CMS-10399 Appendix D Beneficiaries and Family Members Demographic

Appendix D
Medicare Beneficiaries and Family Members Demographic Survey

Kauffman & Associates, Inc.

Centers for Medicare and Medicaid Services
American Indian and Alaska Native Transportation Barriers

Medicare Beneficiaries and Family Members Demographic Survey

Please answer all of the following questions by circling the number that corresponds to the correct
answer or by filling in the appropriate blank.
01. Please indicate your gender.
1
Male
2
Female
02a. What is the month and year of your birth?
____ ____ MONTH

19 ____ ____ YEAR

02b. If you do not know the month and year of your birth, please enter your approximate age.
____ ____ years
03. What is/are your tribal affiliation(s)?

_____________________________________
_____________________________________

04. What is your ZIP code?

___ ___ ___ ___ ___

05. How many years of school have you completed?
____ ____ YEARS Please read the following options and enter the appropriate code; see
below.
00 = 00 to less than 1 year
01 = 01-04 years
02 = 05-08 years
03 = 09-12 years (no high school diploma)
04 = high school diploma or GED
05 = Attended, but did not complete college or university
06 = College degree or more
05b. Did you attend a trade school or receive other specialized training?
1
Yes
2
No
06.

What is your employment status?
1
2
3
4

Full-time employed
Part-time employed
Self-employed
Seasonally employed

Kauffman & Associates, Inc.

5
6
7

Homemaker
Retired
Disabled