i=01)
H3i-1. What was the total monthly amount that you (and other members of your family) were receiving
from other income sources at that time?
PROBE: Your best estimate is fine.
$|
|,|
|
|
|.|
DOLLARS
|
| PER MONTH OR $ $|
CENTS
|,|
|
|
DOLLARS
DON’T KNOW ........................................................................
REFUSED ..............................................................................
|.|
|
| LUMP SUM
CENTS
d
r
(REF)
(All)
H4.
What was (your total income/the total income for you and all the members of your family), before
taxes and other deductions just before your job ended in [fill JOB SEPARATION MONTH,
YEAR]? Please include all of the sources of income we’ve talked about, plus any others you may
have had.
PROBE, IF NEEDED: Include sources such as self-employment, regular jobs, and earnings from
odd side jobs, under-the-table jobs, and other activities, social security,
pensions, rent, interest and dividends, unemployment compensation,
welfare, other public assistance, food stamps, child support, and money
from any other sources. Your best estimate is fine.
INTERVIEWER: ACCEPT A “DON’T KNOW” ANSWER WITHOUT PRESSING
RESPONDENT. GO TO RANGES IN H5 TO GET INCOME AMOUNT.
$|
|
|
|,|
|
DOLLARS
|
|.|
|
|
CENTS
CODE ONE ONLY
PER MONTH.......................................................................... 01
(H6)
PER YEAR ............................................................................. 02
(H6)
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(H4=d OR r)
H5.
Would you say your monthly household income just before [fill JOB SEPARATION MONTH,
YEAR] was less than $3,000 or $3,000 or more?
PROBE: Your best estimate is fine.
INTERVIEWER: IF RESPONDENT STILL SAYS “DON’T KNOW,” RECORD DON’T KNOW
AS THEIR ANSWER AND MOVE ON WITHOUT PRESSING RESPONDENT
FURTHER.
CODE ONE ONLY
LESS THAN $3,000 ............................................................... 01
$3,000 OR MORE .................................................................. 02
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
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E.93
(H5b)
(H6)
(H6)
(H5=02)
H5a.
Would you say it was…
CODE ONE ONLY
$3,000 to under $4,000, .........................................................
$4,000 to under $5,000, .........................................................
$5,000 to under $6,000, .........................................................
$6,000 to under $7,000, .........................................................
$7,000 to under $8,000, .........................................................
$8,000 to under $9,000 ..........................................................
$9,000 to under $10,000, or ...................................................
$10,000 or more? ...................................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
01
02
03
04
05
06
07
08
d
r
GO TO H6
(H5=01)
H5b.
Would you say it was…
CODE ONE ONLY
less than $500, .......................................................................
$500 to under $1,000, ............................................................
$1,000 to under $1,500, .........................................................
$1,500 to under $2,000, .........................................................
$2,000 to under $2,500, or .....................................................
$2,500 to under $3,000? ........................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
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E.94
01
02
03
04
05
06
d
r
(All)
H6.
Now I would like to ask you about your income after your job at [fill EMPLOYER FROM UI
RECORDS OR B1a] ended. Since then, have you (or anyone else in your family) received any
benefits or income from the following sources…
INTERVIEWER: IF SOMEONE WAS ALREADY RECEIVING THE BENEFIT PRIOR TO JOB
LOSS, CODE “YES, ALREADY RECEIVING” WITHOUT ASKING.
CODE ONE PER ROW
PROGRAMS
YES
YES,
ALREADY
RECEIVING
NO
DON’T
KNOW
REFUSED
a.
Food stamp or SNAP benefits?...............................................
01
02
00
d
r
b.
Welfare programs such as [fill STATE TANF NAME]? ..
01
02
00
d
r
c.
General Assistance? ...............................................................
01
02
00
d
r
d.
SSI, SSDI, or other disability benefits? ...................................
01
02
00
d
r
e.
Social Security or Pension benefits? .......................................
01
02
00
d
r
f.
Workers Compensation benefits? ...........................................
01
02
00
d
r
g.
Alimony, child support, or rent payments? ..............................
01
02
00
d
r
h.
Interest and/or dividends? .......................................................
01
02
00
d
r
i.
Any other income sources, not including unemployment
benefits? (SPECIFY) ...............................................................
______________________________________________
01
02
00
d
r
IF ALL ANSWERS TO H6=00, D OR R, GO TO H7.
IF ANY ANSWERS=02, GO TO “-2” QUESTION FOR THAT BENEFIT.
(H6a=01)
H6a-1.
Approximately how soon after your job with [fill EMPLOYER FROM UI RECORDS OR B1a]
ended did you (or someone else in your family) begin receiving food stamp or SNAP benefits?
Would you say it was…
CODE ONE ONLY
ALREADY RECEIVING BENEFIT PRIOR TO JOB LOSS ....
Within one to three months, ...................................................
Within four to six months, .......................................................
Within seven to nine months, .................................................
Within 10 to 12 months, or .....................................................
More than 12 months after your job ended? ..........................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
n
01
02
03
04
05
d
r
(REF)
(H6a=01 OR 02)
H6a-2.
Since [fill JOB SEPARATION MONTH, YEAR], for approximately how many months did you (or
someone else in your family) receive food stamp or SNAP benefits?
|
| | # OF MONTHS
(1-36)
ALL OF THE MONTHS .......................................................... 99
NONE OF THE MONTHS ...................................................... n
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
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E.95
(H6a=01 OR 02)
H6a-3.
How much was received in food stamp or SNAP benefits each month since [fill JOB
SEPARATION MONTH, YEAR]?
IF VARIED, PROBE: Please tell me the average amount received.
ENTER AMOUNT RECEIVED FOR EACH MONTH.
$|
|
|,|
|
|
|.|
DOLLARS
|
| PER MONTH
CENTS
SAME AS BEFORE ...............................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
n
d
r
(REF)
IF NO OTHER BENEFITS WERE RECEIVED GO TO H7.
(H6b=01)
H6b-1.
Approximately how soon after your job with [fill EMPLOYER FROM UI RECORDS OR B1a]
ended did you (or someone else in your family) begin receiving [fill STATE TANF PROGRAM
NAME] benefits? Would you say it was…
CODE ONE ONLY
ALREADY RECEIVING BENEFIT PRIOR TO JOB LOSS ....
Within one to three months, ...................................................
Within four to six months, .......................................................
Within seven to nine months, .................................................
Within 10 to 12 months, or .....................................................
More than 12 months after your job ended? ..........................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
n
01
02
03
04
05
d
r
(REF)
(H6b=01 OR 02)
H6b-2.
Since [fill JOB SEPARATION MONTH, YEAR], for approximately how many months did you (or
someone else in your family) receive [fill STATE TANF PROGRAM NAME] benefits?
| | | # OF MONTHS
(1-36)
ALL OF THE MONTHS .......................................................... 99
NONE OF THE MONTHS ...................................................... n
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(H6b=01 OR 02)
H6b-3.
How much was received in [fill STATE TANF PROGRAM NAME] benefits each month since
[fill JOB SEPARATION MONTH, YEAR]?
IF VARIED, PROBE: Please tell me the average amount received.
ENTER AMOUNT RECEIVED FOR EACH MONTH.
$|
|
|,|
|
DOLLARS
|
|.|
|
| PER MONTH
CENTS
SAME AS BEFORE ...............................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
IF NO OTHER BENEFITS WERE RECEIVED GO TO H7.
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E.96
n
d
r
(REF)
(H6c=01)
H6c-1.
Approximately how soon after your job with [fill EMPLOYER FROM UI RECORDS OR B1a]
ended did you (or someone else in your family) begin receiving general assistance benefits?
Would you say it was…
CODE ONE ONLY
ALREADY RECEIVING BENEFIT PRIOR TO JOB LOSS ....
Within one to three months, ...................................................
Within four to six months, .......................................................
Within seven to nine months, .................................................
Within 10 to 12 months, or .....................................................
More than 12 months after your job ended? ..........................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
n
01
02
03
04
05
d
r
(REF)
(H6c=01 OR 02)
H6c-2.
Since [fill JOB SEPARATION MONTH, YEAR], for approximately how many months did you (or
someone else in your family) receive general assistance benefits?
| | | # OF MONTHS
(1-36)
ALL OF THE MONTHS .......................................................... 99
NONE OF THE MONTHS ...................................................... n
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(H6c=01 OR 02)
H6c-3.
How much was received in general assistance benefits each month since [fill JOB
SEPARATION MONTH, YEAR]?
IF VARIED, PROBE: Please tell me the average amount received.
ENTER AMOUNT RECEIVED FOR EACH MONTH.
$|
|
|,|
|
DOLLARS
|
|.|
|
| PER MONTH
CENTS
SAME AS BEFORE ...............................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
n
d
r
(REF)
IF NO OTHER BENEFITS WERE RECEIVED GO TO H7.
(H6d=01)
H6d-1.
Approximately how soon after your job with [fill EMPLOYER FROM UI RECORDS OR B1a]
ended did you (or someone else in your family) begin SSI, SSDI, or other disability benefits?
Would you say it was…
CODE ONE ONLY
ALREADY RECEIVING BENEFIT PRIOR TO JOB LOSS ....
Within one to three months, ...................................................
Within four to six months, .......................................................
Within seven to nine months, .................................................
Within 10 to 12 months, or .....................................................
More than 12 months after your job ended? ..........................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
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E.97
n
01
02
03
04
05
d
r
(REF)
(H6d=01 OR 02)
H6d-2.
Since [fill JOB SEPARATION MONTH, YEAR], for approximately how many months did you (or
someone else in your family) receive SSI, SSDI or other disability benefits?
| | | # OF MONTHS
(1-36)
ALL OF THE MONTHS .......................................................... 99
NONE OF THE MONTHS ...................................................... n
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(H6d=01 OR 02)
H6d-3.
How much was received in SSI, SSDI or other disability benefits each month since [fill JOB
SEPARATION MONTH, YEAR]?
IF VARIED, PROBE: Please tell me the average amount received.
ENTER AMOUNT RECEIVED FOR EACH MONTH.
$|
|
|,|
|
DOLLARS
|
|.|
|
| PER MONTH
CENTS
SAME AS BEFORE ...............................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
n
d
r
(REF)
IF NO OTHER BENEFITS WERE RECEIVED GO TO H7.
(H6e=01)
H6e-1.
Approximately how soon after your job with [fill EMPLOYER FROM UI RECORDS OR B1a]
ended did you (or someone else in your family) begin receiving Social Security or pension
benefits? Would you say it was…
CODE ONE ONLY
ALREADY RECEIVING BENEFIT PRIOR TO JOB LOSS ....
Within one to three months, ...................................................
Within four to six months, .......................................................
Within seven to nine months, .................................................
Within 10 to 12 months, or .....................................................
More than 12 months after your job ended? ..........................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
n
01
02
03
04
05
d
r
(REF)
(H6e=01 OR 02)
H6e-2.
Since [fill JOB SEPARATION MONTH, YEAR], for approximately how many months did you (or
someone else in your family) receive Social Security or pension benefits?
| | | # OF MONTHS
(1-36)
ALL OF THE MONTHS .......................................................... 99
NONE OF THE MONTHS ...................................................... n
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
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E.98
(H6e=01 OR 02)
H6e-3.
How much was received in Social Security or pension benefits each month since [fill JOB
SEPARATION MONTH, YEAR]?
IF VARIED, PROBE: Please tell me the average amount received.
ENTER AMOUNT RECEIVED FOR EACH MONTH.
$|
|
|,|
|
|
|.|
DOLLARS
|
| PER MONTH
CENTS
SAME AS BEFORE ...............................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
n
d
r
(REF)
IF NO OTHER BENEFITS WERE RECEIVED GO TO H7.
(H6f=01)
H6f-1.
Approximately how soon after your job with [fill EMPLOYER FROM UI RECORDS OR B1a]
ended did you (or someone else in your family) begin receiving Worker’s Compensation
benefits? Would you say it was…
CODE ONE ONLY
ALREADY RECEIVING BENEFIT PRIOR TO JOB LOSS ....
Within one to three months, ...................................................
Within four to six months, .......................................................
Within seven to nine months, .................................................
Within 10 to 12 months, or .....................................................
More than 12 months after your job ended? ..........................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
n
01
02
03
04
05
d
r
(REF)
(H6f=01 OR 02)
H6f-2.
Since [fill JOB SEPARATION MONTH, YEAR], for approximately how many months did you (or
someone else in your family) receive Worker’s Compensation benefits?
| | | # OF MONTHS
(1-36)
ALL OF THE MONTHS .......................................................... 99
NONE OF THE MONTHS ...................................................... n
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(H6f=01 OR 02)
H6f-3.
How much was received in Worker’s Compensation benefits each month since [fill JOB
SEPARATION MONTH, YEAR]?
IF VARIED, PROBE: Please tell me the average amount received.
ENTER AMOUNT RECEIVED FOR EACH MONTH.
$|
|
|,|
|
DOLLARS
|
|.|
|
| PER MONTH
CENTS
SAME AS BEFORE ...............................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
IF NO OTHER BENEFITS WERE RECEIVED GO TO H7.
Prepared by Mathematica Policy Research
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
E.99
n
d
r
(REF)
(H6g=01)
H6g-1.
Approximately how soon after your job with [fill EMPLOYER FROM UI RECORDS OR B1a]
ended did you (or someone else in your family) begin receiving alimony, child support, or rent
payments? Would you say it was…
CODE ONE ONLY
ALREADY RECEIVING BENEFIT PRIOR TO JOB LOSS ....
Within one to three months, ...................................................
Within four to six months, .......................................................
Within seven to nine months, .................................................
Within 10 to 12 months, or .....................................................
More than 12 months after your job ended? ..........................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
n
01
02
03
04
05
d
r
(REF)
(H6g=01 OR 02)
H6g-2.
Since [fill JOB SEPARATION MONTH, YEAR], for approximately how many months did you (or
someone else in your family) receive alimony, child support, or rent payments?
| | | # OF MONTHS
(1-36)
ALL OF THE MONTHS .......................................................... 99
NONE OF THE MONTHS ...................................................... n
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(H6g=01 OR 02)
H6g-3.
How much was received in alimony, child support, or rent payments each month since [fill
JOB SEPARATION MONTH, YEAR]?
IF VARIED, PROBE: Please tell me the average amount received.
ENTER AMOUNT RECEIVED FOR EACH MONTH.
$|
|
|,|
|
DOLLARS
|
|.|
|
| PER MONTH
CENTS
SAME AS BEFORE ...............................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
n
d
r
(REF)
IF NO OTHER BENEFITS WERE RECEIVED GO TO H7.
(H6h=01)
H6h-1.
Approximately how soon after your job with [fill EMPLOYER FROM UI RECORDS OR B1a]
ended did you (or someone else in your family) begin receiving interest and dividend
payments? Would you say it was…
CODE ONE ONLY
ALREADY RECEIVING BENEFIT PRIOR TO JOB LOSS ....
Within one to three months, ...................................................
Within four to six months, .......................................................
Within seven to nine months, .................................................
Within 10 to 12 months, or .....................................................
More than 12 months after your job ended? ..........................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
Prepared by Mathematica Policy Research
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PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
n
01
02
03
04
05
d
r
(REF)
(H6h=01 OR 02)
H6h-2.
Since [fill JOB SEPARATION MONTH, YEAR], for approximately how many months did you (or
someone else in your family) receive interest and dividend payments?
| | | # OF MONTHS
(1-36)
ALL OF THE MONTHS .......................................................... 99
NONE OF THE MONTHS ...................................................... n
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(H6h=01 OR 02)
H6h-3.
How much was received in interest and dividend payments each month since [fill JOB
SEPARATION MONTH, YEAR]?
IF VARIED, PROBE: Please tell me the average amount received.
ENTER AMOUNT RECEIVED FOR EACH MONTH.
$|
|
|,|
|
DOLLARS
|
|.|
|
| PER MONTH
CENTS
SAME AS BEFORE ...............................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
n
d
r
(REF)
IF NO OTHER BENEFITS WERE RECEIVED GO TO H7.
(H6i=01)
H6i-1.
Approximately how soon after your job with [fill EMPLOYER FROM UI RECORDS OR B1a]
ended did you (or someone else in your family) begin receiving income from other sources?
Would you say it was…
CODE ONE ONLY
ALREADY RECEIVING BENEFIT PRIOR TO JOB LOSS ....
Within one to three months, ...................................................
Within four to six months, .......................................................
Within seven to nine months, .................................................
Within 10 to 12 months, or .....................................................
More than 12 months after your job ended? ..........................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
n
01
02
03
04
05
d
r
(REF)
(H6i=01 OR 02)
H6i-2.
Since [fill JOB SEPARATION MONTH, YEAR], for approximately how many months did you (or
someone else in your family) receive income from other sources?
| | | # OF MONTHS
(1-36)
ALL OF THE MONTHS .......................................................... 99
NONE OF THE MONTHS ...................................................... n
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
Prepared by Mathematica Policy Research
E.101
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(H6i=01 OR 02)
H6i-3.
How much was received in income from other sources each month since [fill JOB
SEPARATION MONTH, YEAR]?
IF VARIED, PROBE: Please tell me the average amount received.
ENTER AMOUNT RECEIVED FOR EACH MONTH.
$|___|, |
|
|
DOLLARS
|.|
|
| PER MONTH OR $ |___|,|
CENTS
|
|
DOLLARS
SAME AS BEFORE ...............................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
|.|
|
| LUMP SUM
CENTS
n
d
r
(REF)
(All)
H7.
Now I have a few questions about your unemployment insurance claim filed in [fill UI CLAIM
MONTH, YEAR]. For how many total weeks or months did you receive unemployment
insurance benefits for this claim?
PROBE: Your best estimate is fine.
PROBE IF NEEDED: Before taxes.
| | | WEEKS
(01-99)
OR | | | MONTHS (H7b)
(01-25)
STILL RECEIVING .................................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
n
d
r
(H7b)
(H7=d OR r)
H7a.
Would you say…
CODE ONE ONLY
less than 2 months, ................................................................
2 to 4 months, ........................................................................
4 to 6 months, ........................................................................
6 to 8 months, ........................................................................
8 to 10 months, ......................................................................
10 to 12 months, ....................................................................
12 to 15 months, ....................................................................
15 to 18 months, ....................................................................
18 to 21 months, or ................................................................
more than 21 months? ...........................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
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01
02
03
04
05
06
07
08
09
10
d
r
(All)
H7b.
What (was/is) the amount you receive(d) in unemployment insurance benefits for this claim?
PROBE: Your best estimate is fine.
$|
|,|
|
|
DOLLARS
|.|
|
|
CENTS
CODE ONE ONLY
PER WEEK ............................................................................ 01
PER TWO WEEKS ................................................................ 02
PER MONTH.......................................................................... 03
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r (REF)
(H7 NE n)
H8.
Have you filed any additional unemployment insurance claims since the claim you filed on [fill UI
CLAIM DATE]?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(H9)
(H9)
(H9)
(H8=01)
H8a.
How many additional claims have you filed since [fill UI CLAIM DATE]?
| | | # OF CLAIMS
(1-10)
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(H8=01)
H8a.
In what month and year did you file your next claim (after the one you filed in [fill UI CLAIM
DATE])?
| | |/|
MONTH
| | |
YEAR
|
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(H8=01)
H8b.
For how many total weeks or months did you receive unemployment insurance benefits for this
claim?
PROBE: Your best estimate is fine.
| | | WEEKS
(01-99)
OR |___|___| MONTHS (H9)
(01-25)
STILL RECEIVING .................................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
Prepared by Mathematica Policy Research
E.103
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
n
d
r
(H9)
(H8b=d OR r)
H8c.
Would you say…
CODE ONE ONLY
less than 2 months, ................................................................ 01
2 to 4 months, ........................................................................ 02
4 to 6 months, ........................................................................ 03
6 to 8 months, ........................................................................ 04
8 to 10 months, ...................................................................... 05
10 to 12 months, .................................................................... 06
12 to 15 months, .................................................................... 07
15 to 18 months, .................................................................... 08
18 to 21 months, or ................................................................ 09
more than 21 months? ........................................................... 10
DON’T KNOW ........................................................................
d
REFUSED ..............................................................................
r
PROGRAMMER:
CHECK B12. IF ANY HOUSEHOLD MEMBER IS 16 OR OLDER, ASK H9 – H12.
OTHERWISE, GO TO I1.
(B12 GE 16)
H9.
Since [fill UI CLAIM MONTH, YEAR], has anyone else in your family received unemployment
insurance benefits?
YES ........................................................................................ 01
NO .......................................................................................... 00
(H12)
DON’T KNOW ........................................................................
d
(H12)
REFUSED ..............................................................................
r
(H12)
(H9=01)
H10.
For how many total weeks or months did others in your family receive unemployment insurance
benefits?
PROBE: Your best estimate is fine.
| | | WEEKS OR | | | MONTHS
(01-99)
(01-25)
(H11)
DON’T KNOW ........................................................................
d
REFUSED ..............................................................................
r
Prepared by Mathematica Policy Research
E.104
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(H10=d OR r)
H10a.
Would you say…
CODE ONE ONLY
less than 2 months, ................................................................ 01
2 to 4 months, ........................................................................ 02
4 to 6 months, ........................................................................ 03
6 to 8 months, ........................................................................ 04
8 to 10 months, ...................................................................... 05
10 to 12 months, .................................................................... 06
12 to 15 months, .................................................................... 07
15 to 18 months, .................................................................... 08
18 to 21 months, or ................................................................ 09
more than 21 months? ........................................................... 10
DON’T KNOW ........................................................................
d
REFUSED ..............................................................................
r
(H9=01)
H11.
What was the amount that others in your family received in unemployment insurance benefits?
PROBE: Your best estimate is fine.
$|
|,|
|
DOLLARS
|
|.|
|
| BENEFIT AMOUNT
CENTS
CODE ONE ONLY
PER WEEK ............................................................................ 01
PER TWO WEEKS ................................................................ 02
PER MONTH.......................................................................... 03
DON’T KNOW ........................................................................
d
REFUSED ..............................................................................
r
(REF)
(B12 GE 16)
H12.
Since [fill UI CLAIM MONTH, YEAR], did anyone else in your household begin working or begin
working more hours?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................
d
REFUSED ..............................................................................
r
Prepared by Mathematica Policy Research
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SECTION I: FINANCIAL WELL-BEING
(All)
I1.
We’re almost finished. My next questions are about financial obligations you had when your job
ended in [fill JOB SEPARATION MONTH, YEAR]. What was your living arrangement at that
time? Did you…
CODE ONE ONLY
Own your home, .....................................................................
Rent your home,.....................................................................
Live with family or friends and pay part of the rent
or mortgage, ........................................................................
Live with family or friends and not pay, or ............................
Live in some other housing arrangement? ............................
LIVE IN A GROUP SHELTER, ..............................................
LIVE IN AN ASSISTED LIVING FACILITY, OR.....................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
01
02
03
04
05
06
07
d
r
(I1a)
(I1b)
GO TO I2
(I1=01)
I1a.
Did you have a mortgage on your home?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
GO TO I2
(I1=07)
I1b.
What was your living arrangement in [fill JOB SEPARATION MONTH, YEAR]?
RECORD VERBATIM
DON’T KNOW ........................................................................
REFUSED ..............................................................................
Prepared by Mathematica Policy Research
E.106
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
d
r
(All)
I2.
At the time just before your job ended in [fill JOB SEPARATION MONTH, YEAR], did you (or
anyone else in your family) have any…
CODE ONE FOR EACH
YES
NO
DON’T
KNOW
REFUSED
a. automobile loans? .....................................................................
01
00
d
r
b. student loans? ..........................................................................
01
00
d
r
c. balances on credit cards that you carried over from one month
to the next? ...............................................................................
01
00
d
r
d. medical bills? ............................................................................
01
00
d
r
e. personal loans owed to your parents or other individuals? .......
01
00
d
r
IF ALL ANSWERS TO I2=00, D OR R, GO TO I4.
(I2a, b, c, d, e, OR f=01)
I3.
What was the total amount of debt and loans you owed in [fill JOB SEPARATION MONTH,
YEAR]? (IF I1a=01, SAY: Please do not include mortgage payments here.)
PROBE: Your best estimate is fine.
$|
|
|
| ,|
|
|
| TOTAL DEBT AT JOB SEPARATION
(I3b)
DOLLARS
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(I3=d OR r)
I3a.
Would you say it was…
CODE ONE ONLY
less than $5,000, ....................................................................
between $5,000 to under $10,000, ........................................
between $10,000 to under $15,000, ......................................
between $15,000 to under $20,000, ......................................
between $20,000 to under $25,000, or ..................................
between $25,000 to under $30,000? .....................................
or more than $30,000? ...........................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
Prepared by Mathematica Policy Research
E.107
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
01
02
03
04
05
06
07
d
r
(I2a, b, c, d, e, OR f=01)
I3b.
What were your minimum monthly required payments toward your debts and loans in [fill JOB
SEPARATION MONTH, YEAR]?
PROBE:
$|
This is the lowest amount you could pay to keep your account in good standing.
Your best estimate is fine.
|
|,|
|
|
| MINIMUM PAYMENTS AT JOB SEPARATION
DOLLARS
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(I2a, b, c, d, e, OR f=01)
I3c.
While your minimum monthly required payments were [fill I3b AMOUNT], how much did you
usually pay each month toward your debts and loans just before [fill JOB SEPARATION
MONTH, YEAR]?
$|
|
|,|
|
|
| USUAL MONTHLY PAYMENTS AT JOB SEPARATION
DOLLARS
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(All)
I4.
Now, please think about the twelve months after your job ended. Did you have any trouble
making payments on any of your monthly bills or loan payments during the twelve months after
your job ended?
INTERVIEWER: THIS INCLUDES MORTGAGE PAYMENTS.
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
Prepared by Mathematica Policy Research
E.108
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(I11)
(I4=01, d OR r)
I5.
Did you have trouble paying any of the following bills in the twelve months after your job with [fill
EMPLOYER FROM UI RECORDS OR B1a] ended.. (READ a-h)?
PROGRAMMER: SHOW I5b –I5f ONLY IF I2a – I2e =01.
CODE ONE FOR EACH
YES
NO
DON’T
KNOW
REFUSED
01
00
d
r
01
00
d
r
01
00
d
r
01
00
d
r
01
00
d
r
01
00
d
r
01
00
d
r
h. your rent? ...........................................................................
01
00
d
r
i.
01
00
d
r
a. utility bills? ..........................................................................
(I2a=01)
b. automobile loans? ..............................................................
(I2b=01)
c. student loans? ....................................................................
(I2c=01)
d. credit card bills?..................................................................
(I2d=01)
e. medical bills? ......................................................................
(I2e=01)
f.
personal loans owed to your parents or other individuals?
(I1a=01)
g. your mortgage? ..................................................................
(I1=02 OR 03)
other bills or loans? (SPECIFY) [specify] ...........................
(I4=01, d OR r)
I6.
Since [fill JOB SEPARATION MONTH, YEAR], did you move to a new place to live because you
were unable to pay your rent, mortgage or other bills?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(I4=01, d OR r)
I7.
Since [fill JOB SEPARATION MONTH, YEAR], did you need to sell a car, appliance, furniture, or
jewelry because you were unable to pay your rent, mortgage or other bills?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
Prepared by Mathematica Policy Research
E.109
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(I4=01, d OR r)
I8.
Did you have to withdraw money from a 401K or other retirement account in the twelve months
after your job with [fill EMPLOYER FROM UI RECORDS OR B1a] ended because you were
unable to pay your rent, mortgage or other bills?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(I5g=01)
I9.
Since [fill JOB SEPARATION MONTH, YEAR], have you…
CODE ONE FOR EACH ROW
NO
DON’T
KNOW
REFUSED
a. missed or been late on a mortgage payment? .............. 01
00 (I11)
d (I11)
r (I11)
b. received a notice that your mortgage was in default? ... 01
00 (I11)
d (I11)
r (I11)
c. had your house foreclosed on? ..................................... 01 (I9a)
00 (I11)
d (I11)
r (I11)
YES
(I9c=01)
I9a.
In what month and year was your home foreclosed?
| | |/|
MONTH
(1-12)
|
| |
YEAR
|
(2009-2012)
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
GO TO I11
(I5h=01)
I10.
Since [fill JOB SEPARATION MONTH, YEAR], have you…
CODE ONE FOR EACH ROW
YES
NO
DON’T
KNOW
REFUSED
a. been charged a late fee or missed a rent payment? .....
01
00 (I11)
d (I11)
r (I11)
b. received a notice of eviction? ........................................
01
00 (I11)
d (I11)
r (I11)
c. been evicted?.................................................................
01
00 (I11)
d (I11)
r (I11)
Prepared by Mathematica Policy Research
E.110
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(I4=01, d OR r)
I11.
Did you declare personal bankruptcy at any time after [fill JOB SEPARATION MONTH, YEAR]?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(I12)
(I12)
(I12)
(I11=01)
I11a.
In what month and year did you declare personal bankruptcy?
| | |/|
MONTH
(1-12)
|
| |
YEAR
|
(2009-2012)
DON’T KNOW ........................................................................
REFUSED ..............................................................................
d
r
(All)
I12.
I’d also like to ask you about the foods eaten in your household during the twelve months after
your job with [fill EMPLOYER FROM UI RECORDS OR B1a] ended. Which of the following
statements best describes the food eaten in your household at that time. Would you say that you
had enough of the kinds of food you wanted to eat, enough but not always the kinds of food you
wanted to eat, sometimes not enough to eat, or often not enough to eat?
CODE ONE ONLY
ENOUGH OF KINDS WANTED TO EAT...............................
ENOUGH BUT NOT ALWAYS THE KIND OF FOOD
WANTED TO EAT...............................................................
SOMETIMES NOT ENOUGH TO EAT ..................................
OFTEN NOT ENOUGH TO EAT ...........................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
01
02
03
04
d
r
(All)
I12a.
During that same time did you (and your family) start to eat out less?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(All)
I13.
In [fill JOB SEPARATION MONTH, YEAR], did you have any savings in bank accounts?
PROBE: Please do not include money you may have had in retirement accounts.
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
Prepared by Mathematica Policy Research
E.111
PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
(J1)
(J1)
(J1)
(I13=01)
I14. Did you have enough savings to cover all of your living expenses for three months?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(I16)
(I16)
(I16)
(I14=01)
I15.
Did you have enough savings to cover all of your living expenses for six months?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(I13=01)
I16.
When your job ended in [fill JOB SEPARATION MONTH, YEAR] about how much savings did
you have in your bank accounts? Please do not include money you may have had in retirement
accounts. Would you say you had less than $5,000, $5,000 to $10,000, $10,000 to $15,000,
$15,000 to $20,000, or more than $20,000?
PROBE: Please do not include money you may have had in retirement accounts.
PROBE: Your best estimate is fine.
CODE ONE ONLY
LESS THAN $5,000 ...............................................................
$5,000 TO UNDER $10,000 ..................................................
$10,000 TO UNDER $15,000 ................................................
$15,000 TO UNDER $20,000 ................................................
MORE THAN $20,000 ...........................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
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02
03
04
05
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(REF)
SECTION J: BACKGROUND
(All)
J1.
Now, I just have a few final questions about you. Do you consider yourself to be of Hispanic,
Latino, or Spanish origin?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
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(All)
J2.
I’m going to read you a list of five race categories. Please choose one or more races that you
consider yourself to be. Would you say you are…
INTERVIEWER: PROBE ONLY IF RESPONSE IS HISPANIC OR HISPANIC ORIGIN.
CODE ALL THAT APPLY
White, ..................................................................................... 01
Black or African-American, .................................................... 02
American Indian or Alaskan Native, ....................................... 03
Asian, or ................................................................................. 04
Native Hawaiian or Pacific Islander? ..................................... 05
OTHER (SPECIFY) [specify] ................................................. 06
DON’T KNOW ........................................................................
d
REFUSED ..............................................................................
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J3.
What was the highest diploma or degree you had received at the time your job at [fill EMPLOYER
FROM UI RECORDS OR B1a] ended?
PROBE: How far did you go in school?
INTERVIEWER:IF ATTENDED SCHOOL BUT COMPLETED LESS THAN HIGH SCHOOL,
CODE AS 1. IF NEVER ATTENDED SCHOOL, CODE AS 10.
INTERVIEWER:IF RESPONDENT SAYS THEY WERE HOME SCHOOLED, PROBE FOR
HIGHEST YEAR, GRADE, DEGREE, OR CERTIFICATE COMPLETED.
INTERVIEWER:IF RESPONDENT SAYS HIGH SCHOOL, PROBE: Did you receive a diploma,
GED, or certificate of completion?
CODE ONE ONLY
DID NOT COMPLETE HIGH SCHOOL OR GED ..........................
HIGH SCHOOL: DIPLOMA ............................................................
HIGH SCHOOL: GED ....................................................................
CERTIFICATE OF COMPLETION.................................................
SOME COLLEGE/SOME POSTSECONDARY
VOCATIONAL COURSES ........................................................
2-YEAR OR 3-YEAR COLLEGE DEGREE (ASSOCIATE’S
DEGREE) OR VOCATIONAL SCHOOL DIPLOMA .................
4-YEAR COLLEGE DEGREE (BACHELOR’S DEGREE) .............
SOME GRADUATE WORK/NO GRADUATE DEGREE ...............
GRADUATE OR PROFESSIONAL DEGREE
(e.g., MA, MBA, Ph.D., JD, MD) ...............................................
NEVER ATTENDED SCHOOL ......................................................
DON’T KNOW ................................................................................
REFUSED ......................................................................................
01
02
03
04
05
06
07
08
09
10
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(All)
J4.
Is your current marital status different from when your job ended in [fill UI CLAIM DATE]?
YES ........................................................................................ 01
NO .......................................................................................... 00
DON’T KNOW ........................................................................ d
REFUSED ..............................................................................
r
(K1)
(K1)
(K1)
(J4=01)
J4a.
What is your current marital status—are you now married, living with a partner, separated,
divorced, widowed, or have you never been married?
CODE ONE ONLY
MARRIED.......................................................................................
LIVING WITH A PARTNER ...........................................................
SEPARATED .................................................................................
DIVORCED ....................................................................................
WIDOWED .....................................................................................
NEVER MARRIED .........................................................................
DON’T KNOW ................................................................................
REFUSED ......................................................................................
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SECTION K: CLOSING AND CONTACT INFORMATION
(All)
K1.
PROGRAMMER: IF WE HAVE NAME, ADDRESS, AND PHONE NUMBER FROM EITHER
THE SCREENER OR FROM THE OTHER PRELOADED INFORMATION
DISPLAY THAT NAME, ADDRESS, AND PHONE NUMBER.
That was the last interview question. Now I would like to ask you a few general questions about
this experience.
K2.
What is your overall reaction to the survey? RECORD VERBATIM
DON’T KNOW ........................................................................
REFUSED ..............................................................................
K3.
d
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How do you feel about the length of the survey?
PROBE: Was the length reasonable? Was it too long?
CODE ONE ONLY
REASONABLE LENGTH ....................................................... 01
TOO LONG ............................................................................ 02
OTHER (SPECIFY) [specify] ................................................. 03
DON’T KNOW ........................................................................
REFUSED ..............................................................................
K4.
d
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Were there questions or topics in the survey that you found hard to understand or difficult to
answer? Which ones? RECORD VERBATIM
DON’T KNOW ........................................................................
REFUSED ..............................................................................
K5.
d
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How likely would you be to participate in a study like this if you received a letter from the
U.S. Department of Labor? Would you be…
CODE ONE ONLY
very likely, ..............................................................................
somewhat likely, .....................................................................
somewhat unlikely, or.............................................................
very unlikely? .........................................................................
DON’T KNOW ........................................................................
REFUSED ..............................................................................
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K6.
Are there any other comments or reactions that you would like to share about your experience
doing this pretest? RECORD VERBATIM
DON’T KNOW ........................................................................
REFUSED ..............................................................................
K7.
d
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Thank you again for your input. Please tell me the correct spelling of your name and your current
mailing address so that we can mail your check for $50.
PROBE: Is there an apartment number?
NAME (VERIFY SPELLING)
ADDRESS LINE 1
ADDRESS LINE 2
CITY/TOWN
STATE
ZIP CODE
TELEPHONE
DON’T KNOW ........................................................................
d
REFUSED ..............................................................................
r
Thanks again and best wishes to you.
INTERVIEWER: GO BACK AND CODE QUESTION G4 BEFORE CLOSING THIS CASE.
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PART A. APP_E_COBRA Subsidy Study Survey (7-20-11 dab)-q17.docx
| File Type | application/pdf |
| File Title | Impact of the ARRA Subsidy on COBRA Take-Up Draft COBRA Subsidy Study Survey |
| Subject | Questionnaire |
| Author | JMilliner-Waddell |
| File Modified | 2012-03-14 |
| File Created | 2012-03-14 |