Stage 1 36-month Survey

BOND Implementation and Evaluation

Contract No. SS00-10-60011

Benefit Offset National Demonstration
Stage 1 36-Month Follow-up Survey Instrument

Reviewer Note:


In programming, we will address text modifications to allow for PROXY ADMINISTRATION as
shown in A1-A7.



We need to update the SGA amount references throughout to reflect 2014 amounts when
available.



Throughout, questions preceded by * indicate that they are not asked if the respondent is a proxy.



, questions preceded by * indicate that they are not asked if the respondent is a proxy.

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Table of Contents

SECTION A: CONFIRMATION OF RESPONDENT / SCREENER / INTRODUCTIONS ..... 2
SECTION B: EDUCATION AND TRAINING......................................................................... 7
SECTION C: CURRENT EMPLOYMENT STATUS............................................................ 11
SECTION D: BARRIERS TO EMPLOYMENT .................................................................... 28
SECTION E: INCOME ........................................................................................................ 32
SECTION F: HEALTH AND FUNCTIONAL STATUS......................................................... 37
SECTION G: HEALTH INSURANCE .................................................................................. 42
SECTION H: FINANCIAL HARDSHIP ................................................................................ 43
SECTION I:

PERSONAL CHARACTERISTICS ................................................................ 46

SECTION J:

RESPONDENT CONTACT INFORMATION ................................................. 48

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Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507,
as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these
questions unless we display a valid Office of Management and Budget control number. The OMB control
number for this information collection is [0960-0785], expiring [February 28, 2014]. We estimate that it will take
about 49 minutes to read the instructions, gather the facts, and answer the questions. You may send
comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.

SECTION A: CONFIRMATION OF RESPONDENT / SCREENER /
INTRODUCTIONS
NOTE TO INTERVIEWER: DO NOT READ TEXT IN ALL CAPS.
Hello, my name is _________ I work for Mathematica Policy Research, a national research company
based in Princeton, New Jersey. Thank you for taking the time to speak with me today. You may have
received a letter in the past week or so that explained about this interview.
IF TREATMENT GROUP: we are conducting a study for the Social Security Administration. The study is
about a new program that they are trying called the Benefit Offset National Demonstration or BOND. You
may recall receiving letters from SSA about this program beginning in 2011.
IF CONTROL GROUP: we are conducting a study for the Social Security Administration to find out more
about the experiences of people receiving Social Security Disability Benefits. We are interviewing many
disability beneficiaries across the country as part of this study.
At this time, we’d like to have you participate in an interview. [IF TELEPHONE: At the end of the
interview, I will send you a check for $25 to thank you for your time. You should receive it within a month]
[IF IN-PERSON: At the end of the interview, I will give you a $25 money order to thank you for your time.]
The purpose of this interview is to learn more about the types of jobs you and other people who receive
Social Security disability benefits may have, and in any schooling or job training you may have
participated in over the past 3 years. We are also interested in learning whether or not you have worked
with a benefits counselor over the past 3 years.
Your participation in this study is completely voluntary. It will in no way affect your current or future
receipt of benefits. You can stop the interview at any time. If any question makes you feel
uncomfortable, you can refuse to answer that question.
All information you provide is confidential and it will be protected to the fullest extent possible by law,
including the Privacy Act. By law, we may need to notify someone if keeping that information confidential
could harm you or someone else. Three groups of people will see your answers: the interviewer, the
researchers doing the study, and the Social Security Administration that funded the study. Your name will
not be attached to your survey answers in the data files used by these groups. Answering the questions
in this survey will not affect any disability benefits you receive now, or may receive in the future. Your
name will never appear in any report. Research reports will only present summary information. The
researchers will not use names or individual identifying information in any research report.
Do you have any questions before we begin?
IF YES: Interviewer respond to questions as they arise.
If NO: Alright then, do you mind if we start the interview now? It should take approximately 49
minutes..

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REVIEWER NOTE: There is also a screener to verify the identity of the respondent that begins by
checking birth date and continues by checking other data (perhaps name of informant) if
interviewer cannot verify birth date. To simplify review, verification screeners have been removed
from this draft.
Screeners vary depending upon:
 if a proxy is needed; or
 if there is a language barrier.
* INDICATES QUESTIONS THAT WILL NOT BE ASKED OF PROXIES.

A1.

[Are you currently/Is (s/)he] working at a job or business for pay or profit? This includes work you
may do for a business that you own.
IF NEEDED READ: By ‘working at a job for pay or profit’ we mean at a job where you get paid
money for the work you do.
[INTERVIEWER: IF R IS SELF-EMPLOYED, CODE RESPONSE AS YES]
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

A2.

[Are you currently/Is (s/)he]currently enrolled in school or taking any classes?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

A3.

[Do you/Does (s)/he] currently do any volunteer work for an organization?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

A4.

In general, would you say [your/his/her] health is . . .

(SF-12)

Excellent,................................................................................................ 1
Very good, .............................................................................................. 2
Good, ..................................................................................................... 3
Fair, or .................................................................................................... 4

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Poor? ...................................................................................................... 5
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

A5.

Compared to {THIS MONTH, LAST YEAR}, how would you rate [your/his/her] health in general
now?
Much better now,.................................................................................... 1
Somewhat better now, ........................................................................... 2
About the same, ..................................................................................... 3
Somewhat worse now, or ....................................................................... 4
Much worse now? .................................................................................. 5
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

A6.

What is [your/his/her] current marital status? [Are you/Is (s)/he] now married, widowed, divorced,
separated or have you never been married?
MARRIED............................................................................................... 1
WIDOWED ............................................................................................. 2
DIVORCED ............................................................................................ 3
SEPARATED ......................................................................................... 4
NEVER MARRIED ................................................................................. 5
REFUSED .............................................................................................. 7 (SKIP TO SECT B)
DON’T KNOW ........................................................................................ 8 (SKIP TO SECT B)

A7.

[Are you/Is (s)/he] currently living with a spouse or with someone who is like a spouse to
[you/him/her]?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

A8.

PROGRAMMER: CHECK FOR ABILITY TO CONTINUE WITH SELF-RESPONSE. HOW MANY
ITEMS IN QUESTIONS A1-A7 ARE ANSWERED REFUSED OR DON’T KNOW?
1 OR 2 .................................................................................................... 1
3 OR MORE ........................................................................................... 2

(SKIP TO SECT B)

[INSTRUCTION: IF RESPONDENT FAILS SCREENER, CATI/CAPI WILL PROMPT FOR NAME OF A
PROXY RESPONDENT. IF PROXY IS AVAILABLE SCREENERS WILL REPEAT WITH PROXY. IF NO
PROXY AVAILABLE INTERVIEWER WILL TERMINATE]

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A9.

Contract No. SS00-10-60011

It seems like some of these questions are difficult for you. Is there anyone who can help do this
interview with you or answer questions for you?
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (THANK/END)
REFUSED .............................................................................................. 7 (THANK/END)
DON’T KNOW ........................................................................................ 8 (THANK/END)

A10.

A9a.

What is his/her first name?

A9b.

What is his/her middle name?

A9c.

What is his/her last name?

A9d.

Does his/her name have a suffix?

What is (his/her) street address?
A10a. Is there a complex/building name?
A10b. Is there an apartment number?
A10c.

In what city?

A10d. In what state?
A10e. What is the zip code?

A11.

What's the best phone number to reach (him/her) at starting with the area code?
Telephone # with area code: (_______) ________-________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

A12.

Is she/he a friend or a relative, or what is (his/her) relationship to you?
ACCEPT ONE RESPONSE ONLY.
FRIEND .................................................................................................. 1
RELATIVE .............................................................................................. 2
LEGAL GUARDIAN................................................................................ 3
CASE MANAGER .................................................................................. 4
OTHER (SPECIFY):____________________________ ...................... 5
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

PROXY. INTERVIEWER- NOTE IF A PROXY IS COMPLETING THE SURVEY:

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1 – YES, PROXY IS COMPLETING INTERVIEW
2 – NO, BENEFICIARY IS COMPLETING INTERVIEW

IF PROXY=1:
DISPLAY: Thank you for agreeing to help [INTERVIEWER: INSERT BENEFICIARY’S NAME].
(IF NECESSARY/CONTACTING PROXY AT A LATER TIME): Hello, my name is _________, and I work
Mathematica Policy Research, in Princeton, New Jersey. Thank you for taking the time to speak with me
today.
We are conducting a study for the Social Security Administration. As part of this study, we will interview
thousands of people who currently receive Social Security Disability Benefits. The study is about a new
program that they are administering called the Benefit Offset National Demonstration or BOND. As part
of this study, we are interviewing many disability beneficiaries across the country.
[BENEFICIARY’S NAME] was selected to participate in this interview.
When we attempted to complete this survey previously, it was determined that it would be helpful to have
someone knowledgeable about his/her work experience, health, and disability benefits complete the
survey on their behalf. [BENEFICIARY NAME] suggested that you would be a good person to help
complete this survey.
The purpose of this study is to learn about his/her past work experience and future work goals he/she
may have. We will also ask some questions about his/her health. Your and his/her participation in this
interview is completely voluntary. It will in no way affect his/her current or future receipt of benefits. You
can stop the interview at any time. If any question makes you feel uncomfortable, you can refuse to
answer that question.
Do you have any questions about the survey before we begin?
IF YES: Interviewer respond to questions as they arise.
IF NO: Alright then, do you mind if we start the interview now? It should take approximately 49
minutes. At the end of the interview I will [send [beneficiary] a check for $25 to thank you
for your time.])

PROGRAMMER: LOOP BACK TO A1 AND REPEAT A1-A7 WITH THE PROXY BEFORE
CONTINUING SURVEY.

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SECTION B: EDUCATION AND TRAINING
I would like to continue by talking about your education and training experiences

Return to Work Activities—Education and Training
B1.

What is the highest grade in school that you have completed?
INTERVIEWER: ENTER HIGHEST GRADE COMPLETED IN SPACE PROVIDED FOR GRADE.
IF BEYOND GRADE 12, SELECT APPROPRIATE CODE.
KINDERGARTEN OR PRE-KINDERGARDEN ..................................1
1st GRADE...........................................................................................2
2nd GRADE ..........................................................................................3
3rd GRADE ..........................................................................................4
4th GRADE ..........................................................................................5
5th
GRADE ...........................................................................................6
th
6 GRADE ..........................................................................................7
7th GRADE ..........................................................................................8
8th GRADE ..........................................................................................9
9th GRADE ........................................................................................10
10th GRADE ......................................................................................11
11th GRADE ......................................................................................12
12th GRADE ......................................................................................13
SOME COLLEGE/SOME POSTSECONDARY VOCATIONAL
COURSES ......................................................................................14
2-YEAR OR 3-YEAR COLLEGE DEGREE (ASSOCIATE’S
DEGREE) OR VOCATIONAL SCHOOL DIPLOMA .....................15
4-YEAR COLLEGE DEGREE (BACHELOR’S DEGREE) ...............16
SOME GRADUATE WORK/NO GRADUATE DEGREE ..................17
GRADUATE OR PROFESSIONAL DEGREE
(e.g., MA, MBA, Ph.D., J.D., M.D.) .................................................18
NEVER ATTENDED SCHOOL .........................................................19
SPECIAL EDUCATION WITH NO CERTIFICATE OF
COMPLETION ................................................................................20
SPECIAL EDUCATION WITH A CERTIFICATE OF
COMPLETION ................................................................................21
DON’T KNOW ...................................................................................98
REFUSED .........................................................................................99

B1a.

Do you have a high school diploma or a GED? (INTERVIEWER: IF “YES”, CLARIFY
FOR HIGH SCHOOL DIPLOMA OR GED.)
YES, HIGH SCHOOL DIPLOMA ........................................................1
YES, GED ...........................................................................................2

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YES, BOTH .........................................................................................3
NO, NEITHER .....................................................................................4
DON’T KNOW .....................................................................................8
REFUSED ...........................................................................................9

B2.

PROGRAMMER: B2=YES IF A2=1 (SAMPLE MEMBER IS CURRENTLY ENROLLED IN
SCHOOL OR TAKING ANY CLASSES). IF A2=NO, REFUSED, DK, CODE B2 ACCORDINGLY
AND SKIP TO B6.
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO B6)
REFUSED .............................................................................................. 7 (SKIP TO B6)
DON’T KNOW ........................................................................................ 8 (SKIP TO B6)

B3.

Are you working toward a degree, a certificate or license, or are you just taking classes?
WORKING TOWARD DEGREE ............................................................ 1
WORKING TOWARD CERTIFICATE/ LICENSE .................................. 2
ONLY TAKING CLASSES ..................................................................... 3 (SKIP TO B6)
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

B4.

Toward what type of {degree/certificate or license} are you working?
GED OR HIGH SCHOOL EQUIVALENCE PROGRAM/COURSES ..... 1
VOCATIONAL OR TRAINING PROGRAM ........................................... 2
ASSOCIATE DEGREE PROGRAM (AA DEGREE) .............................. 3
UNDERGRADUATE DEGREE PROGRAM (BA, BS DEGREE) ........... 4
GRADUATE DEGREE PROGRAM (e.g., MA, MS, MD, EdD) .............. 5
OTHER_________________________________ ................................ 6
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

B5.

Are you a full-time or part-time student?
FULL-TIME............................................................................................. 1
PART-TIME ............................................................................................ 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

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B6.

Contract No. SS00-10-60011

Now I would like to ask you about any [other] training you may have had since [RADATE].
[SINCE RADATE], have you done any additional schooling or other type of training program that
lasted at least two weeks and that was designed to help you find a job, improve your job skills, or
learn a new job?
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO C1)
REFUSED .............................................................................................. 7 (SKIP TO C1)
DON’T KNOW ........................................................................................ 8 (SKIP TO C1)

B7.

[IF CURRENTLY IN TRAINING A2=1 Not including the program(s) you already told me about,
how many other school or training programs have you done since [RADATE]?
[IF NOT CURRENTLY IN TRAINING A2=2] Altogether, how many school or training programs
have you gone to since [RADATE]?
_______# PROGRAMS
REFUSED .............................................................................................-2 (SKIP TO C1)
DON’T KNOW .......................................................................................-1 (SKIP TO C1)

QUESTIONS B8-B11 ARE REPEATED FOR EACH EPISODE OF EDUCATION/TRAINING REPORTED IN B7, TO
COLLECT DETAILED INFORMATION ABOUT EACH SPELL OF EDUCATION OR TRAINING RECEIVED SINCE
RANDOM ASSIGNMENT. CATI/CAPI PROGRAMMING WILL ALLOW FOR UP TO 5 SPELLS OF EDUCATION
AND TRAINING.

B8.

You said that you have gone to [Number of trainings from B6] education or training programs
since [RADATE]. Beginning with the most recent program, please tell me the name of the
program you went to
NAME 1___________________________________________________________
B8a.

What is the name of the next training program you went to?
NAME 2___________________________________________________________
NAME 3___________________________________________________________
NAME 4___________________________________________________________
NAME 5___________________________________________________________

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IF B7>5 THEN TAKE 5 MOST RECENT PROGRAMS.
B9.

Think about [TRAINING PROGRAM NAME1…5], what kind of schooling or training [is/was] that?
REGULAR HIGH SCHOOL, DIRECTED TOWARD A HS DIPLOMA ... 1
PREPARATION FOR A GED EXAM ..................................................... 2
2-YEAR COLLEGE DIRECTED TOWARD A DEGREE ........................ 3
4-YEAR COLLEGE DIRECTED TOWARD A DEGREE ........................ 4
GRADUATE COURSES ........................................................................ 5
COLLEGE COURSES NOT DIRECTED TOWARD A DEGREE .......... 6
VOCATIONAL EDUCATION OUTSIDE A COLLEGE (BUSINESS or
TECHNICAL SCHOOLS, EMPLOYER OR UNION-PROVIDED
TRAINING, AND MILITARY TRAINING IN VOCATIONAL BUT
NOT MILITARY SKILLS OR JTPA ...................................................... 7
NON-VOCATIONAL ADULT EDUCATION NOT DIRECTED
TOWARD A DEGREE (BASIC EDUCATION, LITERACY TRAINING,
ENGLISH AS A SECOND LANGUAGE .............................................. 8
JOB SEARCH ASSISTANCE, JOB FINDING, ORIENTATION
TO THE WORLD OF WORK ............................................................... 9
OTHER (SPECIFY) __________________________________ ........ 96
REFUSED ............................................................................................ 97
DON’T KNOW ...................................................................................... 98

B10.

Since [RADATE], how many weeks have you gone to [TRAINING PROGRAM NAME1…5]?
NUMBER OF WEEKS: ______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

B11.

During those weeks, how many hours a week did you usually spend in [TRAINING PROGRAM
NAME 1…5]?
NUMBER OF HOURS: _______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

REPEAT B8-B11 FOR EACH PROGRAM NAME LISTED IN B7

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SECTION C: CURRENT EMPLOYMENT STATUS
These next questions are about your current work activities.
C1.

PROGRAMMER: CHECK A1 IS SAMPLE MEMBER CURRENTLY WORKING AT A JOB OR
BUSINESS FOR PAY OR PROFIT? CARRY RESPONSE FROM A1 HERE
YES ........................................................................................................ 1 (SKIP TO C4)
NO .......................................................................................................... 2

C2.

Now I’d like you to think about the last four weeks. Have you been looking for work during the
last four weeks?
IF NEEDED READ: By looking for work, I mean looking for a job, either full-time or part-time, for
which you will be paid.
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

C3.

When did you last work for pay at a job for at least one month? INTERVIEWER PROBE FOR
MONTH AND YEAR
|__|__|
MO

|__|__|__|__|
YEAR

REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1
IF RESPONDENT INDICATES THAT HE/SHE IS CURRENTLY WORKING IN C3, CATI/CAPI PROBE:
‘I’m sorry, I must have entered something incorrectly. [CHECK QUESTION A1].

IF A1=2,7,8 (not employed) SKIP TO C26

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[ASK ONLY OF THOSE EMPLOYED (A1=1)] Now I am going to ask some questions about the jobs you
currently have. When answering these questions, please include both part-time and full-time jobs, but
only include jobs you work at for pay or profit. This could be work you do for a business that you own.
(NBS modified)

C4.

How many jobs do you currently have?
NUMBER OF JOBS: ______________ (RANGE 1-6)
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C5.

Now I have a few questions about your [current/main] job. [IF MORE THAN ONE JOB [C4>1]
READ: Your main job is the job where you work the most hours]. What kind of business or
industry is this? That is, what do they make or do where you work? (RECORD VERBATIM)
(CPS/MTO modified)
_________________________________________
_________________________________________
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

C6.

What kind of work do you do? That is, what is your occupation? For example, plumber, typist,
farmer [RECORD VERBATIM] (CPS/MTO modified)
_________________________________________
_________________________________________
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

C7.

What are your usual duties or activities at this job? For example: typing, keeping account books,
filing, selling cars, operating printing press, laying brick. [RECORD VERBATIM] (CPS/MTO
modified)
_________________________________________
_________________________________________
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

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C8.

Contract No. SS00-10-60011

Are you self-employed at this job? (NBS)
PROBE: Self-employed means that you work for yourself or own your own business.
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

C9.

Is this job a temporary or seasonal job? (NEW)
A Temporary job is one in which a person is hired to meet the short-term and/or project needs of
an employer. Temporary help has come to be used across a broad range of skills and
occupations to substitute for employees on leave, on vacation, or in emergencies, or to provide
supplemental support where there are temporary skills shortages or specific projects or peak load
needs.
A seasonal job is one in which a person is hired to support existing staff during a busy season—
such as holiday help or summer work.
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

C10.

In what month and year did you start working there?
IF SELF-EMPLOYED [C8=1] ASK:
In what month and year did you start this business? (NBS: Modified)
INTERVIEWER: ENTER MONTH HERE AND YEAR ON NEXT SCREEN
PROBE: Your best estimate is fine.
|__|__|
MO

|__|__|__|__|
YEAR

REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1
For this study, we need some information on how much often you work and how much you are paid on
this job. Please remember that we will keep all of your responses private.

C11.

How many hours per week do you typically work at this job?
NUMBER OF HOURS PER WEEK: ______________
REFUSED .............................................................................................-2

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DON’T KNOW .......................................................................................-1
[Programming in CATI/CAPII will control for main job versus current job, depending on the
response to C4.]

C12.

Before taxes and other deductions how much are you paid on this job? (NBS-modified)
$___________.______
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C12a. Is that amount paid hourly, daily, weekly, bi-weekly, twice a month, monthly, annually, or
per unit?
HOURLY ................................................................................................ 1
DAILY ..................................................................................................... 2
WEEKLY ................................................................................................ 3
EVERY TWO WEEKS............................................................................ 4
TWICE A MONTH .................................................................................. 5
MONTHLY.............................................................................................. 6
ANNUALLY ............................................................................................ 7
PER UNIT OR PIECE ............................................................................ 8
REFUSED ............................................................................................ 97
DON’T KNOW ...................................................................................... 98

C13.

How many days a week do you usually work? (CPS; MTO Interim Evaluation)
NUMBER OF DAYS PER WEEK: ______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C14.

How many weeks a year do you get paid for? (CPS; MTO Interim Evaluation)
NUMBER OF WEEK: ______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

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C15.

Contract No. SS00-10-60011

[ASK IF RATE OF PAY IS PER UNIT (C12A=8) ELSE SKIP TO C16] For how many [UNIT]s are
you usually paid per week (on this job)?
NUMBER OF UNITS: ______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C16.

[ASK IF RATE OF PAY HOURLY (C12A=1) ELSE SKIP TO C17] How many hours per week
are you paid for at this rate? (CPS; MTO Interim Evaluation)
NUMBER OF HOURS PER WEEK: ______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C17.

Do you usually receive tips, or commissions (at your main job)? (CPS–modified)
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO C18)
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

C17a. (At your main job,) how much do you usually earn in tips or commissions, before taxes or
other deductions? (CPS-modified)
Enter dollar amount

$___________.______
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Do not read to respondent Enter periodicity
1 Per hour
2 Per day
3 Per week
4 Per month
5 Per year
6 Other

C18.

I’d like you to think about your earnings in a typical week. How much do you typically earn,
before taxes or other deductions, in a typical week at this job?

Abt Associates Inc.

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Contract No. SS00-10-60011

PROBE: Your best estimate is fine.
$___________.______
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1
C19.

I’d like you to think about the past year. Have you received any promotions at this job during the
past year?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

C19a. I’d like you to think about the past year. Have you received any bonuses or awards at
this job during the past year?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Abt Associates Inc.

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C20.

Contract No. SS00-10-60011

(IF SELF EMPLOYED [C8=1], SKIP TO C21). Now, I’d like to ask you a few more questions
about your current job. I am going to read to you a list of benefits that some employers offer their
employees. Please tell me whether or not your current employer offers you any of these benefits.
Does your employer offer you or your co-workers…
PROGRAMMER: USE “MAIN” IF C4>01, OTHERWISE USE “CURRENT.”
IF NECESSARY READ: Please answer ‘yes’ if you are eligible for the benefit even if you haven’t
started to receive it yet. (NBS-Modified)
YES

NO

REF

DK

C20a. Health care insurance? (IF NECESSARY:
medical and/or hospital)

1

2

7

8

C20b. Dental benefits?

1

2

7

8

C20c. Sick days with pay?

1

2

7

8

C20d. Paid vacation?

1

2

7

8

C20e. Free or low-cost childcare?

1

2

7

8

1

2

7

8

C20g. Long-term disability benefits?

1

2

7

8

C20h. Pension or retirement benefits?

1

2

7

8

C20i.

Short-term disability benefits?

1

2

7

8

C20j.

Flexible health or dependent care spending accounts?

1

2

7

8

C20f.

C21.

Transportation, a transportation allowance, or
transportation discounts?

Now I have a few questions about your work related expenses, including transportation to work.
During the typical week, how do you get to work?
Did you drive, ride in someone else's vehicle, take public transportation, use some combination,
or some other way?
ENTER ALL THAT APPLY. READ IF NECESSARY
DRIVE OWN VEHICLE .......................................................................... 1
RIDE IN SOMEONE ELSE'S VEHICLE/VAN POOL ............................. 2
PUBLIC TRANSPORTATION (BUS, TRAIN, SUBWAY, ETC.) ............ 3
WALK OR BICYCLE .............................................................................. 4
SOME OTHER WAY (SPECIFY) ........................................................... 5
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Abt Associates Inc.

(SKIP TO C21B)
(SKIP TO C21C)
(SKIP TO C21C)
(SKIP TO C21c)
(SKIP TO C21c)
(SKIP TO C21c)

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C21a. Altogether, about how many miles per week do you usually drive your vehicle as part of
your work commute?
____ MILES PER WEEK
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C21b. Do you have to pay for parking or tolls as a part of your work-commuting expenses?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

C21c. During a typical week, about how much are your work commuting expenses?

$ ______ PER WEEK
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C22.

Not counting expenses your employer paid, do you have any work-related expenses such as
licenses, permits, union dues, special tools, or uniforms for your work?
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO C23)
REFUSED .............................................................................................. 7 (SKIP TO C23)
DON’T KNOW ........................................................................................ 8 (SKIP TO C23)
C22a. Altogether, how much do you spend for such items?
$ _____________________________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

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Is that per….
Week ...................................................................................................... 1
Every other week ................................................................................... 2
Month ..................................................................................................... 3
Quarter ................................................................................................... 4
Year ........................................................................................................ 5
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

C23.

During the last four months, did you or your family pay for any child care arrangements for your
child(ren) while you worked? Include cost of preschool and nursery school; but do not include
tuition for private kindergarten or grade school.
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO C24)
NO CHILDREN/NOT APPLICABLE....................................................... 3
REFUSED .............................................................................................. 7 (SKIP TO C24)
DON’T KNOW ........................................................................................ 8 (SKIP TO C24)
C23a. How much do you pay for child care while you work?
$ _____________________________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1
Is that per…
WEEK ..................................................................................................... 1
EVERY OTHER WEEK .......................................................................... 2
MONTH .................................................................................................. 3
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

C24.

Do you use any special equipment related to your disability that helps you work at your job, for
example a brace, cane, wheelchair, modified computer hardware or modified computer software?
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO C25)
REFUSED .............................................................................................. 7 (SKIP TO C25)
DON’T KNOW ........................................................................................ 8 (SKIP TO C25)

Abt Associates Inc.

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Contract No. SS00-10-60011

C24a. What kinds of special equipment do you/ use? Anything else?
FORMAT EACH ITEM SO THAT THE VALUES ARE 0=NOT SELECTED; 1=SELECTED
ENTER ALL THAT APPLY. READ IF NECESSARY
BRACE ................................................................................................... 1
CANE/CRUTCHES/WALKER ................................................................ 2
WHEELCHAIR ....................................................................................... 3
MODIFIED COMPUTER HARDWARE .................................................. 4
MODIFIED COMPUTER SOFTWARE .................................................. 5
OTHER (SPECIFY) ................................................................................ 6
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8
C24b. Who pays or paid for the equipment you use?
PROBE: For example, you or your family, insurance or Medicaid, or someone else?
ENTER ALL THAT APPLY. READ IF NECESSARY
SELF ...................................................................................................... 1
FAMILY .................................................................................................. 2
HEALTH INSURANCE ........................................................................... 3
MEDICARE ............................................................................................ 4
MEDICAID.............................................................................................. 5
EMPLOYER ........................................................................................... 6
STATE VOCATIONAL REHABILITATION AGENCY ............................ 7
NON-PROFIT ORGANIZATION ..............................................................
SERVING PEOPLE WITH DISABILITIES .......................................... 8
WORKER’S COMPENSATION ............................................................. 9
DISABILITY INSURANCE ................................................................... 10
OTHER (SPECIFY) .............................................................................. 11
REFUSED ............................................................................................ 97
DON’T KNOW ...................................................................................... 98

Abt Associates Inc.

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Contract No. SS00-10-60011

C24c. ASK IFC24b = SELF OR FAMILY: How much do/did you or your family have to pay?
READ IF NECESSARY: Is that a one-time payment, per week, per month, per year, or some
other time period?
$_______________________________________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1
ONE TIME PAYMENT.. .............................................................. .......... 1
PER WEEK ........................................................................................... 2
PER MONTH ..................................................................... ....................3
PER YEAR.......... ............................................................... ................... 4
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

C25.

Do you use any personal assistance services related to your/his/her disability that helps you
work, for example, a job coach, a sign language interpreter, a reader or interpreter for the blind,
or a personal care attendant?
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO C26)
REFUSED .............................................................................................. 7 (SKIP TO C26)
DON’T KNOW ........................................................................................ 8 (SKIP TO C26)

C25a. What kind of personal assistance services do you use? Anything else?
ENTER ALL THAT APPLY. READ IF NECESSARY
JOB COACH.......................................... ................................................1
SIGN LANGUAGE INTERPRETER. ...................................................... 2
READER/INTERPRETER FOR THE BLIND ........................................ 3
PERSONAL CARE ATTENDANT/PERSONAL ASSISTANT ................ 4
OTHER (SPECIFY) ................................................................................ 5
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Abt Associates Inc.

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C25b. Who pays for the personal assistance services you use?
PROBE: For example, you or your family/ insurance or Medicaid, or someone else?
ENTER ALL THAT APPLY. READ IF NECESSARY
SELF ...................................................................................................... 1
FAMILY .................................................................................................. 2
HEALTH INSURANCE ........................................................................... 3
MEDICARE ............................................................................................ 4
MEDICAID.............................................................................................. 5
EMPLOYER ........................................................................................... 6
STATE VOCATIONAL REHABILITATION AGENCY ............................ 7
NON-PROFIT ORGANIZATION ..............................................................
SERVING PEOPLE WITH DISABILITIES .......................................... 8
WORKER’S COMPENSATION ............................................................. 9
DISABILITY INSURANCE ................................................................... 10
OTHER (SPECIFY) .............................................................................. 11
REFUSED ............................................................................................ 97
DON’T KNOW ...................................................................................... 98

C25c. ASK IFC25b = SELF OR FAMILY: How much do/did you or your family have to pay?
READ IF NECESSARY: Is that a one-time payment, per week, per month, per year, or some
other time period?
$________________________________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

ONE TIME PAYMENT.. .............................................................. .......... 1
OR
PER WEEK ........................................................................................... 2
PER MONTH ..................................................................... ....................3
PER YEAR.......... ............................................................... ................... 4
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Abt Associates Inc.

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C26.

Contract No. SS00-10-60011

Next, I would like to ask you about different types of services or supports that you may have
received to improve your ability to work. For each service I read, please tell me if it is
something you have used since [RADATE], if you needed, but did not use it, or if you did not
need it. [NBS modified]
Yes
Used

Not
Used

Not
Needed

REF

DK

C26a. A work or job assessment?

1

2

3

7

8

C26b. Help to find a job?

1

2

3

7

8

C26c. Training to learn a new job or skill?

1

2

3

7

8

C26d. Advice about modifying your job or work
place?

1

2

3

7

8

C26e. On-the-job training, job coaching, or
support services?

1

2

3

7

8

C26f. Personal care assistance?

1

2

3

7

8

C26g. Transportation assistance?

1

2

3

7

8

C26h. Help in keeping a job?

1

2

3

7

8

C26i. Any kind of assistive device (a piece of
equipment to make it easier for you to live
independently or work?

1

2

3

7

8

C26j. Anything else that I did not mention?
SPECIFY__________________________

1

2

3

7

8

Since [RADATE] did you get…

C27.

[IF C26g=YES ASKC27 ELSE SKIP TO C28] I’d like to know more about the type of
transportation assistance you received. Did the transportation assistance you received include
assistance in transportation costs such as bus tokens or subway passes?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

C27a. Did it (also) include aid for a specific purpose such as modifying an existing vehicle to be
more accessible?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Abt Associates Inc.

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C28.

Contract No. SS00-10-60011

[FOR EACH YES IN C26a-hASK:] How many hours of service did you receive in total, over the
past 3 years?
NUMBER OF HOURS OF SERVICE [C26 ACTIVITY]: ______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C29.

C30.

[IF C26c = YES, ASK C29; ELSE IF C26E = YES, SKIP TO C31; ELSE IF A1=1, SKIP TO C33;
ELSE SKIP TO C35.] Where did you go to receive the training to learn a new job or skill? Did you
go to . . .
Yes

No

REF

DK

C29a. A vocational rehabilitation agency?

1

2

7

8

C29b. A welfare agency?

1

2

7

8

C29c. A mental health agency?

1

2

7

8

C29d. A workforce center or unemployment office

1

2

7

8

C29e. Your employer

1

2

7

8

C29f. Other state agency?

1

2

7

8

C29g. OTHER(SPECIFY:_______________)

1

2

7

8

Who referred you to place(s) that you went for training or to learn a new job skill?
INTERVIEWER: MARK ONLY ONE. IF R INDICATES IT WAS THEIR IDEA CODE WAS NOT
REFERRED HERE.
PARENT/GUARDIAN............................................................................. 1
SPOUSE/PARTNER .............................................................................. 2
FRIEND .................................................................................................. 3
JOB COACH .......................................................................................... 4
EMPLOYER/SUPERVISOR .................................................................. 5
OTHER RELATIVE ................................................................................ 6
BENEFIT SPECIALIST .......................................................................... 7
MEDICAL PROVIDER ........................................................................... 8
WAS NOT REFERRED BY ANYONE ................................................... 9
OTHER (SPECIFY____________________________________) ..... 10
REFUSED ............................................................................................ 97
DON’T KNOW ...................................................................................... 98

[IF C26e=YES, ASK C31 ELSE SKIP TO C33]

Abt Associates Inc.

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C31.

C32.

Contract No. SS00-10-60011

Where did you go or who provided the on the job training, job coaching, or support services?
C31a. A vocational rehabilitation agency?

1

2

7

8

C31b. A welfare agency?

1

2

7

8

C31c. A mental health agency?

1

2

7

8

C31d. A workforce center or unemployment office

1

2

7

8

C31e. Your employer

1

2

7

8

C31f. Other state agency?

1

2

7

8

C31g. OTHER(SPECIFY:_______________)

1

2

7

8

Who referred you to place(s) that you went for on-the-job training, job coaching, or support
services?
INTERVIEWER: MARK ONLY ONE.
IF R INDICATES IT WAS THEIR IDEA CODE WAS NOT REFERRED BY ANYONE.
PARENT/GUARDIAN............................................................................. 1
SPOUSE/PARTNER .............................................................................. 2
FRIEND .................................................................................................. 3
JOB COACH .......................................................................................... 4
EMPLOYER/SUPERVISOR .................................................................. 5
OTHER RELATIVE ................................................................................ 6
BENEFIT SPECIALIST .......................................................................... 7
MEDICAL PROVIDER ........................................................................... 8
WAS NOT REFERRED BY ANYONE ................................................... 9
OTHER (SPECIFY____________________________________) ..... 10
REFUSED ............................................................................................ 97
DON’T KNOW ...................................................................................... 98

Abt Associates Inc.

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Contract No. SS00-10-60011

UNEMPLOYED RESPONDENTS (A1=2,7,8) SKIP TO C35

C33.

[IF SELF-EMPLOYED (C8=1) SKIP TO C34] Please tell me whether or not your {main/current}
employer has made any accommodations because of your physical or mental condition. Has
your employer ... (NBS-modified)

NO

NOT
NEEDED

REF

DK

C33a.

Provided you with any special equipment or
assistive technology

1

2

3

7

8

C33b.

Kept your job available to you, even though you
have to go out on disability from time to time?

1

2

3

7

8

C33c.

Arranged for co-workers or others to help you
when you need it?
Provided you with any modified computer
hardware?
Provided you with any modified computer
software?
Made any other changes that I didn’t mention to
accommodate your condition in the workplace?
(SPECIFY:_______________)

1

2

3

7

8

1

2

3

7

8

1

2

3

7

8

1

2

3

7

8

C33d.
C33e.
C33f.

C34.

YES

* Taking all things into account, how satisfied are you with your [main/current] job? Would you
say you are:
PROGRAMMER: USE “MAIN” IF C4>01, OTHERWISE USE “CURRENT.”
Very satisfied ......................................................................................... 1
Somewhat satisfied ............................................................................... 2
Not very satisfied ................................................................................... 3
Not at all satisfied? ................................................................................ 4
REFUSED ............................................................................................ 97
DON’T KNOW ...................................................................................... 98

Abt Associates Inc.

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Contract No. SS00-10-60011

ASK ALL RESPONDENTS
C35.

Now, I would like to ask you some questions about how you usually spend your time. In an
ordinary week, about how many hours do you spend in each of these activities:
[INTERVIEWER: IF NONE, ENTER 0. IF LESS THAN 1, ENTER 1]
Number of
Hours per Week

C36.

C35a.

Working in a job for which you are paid?

|__|__|__|

C35b.

Doing unpaid work at a family business?

|__|__|__|

C35c.

(if C37a orC37b >0) Commuting to and from work?

|__|__|__|

C35d.

In volunteer work for an organization?

|__|__|__|

C35e.

In school, working toward a degree, or in a training program?

|__|__|__|

C35f.

In home-making or home maintenance activities including caring for
others, housekeeping, food preparation, yard work or house repairs?

|__|__|__|

C35g.

In personal health care and self grooming activities?

|__|__|__|

[IF A3 = 1 OR C35d>0, ASK C36, ELSE SKIP TO D1] Did any of the volunteer or unpaid work
we just discussed lead you to a paid job?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Abt Associates Inc.

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Contract No. SS00-10-60011

SECTION D: BARRIERS TO EMPLOYMENT
Personal Views
Now I am going to read you a few statements. I’m going to ask whether or not you agree with each one.
Please remember that there is no right or wrong answer, the questions are simply asking what you think
about each one.
D1.

* For the following statements, please tell me whether you strongly agree, agree, neither agree
nor disagree, disagree, or strongly disagree. (NBS modified)
Agree

Neither
Agree Nor
Disagree

Disagree

Strongly
Disagree

NA

REF

DK

1

2

3

4

5

6

7

8

D1b. I am limited in my ability to
work because I do not have
reliable transportation to and
from work.

1

2

3

4

5

6

7

8

D1c. I am limited in my ability to
work because I am caring for
children or others

1

2

3

4

5

6

7

8

D1d. It is difficult for me to work
because I am afraid I will lose
my disability benefits

1

2

3

4

5

6

7

8

D1e. I am limited in my ability to
work because I am finishing a
school or training program

1

2

3

4

5

6

7

8

1

2

3

4

5

6

7

8

D1g. I don’t have the skills or
training I need to return to
work.

1

2

3

4

5

6

7

8

D1h. It will be difficult to re-qualify
for Social Security disability
benefits in the future if I work.

1

2

3

4

5

6

7

8

Strongly
Agree
D1a. I am limited in my ability to
work because of a physical or
mental condition.

D1f.

Many workplaces are not
accessible to people with my
disability

Now I am going to read you a few statements. I’m going to ask whether or not you agree with each one.
Please remember that there is no right or wrong answer, the questions are simply asking what you think
about each one.
D2.

* Do your personal goals include [IF A1=2] getting a job], moving up in a job or learning new job
skills?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Abt Associates Inc.

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D3.

Contract No. SS00-10-60011

Are you currently receiving Social Security disability benefits?
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO D4)
REFUSED .............................................................................................. 7 (SKIP TO D4)
DON’T KNOW ........................................................................................ 8 (SKIP TO D4)

*D3a.

Do your personal goals include someday working and earning enough to stop receiving
Social Security disability benefits?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Awareness of Features of Bond Program
D4. * Before today, had you ever heard of the Benefit Offset National Demonstration, or the BOND
program?
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO D5)
REFUSED .............................................................................................. 7 (SKIP TO D5)
DON’T KNOW ........................................................................................ 8 (SKIP TO D5)

D4a.

* [IF D4=YES] If asked, how would you describe the BOND program to a friend or
relative? [RECORD VERBATIM]
_____________________________________________________________
_____________________________________________________________

INTERVIEWER READS THIS INTRODUCTION: Under the current rules of the Social Security Disability
Insurance program, disability beneficiaries are allowed to earn up to $1040 per month without a change to
your benefits. This limit is called the level of Substantial Gainful Activity or SGA and the Social Security
increases this limit each year to adjust for inflation. When disability beneficiaries go to work while
receiving disability benefits, SSA ignores the cap of $1040 for up to 9 months, no matter how much a
beneficiary earns from work.

Abt Associates Inc.

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Contract No. SS00-10-60011

D5. * We’d like to know which of the following things you think would happen to your monthly
disability cash benefits if you were to work and earn more than the SGA limit of $1040 month
after those initial months have passed. Thinking about the amount of your disability cash
benefits, if you earned more than $1,000 after those initial months…
*D5a.

Do you think you would lose your monthly benefits completely? That is, would the
amount of your benefits fall to $0?
YES ........................................................................................................ 1 (SKIP TO D6)
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

D5b.

* Do you think your benefits would be reduced but that you would be able to keep
receiving some of your monthly disability benefits?
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO D5d)
REFUSED .............................................................................................. 7 (SKIP TO D5d)
DON’T KNOW ........................................................................................ 8 (SKIP TO D5d)

D5c.

* [IF D5b=YES] How do you think those benefits would be reduced? Do you think that
they would be reduced…
By the full amount of your benefit? ....................................................... 1
By half of the amount of your benefits, that is a $1 reduction in benefits
for every $2 you earn from work? .......................................................... 2
By some other amount? ........................................................................ 3
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

D5d.

(SKIP TO D6)
(SKIP TO D6)
(SKIP TO D6)
(SKIP TO D6)
(SKIP TO D6)

*[ASK IF D5b=2,8,9] Do you think your disability benefits would stay the same? That is,
nothing would happen to your monthly disability benefits if you earned more than $1040
per month after the initial nine months that SSA allows?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Abt Associates Inc.

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D6.

Contract No. SS00-10-60011

Now, we’d like to know which of the following things you think would happen to your eligibility for
disability benefits if you were to work and earn more than the SGA limit of $1040 month after
those initial months have passed. Thinking about your eligibility for disability benefits…
D6a.

* Do you think you would remain eligible for disability benefits in the future, no matter how
much you earn from work? That is, you would never have to re-apply for benefits?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

D6b.

* Do you think you would remain eligible for disability benefits for awhile, but eventually
you would no longer be eligible to receive benefits? That is, do you think eventually you
would have to re-apply for benefits?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Abt Associates Inc.

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Contract No. SS00-10-60011

SECTION E: INCOME
I’m going to ask you about the income you personally received last month, that is, in [INSERT LAST
MONTH, THIS YEAR]. This includes income and benefits from different programs. When answering
these questions, please think only about your own earnings and benefits, and don’t include earnings
or benefits that other family members may have received.
E1.

IF D3=1, ASK, OTHERWISE, SKIP TO E2A
E1a.

You just told me you get income from Social Security (or SSDI). How much do you get
each month?
INTERVIEWER: ROUND TO NEAREST DOLLAR
$___________.______ (SKIP TO E2)
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

E1b.

Was it more than or less than $300?
$300 OR MORE ..................................................................................... 1
LESS THAN $300 .................................................................................. 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

E2.

(In addition to your Social Security or SSDI, last/ Last) month did you receive any income from…
[READ EACH SOURCE. IF RESPONDENT VOLUNTEERS ‘I ONLY GET SSDI or SOCIAL
SECURITY’ SKIP TO E4
YES

NO

REF

DK

E2a. Veterans’ benefits?

1

2

7

8

E2b. Public assistance or welfare payments?

1

2

7

8

E2c. Workers’ compensation?

1

2

7

8

E2d. Private disability insurance?

1

2

7

8

E2e. Unemployment benefits?

1

2

7

8

E2f. Private pensions or government employee pensions?

1

2

7

8

E2g. Disability insurance for a Disabled adult child?

1

2

7

8

E2h. Other sources on a regular basis but not from jobs or
Social Security?

1

2

7

8

E2i. Other sources not on a regular basis?

1

2

7

8

E2j. IF VOLUNTEERED BY RESPONDENT: SSDI ONLY

1

2

7

8

Abt Associates Inc.

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E3.

Contract No. SS00-10-60011

How much income did you receive last month from {SOURCE FROM F2}?
INTERVIEWER: ROUND TO NEAREST DOLLAR
$___________.______ (GO TO E2 FOR NEXT SOURCE OR E4 IF NO OTHER
SOURCES OF INCOME)
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1 (ASK E2a)

E3a.

Was it more than or less than $300?
$300 OR MORE ..................................................................................... 1 (SKIP TO E2b)
LESS THAN $300 .................................................................................. 2 (SKIP TO E2c)
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

E3b

Was it more than or less than $500?
$500 OR MORE ..................................................................................... 1
LESS THAN $500 .................................................................................. 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

GO TO E2 FOR NEXT SOURCE
OR E4

E3c.

Was it more than or less than $150?
$150 OR MORE ..................................................................................... 1
LESS THAN $150 .................................................................................. 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

GO TO E2 FOR NEXT SOURCE
OR E4

Abt Associates Inc.

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E4.

Contract No. SS00-10-60011

Did you or any member of your household receive SNAP benefits (Supplemental Nutrition
Assistance Program) or food stamps last month?
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO E5)
REFUSED .............................................................................................. 7 (SKIP TO E5)
DON’T KNOW ........................................................................................ 8 (SKIP TO E5)

E4a.

What was the dollar value of the SNAP benefit (Supplemental Nutrition Assistance
Program) or food stamps you received last month?
INTERVIEWER: ROUND TO NEAREST DOLLAR
$___________.______
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

E5.

Did you or any member of your household receive assistance from any other government
source? For example: energy assistance or child care assistance.
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO E8)
REFUSED .............................................................................................. 7 (SKIP TO E8)
DON’T KNOW ........................................................................................ 8 (SKIP TO E8)

E6.

What type of other assistance did you receive?
______________________________________________________
REFUSED ............................................................................................ 97
DON’T KNOW ...................................................................................... 98

E7.

How much income did you receive last month from this other assistance? (INCLUDE INCOME
FROM ALL OTHER SOURCES LISTED IN E6)
INTERVIEWER: ROUND TO NEAREST DOLLAR
$___________.______
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

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E8.

Contract No. SS00-10-60011

Do you currently receive any governmental housing assistance in paying rent, such as through
public housing or Section 8 or a Housing Choice Voucher? (HOPE VI, MTO)
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

E9.
INTERVIEWER CHECK: IF EITHER A6 OR A7 = 1, ASK E9a. OTHERWISE, SKIP TO E10.
These next two questions are about your spouse/partner’s work activity during the last calendar year.
E9a.
Did your spouse (or partner) work during the last calendar year?
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO E10)
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

E9b.

How much did your spouse earn from work last year?
ENTER DOLLAR AMOUNT: $___________.______
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Now I’d like you to think about the income of all members in your household.

E10.

What was the total combined income of all members of this household during the [LAST
CALENDAR YEAR]? Please include money from jobs, work on the side, welfare, SSI, help from
your family and friends, and any other money income received by you or any other household
member. (Effects of Housing Choice Vouchers on Welfare Families)
ENTER DOLLAR AMOUNT: $___________.______ ............................ (SKIP TO F1)
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1
E10a. Would it amount to $10,000 or more?
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO E10e)
REFUSED .............................................................................................. 7 (SKIP TO E10e)
DON’T KNOW ........................................................................................ 8 (SKIP TO E10e)

Abt Associates Inc.

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Contract No. SS00-10-60011

E10b. Would it amount to $20,000 or more?
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO E10d)
REFUSED .............................................................................................. 7 (SKIP TO E10d)
DON’T KNOW ........................................................................................ 8 (SKIP TO E10d)

E10c.

Would it amount to $25,000 or more?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

(SKIP TO F1)

E10d. Would it amount to $15,000 or more?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

(SKIP TO F1)

E10e. Would it amount to $5,000 or more?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Abt Associates Inc.

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Contract No. SS00-10-60011

SECTION F: HEALTH AND FUNCTIONAL STATUS
The next few questions ask about your health and how well you are able to do your usual activities.
As I read each item, please tell me if your health now limits you a lot, limits you a little, or does not limit
you at all in these activities.

F1.

Does your health now limit you in moderate activities such as moving a table, pushing a vacuum
cleaner, bowling, or playing golf? Does it limit you…

(SF-12)

A lot, ...................................................................................................... 1
A little, or ............................................................................................... 2
Not at all? ............................................................................................... 3

F2.

Does your health now limit you in climbing several flights of stairs? Does it limit you…

(SF-12)

A lot, ...................................................................................................... 1
A little, or ............................................................................................... 2
Not at all? ............................................................................................... 3

The next two questions ask about your physical health and your daily activities.

F3.

* During the past 4 weeks, how much of the time have you accomplished less than you would
have liked to as a result of your physical health? Would you say…

(SF-12)

All of the time, ........................................................................................ 1
Most of the time,..................................................................................... 2
Some of the time, ................................................................................... 3
A little of the time, or .............................................................................. 4
None of the time? ................................................................................... 5

F4.

During the past 4 weeks, how much of the time were you limited in the kind of work or other
regular daily activities you do as a result of your physical health? Would you say…

(SF-12)

All of the time, ........................................................................................ 1
Most of the time,..................................................................................... 2
Some of the time, ................................................................................... 3
A little of the time, or .............................................................................. 4
None of the time? ................................................................................... 5

Abt Associates Inc.

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Contract No. SS00-10-60011

Now I will ask about any emotional problems and your daily activities.

F5.

* During the past 4 weeks, how much of the time have you accomplished less than you would
have liked to as a result of any emotional problems, such as feeling depressed or anxious?
Would you say…

(SF-12)

All of the time, ........................................................................................ 1
Most of the time,..................................................................................... 2
Some of the time, ................................................................................... 3
A little of the time, or .............................................................................. 4
None of the time? ................................................................................... 5

F6.

* During the past 4 weeks, how much of the time did you not do work or other activities as
carefully as usual as a result of any emotional problems, such as feeling depressed or anxious?
Would you say…

(SF-12)

All of the time, ........................................................................................ 1
Most of the time,..................................................................................... 2
Some of the time, ................................................................................... 3
A little of the time, or .............................................................................. 4
None of the time? ................................................................................... 5

F7.

* During the past 4 weeks, how much did pain interfere with your normal work, including both
work outside the home and housework? Did it interfere.

(SF-12)

Not at all, ................................................................................................ 1
A little bit, ................................................................................................ 2
Moderately, ............................................................................................ 3
Quite a bit, or.......................................................................................... 4
Extremely? ............................................................................................. 5

These next questions are about how you feel and how things have been with you during the past 4
weeks. For each question, please give me the one answer that comes closest to the way you have been
feeling.

F8.

* During the past 4 weeks, how much of the time have you felt calm and peaceful? Would you
say…

(SF-12)

All of the time, ........................................................................................ 1
Most of the time,..................................................................................... 2
Some of the time, ................................................................................... 3
A little of the time, or .............................................................................. 4
None of the time? ................................................................................... 5

Abt Associates Inc.

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F9.

Contract No. SS00-10-60011

* During the past 4 weeks, how much of the time did you have a lot of energy? Would you say…

(SF-12)

All of the time, ........................................................................................ 1
Most of the time,..................................................................................... 2
Some of the time, ................................................................................... 3
A little of the time, or .............................................................................. 4
None of the time? ................................................................................... 5

F10.

* During the past 4 weeks, how much of the time have you felt downhearted and depressed?
Would you say…

(SF-12)

All of the time, ........................................................................................ 1
Most of the time,..................................................................................... 2
Some of the time, ................................................................................... 3
A little of the time, or .............................................................................. 4
None of the time? ................................................................................... 5

F11.

* During the past 4 weeks, how much of the time has your physical health or emotional problems
interfered with your social activities, like visiting with friends or relatives? Would you say…

(SF-12)

All of the time, ........................................................................................ 1
Most of the time,..................................................................................... 2
Some of the time, ................................................................................... 3
A little of the time, or .............................................................................. 4
None of the time? ................................................................................... 5

Health Care Service Utilization
Now I’d like you to think about the past 12 months, that is since [interview month last year].
F12.

During the past 12 months, have you stayed overnight in a hospital? (HCC)
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO F14)
REFUSED .............................................................................................. 7 (SKIP TO F14)
DON’T KNOW ........................................................................................ 8 (SKIP TO F14)

F13.
During the past 12 months, how many nights in total did you stay in the hospital?
(HCC)
|__|__| TIMES
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

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Contract No. SS00-10-60011

Now I’d like to ask some general health related questions.

F14.

How tall are you without shoes? (NHIS 97)
IF NECESSARY READ: Please respond in feet and inches?
|__| FEET
(3-8)

|__|__| INCHES
(1-11)

REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

F15.

How much do you weigh without shoes? (NHIS97)
|__|__|__| POUNDS (50-600)
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Now I’d like to ask you some questions about everyday activities and how much difficulty you have doing
these activities. Please give me your best answer even if the questions don’t seem to apply to you.

F16.

Do you need help with personal care such as bathing, dressing, or getting around the house
because of an impairment or a physical or mental health problem?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

F17.

During the past 12 months, about how many days did illness or an injury keep you in bed more
than half of the day? (Please include days that you were an overnight patient in a hospital.)
NUMBER OF DAYS ____________________
NONE ..................................................................................................... 0
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

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F18.

Contract No. SS00-10-60011

Do you need the help of another person in order to get around inside your home?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

F19.

Do you need the help of another person in order to get around outside your home?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

F20.

* [ASK IF PROXY=2] Do you have a lot of trouble concentrating long enough to finish everyday
tasks?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

F21.

*[ASK IF PROXY=2] Do you have a lot of trouble coping with day-to-day stresses?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Abt Associates Inc.

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Contract No. SS00-10-60011

SECTION G: HEALTH INSURANCE
Now, I’m going to ask you about different types of health insurance coverage you might have.

G1. Do you have health insurance coverage now?
(HCC)
[INTERVIEWER: PROBE IF NECESSARY: “For instance, are you covered by a plan that
someone else in your family has, or through a health plan your employer provides, or Medicare,
Medicaid, or a plan you bought on your own?”]
YES ....................................................................................................... 1 (SKIPTO G3)
NO ......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

G2. So, you are uninsured, is that correct?
(HCC)
[INTERVIEWER: PROBE IF NECESSARY: “This means no Medicaid coverage or any other
government sponsored health insurance coverage.”]
YES ....................................................................................................... 1 (SKIPTO H1)
NO ......................................................................................................... 2
REFUSED .............................................................................................. 7 (SKIPTO H1)
DON’T KNOW ........................................................................................ 8 (SKIPTO H1)

G3.

What kinds of health coverage do you have?
PROBE: Any other kind?
INTERVIEWER: CODE ALL THAT APPLY AS 0=NOT SELECTED, 1=SELECTED.
MEDICAID/{STATMED} ......................................................................... 1
MEDICARE ............................................................................................ 2
CHAMPUS/CHAMP-VA, TRICARE, VA, OTHER MILITARY ................ 3
INDIAN HEALTH SERVICE ................................................................... 4
MEDI-GAP ............................................................................................. 5
STATE PROGRAM ................................................................................ 6
PRIVATE INSURANCE THROUGH OWN EMPLOYER ....................... 7
PRIVATE INSURANCE THROUGH SPOUSE/PARTNER/PARENT .... 8
PRIVATE INSURANCE PAID BY SELF/FAMILY .................................. 9
PRIVATE DISABILITY INSURANCE PAID BY SELF/FAMILY ........... 10
OTHER PLAN (SPECIFY)_____________________ ......................... 95
REFUSED ............................................................................................ 97
DON’T KNOW ...................................................................................... 98

Abt Associates Inc.

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Contract No. SS00-10-60011

SECTION H: FINANCIAL HARDSHIP
The next set of questions asks about difficulties people sometimes have in meeting their essential
household expenses. Essential household expenses are things such as mortgage or rent payments,
utility bills, or important medical care. Please think about the past 12 months, that is sicne [interview
month last year], when responding to these questions.

H1.

During the past 12 months, has there been a time when you did not meet all of your essential
expenses?
IF NEEDED: Essential household expenses include such things as mortgage or rent payments,
utility bills or important medical care
.
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

H2.

I’m going to read a list of some specific difficulties people experience when they had difficulty
paying their household expenses. Was there any time in the past 12 months when you did not
pay the full amount of the rent or mortgage?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

H3.

In the past 12 months were you evicted from your home or apartment for not paying the rent or
mortgage?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

H4.

Was there a time in the past 12 months when you could not pay the full amount of the gas, oil, or
electricity bills?
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO H6)
REFUSED .............................................................................................. 7 (SKIP TO H6)
DON’T KNOW ........................................................................................ 8 (SKIP TO H6)

Abt Associates Inc.

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H5.

Contract No. SS00-10-60011

In the past 12 months did the gas or electric company turn off service, or the oil company not
deliver oil because you did not pay?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

H6.

Was there a time in the past 12 months when the telephone or cell phone company disconnected
service because you did not pay?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

H7.

I'm going to read you some statements that people have made about their food situation. For
these statements, please tell me whether it was often true, sometimes true, or never true for you
in the last twelve months.
“The food that I bought just didn't last and I didn't have money to get more." Was that often,
sometimes or never true for you in the last twelve months?
OFTEN TRUE ........................................................................................ 1
SOMETIMES TRUE ............................................................................... 2
NEVER TRUE ........................................................................................ 7
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

H8.

The next statement is: “I couldn't afford to eat balanced meals" Was that often, sometimes or
never true for you in the last twelve months?
OFTEN TRUE ........................................................................................ 1
SOMETIMES TRUE ............................................................................... 2
NEVER TRUE ........................................................................................ 7
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Abt Associates Inc.

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H9.

Contract No. SS00-10-60011

The next questions refer to adults in the household. In the past twelve months did you ever cut
the size of your meals or skip meals because there wasn't enough money for food?
YES ........................................................................................................ 1
NO .......................................................................................................... 2 SKIP to H11
REFUSED .............................................................................................. 7 SKIP to H11
DON’T KNOW ........................................................................................ 8 SKIP to H11

H10. [IF H9=1, ASK] How often did this happen—almost every month, some months but not every
month, or in only 1 or 2 months?
Almost every month ............................................................................... 1
Some months but not every month ........................................................ 2
Only 1 or 2 months ................................................................................. 3
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8
H11.

In the past twelve months, did you ever eat less than you felt you should because there wasn't
enough money to buy food?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

H12.

In the last 12 months, were you every hungry but didn't eat because there wasn't enough money
for food?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Abt Associates Inc.

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SECTION I:

Contract No. SS00-10-60011

PERSONAL CHARACTERISTICS

Demographics
I have a few more questions about you.
I1.

What is your ethnic background? Are you:
Hispanic or Latino, or ............................................................................. 1
Not Hispanic or Latino? .......................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

I2.

What is your race? Do you think of yourself as:
INTERVIEWER: CODE ALL THAT APPLY.
NO

REF

DK

I2a.

Alaska Native or American Indian

1

2

7

8

I2b.

Asian

1

2

7

8

I2c.

Black or African American

1

2

7

8

I2d.

Native Hawaiian or Other Pacific Islander

1

2

7

8

I2e.

White

1

2

7

8

I2f.

IF VOLUNTEERED: MULTIRACIAL (CLARIFY FOR
WHICH RACES AND MARK THOSE IN I2A-I2E AND
THEN MARK MULTIRACIAL)

1

2

7

8

OTHER (SPECIFY_______________)

1

2

7

8

I2g.

I3.

YES

What is the primary language spoken in your home?
ENGLISH ............................................................................................... 1
SPANISH ............................................................................................... 2
AMERICAN SIGN LANGUAGE ............................................................. 3
OTHER(SPECIFY__________________________) ............................ 4
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

I4.

PROGRAMMER: AUTOMARK I4 WITH RESPONDENT GENDER IN Z7:
MALE ..................................................................................................... 1
FEMALE ............................................................................................... 2

Abt Associates Inc.

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Contract No. SS00-10-60011

Current Living Situation
The next questions are about [your/ his/her] current living situation.
I5.

Thinking about the place you live, would you say that this place is a…
[INTERVIEWER: CODE ONE ANSWER.]
[IF RESPONDENT LIVES IN ONE UNIT WITHIN A TWO- OR THREE-FAMILY HOME, CODE
AS REGULAR APARTMENT (03).]
Single family home ................................................................................ 1
Mobile home. ......................................................................................... 2
Regular apartment ................................................................................ 3
Supervised apartment ........................................................................... 4
Group home .......................................................................................... 5
Halfway house........................................................................................ 6
Personal care or board and care home ................................................ 7
Assisted living facility ............................................................................. 8
Nursing or convalescent home .............................................................. 9
Shelter ................................................................................................. 10
Some other type of supervised group residence or facility .................. 11
Something else________________________________ .................... 12
REFUSED ............................................................................................ 97
DON’T KNOW ...................................................................................... 98

I6.

[ASK IF I5=4,5,6,7,8,9,11,97,98, ELSE SKIP TO I7] Is this place primarily for people with hearing
or vision impairments, mental illness psychiatric disabilities, mental retardation, or developmental
disabilities?
YES ........................................................................................................ 1
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

I7.

Not including yourself, how many other people live in your household with you now?
NUMBER OF PEOPLE____________________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

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Contract No. SS00-10-60011

SECTION J: RESPONDENT CONTACT INFORMATION
At this time we’d like to just confirm some information about you. The information we confirm now will
allow us to help us be able to get back in touch with you in the future. [It will also allow us to ensure that
your incentive payment is sent to the correct address.]
J1.

I have your name listed as [READ AND CONFIRM SPELLING OF NAME, FIRST MIDDLE LAST
SUFFIX]. Is that correct?
YES, ALL CORRECT ............................................................................. 1
NO, CORRECT FIRST NAME ............................................................... 2
NO, CORRECT MIDDLE NAME ............................................................ 3
NO, CORRECT LAST NAME ................................................................ 4
NO, CORRECT SUFFIX ........................................................................ 5
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

J2.

J3.

(SKIP TO J3)
(GO TO J2A)
(GO TO J2B)
(GO TO J2C)
(GO TO J2D)
(SKIP TO J3)
(SKIP TO J3)

Could you please tell me how to spell your name.?
J2a.

FIRST:

What is your first name?

J2b.

MIDDLE:

What is your middle name?

J2c.

LAST:

What is your last name?

J2d.

SUFFIX:

Is there anything after your last name, like Jr. or Sr.?

I would like to confirm your date of birth. I have your date of birth as [MM/DD/YYYY]. Is that
correct?
YES ........................................................................................................ 1 (SKIP TO J4)
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7 (SKIP TO J4)
DON’T KNOW ........................................................................................ 8 (SKIP TO J4)

J3a.

What is your date of birth?
____/____/________
MM DD
YYYY
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

Appendix A. BOND Stage 2 Baseline Survey Instrument

48

BOND Implementation and Evaluation

J4.

Contract No. SS00-10-60011

Our records show that your current address is (READ FROM SAMPLE SHEET). Is this correct?
YES, ALL OF THAT IS CORRECT)....................................................... 1
NO–UPDATE STREET .......................................................................... 2
NO–UPDATE APARTMENT/UNIT ........................................................ 3
NO–UPDATE CITY ............................................................................... 4
NO–UPDATE STATE............................................................................. 5
NO–UPDATE ZIP................................................................................... 6
NO–UPDATE TELEPHONE .................................................................. 7
REFUSED ............................................................................................ 97
DON’T KNOW ...................................................................................... 98

J5.

J4a.

STREET:

What is your current street address?

J4b.

APT:

Is there an apartment number?

J4c.

CITY:

In what city do you live?

J4d.

STATE:

In what state do you live?

J4e.

ZIP:

What is your zip code?

(SKIP TO J5)
(GO TO J4a)
(GO TO J4b)
(GO TO J4c)
(GO TO J4d)
(GO TO J4e)
(GO TO J5)
(SKIP TO J5)
(SKIP TO J5)

IF CAPI: Our records show your phone number as [AREA CODE/PHONE NUMBER]
IF CATI: I called you at [AREA CODE/PHONE NUMBER].
Is this the best number to reach you at?
YES ........................................................................................................ 1 (SKIP TO J7)
NO .......................................................................................................... 2
REFUSED .............................................................................................. 7 (SKIP TO J7)
DON’T KNOW ........................................................................................ 8 (SKIP TO J7)

J6.

What is your home phone number, starting with area code?
(____) _____-________
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Abt Associates Inc.

Appendix A. BOND Stage 2 Baseline Survey Instrument

49

BOND Implementation and Evaluation

J7.

Contract No. SS00-10-60011

Do you have a cell phone number?
YES ........................................................................................................ 1
NO .......................................................................................................... 2 (SKIP TO END)
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

J7a.

What is your cell phone number, starting with area code?
(____) _____-________
REFUSED .............................................................................................. 7
DON’T KNOW ........................................................................................ 8

Thank you very much for your time today
IF TELEPHONE: You can expect to receive your $25 check within 4 weeks.
IF IN-PERSON: Here is your $25 money order.

Abt Associates Inc.

Appendix A. BOND Stage 2 Baseline Survey Instrument

50