Form B1 Attachment B – Screening Questionnaire

Form Approved OMB No.

Exp. Date

Screener for MEPS

IN-PERSON TESTING 2017

INTRO

Hello [NAME OF RESPONDENT], my name is . I am calling on behalf of Westat, a research company in Rockville, Maryland. Westat is conducting a research project to test some survey questions about how you pay for any medical expenses you or your family may have. We want to get people’s reactions to the questions, which will help us figure out if we need to make changes to them. The in-person interview will take about 60 minutes and those who complete it will receive $60 cash.

Are you interested in participating?

No – THANK AND END (“Thank you anyway for your time today, and have a great day.”)

Yes – Great, thank you. Now I just need to ask a few questions to make sure that you meet the requirements of the study.

Verify

The interviews will be taking place at Westat’s headquarters, located off of Route 28 -- on Research Boulevard in Rockville, Maryland. Are you within driving or commuting distance of our location?

PROVIDE MORE INFO IF NEEDED: 1600 RESEARCH; NEAR THE CORNER OF RESEARCH AND GUDE DRIVE; 63 OR 54 BUS STOPS IN FRONT OF 1600; ETC.

1. Yes [GO TO Q1]

2. No, not within driving / commuting distance of Westat  THANK AND END (Thank you for taking the time to talk with me today. You are not eligible for this study. Have a great (day/evening)).

1. When was the last time you participated in a research focus group or interview?

2. LESS THAN 6 MONTHS AGO - THANK AND END

3. 6 MONTHS AGO OR MORE

4. NEVER

5. DK - ASK FOR BEST GUESS

6. REF - THANK AND END

ASK ONLY IF NOT OBVIOUS:

2. Are you male or female?

1. MALE

2. FEMALE

3. How old are you?

| | | Age DK/REF

IF UNDER 18, REF OR DK THANK AND END

4. Are you now…

1. Married,

2. Widowed,

3. Divorced,

4. Separated, or

5. Have you never been married?

6. Refused

5. Including yourself, how many adults age 18 or older, usually live in your household?

DK/REF

IF DK OR REF OR ONLY 1 ADULT IN THE HOUSEHOLD THANK AND END

5. How many children, under age 18, usually live in your household?

DK/REF

IF DK OR REF THANK AND END

5. Have you ever served on active duty in the U.S. Armed Forces, military reserve or National Guard?

1. YES

2. NO

3. DK

4. REF

8. Are you currently…

1. Working full-time (30 hours a week or more)  GO TO 9

2. Working part-time (less than 30 hours a week) GO TO 9

3. Looking for work, or  GO TO INTRO BEFORE Q11

4. Not working or looking for work?  GO TO Q10

5. DK

6. REF

[Incl.as working if temporarily away from job due to family or maternity leave, sickness or vacation but plans on returning to job]

9. Are you working as an employee for someone else or are you self-employed?

1. EMPLOYEE

2. SELF-EMPLOYED

3. DK

4. REF

GO TO INTRO BEFORE Q11

10. What is the main reason you are not looking for work? CODE ONLY ONE REASON

1. TAKING CARE OF HOUSE OR FAMILY

2. RETIRED

3. DISABLED

4. OTHER (SPECIFY)

5. DON’T KNOW

6. REFUSED

INTRO: I would now like to ask a few questions about the other people in your household.

11. May I ask for the first names of the people (adults and children) who live in your household? I only ask for the first name to help refer to them during my next few questions about your household. You can use initials or nicknames if you prefer.

IF REF THANK AND END

LIST ALL HOUSEHOLD MEMBERS IN THE GRID PROVIDED.

ASK EACH OF THE FOLLOWING QUESTIONS FOR ALL HOUSEHOLD MEMBERS.

11. How old is [NAME OF P2, P3 etc.]?

12. What is [NAME OF P2, P3, etc.]’s relationship to you? READ IF NECESSARY….

1. SPOUSE [HUSBAND OR WIFE]

2. DOMESTIC PARTNER OR UNMARRIED PARTNER

3. SON OR DAUGHTER [INCL. ADOPTED/ STEP/ FOSTER CHILD]

4. BROTHER/SISTER [INCL. STEP BROTHER/SISTER]

5. PARENT / PARENT IN LAW [INCL. STEP PARENT]

6. GRANDPARENT

7. OTHER RELATIVE

8. OTHER NON-RELATIVE, SPECIFY

9. REF

HH MBRS AGE 18 AND ABOVE ONLY

14. Has [NAME OF P2,P3 etc.] ever served on active duty in the

19. Armed Forces, military reserve or National Guard?

1. YES

2. NO

3. DK

4. REF

15. Is [NAME OF P2, P3, etc.] currently…

    1. Working full-time (30 hours a week or more)  GOT TO 16

    2. Working part-time (less than 30 hours a week) GO TO 16

    3. Looking for work, or  GO TO Q18

    4. Not working or looking for work?  GO TO Q17

    5. DK

    6. REF

[Incl.as working if temporarily away from job due to family or maternity leave, sickness or vacation but plans on returning to job]

15. Is [NAME OF P2, P3, etc.] currently working as an employee for someone else or are they self-employed?

    1. EMPLOYEE

    2. SELF-EMPLOYED

    3. DK

    4. REF

GO TO Q18

17. What is the main reason [NAME OF P2, P3 etc.] is not looking for work? CODE ONLY ONE REASON

1. TAKING CARE OF HOUSE OR FAMILY

2. RETIRED

3. DISABLED

4. OTHER

5. DK

6. REF

	All			Adults only
Person No.	Person Name/ Nickname	Age	Relationship to Respondent (Code 1-7 &9; write in other specify)	Military status (Yes/No/DK/ REF)	Employment status (EmpFT/EmpPT/ SelfFT/ SelfPT/ Unemployed/Home maker/ Retired/Disabled/Other/ DK/REF)
2.
3.
4.
5.
6.
7.
8.
9.
10.

17. Do you, or does anyone in your household, have health coverage through Medicaid or Medical Assistance?

1. YES

2. NO

3. DK

4. REF

19. Do you, or does anyone in your household, get private health insurance through the Affordable Care Act, also known as Obamacare?

1. YES

2. NO

3. DK

4. REF

I now have a few more questions about you.

20. Are you of Hispanic or Latino Origin?

1. YES

2. NO

3. DK

4. REF

21. Are you…

1. American Indian or Alaskan Native

2. Asian

3. Black or African American

4. Native Hawaiian or other pacific islander

5. White

6. Other? Specify

7. Don’t know

8. Refused

22. What is the highest level of education you have completed?

1. 11^TH GRADE OR LESS

2. 12 YEARS OF SCHOOL, NO DIPLOMA

3. GED OR HIGH SCHOOL GRADUATE (DIPLOMA)

4. SOME COLLEGE OR TECHNICAL SCHOOL

5. COLLEGE OR TECHNICAL SCHOOL GRADUATE

6. POST-GRADUATE

7. DK/REF

Question 23 and 24 only included on screener administered when recruitment conducted through targeted organizations or flyers

23. Are you a citizen of the United States?

1. YES  GO TO Q25

2. NO/PENDING  GO TO Q24

3. DK  GO TO Q24

4. REF  GO TO Q25

24. For how many years have you lived in the United States?

Number of years (if less than 1 year write in 0)

24. In whose name is your home owned or rented. Is it your name only, your name jointly with someone else, or in someone else’s’ name?

1. SOLE NAME

2. JOINT NAMES

3. SOMEONE ELSE’S NAME

24. What is your total household income from all sources and before taxes.

Is it…

1. $30,000 or less,

2. More than $30,000 up to $50,000,

3. More than $50,000 up to $90,000, or

4. More than $90,000?

5. DK

6. REF

(Your best guess is fine.)

Thank you for answering all my questions. We are currently in the process of selecting people for the interviews. We may contact you soon to schedule an in-person interview.

[VERIFY THAT PHONE NUMBER IS BEST ONE TO REACH R, AND GET A BACKUP NUMBER IN CASE OF NEED TO REMIND R OF APPOINTMENT TIME. ALSO GET EMAIL ADDRESS.]