Form CMS-10389 Attachment B Survey Instruments

Use Appropriate Versions Of The Survey. The scripts provided in this document use the questions from the Home- and Community-Based Services (HCBS) Experience Survey. There are four different versions:
1. Primary survey in English. For all surveys conducted in English, begin with using this version.
2. Alternate version in English. If an English-speaking respondent finds answering the primary survey cognitively challenging, use this version. Use this only after a respondent is unable to answer three questions with the “never, sometimes, usually, and always” response options.
3. Primary survey in Spanish. For all surveys conducted in Spanish, begin with using this version.
4. Alternate version in Spanish. If a Spanish-speaking respondent finds answering the primary survey cognitively challenging, use this version.
Use Appropriate Response Options:

All questions include a “REFUSED” response option. In this case, “refused” means the respondent did not provide any answer to the question.
For response options of “never, sometimes, usually, and always”, if the respondent cannot use that scale, the alternate version of the survey should be used which uses the response options of “mostly yes and mostly no.” These response options are reserved for individuals who find the “never, sometimes, usually, always” response scale cognitively challenging.
All questions include a “DON’T KNOW” response option. This is used when the respondent indicates that he or she does not know the answer and cannot provide a response to the question.
All questions include an “UNCLEAR” response option. This should be used when a respondent answers, but the interviewer cannot clarify the meaning of the response even after minor probing or the response is completely unrelated to the question—for example, the response to “Do your homemakers listen carefully to what you say?” is “I like to sit by Mary.”
Some responses have skip patterns, which are expressed as “if ‘X’ go to Q#.” That means the interviewer should skip all following questions until Q#.

Use Singular/Plural as needed: Modify items such that the interviewer can use the correct form (singular or plural) of the survey item.
Use Program-Specific Terms: Where appropriate, add in the program-specific terms for staff (e.g., [program-specific term for these types of staff]) but allow the interviewer to modify the term based on the respondent’s choice of the word. It will be necessary to obtain information for program-specific terms. State administrative data should include the following information:

Agency name(s)
Titles of staff who provide care
Names of staff who provide care
Activities that each staff member provides (this will help with identifying appropriate skip logic)
Hours of staff who come to the home

Title

Name

Agency

Roles

Hours

PCA

Jane Doe

Happy Home

Bathing

Dressing

Prepping meals

# of hours

Homemaker

John Doe

Happy Home

Cleaning

# of hours

Please be aware that to conduct this survey, you may need approval from an Institutional Review Board (IRB). Regardless of whether you need IRB approval, you must get the respondent’s consent to participate in the survey. In addition, there may be state statutory requirements that apply to interviewers regarding reporting suspected abuse and neglect. Although information should be kept confidential, these state laws may mandate reporting in certain cases and should be reviewed prior to implementation.

INSTRUCTIONS FOR INTERVIEWER

Interviewers should read aloud all text that appears in initial uppercase and lowercase letters. Text that appears in bold, lowercase letters should be emphasized.
Text in {italics and in braces} will be provided by the program. However, if the interviewee provides another term, use that in place of the program-specific term wherever indicated. For example, some interviewees may refer to their case manager by another title, which should be used instead throughout the survey.
Text in uppercase letters should not be read aloud. For example, “DON’T KNOW,” “REFUSED,” or “UNCLEAR RESPONSE” answer categories appear in uppercase and should not be read to the respondent, but may be used for coding a response. In addition, items that ask the interviewer to INDICATE GENDER and WHETHER SOMEONE HELPED RESPONDENT COMPLETE THIS SURVEY AND HOW should not be read aloud. Interviewer instructions appear in [UPPERCASE LETTERS ENCLOSED IN BRACKETS] and also should not be read aloud.
Skip patterns are indicated with a  [GO TO Q#].
Record each response by selecting the box to the left of the answer.

INTRODUCTION

Hello, my name is {interviewer name}. I am from {name of organization}. How are you today?

Thank you again for letting me talk with you. Today I would like to hear about your life and your experience with the people who help you. What you say will help us learn more about the care you get from {name of program}. It will also help us make the questions that I will be asking you better. We are asking these questions of many other people like you who get services and supports from {name of program}.

I will ask you questions about people who work with you and the help they give you. I will also ask some questions about you. It should take about 30 minutes. [State] and the Centers for Medicare and Medicaid Services are sponsoring this research study.

[PROVIDE CONSENT FORM] You can choose whether or not you want to answer each question. You can also choose if you want to be interviewed at all. The services you get will not change based on what you say. You can stop answering questions at any time. The services you get will not change.

Being in the study will not help you but might help other people who get care and services in the future. There is also a chance the some of the questions might make you sad or upset.

All of your answers will be kept private under the Privacy Act. That means we won’t share what you have to say with anyone except the people who are doing the research. The only people allowed to see your answers will be the people who work on the study and people who make sure we run our study the right way. None of the people who help you will know what you say, unless you want them in the room while we talk. {ADD STATE-SPECIFIC LANGUAGE HERE REGARDING MANDATED REPORTING, IF APPROPRIATE.}

Some people may not be able to answer a question quickly. Some people may not know the answer. This is not a test. If you don’t know the answer to a question, or can’t remember it, let me know. “I don’t remember” could be the best answer.

Also, we can take as much time as you would like to go through the survey. I am not in a hurry. Let me know if you would like me to repeat a question. We can take a break if you would like. We can also stop any time you want.

Do you have any questions before we start?

[ANSWER ANY QUESTIONS RAISED BY THE RESPONDENT, THEN GO TO
COGNITIVE SCREENING QUESTION 1.]

COGNITIVE SCREENING QUESTIONS

CS-1. Today I will ask you about the people paid to help you around your house or in your area. Please tell me in your own words what I will be asking about.

CS-2. Taking part in the survey is completely voluntary. Completely voluntary means you can choose whether or not to talk to me. You are free to participate in the interview or not. You can also stop at any time, for any reason. If you do not participate or you stop early, you will not lose any services that you normally expect to get. What you say will not affect the services you receive, Medicaid, Medicare, or other health insurance. When I say your participation is completely voluntary, what does that mean to you?

CS-3. All of your answers kept private under the Privacy Act. That means we won’t share what you have to say with anyone except the people who are doing the research. We will not use your name in connection with anything you say. Your name won’t be on anything we write for or about the study. We won’t share anything you say with the people paid to help you or the program staff in your state. None of the people who help you will know what you say, unless you want them in the room while we talk. When I say that your answers will be kept private, what does that mean to you?

[IF RESPONDENT CANNOT ANSWER THESE THREE QUESTIONS, STOP THE INTERVIEW AND THANK THE RESPONDENT. IF RESPONDENT CAN, CONTINUE ON]

[MANDATORY STATE INFORMATION EXAMPLE: If we have a reason to think that you are being hurt or are in danger, we have a legal responsibility to tell the [STATE CONTACT].

CS-5. Do you agree to being asked questions about the people who are paid to help you?

YES [CONTINUE TO IDENTIFYING QUESTIONS]

NO [THANK AND END]

Thank you. Just so you have a copy for later, here is information about the study for you to look at later. [PROVIDE RESPONDENT WITH CONSENT INFORMATION]

IDENTIFICATION QUESTIONS

People might be paid to help you get ready in the morning, with housework, go places, or get mental health services. This survey is about the people who are paid to help you in your home and community with everyday activities. It also asks about the services you get.

ID-1. Our records show that you get {program specific term for personal assistance}.
Is that right?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

ID-2. What do you call the person or people who give you {program specific term for personal assistance}? For example, do you call them {program specific term for personal assistance}, staff, personal care attendants, PCAs, workers, or something else?

ID-3. Our records show that you get {program specific term for behavioral health specialist services}. Is that right?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

ID-4. What do you call the person or people who give you {program specific term for behavioral health specialist services}? For example, do you call them {program-specific term for behavioral health specialists}, counselors, peer supports, recovery assistants, or something else?

ID-5. Our records show that you get {program specific term for homemaker services}. Is that right?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

ID-6. What do you call the person or people who give you {program specific term for homemaker services}? For example, do you call them {program-specific term for homemaker}, aides, homemakers, chore workers, or something else?

ID-7. [IF RESPONDENT REPORTS HAVING PCA AND HOMEMAKER STAFF, THEN ASK]. Do the same people who help you with everyday activities also help you to clean your home?

YES  ASK ALL PCA ITEMS AND SELECT HOMEMAKER ITEMS

NO  ASK PCA ITEMS AND SELECT HOMEMAKER ITEMS SEPARATELY

DON’T KNOW  ASK ALL PCA ITEMS AND SELECT HOMEMAKER ITEMS

REFUSED  ASK ALL PCA ITEMS AND SELECT HOMEMAKER ITEMS

UNCLEAR RESPONSE  ASK ALL PCA ITEMS AND SELECT HOMEMAKER ITEMS

ID-8. Our records show that you get {program specific term for case manager services} to help make sure that you have all the services you need, like help from {list of assistance identified previously}. Is that right?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

ID-9. What do you call the person who gives you {program specific term for case manager services}? For example, do you call the person a {program-specific term for case manager}, case manager, care manager, service coordinator, supports coordinator, social worker, or something else?

[RESPONDENT TITLES SHOULD BE AUTOMATICALLY ADDED INTO SECTIONS, WHEREEVER IT STATES {personal assistance/behavioral health staff}, {case manager}, or {homemaker}.]

[IF RESPONSE IS NEGATIVE TO ALL SUPPORTS, THEN GO TO CHOOSING YOUR SERVICES SECTION.]

Primary Survey-English language

SERVICES AND SUPPORTS FROM PERSONAL ASSISTANT AND BEHAVIORAL STAFF

GETTING NEEDED SERVICES FROM PERSONAL ASSISTANT AND BEHAVIORAL HEALTH STAFF

First I would like to talk about the {personal assistance/behavioral health staff}who are paid to help you complete everyday activities—for example, getting dressed, using the bathroom, taking a bath or shower, or going places. How often do {personal assistance/behavioral health staff} come to work on time? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: First I would like to talk about the {personal assistance/behavioral health staff}who are paid to help you complete everyday activities—for example, getting dressed, using the bathroom, taking a bath or shower, or going places. Do {personal assistance/behavioral health staff} come to work on time? Would you say

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How often do {personal assistance/behavioral health staff} work as long as they are supposed to? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Do {personal assistance/behavioral health staff} work as long as they are supposed to? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Sometimes staff cannot come to work on a day that they are scheduled. When staff cannot come to work on a day that they are scheduled, does someone let you know if {personal assistance/behavioral health staff} cannot come that day?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Do you need help from {personal assistance/behavioral health staff} to get dressed or to take a shower or bath?

YES

NO [GO TO Q8]

DON’T KNOW [GO TO Q8]

REFUSED [GO TO Q8]

UNCLEAR RESPONSE [GO TO Q8]

Do you always get dressed or take a shower or bath when you need one?

YES [GO TO Q7]

DON’T KNOW [GO TO Q7]

REFUSED [GO TO Q7]

UNCLEAR RESPONSE [GO TO Q7]

Is this because there are no {personal assistance/behavioral health staff} to help you?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How often do {personal assistance/behavioral health staff} make sure you have enough privacy when you get dressed or take a shower or bath? Would you say…

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Do {personal assistance/behavioral health staff} make sure you have enough privacy when you get dressed or take a shower or bath? Would you say…

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Do you need help from {personal assistance/behavioral health staff} with your meals, such as help making or cooking meals or help eating?

YES

NO [GO TO Q11]

DON’T KNOW [GO TO Q11]

REFUSED [GO TO Q11]

UNCLEAR RESPONSE [GO TO Q11]

Are you always able to get something to eat when you are hungry?

YES [GO TO Q11]

DON’T KNOW [GO TO Q11]

REFUSED [GO TO Q11]

UNCLEAR RESPONSE [GO TO Q11]

Is this because there are no {personal assistance/behavioral health staff} to help you?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Sometimes people need help taking their medicines, such as reminders, help pouring them, or setting up their pills. Do you need help from {personal assistance/behavioral health staff} to take your medicines?

YES

NO [GO TO Q14]

DON’T KNOW [GO TO Q14]

REFUSED [GO TO Q14]

UNCLEAR RESPONSE [GO TO Q14]

Do you always take your medicine when you are supposed to?

YES [GO TO Q14]

DON’T KNOW [GO TO Q14]

REFUSED [GO TO Q14]

UNCLEAR RESPONSE [GO TO Q14]

Is this because there are no {personal assistance/behavioral health staff} to help you?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Help with toileting includes helping someone get on and off the toilet or helping to change disposable briefs or pads. Do you need help from {personal assistance/behavioral health staff} with toileting?

YES

NO [GO TO Q16]

DON’T KNOW [GO TO Q16]

REFUSED [GO TO Q16]

UNCLEAR RESPONSE [GO TO Q16]

Do you get all the help you need with toileting from {personal assistance/behavioral health staff} when you need it?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

HOW WELL PERSONAL ASSISTANT AND BEHAVIORAL HEALTH STAFF COMMUNICATE AND TREAT YOU

The next several questions ask about how {personal assistance/behavioral health staff} treat you.

How often are {personal assistance/behavioral health staff} nice and polite to you? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Are {personal assistance/behavioral health staff} nice and polite to you? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How often are the explanations {personal assistance/behavioral health staff}gives you hard to understand because of an accent or the way the provider speaks English? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Are the explanations {personal assistance/behavioral health staff} give you hard to understand because of an accent or the way {personal assistance/behavioral health staff} speaks English? Would you say. . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How often do {personal assistance/behavioral health staff} treat you the way you want them to? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Do {personal assistance/behavioral health staff} treat you the way you want them to? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How often do {personal assistance/behavioral health staff} explain things in a way that is easy to understand? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Do {personal assistance/behavioral health staff} explain things in a way that is easy to understand? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How often do {personal assistance/behavioral health staff} listen carefully to you?
Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Do {personal assistance/behavioral health staff} listen carefully to you?
Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Do you feel {personal assistance/behavioral health staff} know what kind of help you need with everyday activities, like getting ready in the morning, getting groceries, or going places in your community?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Do {personal assistance/behavioral health staff} encourage you to do things for yourself if you can?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How would you rate the help you get from {personal assistance/behavioral health staff}? Would you say . . .

Excellent,

Very good,

Good,

Fair, or

Poor?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Would you recommend the {personal assistance/behavioral health staff} who help you to your family and friends if they needed help with everyday activities? Would you say you recommend the {personal assistance/behavioral health staff} . . .

Definitely no,

Probably no,

Probably yes, or

Definitely yes?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

SERVICES AND SUPPORT FROM HOMEMAKERS

The next several questions are about the {homemakers}, the staff who are paid to help you do tasks around the home—such as cleaning, grocery shopping, or doing laundry.

GETTING NEEDED SERVICES FROM HOMEMAKERS

How often do {homemakers} come to work on time? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Do {homemakers} come to work on time? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How often do {homemakers} work as long as they are supposed to? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Do {homemakers} work as long as they are supposed to? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Do your household tasks, like cleaning and laundry, always get done when you need them to? [ASK IF HOMEMAKER IS THE SAME AS PCA STAFF]

YES [GO TO Q29]

DON’T KNOW NO [GO TO Q29]

REFUSED NO [GO TO Q29]

UNCLEAR RESPONSE [GO TO Q29]

Is this because there are no {homemakers} to help you? [ASK IF HOMEMAKER IS THE SAME AS PCA STAFF]

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

HOW WELL HOMEMAKERS COMMUNICATE AND TREAT YOU

The next several questions ask about how {homemakers} treat you.

How often are {homemakers} nice and polite to you? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Are {homemakers} nice and polite to you? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How often are the explanations {homemaker} gives you hard to understand because of an accent or the way the provider speaks English? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Are the explanations {homemakers} give you hard to understand because of an accent or the way {homemakers} speaks English? Would you say. . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How often do {homemakers} treat you the way you want them to? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Do {homemakers} treat you the way you want them to? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How often do {homemakers} listen carefully to you? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Do {homemakers} listen carefully to you? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Do you feel {homemakers} know what kind of help you need?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How would you rate the help you get from {homemakers}? Would you say . . .

Excellent,

Very good,

Good,

Fair, or

Poor?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Would you recommend the {homemakers} who help you to your family and friends if they needed {respondent-specific term for homemaker services}? Would you say you recommend the {homemakers} . . .

Definitely no,

Probably no,

Probably yes, or

Definitely yes?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

YOUR CASE MANAGER

Now I would like to talk to you about your {case manager}, the person who helps make sure you have the services you need.

Do you know who your {case manager} is?

YES

NO [GO TO Q44]

DON’T KNOW [GO TO 44]

REFUSED [GO TO Q44]

UNCLEAR RESPONSE [GO TO Q44]

Can you contact this {case manager} when you need to?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Some people need to get equipment, such as wheelchairs or walkers, to help them, and other people need their equipment replaced or repaired. Have you asked this {case manager} for help with getting or fixing equipment?

YES

NO [GO TO Q40]

DON’T KNOW [GO TO Q40]

REFUSED [GO TO Q40]

UNCLEAR RESPONSE [GO TO Q40]

Did this {case manager} work with you when you asked for help with getting or fixing equipment?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Have you asked this {case manager} for help in getting any changes to your services, such as more help from {personal assistance/behavioral health staff and/or homemakers if applicable}, or for help with getting places or finding a job?

YES

NO [GO TO 42]

DON’T KNOW [GO TO 42]

REFUSED [GO TO 42]

UNCLEAR RESPONSE [GO TO 42]

Did this {case manager} work with you when you asked for help with getting other changes to your services?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How would you rate the help you get from the {case manager}? Would you say . . .

Excellent,

Very good,

Good,

Fair, or

Poor?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Would you recommend the {case manager} who helps you to your family and friends if they needed {respondent-specific term for case-management services}? Would you say you recommend the {case manager} . . .

Definitely no,

Probably no,

Probably yes, or

Definitely yes?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

CHOOSING YOUR SERVICES

A [program-specific term for “service plan”]—sometimes called a care plan, goals, or service plan—lists the services you need and who will provide them. Did you work with someone to develop your [program-specific term for “service plan”]?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Does your [program-specific term for “service plan”] include . . .

None of the things that are important to you,

Some of the things that are important to you,

Most of the things that are important to you, or

All of the things that are important to you?

DON’T KNOW [GO TO 47]

REFUSED [GO TO 47]

UNCLEAR RESPONSE [GO TO 47]

Do you feel {personal assistance/behavioral health staff} know what’s on your [program-specific term for “service plan”], including the things that are important to you?

YES

DOES NOT HAVE PERSONAL ASSISTANCE STAFF

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Who would you talk to if you wanted to change your [program-specific term for “service plan”]? Anyone else? [INTERVIEWER MARKS ALL THAT APPLY]

CASE MANAGER

OTHER STAFF

FAMILY/FRIENDS

OTHER

I DON’T KNOW

REFUSED

UNCLEAR RESPONSE

TRANSPORTATION

The next questions ask about how you get to places in your community.

Medical appointments include seeing a doctor, a dentist, a therapist, or someone else who takes care of your health. How often do you have a way to get to your medical appointments? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Medical appointments include seeing a doctor, a dentist, a therapist, or someone else who takes care of your health. Do you have a way to get to your medical appointments? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Do you use a van or some other transportation service? Do not include a van you own.

YES

NO [GO TO Q52]

DON’T KNOW [GO TO Q52]

REFUSED [GO TO Q52]

UNCLEAR RESPONSE [GO TO Q52]

Are you able to get in and out of this ride easily?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How often does this ride arrive on time to pick you up? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Does this ride arrive on time to pick you up? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

PERSONAL SAFETY

The next few questions ask about your personal safety.

Who would you contact in case of an emergency?

FAMILY MEMBER OR FRIEND

CASE MANAGER

AGENCY THAT PROVIDES HOME- AND COMMUNITY-BASED SERVICES

PAID EMERGENCY RESPONSE SERVICE (E.G., LIFELINE)

9–1–1 (FIRST RESPONDERS, POLICE, LAW ENFORCEMENT)

SOMEONE ELSE, PLEASE SPECIFY ___________________

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Is there a person you can talk to if someone hurts you or does something to you that you don’t like?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

The next few questions ask if anyone paid to help you now is treating you badly. This includes {personal assistance/behavioral health staff, homemakers, or your case manager}. We are asking everyone the next questions—not just you. [ADD STATE-SPECIFIC LANGUAGE HERE REGARDING MANDATED REPORTING, IF APPROPRIATE—“I want to remind you that, although your answers are confidential, I have a legal responsibility to tell {STATE} if I hear something that makes me think you are being hurt or are in danger”]

Do any of the {personal assistance/behavioral health staff, homemakers, or your case managers} that you have now take your money or your things without asking you first?

YES

NO [GO TO Q57]

DON’T KNOW [GO TO Q57]

REFUSED [GO TO Q57]

UNCLEAR RESPONSE [GO TO Q57]

Is someone working with you to fix this problem?

YES

NO [GO TO Q57]

DON’T KNOW [GO TO Q57]

REFUSED [GO TO Q57]

UNCLEAR RESPONSE [GO TO Q57]

Who is working with you to fix this problem? Anyone else? [INTERVIEWER MARKS ALL THAT APPLY]

FAMILY MEMBER OR FRIEND

CASE MANAGER

AGENCY

SOMEONE ELSE, PLEASE SPECIFY ___________________

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Do any {staff} that you have now yell, swear, or curse at you?

YES

NO [GO TO Q60]

DON’T KNOW [GO TO Q60]

REFUSED [GO TO Q60]

UNCLEAR RESPONSE [GO TO Q60]

Is someone working with you to fix this problem?

YES

NO [GO TO Q60]

DON’T KNOW[GO TO Q60]

REFUSED[GO TO Q60]

UNCLEAR RESPONSE [GO TO Q60]

Who is working with you to fix this problem? Anyone else? [INTERVIEWER MARKS ALL THAT APPLY]

FAMILY MEMBER OR FRIEND

CASE MANAGER

AGENCY

SOMEONE ELSE, PLEASE SPECIFY ___________________

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Do any {staff} that you have now hit you or hurt you?

YES

NO [GO TO Q63]

DON’T KNOW [GO TO Q63]

REFUSED [GO TO Q63]

UNCLEAR RESPONSE [GO TO Q63]

Is someone working with you to fix this problem?

YES

NO [GO TO Q63]

DON’T KNOW [GO TO Q63]

REFUSED [GO TO Q63]

UNCLEAR RESPONSE [GO TO Q63]

Who is working with you to fix this problem? Anyone else? [INTERVIEWER MARKS ALL THAT APPLY]

FAMILY MEMBER OR FRIEND

CASE MANAGER

AGENCY

SOMEONE ELSE, PLEASE SPECIFY ___________________

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

COMMUNITY INCLUSION AND EMPOWERMENT

Now I’d like to ask you about the things you do in your community.

Do you have any family members who live nearby? Do not include family members you live with.

YES

NO [GO TO Q65]

DON’T KNOW [GO TO Q65]

REFUSED [GO TO Q65]

UNCLEAR RESPONSE [GO TO Q65]

When you want to, how often can you get together with these family members who live nearby? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: When you want to, can you get together with these family members who live nearby? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Do you have any friends who live nearby?

YES

NO [GO TO Q67]

DON’T KNOW [GO TO Q67]

REFUSED [GO TO Q67]

UNCLEAR RESPONSE [GO TO Q67]

When you want to, how often can you get together with these friends who live nearby? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: When you want to, can you get together with these friends who live nearby? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

When you want to, how often can you do things in the community that you like, such as shopping or going out to eat? Would you say . . .

Never

Sometimes

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: When you want to, can you do things in the community that you like, such as shopping or going out to eat? Would you say . . .

Mostly yes, or

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Do you need more help than you get now from {personal assistance/behavioral health staff} to do things in your community?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Do you take part in deciding what you do each day—for example, what you do for fun at home or in your community?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Do you take part in deciding when you do things each day—for example, deciding when you get up, eat, or go to bed?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

The next few questions ask about making changes in {personal assistance/behavioral health staff, homemakers, and case manager}.

Have you asked for a change in {personal assistance staff, behavioral health staff, homemakers, or case manager}?

YES

NO [GO TO Q74]

DON’T KNOW [GO TO Q74]

REFUSED [GO TO Q74]

UNCLEAR RESPONSE [GO TO Q74]

Did someone work with you when you asked to change {personal assistance/behavioral health staff, homemakers, or case manager}?

YES

NO [GO TO EM]

DON’T KNOW [GO TO EM ]

REFUSED [GO TO EM]

UNCLEAR RESPONSE [GO TO EM]

Who did you work with when you asked to change {personal assistance/behavioral health staff, homemakers, or case manager}

Family member or friend [GO TO EM OR Q75]

Case manager [GO TO EM OR Q75]

Agency [GO TO EM OR Q75]

Someone else, please specify ___________________ [GO TO EM
OR Q75]

DON’T KNOW [GO TO EM OR Q75]

REFUSED [GO TO EM OR Q75]

UNCLEAR RESPONSE [GO TO EM OR Q75]

Do you know you can ask someone to change {personal assistance/behavioral health staff, homemakers, or case manager}?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

SUPPLEMENTAL EMPLOYMENT MODULE

Do you work for pay at a job?

YES [GO TO QEM9]

DON’T KNOW [GO TO Q75]

REFUSED [GO TO Q75]

UNCLEAR RESPONSE [GO TO Q75]

Do you want to work for pay at a job?

YES

NO [GO TO EM4]

DON’T KNOW [GO TO Q75]

REFUSED [GO TO Q75]

UNCLEAR RESPONSE [GO TO Q75]

Sometimes people feel that something is holding them back from working when they want to. Is this true for you? If so, what is holding you back from working? (INTERVIEWER LISTENS AND MARKS ALL THAT APPLY)

BENEFITS [GO TO EM5]

HEALTH CONCERNS [GO TO EM5]

DON’T KNOW ABOUT JOB RESOURCES [GO TO EM5]

ADVICE FROM OTHERS [GO TO EM5]

TRAINING/EDUCATION NEED [GO TO EM5]

LOOKING AND CAN’T FIND WORK [GO TO EM5]

ISSUES WITH PREVIOUS EMPLOYMENT [GO TO EM5]

TRANSPORTATION [GO TO EM5]

CHILD CARE [GO TO EM5]

OTHER (_____________________________) [GO TO EM5]

NOTHING IS HOLDING ME BACK  [GO TO EM5]

DON’T KNOW [GO TO EM5]

REFUSED [GO TO EM5]

UNCLEAR RESPONSE [GO TO EM5]

Sometimes people would like to work for pay, but feel that something is holding them back. Is this true for you? If so, what is holding you back from wanting to work? (INTERVIEWER LISTENS AND MARKS ALL THAT APPLY)

BENEFITS [GO TO 75]

HEALTH CONCERNS [GO TO 75]

DON’T KNOW ABOUT JOB RESOURCES [GO TO 75]

ADVICE FROM OTHERS [GO TO 75]

TRAINING/EDUCATION NEED [GO TO 75]

LOOKING AND CAN’T FIND WORK [GO TO 75]

ISSUES WITH PREVIOUS EMPLOYMENT [GO TO 75]

TRANSPORTATION [GO TO 75]

CHILD CARE [GO TO 75]

OTHER (_____________________________) [GO TO 75]

NOTHING/DOESN’T WANT TO WORK [GO TO 75]

DON’T KNOW [GO TO 75]

REFUSED [GO TO 75]

UNCLEAR RESPONSE [GO TO 75]

Have you asked for help in getting a job for pay?

YES [GO TO EM7]

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Do you know you can get help to find a job for pay?

YES [GO TO Q75]

NO [GO TO Q75]

DON’T KNOW [GO TO Q75]

REFUSED [GO TO Q75]

UNCLEAR RESPONSE [GO TO Q75]

Help getting a job can include help finding a place to work or help getting the skills that you need to work. Is someone paid to help you get a job?

YES

NO [GO TO Q75]

DON’T KNOW [GO TO Q75]

REFUSED [GO TO Q75]

UNCLEAR RESPONSE [GO TO Q75]

Are you getting all the help you need to find a job?

YES [GO TO Q75]

NO [GO TO Q75]

DON’T KNOW [GO TO Q75]

REFUSED [GO TO Q75]

UNCLEAR RESPONSE [GO TO Q75]

Who helped you to find the job that you have now? (INTERVIEWER LISTENS AND MARKS ALL THAT APPLY)

EMPLOYMENT/VOCATIONAL STAFF/JOB COACH

CASE MANAGER

OTHER PAID PROVIDERS

OTHER CAREER SERVICES

FAMILY/FRIENDS

ADVERSTISEMENT

SELF-EMPLOYED [GO TO EM11]

OTHER (____________________________)

NO ONE HELPED ME—I FOUND IT MYSELF [GO TO EM11]

DON’T KNOW [GO TO EM11]

REFUSED [GO TO EM11]

UNCLEAR RESPONSE [GO TO EM11]

Did you help to choose the job you have now?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Sometimes people need help from other people to work at their jobs. For example, they may need help getting to or getting around at work, help getting their work done, or help getting along with other workers. Is someone paid to help you with the job you have now?

YES

NO [GO TO Q75]

DON’T KNOW [GO TO Q75]

REFUSED [GO TO Q75]

UNCLEAR RESPONSE [GO TO Q75]

What do you call this person? A job coach, peer support provider, personal assistant, or something else?

USE THIS TERM WHEREVER IT SAYS {job coach} BELOW.

Did you hire your {job coach} yourself?

YES [GO TO Q75]

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Is your {job coach} with you all the time that you are working?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How often does your {job coach} give you all the help you need? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Does your {job coach} give you all the help you need? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How often is your {job coach} nice and polite to you? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Is your {job coach} nice and polite to you? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How often does your {job coach} explain things in a way that is easy to understand? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Does your {job coach} explain things in a way that is easy to understand? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How often does your {job coach} listen carefully to you? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Alternate Version: Does your {job coach} listen carefully to you? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Does your {job coach} encourage you to do things for yourself if you can?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

How would you rate the help you get from your {job coach}? Would you say . . .

Excellent,

Very good,

Good,

Fair, or

Poor?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

ABOUT YOU

Now I just have a few more questions about you.

In general, how would you rate your overall health? Would you say . . . (CM)

Excellent,

Very good,

Good,

Fair, or

Poor?

[IF NECESSARY, ASK, AND VERIFY IF OVER THE PHONE] Are you male or female? (CM)

MALE

FEMALE

What is your age? (CM)

18 TO 24 YEARS [GO TO Q79]

25 TO 34 YEARS [GO TO Q79]

35 TO 44 YEARS [GO TO Q79]

45 TO 54 YEARS [GO TO Q79]

55 TO 64 YEARS [GO TO Q79]

65 TO 74 YEARS [GO TO Q79]

75 YEARS OR OLDER [GO TO Q79]

DON’T KNOW

REFUSED [GO TO Q79]

UNCLEAR RESPONSE

[IF NO ANSWER TO Q77, ASK] In what year were you born?

_____________ (YEAR)

Are you of Hispanic or Latino origin or descent? (CM)

YES, HISPANIC OR LATINO

NO, NOT HISPANIC OR LATINO

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

What is your race? You may choose one or more of the following. Would you say you are . . . (CM)

White

Black or African-American

Asian

Native Hawaiian or other Pacific Islander

American Indian or Alaska Native

OTHER

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Have you ever served as a member of the Armed Forces of the United States—such as the Army, Navy, Air Force, Marines, Coast Guard—in either an active duty, guard, or reserve capacity?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Have you actively participated in any armed conflicts as a member of the Armed Forces? For example, did you serve in World War two, Korea, Vietnam, Grenada, Panama, Desert Storm, or Operation Iraqi Freedom?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Are you currently categorized as a disabled veteran? [IF NECESSARY, ASK] Do you receive or are able to receive any medical or dental care from the U.S. Department of Veterans Affairs for your service related to a disability?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

[ENGLISH VERSION]: What language do you mainly speak at home? Would you say…

English, [GO TO Q85]

Some other language, or

Both English and some other language?

DON’T KNOW [GO TO Q85]

REFUSED [GO TO Q85]

UNCLEAR RESPONSE [GO TO Q85]

84A. What other language do you speak? ________________________________

[SPANISH VERSION]: What language do you mainly speak at home? Would you say . . .

English,

Spanish,

Both English and Spanish, or

Some other language Which one? _____________________

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

[IF NECESSARY, ASK] Do you live with any family members?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

[IF NECESSARY, ASK] Do you live with people who are not family or are not related to you?

YES [GO TO Q88]

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

[IF NECESSARY, ASK] Do you live alone?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

WAS THE RESPONDENT ABLE TO GIVE VALID RESPONSES?

YES

WAS ANY ONE ELSE PRESENT DURING THE INTERVIEW?

YES

NO [END SURVEY]

WHO WAS PRESENT DURING THE INTERVIEW? (MARK ALL THAT APPLY.)

SOMEONE NOT PAID TO PROVIDE SUPPORT TO THE RESPONDENT

STAFF OR SOMEONE PAID TO PROVIDE SUPPORT TO THE RESPONDENT

DID SOMEONE HELP THE RESPONDENT COMPLETE THIS SURVEY?

YES

NO [END SURVEY]

HOW DID THAT PERSON HELP? (MARK ALL THAT APPLY.)

ANSWERED ALL THE QUESTIONS FOR RESPONDENT

RESTATED THE QUESTIONS IN A DIFFERENT WAY OR REMINDED/ PROMPTED THE RESPONDENT

TRANSLATED THE QUESTIONS OR ANSWERS INTO THE RESPONDENT’S LANGUAGE

HELPED WITH THE USE OF ASSISTIVE OR COMMUNICATION EQUIPMENT SO THAT THE RESPONDENT COULD ANSWER THE QUESTIONS

OTHER, SPECIFY__________________________

WHO HELPED THE RESPONDENT? (MARK ALL THAT APPLY.)

SOMEONE NOT PAID TO PROVIDE SUPPORT TO THE RESPONDENT

STAFF OR SOMEONE PAID TO PROVIDE SUPPORT TO THE RESPONDENT

Home- and Community-Based Services Experience Survey

Date: September 7, 2012

Instructions 44

INSTRUCTIONS FOR VENDOR 44

INSTRUCTIONS FOR INTERVIEWER 45

INTRODUCTION 46

INTRODUCTION 47

COGNITIVE SCREENING QUESTIONS 48

IDENTIFICATION QUESTIONS 50

PREGUNTAS DE IDENTIFICACIóN 50

SERVICES AND SUPPORTS FROM PERSONAL ASSISTANT AND BEHAVIORAL STAFF 54

SERVICIOS Y SISTEMAS DE APOYO DE LOS AUXILIARES DE CUIDADOS PERSONALES y el personal de salud mental 54

GETTING NEEDED SERVICES FROM PERSONAL ASSISTANT AND BEHAVIORAL HEALTH STAFF 54

Obtención de los servicios necesarios de parte de los auxiliares de cuidados personales y del personal de salud mental 54

HOW WELL PERSONAL ASSISTANT AND BEHAVIORAL HEALTH STAFF COMMUNICATE AND TREAT YOU 61

SERVICES AND SUPPORT FROM HOMEMAKERS 68

GETTING NEEDED SERVICES FROM HOMEMAKERS 68

Obtención de los servicios necesarios de los ayudantes de oficios domésticos 68

HOW WELL HOMEMAKERS COMMUNICATE AND TREAT YOU 70

Qué tan bien se comunican con usted los ayudantes de oficios domésticos y qué tan bien lo(a) tratan 70

YOUR CASE MANAGER 76

CHOOSING YOUR SERVICES 80

la elección de sus servicios 80

TRANSPORTATION 82

TRANSPORTE 82

PERSONAL SAFETY 85

seguridad personal 85

COMMUNITY INCLUSION AND EMPOWERMENT 90

comunidad y empoderamiento 90

SUPPLEMENTAL EMPLOYMENT MODULE 97

MÓDULO COMPLEMENTARIO SOBRE EMPLEO 97

ABOUT YOU 108

sobre usted 108

Instructions

INSTRUCTIONS FOR VENDOR

Use Appropriate Versions Of The Survey. The scripts provided in this document use the questions from the Home- and Community-Based Services (HCBS) Experience Survey. There are four different versions:
1. Primary survey in English. For all surveys conducted in English, begin with using this version.
2. Alternate version in English. If an English-speaking respondent finds answering the primary survey cognitively challenging, use this version. Use this only after a respondent is unable to answer three questions with the “never, sometimes, usually, and always” response options.
3. Primary survey in Spanish. For all surveys conducted in Spanish, begin with using this version.
4. Alternate version in Spanish. If a Spanish-speaking respondent finds answering the primary survey cognitively challenging, use this version.
Use Appropriate Response Options:

All questions include a “REFUSED” response option. In this case, “refused” means the respondent did not provide any answer to the question.
For response options of “never, sometimes, usually, and always”, if the respondent cannot use that scale, the alternate version of the survey should be used which uses the response options of “mostly yes and mostly no.” These response options are reserved for individuals who find the “never, sometimes, usually, always” response scale cognitively challenging.
All questions include a “DON’T KNOW” response option. This is used when the respondent indicates that he or she does not know the answer and cannot provide a response to the question.
All questions include an “UNCLEAR” response option. This should be used when a respondent answers, but the interviewer cannot clarify the meaning of the response even after minor probing or the response is completely unrelated to the question—for example, the response to “Do your homemakers listen carefully to what you say?” is “I like to sit by Mary.”
Some responses have skip patterns, which are expressed as “if ‘X’ go to Q#.” That means the interviewer should skip all following questions until Q#.

Use Singular/Plural as needed: Modify items such that the interviewer can use the correct form (singular or plural) of the survey item.
Use Program-Specific Terms: Where appropriate, add in the program-specific terms for staff (e.g., [program-specific term for these types of staff]) but allow the interviewer to modify the term based on the respondent’s choice of the word. It will be necessary to obtain information for program-specific terms. State administrative data should include the following information:

Agency name(s)
Titles of staff who provide care
Names of staff who provide care
Activities that each staff member provides (this will help with identifying appropriate skip logic)
Hours of staff who come to the home

Title

Name

Agency

Roles

Hours

PCA

Jane Doe

Happy Home

Bathing

Dressing

Prepping meals

# of hours

Homemaker

John Doe

Happy Home

Cleaning

# of hours

Please be aware that to conduct this survey, you may need approval from an Institutional Review Board (IRB). Regardless of whether you need IRB approval, you must get the respondent’s consent to participate in the survey. In addition, there may be state statutory requirements that apply to interviewers regarding reporting suspected abuse and neglect. Although information should be kept confidential, these state laws may mandate reporting in certain cases and should be reviewed prior to implementation.

INSTRUCTIONS FOR INTERVIEWER

Interviewers should read aloud all text that appears in initial uppercase and lowercase letters. Text that appears in bold, lowercase letters should be emphasized.
Text in {italics and in braces} will be provided by the program. However, if the interviewee provides another term, use that in place of the program-specific term wherever indicated. For example, some interviewees may refer to their case manager by another title, which should be used instead throughout the survey.
Text in uppercase letters should not be read aloud. For example, “DON’T KNOW,” “REFUSED,” or “UNCLEAR RESPONSE” answer categories appear in uppercase and should not be read to the respondent, but may be used for coding a response. In addition, items that ask the interviewer to INDICATE GENDER and WHETHER SOMEONE HELPED RESPONDENT COMPLETE THIS SURVEY AND HOW should not be read aloud. Interviewer instructions appear in [UPPERCASE LETTERS ENCLOSED IN BRACKETS] and also should not be read aloud.
Skip patterns are indicated with a  [GO TO Q#].
Record each response by selecting the box to the left of the answer.

INTRODUCTION

Hello, my name is {interviewer name}. I am from {name of organization}. How are you today?

Being in the study will not help you but might help other people who get care and services in the future. There is also a chance the some of the questions might make you sad or upset.

All of your answers will be kept private under the Privacy Act. That means we won’t share what you have to say with anyone except the people who are doing the research. The only people allowed to see your answers will be the people who work on the study and people who make sure we run our study the right way. . None of the people who help you will know what you say, unless you want them in the room while we talk. {ADD STATE-SPECIFIC LANGUAGE HERE REGARDING MANDATED REPORTING, IF APPROPRIATE.}

Do you have any questions before we start?

[ANSWER ANY QUESTIONS RAISED BY THE RESPONDENT, THEN GO TO
COGNITIVE SCREENING QUESTION 1.]

INTRODUCTION

Hola, Buenos días/tardes me llamo {interviewer name}. Yo trabajo con {name of organization}. ¿Cómo está usted ahora?

Gracias por permitirme hablar con usted. Hoy me gustaría saber más sobre su vida y sobre las experiencias que ha tenido con las personas que le ayudan. Lo que usted diga nos ayudara a aprender más sobre el cuidado que usted recibe de {name of program}. También nos ayudara a mejorar las preguntas que le preguntare en esta entrevista. Le estamos haciendo estas preguntas a mucha gente como usted que reciben servicios y sistemas de apoyo de {name of program}.

Hoy le preguntare sobre las personas que trabajan con usted y sobre la ayuda que le dan. También le preguntare algunas preguntas sobre usted. Esto durara media hora, o sea 30 minutos. [State] y la agencia nacional de gobierno que se llama los Centros de Servicios Medicare & Medicad (Centers for Medicare & Medicaid Services, CMS) están patrocinando este estudio de investigación.

[PROVIDE CONSENT FORM] Usted decide si quiere contestar cada pregunta, o si no quiere contestarla. Usted también puede decidir si desea participar en esta entrevista o no. Los servicios que usted recibe no serán afectados por cualquier cosa que usted diga. Usted puede parar de contestar mis respuestas en cualquier momento. Los servicios que usted recibe no cambiaran.

Su participación en este estudio no le ayudara, pero le podría ayudar a otra gente que reciba cuidados y servicios en el futuro. Puede ser que alguna de las preguntas le moleste o le causen tristeza.

Todas sus respuestas se mantendrán privadas bajo la ley de privacidad, (the Privacy Act). Eso significa que no compartiremos lo que usted diga con otras personas, solo con las personas que están trabajando en esta investigación. Las únicas personas que pueden ver sus respuestas son las personas que trabajan en esta investigación y las personas que aseguran que esta investigación se está conduciendo bien. Ninguna de las personas que le ayudan sabrá lo que usted diga, a menos de que usted los quiera en el cuarto cuando hablemos nosotros. {ADD STATE-SPECIFIC LANGUAGE HERE REGARDING MANDATED REPORTING, IF APPROPRIATE.}

Es posible que algunas personas no puedan contestar una pregunta rápidamente. Algunas personas no sabrán las respuestas. Esto no es un examen. Si no sabe o no recuerda la respuesta a una pregunta que yo le haga, avíseme. Decir “no me acuerdo” podría ser la mejor respuesta.

Esta encuesta puede tomar el tiempo que usted guste, no llevo prisa. Dígame si quiere que yo repita una pregunta. Si usted quiere, podemos parar por un tiempo para descansar. También podemos parar en cualquier momento que usted quiera.

¿Tiene alguna pregunta antes de comenzar la entrevista? [ANSWER ANY QUESTIONS RAISED BY THE RESPONDENT, THEN GO TO COGNITIVE SCREENING QUESTION 1.]

COGNITIVE SCREENING QUESTIONS

CS-1. Today I will ask you about the people paid to help you around your house or in your area. Please tell me in your own words what I will be asking about.

[IF RESPONDENT CANNOT ANSWER THESE THREE QUESTIONS, STOP THE INTERVIEW AND THANK THE RESPONDENT. IF RESPONDENT CAN, CONTINUE ON]

[MANDATORY STATE INFORMATION EXAMPLE: If we have a reason to think that you are being hurt or are in danger, we have a legal responsibility to tell the [STATE CONTACT].

CS-5. Do you agree to being asked questions about the people who are paid to help you?

YES [CONTINUE TO IDENTIFYING QUESTIONS]

NO [THANK AND END]

Thank you. Just so you have a copy for later, here is information about the study for you to look at later. [PROVIDE RESPONDENT WITH CONSENT INFORMATION]

COGNITIVE SCREENING QUESTIONS

CS-1. Hoy le preguntare sobre las personas a las que se les paga para que le ayuden en su casa y en su área. Por favor dígame en sus propias palabras de que le preguntare hoy.

CS-2. Su participación en la encuesta es completamente voluntaria. Completamente voluntaria significa que usted puede decidir si desea hablar conmigo o no. Usted tiene libertad de participar en la entrevista o de no hacerlo. También se puede retirar en cualquier momento y por cualquier razón. Si no participa o si se retira antes de tiempo, no perderá ninguno de los servicios que normalmente espera recibir. Lo que usted diga no afectara los servicios que recibe, su seguro de Medicare o Medicaid, o cualquier otro seguro. Cuando digo que su participación es completamente voluntaria, ¿qué significa eso para usted?

CS-3. Todas sus respuestas se mantendrán privadas bajo la ley de privacidad (the Privacy Act). Eso significa que no compartiremos lo que usted diga con ningún otra persona, solo con las personas que están trabajando en esta investigación. No usaremos su nombre en conexión con nada de lo que diga. Su nombre no estará en nada de lo que escribamos para el estudio o sobre el estudio. No se compartirá nada con las personas que se les paga para ayudarlo/a o el personal del programa de su estado. Ninguna de las personas que le ayudan sabrá lo que usted diga, a menos de que usted los quiera en el cuarto cuando hablemos nosotros. Cuando digo que sus respuestas se mantendrán privadas, ¿qué significa eso para usted?

[IF RESPONDENT CANNOT ANSWER THESE THREE QUESTIONS, STOP THE INTERVIEW AND THANK THE RESPONDENT. IF RESPONDENT CAN, CONTINUE ON]

[MANDATORY STATE INFORMATION EXAMPLE: Si tenemos razón de pensar que alguien lo/a esta lastimando o que usted estas en peligro, tenemos la responsabilidad legal de informarle a [STATE CONTACT].

CS-5. ¿Está de acuerdo que le haga preguntas sobre las personas a las que se les paga para ayudarle?

Sí [CONTINUE TO IDENTIFYING QUESTIONS]

No [THANK AND END]

Gracias. Para que usted tenga una copia, aquí tiene información sobre el estudio que usted puede leer después. [PROVIDE RESPONDENT WITH CONSENT INFORMATION]

IDENTIFICATION QUESTIONS

PREGUNTAS DE IDENTIFICACIóN

Es posible que a algunas personas se les pague para que le ayuden a alistarse por la mañana, a hacer los oficios de la casa, a ir a algún sitio o a recibir servicios de salud mental. Esta encuesta es sobre las personas a las que se les paga para que le ayuden con las actividades que hace normalmente o comúnmente en la casa y en la comunidad. También contiene preguntas sobre los servicios que recibe.

ID-1. Our records show that you get {program specific term for personal assistance}.
Is that right?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

ID-1. Nuestros registros muestran que usted recibe {program specific term for personal assistance}. ¿Es correcta esta información?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

ID-2. ¿Cómo llama usted a la(s) persona(s) que le da(n) {program specific term for personal assistance}? Por ejemplo, ¿les llama {program specific term for personal assistance}, personal, auxiliares de cuidados personales (PCAs por su sigla en inglés), trabajadores o alguna otra cosa?

____________________________________________

ID-3. Our records show that you get {program specific term for behavioral health specialist services}. Is that right?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

ID-3. Nuestros registros muestran que usted recibe {program specific term for behavioral health specialist services}. ¿Es correcta esta información?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

ID-4. ¿Cómo llama usted a la(s) persona(s) que le da(n) {program specific term for behavioral health specialist services}? Por ejemplo, ¿les llama {program specific term for behavioral health specialists}, consejeros, apoyo de personas en la misma situación (peer support en inglés), asistentes de recuperación o alguna otra cosa?

____________________________________________

ID-5. Our records show that you get {program specific term for homemaker services}. Is that right?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

ID-5. Nuestros registros muestran que usted recibe {program specific term for homemaker services}. ¿Es correcta esta información?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

ID-6. ¿Cómo llama usted a la(s) persona(s) que le da(n) {program specific term for homemaker services}? Por ejemplo, ¿les llama {program specific term for homemaker}, ayudantes de oficios domésticos, ayudantes para tareas de la casa o alguna otra cosa?

____________________________________________

ID-7. [IF RESPONDENT REPORTS HAVING PCA AND HOMEMAKER STAFF, THEN ASK]. Do the same people who help you with everyday activities also help you to clean your home?

YES  ASK ALL PCA ITEMS AND SELECT HOMEMAKER ITEMS

NO  ASK PCA ITEMS AND SELECT HOMEMAKER ITEMS SEPARATELY

DON’T KNOW  ASK ALL PCA ITEMS AND SELECT HOMEMAKER ITEMS

REFUSED  ASK ALL PCA ITEMS AND SELECT HOMEMAKER ITEMS

UNCLEAR RESPONSE  ASK ALL PCA ITEMS AND SELECT HOMEMAKER ITEMS

ID-7. [IF R REPORTS HAVING PCA AND HOMEMAKER STAFF, ASK]. Las personas que le ayudan con las actividades que hace normalmente o comúnmente ¿también le ayudan a limpiar la casa?

SÍ  ASK ALL PCA ITEMS AND SELECT HOMEMAKER ITEMS

NO ASK PCA ITEMS AND HOMEMAKER ITEMS SEPERATELY

NO SABE ASK ALL PCA ITEMS AND SELECT HOMEMAKER ITEMS

SE NEGÓ A CONTESTAR ASK ALL PCA ITEMS AND SELECT HOMEMAKER ITEMS

RESPUESTA POCO CLARA ASK ALL PCA ITEMS AND SELECT HOMEMAKER ITEMS

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

ID-8. Nuestros registros muestran que usted recibe {program specific term for case manager services} para asegurarse de que usted reciba todos los servicios que necesita, como ayuda de {list of assistance identified previously}. ¿Es correcta esta información?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

ID-9. ¿Cómo llama usted a la persona que le da {program specific term for case manager services}? Por ejemplo, ¿llama a esa persona {program specific term for case manager}, encargado de caso, encargado de cuidados, coordinador de servicios, coordinador de servicios de apoyo, trabajador social o alguna otra cosa?

____________________________________________

[RESPONDENT TITLES SHOULD BE AUTOMATICALLY ADDED INTO SECTIONS, WHEREVER IT STATES {personal assistance/behavioral health staff}, {case manager}, or {homemaker}.]

[IF RESPONSE IS NEGATIVE TO ALL SUPPORTS, THEN GO TO CHOOSING YOUR SERVICES SECTION.]

SERVICES AND SUPPORTS FROM PERSONAL ASSISTANT AND BEHAVIORAL STAFF

SERVICIOS Y SISTEMAS DE APOYO DE LOS AUXILIARES DE CUIDADOS PERSONALES y el personal de salud mental

GETTING NEEDED SERVICES FROM PERSONAL ASSISTANT AND BEHAVIORAL HEALTH STAFF

Obtención de los servicios necesarios de parte de los auxiliares de cuidados personales y del personal de salud mental

First I would like to talk about the {personal assistance/behavioral health staff}who are paid to help you complete everyday activities—for example, getting dressed, using the bathroom, taking a bath or shower, or going places. How often do {personal assistance/behavioral health staff} come to work on time? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Primero me gustaría hablar sobre {personal assistance/ behavioral health staff} la(s) persona(s) a la(s) que se le(s) paga para que le ayude(n) en sus actividades diarias, como vestirse, ir al baño, bañarse o ducharse, o ir a algún sitio. ¿Con qué frecuencia el/los {personal assistance/ behavioral health staff} llega(n) a trabajar a tiempo? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: First I would like to talk about the {personal assistance/behavioral health staff}who are paid to help you complete everyday activities—for example, getting dressed, using the bathroom, taking a bath or shower, or going places. Do {personal assistance/behavioral health staff} come to work on time? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: Primero me gustaría hablar sobre el/los{personal assistance/ behavioral health staff}, a quien(es) se le(s) paga para que le ayude(n) en sus actividades diarias, como vestirse, ir al baño, bañarse o ducharse, o ir a algún sitio. ¿Llega(n) el/los {personal assistance/ behavioral health staff} a trabajar a tiempo? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How often do {personal assistance/behavioral health staff} work as long as they are supposed to? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

¿Con qué frecuencia {personal assistance/behavioral health staff} trabaja(n) todo el tiempo que se supone que debe(n) trabajar? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Do {personal assistance/behavioral health staff} work as long as they are supposed to? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿Trabaja(n) el/los {personal assistance/behavioral health staff} todo el tiempo que se supone que debe(n) trabajar? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Sometimes staff cannot come to work on a day that they are scheduled. When staff cannot come to work on a day that they are scheduled, does someone let you know if {personal assistance/behavioral health staff} cannot come that day?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

A veces el personal no puede llegar al trabajo en un día en que tenga programado hacerlo. Cuando el personal no puede llegar al trabajo en un día en que tenga programado hacerlo, ¿le avisa alguien si {personal assistance/behavioral health staff} no puede llegar ese día?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Do you need help from {personal assistance/behavioral health staff} to get dressed or to take a shower or bath?

YES

NO [GO TO Q8]

DON’T KNOW [GO TO Q8]

REFUSED [GO TO Q8]

UNCLEAR RESPONSE [GO TO Q8]

4. ¿Necesita ayuda de {el personal de salud mental / los auxiliares de cuidados personales} para vestirse, ducharse o bañarse?

SÍ

NO  [PASE A LA PREGUNTA 8]

NO SABE  [PASE A LA PREGUNTA 8]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 8]

RESPUESTA POCO CLARA  [PASE A LA PREGUNTA 8]

Do you always get dressed or take a shower or bath when you need one?

YES [GO TO Q7]

DON’T KNOW [GO TO Q7]

REFUSED [GO TO Q7]

UNCLEAR RESPONSE [GO TO Q7]

5. ¿Siempre se viste, se ducha o se baña cuando lo necesita?

SÍ  [PASE A LA PREGUNTA 7]

NO SABE  [PASE A LA PREGUNTA 7]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 7]

RESPUESTA POCO CLARA  [PASE A LA PREGUNTA 7]

Is this because there are no {personal assistance/behavioral health staff} to help you?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

¿Esto pasa porque no hay {auxiliares de cuidados personales / personal de salud mental} que le ayude(n)?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How often do {personal assistance/behavioral health staff} make sure you have enough privacy when you get dressed or take a shower or bath? Would you say…

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

¿Con qué frecuencia {personal assistance/behavioral health staff} se asegura(n) de que usted tenga suficiente privacidad cuando se viste, se ducha o se baña? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Do {personal assistance/behavioral health staff} make sure you have enough privacy when you get dressed or take a shower or bath? Would you say…

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿Se asegura(n) el/los {personal assistance/behavioral health staff} de que usted tenga suficiente privacidad cuando se viste, se ducha o se baña? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Do you need help from {personal assistance/behavioral health staff} with your meals, such as help making or cooking meals or help eating?

YES

NO [GO TO Q11]

DON’T KNOW [GO TO Q11]

REFUSED [GO TO Q11]

UNCLEAR RESPONSE [GO TO Q11]

8. ¿Necesita que {el personal de salud mental / los auxiliares de cuidados personales} le ayude(n) con las comidas, por ejemplo, para preparar o cocinar las comidas o para ayudarle a comer?

SÍ

NO  [PASE A LA PREGUNTA 11]

NO SABE [PASE A LA PREGUNTA 11]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 11]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA 11]

Are you always able to get something to eat when you are hungry?

YES [GO TO Q11]

DON’T KNOW [GO TO Q11]

REFUSED [GO TO Q11]

UNCLEAR RESPONSE [GO TO Q11]

9. ¿Siempre puede conseguir algo para comer cuando tiene hambre?

SÍ

NO  [PASE A LA PREGUNTA 11]

NO SABE [PASE A LA PREGUNTA 11]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 11]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA 11]

Is this because there are no {personal assistance/behavioral health staff} to help you?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

¿Esto pasa porque no hay {auxiliares de cuidados personales / personal de salud mental} que le ayude(n)?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Sometimes people need help taking their medicines, such as reminders, help pouring them, or setting up their pills. Do you need help from {personal assistance/behavioral health staff} to take your medicines?

YES

NO [GO TO Q14]

DON’T KNOW [GO TO Q14]

REFUSED [GO TO Q14]

UNCLEAR RESPONSE [GO TO Q14]

11. A veces las personas necesitan ayuda para tomarse sus medicinas, por ejemplo, necesitan ayuda para acordarse de tomárselas, para servirlas o para alistar las pastillas. ¿Necesita que {el personal de salud mental / los auxiliares de cuidados personales} le ayude(n) a tomarse sus medicinas?

SÍ

NO  [PASE A LA PREGUNTA 14]

NO SABE [PASE A LA PREGUNTA 14]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 14]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA 14]

Do you always take your medicine when you are supposed to?

YES [GO TO Q14]

DON’T KNOW [GO TO Q14]

REFUSED [GO TO Q14]

UNCLEAR RESPONSE [GO TO Q14]

12. ¿Siempre se toma su medicina cuando debe tomársela?

SÍ [PASE A LA PREGUNTA 14]

NO SABE [PASE A LA PREGUNTA 14]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 14]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA 14]

Is this because there are no {personal assistance/behavioral health staff} to help you?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

13. ¿Esto pasa porque no hay {auxiliares de cuidados personales / personal de salud mental} que le ayude(n)?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Help with toileting includes helping someone get on and off the toilet or helping to change disposable briefs or pads. Do you need help from {personal assistance/behavioral health staff} with toileting?

YES

NO [GO TO Q16]

DON’T KNOW [GO TO Q16]

REFUSED [GO TO Q16]

UNCLEAR RESPONSE [GO TO Q16]

14. La ayuda para ir al baño incluye ayudarle a alguien a sentarse y levantarse del inodoro o ayudarle a cambiarse de ropa interior o de toallas desechables. ¿Necesita que {el personal de salud mental / los auxiliares de cuidados personales} le ayude(n) a ir al baño?

SÍ

NO  [PASE A LA PREGUNTA 16]

NO SABE [PASE A LA PREGUNTA 16]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 16]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA 16]

Do you get all the help you need with toileting from {personal assistance/behavioral health staff} when you need it?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

15. ¿Recibe usted toda la ayuda que necesita de {el personal de salud mental / los auxiliares de cuidados personales} para ir al baño cuando lo necesita?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

HOW WELL PERSONAL ASSISTANT AND BEHAVIORAL HEALTH STAFF COMMUNICATE AND TREAT YOU

Qué tan bien se comunican con usted los auxiliares de cuidados personales y qué tan bien lo(a) tratan

The next several questions ask about how {personal assistance/behavioral health staff} treat you.

Las siguientes preguntas se refieren a cómo lo(a) trata(n) {el personal de salud mental / los auxiliares de cuidados personales}.

How often are {personal assistance/behavioral health staff} nice and polite to you? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

16. ¿Con qué frecuencia {el personal de salud mental / los auxiliares de cuidados personales} es/son amable(s) y educado(s) con usted? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Are {personal assistance/behavioral health staff} nice and polite to you? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿{El personal de salud mental / los auxiliares de cuidados personales} es/son amable(s) y educado(s) con usted? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How often are {personal assistance/behavioral health staff} hard to understand because of an accent or the way they speak English? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

17. ¿Con qué frecuencia es difícil entender a {el personal de salud mental / los auxiliares de cuidados personales} porque tiene(n) acento o por la forma en que habla(n) español? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Are the explanations {personal assistance/behavioral health staff} give you hard to understand because of an accent or the way {personal assistance/behavioral health staff} speaks English? Would you say. . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿Es difícil entender las explicaciones que le da(n) el/los{el personal de salud mental / los auxiliares de cuidados personales} porque este/estos tiene(n) acento o por la forma en que habla(n) español? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How often do {personal assistance/behavioral health staff} treat you the way you want them to? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

18. ¿Con qué frecuencia {los auxiliares de cuidados personales / el personal de salud mental} lo(a) trata(n) como usted quiere? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Do {personal assistance/behavioral health staff} treat you the way you want them to? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿{El personal de salud mental / los auxiliares de cuidados personales} lo(a) trata(n) como usted quiere? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How often do {personal assistance/behavioral health staff} explain things in a way that is easy to understand? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

19. ¿Con qué frecuencia {el personal de salud mental / los auxiliares de cuidados personales} le explica(n) las cosas de una manera fácil de entender? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Do {personal assistance/behavioral health staff} explain things in a way that is easy to understand? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿{El personal de salud mental / los auxiliares de cuidados personales} le explica(n) las cosas de una manera fácil de entender? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How often do {personal assistance/behavioral health staff} listen carefully to you?
Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

20. ¿Con qué frecuencia {el personal de salud mental / los auxiliares de cuidados personales} lo(a) escuchan con atención? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Do {personal assistance/behavioral health staff} listen carefully to you?
Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿{El personal de salud mental / los auxiliares de cuidados personales} lo(a) escucha(n) con atención? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Do you feel {personal assistance/behavioral health staff} know what kind of help you need with everyday activities, like getting ready in the morning, getting groceries, or going places in your community?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

21. ¿Cree usted que {el personal de salud mental / los auxiliares de cuidados personales} sabe(n) el tipo de ayuda que usted necesita con las actividades diarias, como alistarse por la mañana, hacer mercado o ir a alguna parte de su comunidad?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Do {personal assistance/behavioral health staff} encourage you to do things for yourself if you can?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

22. ¿{El personal de salud mental / los auxiliares de cuidados personales} lo(a) animan a hacer cosas sin ayuda si usted puede hacerlas?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How would you rate the help you get from {personal assistance/behavioral health staff}? Would you say . . .

Excellent,

Very good,

Good,

Fair, or

Poor?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

23. ¿Cómo calificaría la ayuda que recibe de {el personal de salud mental / los auxiliares de cuidados personales}? ¿Diría que es…?

Excelente

Muy buena

Buena

Regular

Mala

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Would you recommend the {personal assistance/behavioral health staff} who help you to your family and friends if they needed help with everyday activities? Would you say you recommend the {personal assistance/behavioral health staff} . . .

Definitely no,

Probably no,

Probably yes, or

Definitely yes?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

24. ¿Les recomendaría a sus familiares y amigos {el personal de salud mental / los auxiliares de cuidados personales} que le ayuda(n) si ellos necesitaran ayuda para realizar las actividades diarias? ¿Diría que recomendaría {el personal de salud mental / los auxiliares de cuidados personales}?

Definitivamente no

Probablemente no

Probablemente sí

Definitivamente sí

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

SERVICES AND SUPPORT FROM HOMEMAKERS

SERVICIOS Y SISTEMAS DE APOYO DE LOS AYUDANTES DE OFICIOS DOMéSTICOS

The next several questions are about the {homemakers}, the staff who are paid to help you do tasks around the home—such as cleaning, grocery shopping, or doing laundry.

Las siguientes preguntas son acerca de los {ayudantes de oficios domésticos}, el personal a quien se le paga para que haga tareas de la casa, como limpiar, hacer mercado o lavar la ropa.

GETTING NEEDED SERVICES FROM HOMEMAKERS

Obtención de los servicios necesarios de los ayudantes de oficios domésticos

How often do {homemakers} come to work on time? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

25. ¿Con qué frecuencia {los ayudantes de oficios domésticos} llegan a tiempo al trabajo? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Do {homemakers} come to work on time? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿Llegan los {los ayudantes de oficios domésticos} a tiempo al trabajo? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How often do {homemakers} work as long as they are supposed to? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

26. ¿Con qué frecuencia {los ayudantes de oficios domésticos} trabajan todo el tiempo que se supone que deben trabajar? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Do {homemakers} work as long as they are supposed to? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿Trabajan {los ayudantes de oficios domésticos} todo el tiempo que se supone que deben trabajar? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Do your household tasks, like cleaning and laundry, always get done when you need them to?

YES [GO TO Q29]

DON’T KNOW NO [GO TO Q29]

REFUSED NO [GO TO Q29]

UNCLEAR RESPONSE [GO TO Q29]

27. Las tareas de la casa, como limpiar y lavar la ropa ¿se hacen siempre cuando usted necesita que se hagan?

SÍ [PASE A LA PREGUNTA 29]

NO SABE  [PASE A LA PREGUNTA 29]

SE NEGÓ A CONTESTAR [PASE A LA PREGUNTA 29]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA 29]

Is this because there are no {homemakers} to help you?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

28. ¿Es porque no hay {ayudantes de oficios domésticos} que le ayuden?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

HOW WELL HOMEMAKERS COMMUNICATE AND TREAT YOU

Qué tan bien se comunican con usted los ayudantes de oficios domésticos y qué tan bien lo(a) tratan

The next several questions ask about how {homemakers} treat you.

Las siguientes preguntas se refieren a la forma en que lo(a) tratan {los ayudantes de oficios domésticos}.

How often are {homemakers} nice and polite to you? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

29. ¿Con qué frecuencia {los ayudantes de oficios domésticos} son amables y educados con usted? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Are {homemakers} nice and polite to you? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿{Los ayudantes de oficios domésticos} son amables y educados con usted? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Are {homemakers} hard to understand because of an accent or the way they speak English?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

30. ¿Es difícil entender a {los ayudantes de oficios domésticos} porque tienen acento o por la forma en que hablan español?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Are the explanations {homemakers} give you hard to understand because of an accent or the way {homemakers} speaks English? Would you say. . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿Es difícil entender las explicaciones que le dan {los ayudantes de oficios domésticos} porque estos tienen acento o por la forma en que hablan español?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How often do {homemakers} treat you the way you want them to? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

31. ¿Con qué frecuencia {los ayudantes de oficios domésticos} lo(a) tratan como usted quiere? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Do {homemakers} treat you the way you want them to? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿{Los ayudantes de oficios domésticos} lo(a) tratan como usted quiere? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How often do {homemakers} listen carefully to you? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

32. ¿Con qué frecuencia {Los ayudantes de oficios domésticos} le escuchan con atención? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Do {homemakers} listen carefully to you? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿{Los ayudantes de oficios domésticos} le escuchan con atención? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Do you feel {homemakers} know what kind of help you need?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

33. ¿Cree usted que {los ayudantes de oficios domésticos} saben el tipo de ayuda que usted necesita?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How would you rate the help you get from {homemakers}? Would you say . . .

Excellent,

Very good,

Good,

Fair, or

Poor?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

34. ¿Cómo calificaría la ayuda que recibe de {los ayudantes de oficios domésticos}? ¿Diría que es…?

Excelente

Muy buena

Buena

Regular

Mala

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Would you recommend the {homemakers} who help you to your family and friends if they needed {respondent-specific term for homemaker services}? Would you say you recommend the {homemakers} . . .

Definitely no,

Probably no,

Probably yes, or

Definitely yes?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

35. ¿Les recomendaría a sus familiares y amigos {los ayudantes de oficios domésticos} que le ayudan si ellos necesitaran {término específico del encuestado para “servicios de ayuda con los oficios domésticos”}? ¿Diría que recomendaría {los ayudantes de oficios domésticos}?

Definitivamente no

Probablemente no

Probablemente sí

Definitivamente sí

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

YOUR CASE MANAGER

su encargado de caso

Now I would like to talk to you about your {case manager}, the person who helps make sure you have the services you need.

Ahora me gustaría hablarle de su {encargado de caso}, la persona que se asegura de que usted reciba los servicios que necesita.

Do you know who your {case manager} is?

YES

NO [GO TO Q44]

DON’T KNOW [GO TO 44]

REFUSED [GO TO Q44]

UNCLEAR RESPONSE [GO TO Q44]

36. ¿Sabe quién es su {encargado de caso}?

SÍ

NO  [PASE A LA PREGUNTA 44]

NO SABE  [PASE A LA PREGUNTA 44

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 44]

RESPUESTA POCO CLARA  [PASE A LA PREGUNTA 44]

Can you contact this {case manager} when you need to?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

37. ¿Puede comunicarse con este {encargado de caso} cuando necesita hacerlo?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Some people need to get equipment, such as wheelchairs or walkers to help them, and other people need their equipment replaced or repaired. Have you asked this {case manager} for help with getting or fixing equipment?

YES

NO [GO TO Q40]

DON’T KNOW [GO TO Q40]

REFUSED [GO TO Q40]

UNCLEAR RESPONSE [GO TO Q40]

38. Algunas personas necesitan conseguir equipo, como sillas de ruedas o andadores, que les sirvan de ayuda y otras personas necesitan que el equipo que tienen sea remplazado o reparado. ¿Le ha pedido ayuda a este {encargado de caso} para conseguir o reparar un equipo?

SÍ

NO  [PASE A LA PREGUNTA 40]

NO SABE  [PASE A LA PREGUNTA 40]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 40]

RESPUESTA POCO CLARA  [PASE A LA PREGUNTA 40]

Did this {case manager} work with you when you asked for help with getting or fixing equipment?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

39. ¿Este {encargado de caso} colaboró con usted cuando le pidió ayuda para conseguir o reparar un equipo?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Have you asked this {case manager} for help in getting any changes to your services, such as more help from {personal assistance/behavioral health staff and/or homemakers if applicable}, or for help with getting places or finding a job?

YES

NO [GO TO 42]

DON’T KNOW [GO TO 42]

REFUSED [GO TO 42]

UNCLEAR RESPONSE [GO TO 42]

40. ¿Le ha pedido ayuda a este {encargado de caso} para hacer cambios en los servicios que recibe, como más ayuda de {el personal de salud mental/los auxiliares de cuidados personales y/o los ayudantes de oficios domésticos}, o para ir a lugares o buscar trabajo?

SÍ

NO  [PASE A LA PREGUNTA 42]

NO SABE  [PASE A LA PREGUNTA 42]

SE NEGÓ A CONTESTAR [ PASE A LA PREGUNTA 42]

RESPUESTA POCO CLARA  [PASE A LA PREGUNTA 42]

Did this {case manager} work with you when you asked for help with getting other changes to your services?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

41. ¿Este {encargado de caso} colaboró con usted cuando le pidió ayuda para hacer otros cambios en los servicios que recibe?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How would you rate the help you get from the {case manager}? Would you say . . .

Excellent,

Very good,

Good,

Fair, or

Poor?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

42. ¿Cómo calificaría la ayuda que recibe de {encargado de caso}? ¿Diría que es…?

Excelente

Muy buena

Buena

Regular

Mala

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Would you recommend the {case manager} who helps you to your family and friends if they needed {respondent-specific term for case-management services}? Would you say you recommend the {case manager} . . .

Definitely no,

Probably no,

Probably yes, or

Definitely yes?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

43. ¿Les recomendaría a sus familiares y amigos el {encargado de caso} que le ayuda a usted si ellos necesitaran {término específico del encuestado para “servicios que presta un encargado de caso”}? ¿Diría que les recomendaría el {encargado de caso}?

Definitivamente no

Probablemente no

Probablemente sí

Definitivamente sí

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

CHOOSING YOUR SERVICES

la elección de sus servicios

A [program-specific term for “service plan”]—sometimes called a care plan, goals, or service plan—lists the services you need and who will provide them. Did you work with someone to develop your [program-specific term for “service plan”]?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

44. En el [término específico del programa para “plan de servicios”], que a veces se llama plan de cuidados, objetivos o plan de servicios, se incluye una lista de los servicios que usted necesita y de las personas que se los darán. ¿Colaboró con alguien para crear su [término específico del programa para “plan de servicios”]?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Does your [program-specific term for “service plan”] include . . .

None of the things that are important to you,

Some of the things that are important to you,

Most of the things that are important to you, or

All of the things that are important to you?

DON’T KNOW [GO TO 47]

REFUSED [GO TO 47]

UNCLEAR RESPONSE [GO TO 47]

45. ¿Qué se incluye en su [término específico de cada programa que se refiere a un “plan de servicios”]?

Ninguna de las cosas que son importantes para usted

Algunas de las cosas que son importantes para usted

La mayoría de las cosas que son importantes para usted

Todas las cosas que son importantes para usted

NO SABE  [PASE A LA PREGUNTA 47]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 47]

RESPUESTA POCO CLARA  [PASE A LA PREGUNTA 47]

Do you feel {personal assistance/behavioral health staff} know what’s on your [program-specific term for “service plan”], including the things that are important to you?

YES

DOES NOT HAVE PERSONAL ASSISTANCE STAFF

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

46. ¿Cree que {los auxiliares de cuidados personales / el personal de salud mental} sabe(n) qué se incluye en su [término específico de cada programa que se refiere a un “plan de servicios”], incluso las cosas que son importantes para usted?

SÍ

NO TIENE AUXILIARES DE CUIDADOS PERSONALES

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Who would you talk to if you wanted to change your [program-specific term for “service plan”]? Anyone else? [INTERVIEWER MARKS ALL THAT APPLY]

CASE MANAGER

OTHER STAFF

FAMILY/FRIENDS

OTHER

I DON’T KNOW

REFUSED

UNCLEAR RESPONSE

47. ¿Con quién hablaría si quisiera cambiar su [término específico de cada programa que se refiere a un “plan de servicios”]? ¿Hablaría con alguien más?

ENCARGADO DE CASO

OTROS MIEMBROS DEL PERSONAL

FAMILIARES/ AMIGOS

OTROS

NO SABE

TRANSPORTATION

TRANSPORTE

The next questions ask about how you get to places in your community.

El tema de las siguientes preguntas es cómo va usted a sitios de su comunidad.

Medical appointments include seeing a doctor, a dentist, a therapist, or someone else who takes care of your health. How often do you have a way to get to your medical appointments? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

48. Entre las citas médicas se incluye ir a ver al doctor, al dentista, al terapeuta o a otra persona que se encargue del cuidado de su salud. ¿Con qué frecuencia tiene forma de llegar a sus citas médicas? ¿Diría que...?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Medical appointments include seeing a doctor, a dentist, a therapist, or someone else who takes care of your health. Do you have a way to get to your medical appointments? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: Entre las citas médicas se incluye ir a ver al doctor, al dentista, al terapeuta o a otra persona que se encargue del cuidado de su salud. ¿Tiene forma de llegar a sus citas médicas? ¿Diría que...?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Do you use a van or some other transportation service? Do not include a van you own.

YES

NO [GO TO Q52]

DON’T KNOW [GO TO Q52]

REFUSED [GO TO Q52]

UNCLEAR RESPONSE [GO TO Q52]

49. ¿Usa una camioneta van o algún otro servicio de transporte? No incluya una camioneta van que le pertenezca a usted.

SÍ

NO  [PASE A LA PREGUNTA 52]

NO SABE  [PASE A LA PREGUNTA 52]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 52]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA 52]

Are you able to get in and out of this ride easily?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

50. ¿Puede subirse y bajarse de este vehículo fácilmente?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How often does this ride arrive on time to pick you up? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

51. ¿Con qué frecuencia llega este vehículo a tiempo a recogerlo(a)? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Does this ride arrive on time to pick you up? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿Llega este vehículo a tiempo a recogerlo(a)? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

PERSONAL SAFETY

seguridad personal

The next few questions ask about your personal safety.

Las siguientes preguntas se refieren a su seguridad personal.

Who would you contact in case of an emergency?

FAMILY MEMBER OR FRIEND

CASE MANAGER

AGENCY THAT PROVIDES HOME- AND COMMUNITY-BASED SERVICES

PAID EMERGENCY RESPONSE SERVICE (E.G., LIFELINE)

9–1–1 (FIRST RESPONDERS, POLICE, LAW ENFORCEMENT)

SOMEONE ELSE, PLEASE SPECIFY ___________________

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

52. ¿Con quién se comunicaría en caso de emergencia?

PARIENTE O AMIGO

ENCARGADO DE CASO

Agencia

servicio de emergencia

911/ PERSONAL DE PRIMEROS AUXILIOS

ALGUIEN MÁS, ESPECIFIQUE___________________

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Is there a person you can talk to if someone hurts you or does something to you that you don’t like?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

53. ¿Hay una persona con quien pueda hablar si alguien lo(a) lastima o le hace algo que a usted no le gusta?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Las siguientes preguntas se refieren a si alguna persona a quien se le paga para ayudarle en este momento lo(a) está tratando mal. Esto incluye a {personal assistance/behavioral health staff, homemakers, or your case manager}. Les estamos haciendo a todos las siguientes preguntas, no solo a usted. [ADD STATE-SPECIFIC LANGUAGE HERE REGARDING MANDATED REPORTING, IF APPROPRIATE: Quiero recordarle que, aunque sus respuestas son confidenciales, tengo la responsabilidad legal de informarle al estado de {STATE} si oigo algo que me haga pensar que alguien lo(a) está lastimando o que usted está en peligro.]

Do any of the {personal assistance/behavioral health staff, homemakers, or your case managers} that you have now take your money or your things without asking you first?

YES

NO [GO TO Q57]

DON’T KNOW [GO TO Q57]

REFUSED [GO TO Q57]

UNCLEAR RESPONSE [GO TO Q57]

54. ¿Alguno de {los auxiliar(es) de cuidados personales, el personal de salud mental, los ayudantes de oficios domésticos o los encargados de caso} que tiene ahora toma su dinero o sus cosas sin preguntarle primero?

SÍ

NO  [PASE A LA PREGUNTA 57]

NO SABE  [PASE A LA PREGUNTA 57]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 57]

RESPUESTA POCO CLARA  [PASE A LA PREGUNTA 57]

Is someone working with you to fix this problem?

YES

NO [GO TO Q57]

DON’T KNOW [GO TO Q57]

REFUSED [GO TO Q57]

UNCLEAR RESPONSE [GO TO Q57]

55. ¿Alguien está colaborando con usted para solucionar este problema?

SÍ

NO  [PASE A LA PREGUNTA 57]

NO SABE  [PASE A LA PREGUNTA 57]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 57]

RESPUESTA POCO CLARA  [PASE A LA PREGUNTA 57]

Who is working with you to fix this problem? Anyone else? [INTERVIEWER MARKS ALL THAT APPLY]

FAMILY MEMBER OR FRIEND

CASE MANAGER

AGENCY

SOMEONE ELSE, PLEASE SPECIFY ___________________

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

56. ¿Quién está colaborando con usted para solucionar este problema? ¿Alguna otra persona?

[INTERVIEWER MARKS ALL THAT APPLY]

PARIENTE O AMIGO

ENCARGADO DE CASO

AgencIA

ALGUIEN MÁS, ESPECIFIQUE ___________________

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Do any {staff} that you have now yell, swear, or curse at you?

YES

NO [GO TO Q60]

DON’T KNOW [GO TO Q60]

REFUSED [GO TO Q60]

UNCLEAR RESPONSE [GO TO Q60]

57. ¿Algún {empleado} de los que tiene ahora le grita, lo(a) insulta o le dice malas palabras?

SÍ

NO  [PASE A LA PREGUNTA 60]

NO SABE  [PASE A LA PREGUNTA 60]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 60]

RESPUESTA POCO CLARA  [PASE A LA PREGUNTA 60]

Is someone working with you to fix this problem?

YES

NO [GO TO Q60]

DON’T KNOW[GO TO Q60]

REFUSED[GO TO Q60]

UNCLEAR RESPONSE [GO TO Q60]

58. ¿Alguien está colaborando con usted para solucionar este problema?

SÍ

NO  [PASE A LA PREGUNTA 60]

NO SABE  [PASE A LA PREGUNTA 60]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 60]

RESPUESTA POCO CLARA  [PASE A LA PREGUNTA 60]

Who is working with you to fix this problem? Anyone else? [INTERVIEWER MARKS ALL THAT APPLY]

FAMILY MEMBER OR FRIEND

CASE MANAGER

AGENCY

SOMEONE ELSE, PLEASE SPECIFY ___________________

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

59. ¿Quién está colaborando con usted para solucionar este problema? ¿Alguna otra persona? [INTERVIEWER MARKS ALL THAT APPLY]

PARIENTE O AMIGO

ENCARGADO DE CASO

AgencIA

ALGUIEN MÁS, ESPECIFIQUE ___________________

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Do any {staff} that you have now hit you or hurt you?

YES

NO [GO TO Q63]

DON’T KNOW [GO TO Q63]

REFUSED [GO TO Q63]

UNCLEAR RESPONSE [GO TO Q63]

60. ¿Algún {empleado} de los que tiene ahora le pega o lo(a) lastima?

SÍ

NO  [PASE A LA PREGUNTA 63]

NO SABE  [PASE A LA PREGUNTA 63]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 63]

RESPUESTA POCO CLARA  [PASE A LA PREGUNTA 63]

Is someone working with you to fix this problem?

YES

NO [GO TO Q63]

DON’T KNOW [GO TO Q63]

REFUSED [GO TO Q63]

UNCLEAR RESPONSE [GO TO Q63]

61. ¿Alguien está colaborando con usted para solucionar este problema?

SÍ

NO  [PASE A LA PREGUNTA 63]

NO SABE  [PASE A LA PREGUNTA 63]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 63]

RESPUESTA POCO CLARA  [PASE A LA PREGUNTA 63]

Who is working with you to fix this problem? Anyone else? [INTERVIEWER MARKS ALL THAT APPLY]

FAMILY MEMBER OR FRIEND

CASE MANAGER

AGENCY

SOMEONE ELSE, PLEASE SPECIFY ___________________

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

62. ¿Quién está colaborando con usted para solucionar este problema? ¿Alguna otra persona?

[INTERVIEWER MARKS ALL THAT APPLY]

pariente o amigo

encargado de caso

Agencia

ALGUIEN MÁS, ESPECIFIQUE ___________________

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

COMMUNITY INCLUSION AND EMPOWERMENT

comunidad y empoderamiento

Now I’d like to ask you about the things you do in your community.

Ahora me gustaría preguntarle sobre las cosas que hace en su comunidad.

Do you have any family members who live nearby? Do not include family members you live with.

YES

NO [GO TO Q65]

DON’T KNOW [GO TO Q65]

REFUSED [GO TO Q65]

UNCLEAR RESPONSE [GO TO Q65]

63. ¿Tiene familiares que vivan cerca? No incluya a los miembros de la familia con los que vive.

SÍ

NO  [PASE A LA PREGUNTA 65]

NO SABE  [PASE A LA PREGUNTA 65]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 65]

RESPUESTA POCO CLARA  [PASE A LA PREGUNTA 65]

When you want to, how often can you get together with these family members who live nearby? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

64. Cuando usted lo desea, ¿con qué frecuencia puede reunirse con estos familiares que viven cerca? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: When you want to, can you get together with these family members who live nearby? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: Cuando usted lo desea, ¿puede reunirse con estos familiares que viven cerca? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Do you have any friends who live nearby?

YES

NO [GO TO Q67]

DON’T KNOW [GO TO Q67]

REFUSED [GO TO Q67]

UNCLEAR RESPONSE [GO TO Q67]

65. ¿Tiene amigos que vivan cerca?

SÍ

NO  [PASE A LA PREGUNTA 67]

NO SABE  [PASE A LA PREGUNTA 67]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 67]

RESPUESTA POCO CLARA  [PASE A LA PREGUNTA 67]

When you want to, how often can you get together with these friends who live nearby? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

66. Cuando usted lo desea, ¿con qué frecuencia puede reunirse con estos amigos que viven cerca? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: When you want to, can you get together with these friends who live nearby? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: Cuando usted lo desea, ¿puede reunirse con estos amigos que viven cerca? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

When you want to, how often can you do things in the community that you like, such as shopping or going out to eat? Would you say . . .

Never

Sometimes

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

67. Cuando usted lo desea, ¿con qué frecuencia puede hacer lo que le gusta en la comunidad, como ir de compras o salir a comer? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: When you want to, can you do things in the community that you like, such as shopping or going out to eat? Would you say . . .

Mostly yes, or

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: Cuando usted lo desea, ¿puede hacer lo que le gusta en la comunidad, como ir de compras o salir a comer? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Do you need more help than you get now from {personal assistance/behavioral health staff} to do things in your community?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

68. ¿Necesita más ayuda de la que recibe ahora de {el personal de salud mental / los auxiliares de cuidados personales} para hacer cosas en su comunidad?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Do you take part in deciding what you do each day—for example, what you do for fun at home or in your community?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

69. ¿Participa en decidir qué hace cada día? Por ejemplo, qué hace para distraerse en casa o en la comunidad.

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Do you take part in deciding when you do things each day—for example, deciding when you get up, eat, or go to bed?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

70. ¿Participa en decidir el horario de sus actividades de cada día? Por ejemplo, cuándo se levanta, cuándo come o cuándo se acuesta.

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

The next few questions ask about making changes in {personal assistance/behavioral health staff, homemakers, and case manager}.

El tema de las siguientes preguntas es cómo pedir cambios de {auxiliares de cuidados personales / personal de salud mental, ayudantes de oficios domésticos y encargado de caso}.

Have you asked for a change in {personal assistance staff, behavioral health staff, homemakers, or case manager}?

YES

NO [GO TO Q74]

DON’T KNOW [GO TO Q74]

REFUSED [GO TO Q74]

UNCLEAR RESPONSE [GO TO Q74]

71. ¿Ha pedido que le cambien {el personal de salud mental, los auxiliares de cuidados personales, los ayudantes de oficios domésticos o el encargado de caso}?

SÍ

NO  [PASE A LA PREGUNTA 74]

NO SABE  [PASE A LA PREGUNTA 74]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 74]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA 74]

Did someone work with you when you asked to change {personal assistance/behavioral health staff, homemakers, or case manager}?

YES

NO [GO TO EM]

DON’T KNOW [GO TO EM ]

REFUSED [GO TO EM]

UNCLEAR RESPONSE [GO TO EM]

72. ¿Alguien de la agencia colaboró con usted cuando pidió que le cambiaran {el personal de salud mental, los auxiliares de cuidados personales, los ayudantes de oficios domésticos o el encargado de caso}?

¹ SÍ  [PASE A LAS PREGUNTAS DE EMPLEO]

² NO  [PASE A LAS PREGUNTAS DE EMPLEO]

⁹⁷ NO SABE  [PASE A LAS PREGUNTAS DE EMPLEO]

⁹⁸ SE NEGÓ A CONTESTAR  [PASE A LAS PREGUNTAS DE EMPLEO]

⁹⁹ RESPUESTA POCO CLARA [PASE A LAS PREGUNTAS DE EMPLEO]

Who did you work with when you asked to change {personal assistance/behavioral health staff, homemakers, or case manager}

Family member or friend [GO TO EM OR Q75]

Case manager [GO TO EM OR Q75]

Agency [GO TO EM OR Q75]

Someone else, please specify ___________________ [GO TO EM
OR Q75]

DON’T KNOW [GO TO EM OR Q75]

REFUSED [GO TO EM OR Q75]

UNCLEAR RESPONSE [GO TO EM OR Q75]

73. ¿Quién colaboró con usted cuando pidió que le cambiaran {el personal de salud mental, los auxiliares de cuidados personales, los ayudantes de oficios domésticos o el encargado de caso}?

pariente o amigo [PASE A LAS PREGUNTAS DE EMPLEO O A LA PREGUNTA 75]

encargado de caso [PASE A LAS PREGUNTAS DE EMPLEO O A LA PREGUNTA 75]

Agencia [PASE A LAS PREGUNTAS DE EMPLEO O A LA PREGUNTA 75]

ALGUIEN MÁS, ESPECIFIQUE ___________________[PASE A LAS PREGUNTAS DE EMPLEO O A LA PREGUNTA 75]

NO SABE[PASE A LAS PREGUNTAS DE EMPLEO O A LA PREGUNTA 75]

SE NEGÓ A CONTESTAR [PASE A LAS PREGUNTAS DE EMPLEO O A LA PREGUNTA 75]

RESPUESTA POCO CLARA [PASE A LAS PREGUNTAS DE EMPLEO O A LA PREGUNTA 75]

Do you know you can ask someone to change {personal assistance/behavioral health staff, homemakers, or case manager}?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

74. ¿Sabe que puede pedirle a alguien que le cambien {el personal de salud mental, los auxiliares de cuidados personales, los ayudantes de oficios domésticos o el encargado de caso}?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

SUPPLEMENTAL EMPLOYMENT MODULE

MÓDULO COMPLEMENTARIO SOBRE EMPLEO

Do you work for pay at a job?

YES [GO TO QEM9]

DON’T KNOW [GO TO Q75]

REFUSED [GO TO Q75]

UNCLEAR RESPONSE [GO TO Q75]

EM1. ¿Tiene un trabajo por el cual le pagan?

SÍ [PASE A LA PREGUNTA EM9]

NO SABE  [PASE A LA PREGUNTA 75]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 75]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA 75]

Do you want to work for pay at a job?

YES

NO [GO TO EM4]

DON’T KNOW [GO TO Q75]

REFUSED [GO TO Q75]

UNCLEAR RESPONSE [GO TO Q75]

EM2. ¿Quiere tener un trabajo por el cual le paguen?

SÍ

NO  [PASE A LA PREGUNTA EM4]

NO SABE  [PASE A LA PREGUNTA 75]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 75]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA 75]

Sometimes people feel that something is holding them back from working when they want to. Is this true for you? If so, what is holding you back from working? (INTERVIEWER LISTENS AND MARKS ALL THAT APPLY)

BENEFITS [GO TO EM5]

HEALTH CONCERNS [GO TO EM5]

DON’T KNOW ABOUT JOB RESOURCES [GO TO EM5]

ADVICE FROM OTHERS [GO TO EM5]

TRAINING/EDUCATION NEED [GO TO EM5]

LOOKING AND CAN’T FIND WORK [GO TO EM5]

ISSUES WITH PREVIOUS EMPLOYMENT [GO TO EM5]

TRANSPORTATION [GO TO EM5]

CHILD CARE [GO TO EM5]

OTHER (_____________________________) [GO TO EM5]

NOTHING IS HOLDING ME BACK  [GO TO EM5]

DON’T KNOW [GO TO EM5]

REFUSED [GO TO EM5]

UNCLEAR RESPONSE [GO TO EM5]

EM3. A veces, uno cree que hay algo que le impide trabajar cuando quisiera. ¿Es éste su caso? Si es así, ¿qué le impide trabajar? (LISTEN AND CHECK ALL THAT APPLY)

PRESTACIONES O BENEFICIOS [PASE A LA PREGUNTA EM5]

PROBLEMAS DE SALUD [PASE A LA PREGUNTA EM5]

NO TIENE INFORMACIÓN SOBRE RECURSOS LABORALES [PASE A LA PREGUNTA EM5]

OTRAS PERSONAS LE HAN ACONSEJADO NO HACERLO [PASE A LA PREGUNTA EM5]

NECESITA CAPACITACIÓN O EDUCACIÓN [PASE A LA PREGUNTA EM5]

ESTÁ BUSCANDO TRABAJO PERO NO ENCUENTRA [PASE A LA PREGUNTA EM5]

PROBLEMAS CON EMPLEO ANTERIOR [PASE A LA PREGUNTA EM5]

TRANSPORTE [PASE A LA PREGUNTA EM5]

CUIDADO DE LOS HIJOS [PASE A LA PREGUNTA EM5]

OTRO (_____________________________) [PASE A LA PREGUNTA EM5]

NADA SE LO IMPIDE [PASE A LA PREGUNTA EM5]

NO SABE  [PASE A LA PREGUNTA EM5]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA EM5]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA EM5]

Sometimes people would like to work for pay, but feel that something is holding them back. Is this true for you? If so, what is holding you back from wanting to work? (INTERVIEWER LISTENS AND MARKS ALL THAT APPLY)

BENEFITS [GO TO 75]

HEALTH CONCERNS [GO TO 75]

DON’T KNOW ABOUT JOB RESOURCES [GO TO 75]

ADVICE FROM OTHERS [GO TO 75]

TRAINING/EDUCATION NEED [GO TO 75]

LOOKING AND CAN’T FIND WORK [GO TO 75]

ISSUES WITH PREVIOUS EMPLOYMENT [GO TO 75]

TRANSPORTATION [GO TO 75]

CHILD CARE [GO TO 75]

OTHER (_____________________________) [GO TO 75]

NOTHING/DOESN’T WANT TO WORK [GO TO 75]

DON’T KNOW [GO TO 75]

REFUSED [GO TO 75]

UNCLEAR RESPONSE [GO TO 75]

EM4. A veces a uno le gustaría tener un trabajo por el cual le paguen, pero le parece que algo se lo impide. ¿Es éste su caso? Si es así, ¿qué le impide querer trabajar? (LISTEN AND CHECK ALL THAT APPLY)

PRESTACIONES O BENEFICIOS [PASE A LA PREGUNTA 75]

PROBLEMAS DE SALUD [PASE A LA PREGUNTA 75]

NO TIENE INFORMACIÓN SOBRE RECURSOS LABORALES [PASE A LA PREGUNTA 75]

OTRAS PERSONAS LE HAN ACONSEJADO NO HACERLO [PASE A LA PREGUNTA 75]

NECESITA CAPACITACIÓN O EDUCACIÓN [PASE A LA PREGUNTA 75]

ESTÁ BUSCANDO TRABAJO PERO NO ENCUENTRA [PASE A LA PREGUNTA 75]

PROBLEMAS CON EMPLEO ANTERIOR [PASE A LA PREGUNTA 75]

TRANSPORTE [PASE A LA PREGUNTA 75]

CUIDADO DE LOS HIJOS [PASE A LA PREGUNTA 75]

OTRO (_____________________________) [PASE A LA PREGUNTA 75]

NADA, NO QUIERE TRABAJAR [PASE A LA PREGUNTA 75]

NO SABE  [PASE A LA PREGUNTA 75]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 75]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA 75]

Have you asked for help in getting a job for pay?

YES [GO TO EM7]

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

EM5. ¿Ha pedido ayuda para encontrar trabajo por el cual le paguen?

SÍ

NO  [PASE A LA PREGUNTA EM7]

NO SABE  [PASE A LA PREGUNTA EM7]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA EM7]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA EM7]

Do you know you can get help to find a job for pay?

YES [GO TO Q75]

NO [GO TO Q75]

DON’T KNOW [GO TO Q75]

REFUSED [GO TO Q75]

UNCLEAR RESPONSE [GO TO Q75]

EM6. ¿Sabe que puede recibir ayuda para encontrar un trabajo por el cual le paguen?

SÍ

NO  [PASE A LA PREGUNTA 75]

NO SABE  [PASE A LA PREGUNTA 75]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 75]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA 75]

Help getting a job can include help finding a place to work or help getting the skills that you need to work. Is someone paid to help you get a job?

YES

NO [GO TO Q75]

DON’T KNOW [GO TO Q75]

REFUSED [GO TO Q75]

UNCLEAR RESPONSE [GO TO Q75]

EM7. La ayuda para encontrar trabajo puede incluir ayuda para encontrar un lugar en donde trabajar o ayuda para recibir la capacitación que necesita para trabajar. ¿Le pagan a alguien para que le ayude a encontrar trabajo?

SÍ [PASE A LA PREGUNTA 75]

NO  [PASE A LA PREGUNTA 75]

NO SABE  [PASE A LA PREGUNTA 75]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 75]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA 75]

EM8. Are you getting all the help you need to find a job?

YES [GO TO Q75]

NO [GO TO Q75]

DON’T KNOW [GO TO Q75]

REFUSED [GO TO Q75]

UNCLEAR RESPONSE [GO TO Q75]

EM8. ¿Está recibiendo toda la ayuda que necesita para encontrar un trabajo?

SÍ

NO  [PASE A LA PREGUNTA 75]

NO SABE  [PASE A LA PREGUNTA 75]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 75]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA 75]

EM9. Who helped you to find the job that you have now? (INTERVIEWER LISTENS AND MARKS ALL THAT APPLY)

EMPLOYMENT/VOCATIONAL STAFF/JOB COACH

CASE MANAGER

OTHER PAID PROVIDERS

OTHER CAREER SERVICES

FAMILY/FRIENDS

ADVERSTISEMENT

SELF-EMPLOYED [GO TO EM11]

OTHER (____________________________)

NO ONE HELPED ME—I FOUND IT MYSELF [GO TO EM11]

DON’T KNOW [GO TO EM11]

REFUSED [GO TO EM11]

UNCLEAR RESPONSE [GO TO EM11]

EM9. ¿Quién le ayudó a encontrar el trabajo que tiene ahora? (LISTEN AND CHECK ALL THAT APPLY)

PERSONAL LABORAL / PERSONAL VOCACIONAL / ENTRENADOR LABORAL

ENCARGADO DE CASO

OTROS PROVEEDORES A QUIENES SE LES PAGA

OTROS SERVICIOS DE ORIENTACIÓN LABORAL

FAMILIARES O AMIGOS

ANUNCIO PUBLICITARIO

TRABAJA POR SU CUENTA [PASE A LA PREGUNTA EM11]

OTRO (____________________________)

NADIE LE AYUDÓ. LO ENCONTRÓ SOLO(A) [PASE A LA PREGUNTA EM11]

NO SABE [PASE A LA PREGUNTA EM11]

SE NEGÓ A CONTESTAR [PASE A LA PREGUNTA EM11]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA EM11]

Did you help to choose the job you have now?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

EM10. ¿Contribuyó a escoger el trabajo que tiene ahora?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Sometimes people need help from other people to work at their jobs. For example, they may need help getting to or getting around at work, help getting their work done, or help getting along with other workers. Is someone paid to help you with the job you have now?

YES

NO [GO TO Q75]

DON’T KNOW [GO TO Q75]

REFUSED [GO TO Q75]

UNCLEAR RESPONSE [GO TO Q75]

EM11. A veces uno necesita ayuda de los demás para hacer su trabajo. Por ejemplo, puede necesitar ayuda para llegar al trabajo o para ir de un lugar a otro en el sitio donde trabaja, para hacer el trabajo o para llevarse bien con los otros empleados. ¿Le pagan a alguien para ayudarle en el trabajo que tiene ahora?

SÍ

NO  [PASE A LA PREGUNTA 75]

NO SABE  [PASE A LA PREGUNTA 75]

SE NEGÓ A CONTESTAR  [PASE A LA PREGUNTA 75]

RESPUESTA POCO CLARA [PASE A LA PREGUNTA 75]

What do you call this person? A job coach, peer support provider, personal assistant, or something else?

USE THIS TERM WHEREVER IT SAYS {job coach} BELOW.

EM12. ¿Cómo llama a esta persona? ¿Entrenador laboral (job coach en inglés), proveedor de apoyo para personas en la misma situación (peer support en inglés), asistente personal o alguna otra cosa?

USE THIS TERM WHEREVER IT SAYS {job coach} BELOW.

Did you hire your {job coach} yourself?

YES [GO TO Q75]

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

EM13. ¿Contrató usted mismo a su {entrenador laboral}?

SÍ [PASE A LA PREGUNTA 75]

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Is your {job coach} with you all the time that you are working?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

EM14. ¿Su {entrenador laboral} está con usted todo el tiempo que usted está trabajando?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How often does your {job coach} give you all the help you need? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

EM15. ¿Con qué frecuencia su {entrenador laboral} le da toda la ayuda que usted necesita?¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Does your {job coach} give you all the help you need? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿Su {entrenador laboral} le da toda la ayuda que usted necesita?¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How often is your {job coach} nice and polite to you? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

EM16. ¿Con qué frecuencia su {entrenador laboral} es amable y educado con usted? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Is your {job coach} nice and polite to you? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿Su {entrenador laboral} es amable y educado con usted? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How often does your {job coach} explain things in a way that is easy to understand? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

EM17. ¿Con qué frecuencia su {entrenador laboral} le explica cosas de una manera fácil de entender? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Does your {job coach} explain things in a way that is easy to understand? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿Su {entrenador laboral} le explica cosas de una manera fácil de entender? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

How often does your {job coach} listen carefully to you? Would you say . . .

Never,

Sometimes,

Usually, or

Always?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

EM18. ¿Con qué frecuencia su {entrenador laboral} lo(a) escucha con atención? ¿Diría que…?

Nunca

A veces

Casi siempre

Siempre

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Alternate Version: Does your {job coach} listen carefully to you? Would you say . . .

Mostly yes, or,

Mostly no?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

Versión Alternativa: ¿Su {entrenador laboral} lo(a) escucha con atención? ¿Diría que…?

En general, sí

En general, no

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Does your {job coach} encourage you to do things for yourself if you can?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

EM19. ¿Su {entrenador laboral} lo(a) anima a hacer cosas sin ayuda si usted puede hacerlas?

SÍ

NO SABE

REFUSED

RESPUESTA POCO CLARA

How would you rate the help you get from your {job coach}? Would you say . . .

Excellent,

Very good,

Good,

Fair, or

Poor?

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

EM20. ¿Cómo calificaría la ayuda que recibe de su {entrenador laboral}? ¿Diría que es…?

Excelente

Muy buena

Buena

Regular

Mala

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

ABOUT YOU

sobre usted

Now I just have a few more questions about you.

Ahora tengo unas cuantas preguntas sobre usted.

In general, how would you rate your overall health? Would you say . . .

Excellent,

Very good,

Good,

Fair, or

Poor?

75. En general, ¿cómo calificaría toda su salud? ¿Diría que…?

Excelente

Muy buena

Buena

Regular

Mala

[IF NECESSARY, ASK, AND VERIFY IF OVER THE PHONE] Are you male or female?

MALE

FEMALE

76. [IF NECESSARY, ASK, AND VERIFY IF OVER THE PHONE] ¿Es usted hombre o mujer?

Hombre

Mujer

What is your age? (CM)

18 TO 24 YEARS [GO TO Q79]

25 TO 34 YEARS [GO TO Q79]

35 TO 44 YEARS [GO TO Q79]

45 TO 54 YEARS [GO TO Q79]

55 TO 64 YEARS [GO TO Q79]

65 TO 74 YEARS [GO TO Q79]

75 YEARS OR OLDER [GO TO Q79]

DON’T KNOW

REFUSED [GO TO Q79]

UNCLEAR RESPONSE

77. ¿Qué edad tiene?

ENTRE 18 Y 24 Años [GO TO Q86]

ENTRE 25 Y 34 Años [GO TO Q86]

ENTRE 35 Y 44 Años [GO TO Q86]

ENTRE 45 Y 54 Años [GO TO Q86]

ENTRE 55 Y 64 Años [GO TO Q86]

ENTRE 65 Y 74 Años [GO TO Q86]

75 Años O MÁS [GO TO Q86]

NO SABE

SE NEGÓ A CONTESTAR [GO TO Q86]

RESPUESTA POCO CLARA

[IF NO ANSWER TO Q77, ASK] In what year were you born?

_____________ (YEAR)

78. [IF NO ANSWER TO Q78, ASK] ¿En qué año nació?

_____________ (Año)

Are you of Hispanic or Latino origin or descent? (CM)

YES, HISPANIC OR LATINO

NO, NOT HISPANIC OR LATINO

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

79. ¿Es de origen o ascendencia hispana o latina?

Sí, hispano(A) o latino(A)

No, ni hispano(A) ni latino(A)

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

What is your race? You may choose one or more of the following. Would you say you are . . .

White

Black or African-American

Asian

Native Hawaiian or other Pacific Islander

American Indian or Alaska Native

OTHER

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

80. ¿A qué raza pertenece? Puede escoger una o más de las siguientes. ¿Diría que es…?

Blanco(a)

Negro(a) o afroamericano(a)

Asiático(a)

Nativo(a) de Hawai o de otras islas del Pacifico

Indígena americano(a) o nativo(a) de Alaska

OTRO

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Have you ever served as a member of the Armed Forces of the United States—such as the Army, Navy, Air Force, Marines, Coast Guard—in either an active duty, guard, or reserve capacity?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

81. ¿Alguna vez ha pertenecido a las fuerzas armadas de los Estados Unidos, como el Ejército, la Armada, la Fuerza Aérea, los Infantes de Marina o los Guardacostas, ya sea en el servicio activo, en la guardia o en la reserva?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Have you actively participated in any armed conflicts as a member of the Armed Forces? For example, did you serve in World War two, Korea, Vietnam, Grenada, Panama, Desert Storm, or Operation Iraqi Freedom?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

82. ¿Ha participado en algún conflicto armado como miembro de las fuerzas armadas? Por ejemplo, prestó sus servicios en la Segunda Guerra Mundial, en la Guerra de Corea, en la Guerra de Vietnam, en el Conflicto de Panamá, en la Operación Tormenta del Desierto o en la Operación de Liberación de Iraq?

SÍ

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

Are you currently categorized as a disabled veteran? [IF NECESSARY, ASK] Do you receive or are able to receive any medical or dental care from the U.S. Department of Veterans Affairs for your service related to a disability?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

83. ¿Lo clasifican en este momento como veterano discapacitado? [IF NECESSARY, ASK] ¿Recibe o puede recibir atención médica o dental del Departamento de Asuntos de Veteranos de los Estados Unidos por el servicio que prestó y que tiene que ver con su discapacidad?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

[ENGLISH VERSION]: What language do you mainly speak at home? Would you say…

English, [GO TO Q85]

Some other language, or

Both English and some other language?

DON’T KNOW [GO TO Q85]

REFUSED [GO TO Q85]

UNCLEAR RESPONSE [GO TO Q85]

84. What other language do you speak? ________________________________

[SPANISH VERSION]: What language do you mainly speak at home? Would you say . . .

English,

Spanish,

Both English and Spanish, or

Some other language Which one? _____________________

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

84. [SPANISH VERSION]: ¿Qué idioma habla usted principalmente en casa? ¿Diría que…?

Inglés

Español

Ambos: inglés y español

Español y otro idioma

Otro idioma ¿Cuál? _____________________

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

[IF NECESSARY, ASK] Do you live with any family members?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

85. [IF NECESSARY, ASK] ¿Vive con familiares?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

[IF NECESSARY, ASK] Do you live with people who are not family or are not related to you?

YES [GO TO Q88]

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

86. [IF NECESSARY, ASK] ¿Vive con personas que no son de su familia ni tienen ningún parentesco con usted?

SÍ  [PASE A LA PREGUNTA 88]

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

[IF NECESSARY, ASK] Do you live alone?

YES

DON’T KNOW

REFUSED

UNCLEAR RESPONSE

87. [IF NECESSARY, ASK] ¿Vive solo(a)?

SÍ

NO SABE

SE NEGÓ A CONTESTAR

RESPUESTA POCO CLARA

WAS THE RESPONDENT ABLE TO GIVE VALID RESPONSES?

YES

88. ¿EL ENTREVISTADO PUDO DAR RESPUESTAS VÁLIDAS?

SÍ

WAS ANY ONE ELSE PRESENT DURING THE INTERVIEW?

YES

NO [END SURVEY]

89. ¿ESTUVO ALGUNA OTRA PERSONA PRESENTE DURANTE LA ENTREVISTA?

SÍ

NO  [END SURVEY]

WHO WAS PRESENT DURING THE INTERVIEW? (MARK ALL THAT APPLY.)

SOMEONE NOT PAID TO PROVIDE SUPPORT TO THE RESPONDENT

STAFF OR SOMEONE PAID TO PROVIDE SUPPORT TO THE RESPONDENT

90. ¿QUIÉN ESTUVO PRESENTE DURANTE LA ENTREVISTA? (MARQUE TODAS LAS OPCIONES QUE CORRESPONDAN)

ALGUIEN A QUIEN NO SE LE PAGA PARA QUE LE PROPORCIONE APOYO AL ENTREVISTADO

UN MIEMBRO DEL PERSONAL O ALGUIEN A QUIEN SE LE PAGA PARA QUE LE PROPORCIONE APOYO AL ENTREVISTADO

DID SOMEONE HELP THE RESPONDENT COMPLETE THIS SURVEY?

YES

NO [END SURVEY]

91. ¿ALGUIEN LE AYUDÓ AL ENTREVISTADO A RESPONDER ESTA ENCUESTA?

SÍ

NO  [END SURVEY]

HOW DID THAT PERSON HELP? (MARK ALL THAT APPLY.)

ANSWERED ALL THE QUESTIONS FOR RESPONDENT

RESTATED THE QUESTIONS IN A DIFFERENT WAY OR REMINDED/ PROMPTED THE RESPONDENT

TRANSLATED THE QUESTIONS OR ANSWERS INTO THE RESPONDENT’S LANGUAGE

HELPED WITH THE USE OF ASSISTIVE OR COMMUNICATION EQUIPMENT SO THAT THE RESPONDENT COULD ANSWER THE QUESTIONS

OTHER, SPECIFY__________________________

92. ¿CÓMO LE AYUDÓ ESA PERSONA? MARQUE TODAS LAS OPCIONES QUE CORRESPONDAN.

RESPONDIÓ A TODAS LAS PREGUNTAS POR EL ENTREVISTADO

FORMULÓ LAS PREGUNTAS DE DIFERENTE MANERA O LE RECORDÓ / LE DIO PISTAS AL ENTREVISTADO

TRADUJO LAS PREGUNTAS O RESPUESTAS AL IDIOMA DEL ENTREVISTADO

AYUDÓ MEDIANTE EL USO DE UN EQUIPO DE ASISTENCIA O DE COMUNICACIONES PARA QUE EL ENTREVISTADO PUDIERA RESPONDER A LAS PREGUNTAS

OTRA (ESPECIFIQUE)__________________________

WHO HELPED THE RESPONDENT? (MARK ALL THAT APPLY.)

SOMEONE NOT PAID TO PROVIDE SUPPORT TO THE RESPONDENT

STAFF OR SOMEONE PAID TO PROVIDE SUPPORT TO THE RESPONDENT

93. ¿QUIÉN LE AYUDÓ AL ENTREVISTADO? (MARQUE TODAS LAS OPCIONES QUE CORRESPONDAN)

ALGUIEN A QUIEN NO SE LE PAGA PARA QUE LE PROPORCIONE APOYO AL ENTREVISTADO

UN MIEMBRO DEL PERSONAL O ALGUIEN A QUIEN SE LE PAGA PARA QUE LE PROPORCIONE APOYO AL ENTREVISTADO

HCBS Experience Survey Page 4 of 135

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Home and Community Based Services Experience Survey
Author	Thomson Reuters;American Institutes for Research
File Modified	0000-00-00
File Created	2021-01-30

Form CMS-10389 Attachment B Survey Instruments

Home and Community-Based Services (HCBS) Experience Survey

Attachement B_Survey_Instruments_9_18_12

Home and Community-Based Services (HCBS) Experience Survey

OMB: 0938-1186

Contents

Instructions

INSTRUCTIONS FOR VENDOR

INSTRUCTIONS FOR INTERVIEWER

INTRODUCTION

COGNITIVE SCREENING QUESTIONS

IDENTIFICATION QUESTIONS

Primary Survey-English language

SERVICES AND SUPPORTS FROM PERSONAL ASSISTANT AND BEHAVIORAL STAFF

GETTING NEEDED SERVICES FROM PERSONAL ASSISTANT AND BEHAVIORAL HEALTH STAFF

HOW WELL PERSONAL ASSISTANT AND BEHAVIORAL HEALTH STAFF COMMUNICATE AND TREAT YOU

SERVICES AND SUPPORT FROM HOMEMAKERS

GETTING NEEDED SERVICES FROM HOMEMAKERS

HOW WELL HOMEMAKERS COMMUNICATE AND TREAT YOU

YOUR CASE MANAGER

CHOOSING YOUR SERVICES

TRANSPORTATION

PERSONAL SAFETY

COMMUNITY INCLUSION AND EMPOWERMENT

SUPPLEMENTAL EMPLOYMENT MODULE

ABOUT YOU

Contents

Instructions

INSTRUCTIONS FOR VENDOR

INSTRUCTIONS FOR INTERVIEWER

INTRODUCTION

INTRODUCTION

COGNITIVE SCREENING QUESTIONS

COGNITIVE SCREENING QUESTIONS

IDENTIFICATION QUESTIONS

PREGUNTAS DE IDENTIFICACIóN

SERVICES AND SUPPORTS FROM PERSONAL ASSISTANT AND BEHAVIORAL STAFF

SERVICIOS Y SISTEMAS DE APOYO DE LOS AUXILIARES DE CUIDADOS PERSONALES y el personal de salud mental

GETTING NEEDED SERVICES FROM PERSONAL ASSISTANT AND BEHAVIORAL HEALTH STAFF

Obtención de los servicios necesarios de parte de los auxiliares de cuidados personales y del personal de salud mental

HOW WELL PERSONAL ASSISTANT AND BEHAVIORAL HEALTH STAFF COMMUNICATE AND TREAT YOU

SERVICES AND SUPPORT FROM HOMEMAKERS

GETTING NEEDED SERVICES FROM HOMEMAKERS

Obtención de los servicios necesarios de los ayudantes de oficios domésticos

HOW WELL HOMEMAKERS COMMUNICATE AND TREAT YOU

Qué tan bien se comunican con usted los ayudantes de oficios domésticos y qué tan bien lo(a) tratan

YOUR CASE MANAGER

CHOOSING YOUR SERVICES

la elección de sus servicios

TRANSPORTATION

TRANSPORTE

PERSONAL SAFETY

seguridad personal

COMMUNITY INCLUSION AND EMPOWERMENT

comunidad y empoderamiento

SUPPLEMENTAL EMPLOYMENT MODULE

MÓDULO COMPLEMENTARIO SOBRE EMPLEO

ABOUT YOU

sobre usted