CMS-P-0015A Comm2017R79DIQ

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

DIQ-DEMOGRAPHICS AND INCOME

Question Text/Description

Code List

Routing

DEMOGRAPHICS AND INCOME QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C003
SPALIVE=ALL
SEASON=FALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after SCQ.
NOTES: USQ removed from Fall round in R79. Therefore, DIQ is now asked after SCQ.
DIINT

HISPORIG

DIINTROA

DI1A

no entry

yes/no

The next few questions are about Hispanic origin and race.

DI1A - HISPORIG

[Are you/Is (SP)] of Hispanic, (Latino/Latina), or Spanish origin?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) DI1B - HISPORDT
(02) DI2A - RACECODE
(-8) DI2A - RACECODE
(-9) DI2A - RACECODE

(01) 1 MEXICAN/MEXICAN AMERICAN/CHICANO(A)
(02) PUERTO RICAN
(03) CUBAN
(91) OTHER HISPANIC, LATINO(A), OR SPANISH
ORIGIN
(-8) Don't Know
(-9) Refused

(01) DI2A - RACECODE
(02) DI2A - RACECODE
(03) DI2A - RACECODE
(91) DI1B - HISPDTOS
(-8) DI2A - RACECODE
(-9) DI2A - RACECODE

HISPORDT

DI1B

code all

SHOW CARD DI1
Looking at this card, [are you/is (SP)] Mexican, Mexican American, or (Chicano/Chicana), Puerto Rican, Cuban,
or of another Hispanic, (Latino/Latina) or Spanish origin?
CHECK ALL THAT APPLY.

HISPDTOS

DI1B

verbatim text

OTHER ORIGIN (SPECIFY)

(01) continuous answer

DI2A - RACECODE

(01) AMERICAN INDIAN OR ALASKA NATIVE
(02) ASIAN
(03) BLACK OR AFRICAN AMERICAN
(04) NATIVE HAWAIIAN OR OTHER PACIFIC
ISLANDER
(05) WHITE
(-8) Don't Know
(-9) Refused

(01) BOX DI2B
(02) BOX DI2B
(03) BOX DI2B
(04) BOX DI2B
(05) BOX DI2B
(-8) BOX DI2B
(-9) BOX DI2B

(01) ASIAN INDIAN
(02) CHINESE
(03) FILIPINO
(04) JAPANESE
(05) KOREAN
(06) VIETNAMESE
(91) OTHER ASIAN GROUP
(-8) Don't Know
(-9) Refused

(01) BOX DI2C
(02) BOX DI2C
(03) BOX DI2C
(04) BOX DI2C
(05) BOX DI2C
(06) BOX DI2C
(91) DI2B - RACEASOS
(-8) BOX DI2C
(-9) BOX DI2C

(01) continuous answer

BOX DI2C

RACECODE

RACEASDT

DI2A

code all

SHOW CARD DI2
Looking at this card, what [is/was] [your/(SP)'s] race?
[ASK IF NECESSARY: Are there any options from this card that you would like me to record?]

BOX DI2B

routing

IF DI2A-RACECODE INCLUDES 2/Asian, GO TO DI2B - RACEASDT.
ELSE GO TO BOX DI2C.

DI2B

code all

SHOW CARD DI3
Looking at this card, [are you/is (SP)] Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese or some
other Asian group?
You can choose more than one group.
CHECK ALL THAT APPLY.

RACEASOS

DI2B

verbatim text

OTHER ASIAN GROUP (SPECIFY)

BOX DI2C

routing

IF DI2A-RACECODE INCLUDES 4/NatHawOrOthPaclsl, GO TO DI2C - RACEPIDT.
ELSE GO TO ENGWELL - D12F
(01) ENGWELL - D12F
(02) ENGWELL - D12F
(03) ENGWELL - D12F
(91) DI2C - RACEPIOS
(-8) ENGWELL - D12F
(-9) ENGWELL - D12F
ENGWELL - D12F

RACEPIDT

DI2C

code all

SHOW CARD DI4
(01) NATIVE HAWAIIAN
Looking at this card, [are you/is (SP)] Native Hawaiian, Guamanian or Chamorro, Samoan, or some other Pacific (02) GUAMANIAN OR CHAMORRO
Islander group?
(03) SAMOAN
(91) OTHER PACIFIC ISLANDER GROUP
You can choose more than one group.
(-8) Don't Know
CHECK ALL THAT APPLY.
(-9) Refused

RACEPIOS

DI2C

verbatim text

OTHER PACIFIC ISLANDER GROUP (SPECIFY)

(01) continuous answer

How well [do you/does (SP)] speak English? Would you say…

(01) Very well
(02) Well
(03) Not Well, or
(04) Not at all?
(-8) Don't Know
(-9) Refused

ENGWELL

DI2F

code one

DI2FB - ENGREAD

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2017 MCBS Community Questionnaire

Variable Name

ENGREAD

OTHRLANG

MR Screen Name

DI2FB

DI2D

Question Type

code one

yes/no

DIQ-DEMOGRAPHICS AND INCOME

Question Text/Description

Code List

Routing

How well [do you/does (SP)] read English? Would you say…

(01) Very well
(02) Well
(03) Not Well, or
(04) Not at all?
(-8) Don't Know
(-9) Refused

OTHRLANG - D12D

[Do you/Does (SP)] speak a language other than English at home?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) DI2E - WHATLANG
(02) DI3INTRO - DIINT3
(-8) DI3INTRO - DIINT3
(-9) DI3INTRO
(01) DI3INTRO - DIINT3
(02) DI3INTRO - DIINT3
(03) DI3INTRO - DIINT3
(91) DI2E - WHTLNGOS
(-8) D13INTRO - D13
(-9) D13INTRO - D13
D13INTRO - DINT3

WHATLANG

DI2E

code one

What [is/was] this language?

(01) SPANISH
(02) FRENCH
(03) GERMAN
(91) OTHER
(-8) Don't Know
(-9) Refused

WHTLNGOS

DI2E

verbatim text

SOME OTHER LANGUAGE (SPECIFY)

(01) continuous answer

DIINT3

DI3INTRO

no entry

The next questions are about education and income.

DI3A - SPDEGRCV
(01) NO SCHOOLING COMPLETED
(02) NURSERY SCHOOL TO 8TH GRADE
(03) 9TH-12TH GRADE, NO DIPLOMA
(04) HIGH SCHOOL GRADUATE (HIGH SCHOOL
DIPLOMA OR THE EQUIVALENT)
(05) VOCATIONAL/TECHNICAL/BUSINESS/TRADE
SCHOOL CERTIFICATE OR DIPLOMA (BEYOND THE
HIGH SCHOOL LEVEL)
DI4INTRO - DIINT4
(06) SOME COLLEGE, BUT NO DEGREE
(07) ASSOCIATE DEGREE
(08) BACHELOR'S DEGREE
(09) MASTER'S, PROFESSIONAL OR DOCTORATE
DEGREE
(-8) Don't Know
(-9) Refused

SPDEGRCV

DI3A

code one

SHOW CARD DI5
What is the highest degree or level of school [you have/(SP) has] completed?
[IF THE SAMPLE PERSON ATTENDED SCHOOL IN A FOREIGN COUNTRY, IN AN UNGRADED SCHOOL,
HOME SCHOOLING, OR UNDER OTHER UNIQUE CIRCUMSTANCES, REFER THE RESPONDENT TO THE
SHOWCARD AND ASK FOR THE NEAREST EQUIVALENT.]

DIINT4

DI4INTRO

no entry

In studies like this, people are sometimes grouped together according to income.

DI4 - SPINC25K

code one

Was [your and your spouse's/(SP's) and (his/her) spouse's/[your/(SP's)]] total income during the past 12 months
less than $25,000 or $25,000 or more, before taxes? Include income from jobs, Social Security, Railroad
Retirement, other retirement income, Supplemental Security Income (SSI), pensions, interest, and any other
(01) LESS THAN $25,000/YEAR
sources.
(02) $25,000 OR MORE/YEAR
(03) LESS THAN $2080/MONTH
[PROBE IF NECESSARY: In estimating [your/(SP's)] total income, you can respond for all of the past 12
(04) $2080/MONTH OR MORE
months, or provide a one month estimate.]
(-8) Don't Know
(-9) Refused
[EXPLAIN IF NECESSARY: Income is important in analyzing the information we collect. For example, this
information helps us learn whether persons in one income group use certain types of medical care services or
have certain medical conditions more or less often than those in another group.]

(01) DI5A - SPINCLET
(02) DI5A - SPINCLET
(03) DI5A - SPINCLET
(04) DI5A - SPINCLET
(-8) BOX DI3
(-9) BOX DI3

SPINC25K

SPINCLET

DI4

DI5A

code one

SHOW CARD DI6
Looking at this card, which letter best represents [your and your spouse's/(SP's) and (his/her)
spouse's/[your/(SP's)]] total income before taxes during the past 12 months? Include income from jobs, Social
Security, Railroad Retirement, other retirement income, and the other sources of income we just talked about.
[EXPLAIN IF NECESSARY: Income is important in analyzing the information we collect. For example, this
information helps us learn whether persons in one income group use certain types of medical care services or
have certain medical conditions more or less often than those in another group.]

BOX DI3

routing

(01) A. Less than $5,000
(02) B. $5,000 - less than $10,000
(03) C. $10,000 - less than $15,000
(04) D. $15,000 - less than $20,000
(05) E. $20,000 - less than $25,000
(06) F. $25,000 - less than $30,000
(07) G. $30,000 - less than $40,000
(08) H. $40,000 - less than $50,000
(09) I. $50,000 - less than $66,000
(10) J. $66,000 - less than $109,000
(11) K. $109,000 or more
(-8) Don't Know
(-9) Refused

BOX DI3

GO TO END SECTION.

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