Form 2 Telephone Demographic Questions

APPENDIX 1A REVISED

(October, 2012)

TELEPHONE Questions

customer service and demographics questions –

TEXT AND SCREENSHOTS

DATA COLLECTION INSTRUMENTS and

electronic contact Record Form (ECRF)

Electronic Coding Records Form (ECRF): seen within the Service Tab

Spanish Version

Electronic Coding Records Form (ECRF): seen within the Service Tab

Customer Service Questions

Customer Service Questions Asked of CIS Client:

1. Have you used our service before?

2. How did you find our number to call?

3. What is your zip code?

Demographic Survey Text Questions

What is your age?

Age

Don’t know

What is your Sex?

Male

Female

Which of These Ethnicities Best Describes You?

Hispanic or Latino

Not Hispanic or Latino

Which of These Races Best Describes You? You can select more than one:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

What Is the Highest Level of Education You Have Completed?

Grade school

Some high school

High school graduate

Some college

College graduate

Post-graduate

Not sampled

Refusal

Did not ask

Don’t know

Did not complete

Is There a Place You Usually Go to When You are Sick or Need Advice About Your Health?

Yes

No

Don't Know

Did not complete

Not sampled

Refused

Did not ask

What Kind of Place Do You Go Most Often?

A doctor’s office

A clinic, health center, or hospital clinic

The emergency room, or

Some other place

No one place

Valid skip

Don’t know

Did not complete

Not sampled

Refused

Did not ask

In the Last 12 Months, Did You Have Any Kind of Healthcare Coverage, Including Health Insurance, Prepaid Plans Such As HMOs or Government Plans Such as Medicare?

Yes

No

Don’t know

Did not complete

Not sampled

Refused

Did not ask

Would You Say You Had This Coverage During All 12 Months or Less Than 12 Months?

All 12 months

Less than 12 months

Valid skip

Don’t know

Did not complete

Not sampled

Refused

Did not ask

Which Type of Coverage Did You Have?

Was it public, such as Medicare, Medicaid, or other government plans?

Was it private, such as an HMO, Blue Cross, Kaiser, Aetna?

Or, was it both public and private?

Valid skip

Don’t know

Did not complete

Not sampled

Refused

Did not ask

The final questions are about your family income. I understand that this is sensitive information and I would like to stress again that all of the information you provide is confidential. What Was Your Total Household Income from All Sources Before Taxes Last Year? Just Stop Me When I Get to the Right Category

Less than $10,000

$10,000 to $19,000

$20,000 to $29,000

$30,000 to $39,000

$40,000 to $59,000

$60,000 to $79,000

$80,000 or more

Don’t know

Did not complete

Not sampled

Refused

Including Yourself, How Many People Living in Your Household are Supported by This Total Household Income?

Total People

Valid skip

Don’t know

Did not complete

Not sampled

Refused

Did not ask

Demographic Survey Screen Shots

Note: The Information Specialist only asks callers their age. The other radio buttons are only for internal coding.

Note: The Information Specialist only asks callers their gender. The other radio buttons are only for internal coding.

Note: The Information Specialist only asks callers whether they are Hispanic or Latino or Not Hispanic or Latino. The other radio buttons are only for internal coding.

Note: The Information Specialist only asks callers their heritage (first 5 options). The other radio buttons are only for internal coding.

Note: The Information Specialist only asks callers their level of education. The other radio buttons are only for internal coding.

Note: The Information Specialist only asks callers if there is a specific place they go to for medical advice. The other radio buttons are only for internal coding.

Note: The Information Specialist only asks callers where they go for medical advice. The other radio buttons are only for internal coding.

Note: The Information Specialist only asks callers if they have healthcare coverage including health insurance, prepaid plans such as HMOs, or government plans such as Medicare. The other radio buttons are only for internal coding.

Note: The Information Specialist only asks callers whther or not the have had coverage for 12 months or less than 12 months. The other radio buttons are only for internal coding.

Note: The Information Specialist only asks callers what type of coverage they have/had. The other radio buttons are only for internal coding.

Note: The Information Specialist only asks callers their income range. The other radio buttons are only for internal coding.

Note: The Information Specialist only asks callers how many people live in their household that are supported by their total household income. The other radio buttons are only for internal coding.

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