Form 2 Telephone Clients - Demographic Questions

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:

Top of Form

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