APPENDIX 1 A
DATA COLLECTION INSTRUMENTS and
electronic contact Record Form (ECRF)
TELEPHONE Questions
(customer service and demographics questions)
Public Burden Statement
Electronic Coding Records Form (ECRF): seen within the Service Tab
Spanish Version
Electronic Coding Records Form (ECRF): seen within the Service Tab
Customer Service Questions
Demographic Questions:
What is your age?
Age |
Don’t know |
Break off |
Did not complete |
Callers age 96 or older |
Not sampled |
Refusal |
Did not ask |
What is your Sex?
Male |
Female |
Don’t know |
Did Not Complete |
Not sampled |
Refusal |
Did not ask |
Which of These Ethnicities Best Describes You?
Hispanic or Latino |
Not Hispanic or Latino |
Don’t know |
Did not complete |
Not sampled |
Refusal |
Did not ask |
Which of These Races Best Describes You? You can select more than one:
American Indian or Alaska Native |
Asian |
Black or African American |
Native Hawaiian or Other Pacific Islander |
White |
Don’t know |
Did not complete |
Not sampled |
Refusal |
Did not ask |
What Is the Highest Level of Education You Have Completed?
Grade school |
Some high school |
High school graduate |
Some college |
College graduate |
Post-graduate |
Not sampled |
Refusal |
Did not ask |
Don’t know |
Did not complete |
Is There a Place You Usually Go to When You are Sick or Need Advice About Your Health?
Yes |
No |
Don't Know |
Did not complete |
Not sampled |
Refused |
Did not ask |
What Kind of Place Do You Go Most Often?
A doctor’s office |
A clinic, health center, or hospital clinic |
The emergency room, or |
Some other place |
No one place |
Valid skip |
Don’t know |
Did not complete |
Not sampled |
Refused |
Did not ask |
In the Last 12 Months, Did You Have Any Kind of Healthcare Coverage, Including Health Insurance, Prepaid Plans Such As HMOs or Government Plans Such as Medicare?
Yes |
No |
Don’t know |
Did not complete |
Not sampled |
Refused |
Did not ask |
Would You Say You Had This Coverage During All 12 Months or Less Than 12 Months?
All 12 months |
Less than 12 months |
Valid skip |
Don’t know |
Did not complete |
Not sampled |
Refused |
Did not ask |
Which Type of Coverage Did You Have?
Was it public, such as Medicare, Medicaid, or other government plans? |
Was it private, such as an HMO, Blue Cross, Kaiser, Aetna? |
Or, was it both public and private? |
Valid skip |
Don’t know |
Did not complete |
Not sampled |
Refused |
Did not ask |
The final questions are about your family income. I understand that this is sensitive information and I would like to stress again that all of the information you provide is confidential. What Was Your Total Household Income from All Sources Before Taxes Last Year? Just Stop Me When I Get to the Right Category
Less than $10,000 |
$10,000 to $19,000 |
$20,000 to $29,000 |
$30,000 to $39,000 |
$40,000 to $59,000 |
$60,000 to $79,000 |
$80,000 or more |
Don’t know |
Did not complete |
Not sampled |
Refused |
Including Yourself, How Many People Living in Your Household are Supported by This Total Household Income?
Total People |
Valid skip |
Don’t know |
Did not complete |
Not sampled |
Refused |
Did not ask |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | ilene Holly Burstyn |
File Modified | 0000-00-00 |
File Created | 2021-01-30 |