Annual Interview (Quarters 4, 8, and 11)

6464 Supported Employment Demonstration Attachment A. Introductory Letter 05-03-17

[Study Letterhead]
[Date]
Dear [Denied Applicant Name]:
You have been selected to participate in the Supported Employment
Demonstration, a national study by the Social Security Administration (SSA). The
study aims to provide people with specialized employment and behavioral health
services to help them get a good job. There is no cost to you to participate. SSA
will pay for all of the services provided by the study.
The study includes people between the ages of 18 and 50 who applied for Social
Security disability benefits but were recently denied. According to SSA records,
this applies to you. If you are interested in learning more about this opportunity,
we would like to tell you about it.
Your decision whether to participate in the Supported Employment Demonstration
is voluntary and will not affect your eligibility to receive benefits from SSA in the
future. By participating in this study, your health may improve and this may lead to
better life functioning and work. You will also help SSA improve their programs in
order to help other people who share your circumstances.
The enclosed brochure describes the study. In the coming week, [RA’s name], a
Research Assistant with the Supported Employment Demonstration, will call you
to discuss the study and what kinds of services you may be eligible to receive. You
can also call [Ms./Mr.] [RA’s last name] directly at (xxx) xxx-xxxx.
We very much look forward to your participation in this important study.
Sincerely,

William Frey, Ph.D.
Study Director
SSA Supported Employment Demonstration

6464 Supported Employment Demonstration Attachment B. Study Brochure 05-03-17

SUPPORTED EMPLOYMENT DEMONSTRATION
FRONT COVER
What is the Supported Employment Demonstration?
The Supported Employment Demonstration is an important research study that aims to provide employment
services and behavioral health services to people who have been denied Social Security disability benefits to
help them get a good job. The Supported Employment Demonstration will study three groups of people: A fullservice treatment group will receive, at no cost, supported employment services, behavioral health and related
services, and assistance with managing their medicines, if needed. A basic-service treatment group will receive,
at no cost, supported employment services as well as behavioral health and related services. A usual services
(control) group will receive a resource manual listing behavioral health and employment services available in
the local area and nationally that may help people find and keep a job.

INSIDE LEFT PANEL
Who Can Participate in the Supported Employment Demonstration?
The Supported Employment Demonstration includes people between the ages of 18 and 50 who applied for
Social Security disability benefits but were recently denied. To participate, people must be interested in getting
a job. Individuals can still participate in the study even if they decide to appeal or reapply for Social Security
benefits, and study participation will not affect their appeal or reapplication.

Middle of Brochure
Why Participate in the Supported Employment Demonstration?
Your participation in this study will provide many benefits:


If assigned to the full-service treatment group, you will receive state-of-the-art employment services,
behavioral health and related services, and assistance from a nurse coordinator to help manage your
medicines, if needed, at no cost to you.



If you are in the basic-service treatment group, you will receive state-of-the-art employment services and
behavioral health and related services, at no cost to you.



If you are in the usual services (control) group, you will receive comprehensive information about
employment services, behavioral health services and related resources available in the local area as well as
nationally that can help you find and keep a job.



As a result of your participation in this study, your health may improve and this may lead to better life
functioning and work.

1|Page

6464 Supported Employment Demonstration Attachment B. Study Brochure 05-03-17



You will receive a total of $440 for your time spent answering questions about your interest in work, your
health, and the employment and healthcare services you may receive.



You will help many people who share your circumstances because this study will likely affect national
policy on work and disability for many years.



You will make an important contribution to what we know today about the kinds of services that can help
people like yourself to get and keep a good job.

Back Left Panel
Who is Conducting the Supported Employment Demonstration?
The Social Security Administration (SSA) is conducting the Supported Employment Demonstration and has
contracted with Westat, a national research company, to carry out the study on behalf of SSA. The study is led
by Westat Co-Principal Investigators William Frey, Ph.D., and Robert Drake, M.D., Ph.D.
The Supported Employment Demonstration will be carried out in more than 30 locations across 20 states,
including:
[Insert list of cities and states]

Back Cover
For More Information
If you have any questions about the Supported Employment Demonstration, please contact the Social Security
Administration or Westat:
Social Security Administration
Office of Research, Demonstration, and Employment Support
6401 Security Boulevard
Baltimore, MD 21235
Email: [email protected]
Website: www.ssa.gov/disabilityresearch/earlyintervention.htm
Supported Employment Demonstration
Westat
1600 Research Blvd
Rockville, MD 20850
Toll-Free: [insert toll-free number]
Email: [email protected]
Website: www.SupportEmploy.org
2|Page

6464 Supported Employment Demonstration Attachment C. Initial Phone Call Sample Script 05-03-17

Sample Script for Initial Phone Call
Hello, may I speak with [denied applicant’s name]?
If respondent asks who’s calling:
My name is [RA’s name] and I am calling about an important research study by the Social
Security Administration.
If respondent insists on more information:
I am calling about an opportunity for [denied applicant’s name] to be a part of a research
study that can help people improve their health and find a good job.
If denied applicant is not available (depending on respondent’s response):
When is a good time to reach [denied applicant’s name]?
May I leave a message for [denied applicant’s name]?
I will try to reach [denied applicant’s name] another time.
Thank you for your time and have a good day.
If respondent indicates that the denied applicant is no longer at resident or that address:
Can you provide me with [denied applicant’s name] current telephone number and/or
address?
Can you provide me with the contact information for someone who has [his/her] contact
information?
Can you forward a message to [denied applicant’s name] and ask [him/her] to contact me
at his/her earliest convenience?

1

6464 Supported Employment Demonstration Attachment C. Initial Phone Call Sample Script 05-03-17

If leaving a message for denied applicant:
My name is [RA’s name]. I am calling about a research study by the Social Security
Administration. I would like to talk to you more about the study and how it can help you.
Please call me at [RA’s contact number] or email me at [email protected].
Once denied applicant is on the phone:
If this is a preliminary call to obtain the mailing address because the
introductory letter could not be mailed, follow the script in this box.
If not, skip this section.
My name is [RA’s name]. I am calling about the Supported Employment
Demonstration, a research study by the Social Security Administration. I would like
to mail you a letter and brochure about the study. After you receive the information, I
will call you again to go over the details. Can you please provide me with your
current mailing address so I can send this to you today?
My name is [RA’s name]. I am calling about the Supported Employment Demonstration,
a research study by the Social Security Administration. I would like to tell you more
about the study. Did you receive a letter and brochure about it in the mail?
If the denied applicant cannot recall the letter, provide prompts as follows:
The letter included general information about the Supported Employment Demonstration
and a brochure about the study. It also said that someone would call you.
If denied applicant did not receive introductory letter:
I sent the letter to [address on file] on [insert date or approximate date]. Is this your
current address?
If yes: I will resend the letter to you today.
If no: Please provide me with your current address so I can mail the introductory
letter to you.
2

6464 Supported Employment Demonstration Attachment C. Initial Phone Call Sample Script 05-03-17

If denied applicant received the introductory letter:
I am calling to tell you more about the study but first I would first like to confirm, are you
interested in getting a job?
If no: At this time, you are not eligible to participate in the study.
Thank you for your time.
If yes: I would like to schedule a time to meet with you so I can provide you with more
information about the Supported Employment Demonstration. You will also have
time to ask me questions and learn how to participate in the study. I am available
to meet with you on [list of dates/time for individual or group meetings].
Once date and time is selected: We can meet at my office, I can come to your
home, or we can meet at another place nearby. What do you prefer?
Once location is selected: Great! I will see you [confirm date and time] at
[confirm location – if at RA office or location nearby, provide address and offer to
send directions]. If you have questions or need to reschedule, please call me at
[RA’s contact number].
I look forward to meeting you. Thank you and have a good day. Goodbye.

3

6464 Supported Employment Demonstration Attachment D. Study Overview and FAQs 05-03-17

Supported Employment Demonstration
We invite you to participate in the Supported Employment Demonstration, a national study by the
Social Security Administration. This handout provides you with a brief overview of the study and
answers to frequently asked questions.

Overview of the Supported Employment Demonstration
The Supported Employment Demonstration is a research study by the Social Security
Administration (SSA). SSA has contracted with Westat, a national research company, to carry out
the Supported Employment Demonstration on behalf of SSA. Westat has also contracted with
employment and health agencies across the United States to provide services to participants in the
study.
Study participants include people who applied for Social Security disability benefits but recently
received a denial of their application. A total of 3,000 disability applicants from locations across the
country will be randomly selected to participate in the study. If you decide to participate, you will
be among this select group of people. People often participate in studies like this one as a way of
helping to improve programs for others in similar circumstances.
The purpose of this study is to find out if providing high quality employment services and
behavioral health services helps these people find good jobs they want and function better overall in
their daily lives. SSA also wants to know which services and treatments work best and what they
cost.
Individuals who agree to participate in this study will be randomly assigned to one of three groups
for a period of three years:


One third of the study participants will be assigned to the Full-Service Treatment Group. These
participants will receive employment services, behavioral health and related services, and
assistance from a nurse care coordinator. They will also receive reimbursement for out-ofpocket expenses associated with approved behavioral health services and treatments not covered
by their insurance, as well as reimbursement for approved work-related expenses.



Another third of the study participants will be assigned to the Basic-Service Treatment Group.
These participants will receive employment services and behavioral health and related services.
Also, they will receive reimbursement for out-of-pocket expenses associated with approved
behavioral health services and treatments not covered by their insurance, as well as
reimbursement for approved work-related expenses.



The remaining third of participants will be assigned to the Usual Services Group (Control
Group). These participants will receive comprehensive information about employment services,

1

6464 Supported Employment Demonstration Attachment D. Study Overview and FAQs 05-03-17

behavioral health services and related resources available in their local area, as well as state and
national resources that can help them find and keep a job.
All participants in the Supported Employment Demonstration will receive a total of $440 as a thank
you for their time spent answering questions about their interest in work, their health and the
services they may receive over the course of the three-year study period, as follows:


At the beginning of the study, participants will receive $50 for completing an in-person
interview about their health, work history and health care. This interview will take about 45
minutes.



In the first two weeks of the study, participants will receive $45 for completing an interview
about their mental and emotional health to be conducted in-person or by telephone, whichever is
most convenient. This interview will take about 40 minutes.



Participants will receive a total of $345 for completing a series of telephone interviews about
their health, work history and health care, occurring once every three months until the end of the
study. They will receive $25 for completing each of nine quarterly interviews, which will take
about 20 minutes each; and $40 for completing each of three annual interviews, which will take
about 30 minutes each.

At the end of the three-year study period, the study will no longer pay for any services. However,
study staff will work with participants to prepare a transition plan as they approach the end of the
three-year study period. Although there is no guarantee that their services will be continued, this
transition plan can help to ensure that after the study ends, individuals can continue to receive the
services they need through other programs.

2

6464 Supported Employment Demonstration Attachment D. Study Overview and FAQs 05-03-17

Frequently Asked Questions
About the Supported Employment Demonstration
Why is the Social Security Administration (SSA) doing this study?
SSA wants to know if providing better access to employment services and behavioral health
services will help people who were recently denied Social Security disability benefits find good
jobs and function better overall in their daily lives. SSA also wants to know which services and
treatments work best and what they cost.
Why is this study important?
Many people who are experiencing physical or mental health problems still want to have good jobs
that interest them. Unfortunately, many of them cannot get the necessary health care, medicines or
employment support. This study will find out how best to provide people with the help that they
need. If this study is successful, SSA will consider changing their programs in order to better
support people like yourself to get and keep a good job.
Who is conducting this study?
The Social Security Administration is conducting the Supported Employment Demonstration and
has contracted with Westat, a national research company, to carry out the study on behalf of SSA.
Westat has also contracted with employment and health agencies across the United States to provide
services to participants in the study.
What is Westat?
Westat is an employee-owned research organization headquartered in Rockville, Maryland. Westat
has more than 50 years of experience conducting national, health-related research projects for many
agencies of the U.S. Government, including SSA.
Why did SSA choose me to participate in the study?
Individuals who applied for disability benefits and recently received a denial of benefits were
randomly selected for participation. We will continue to randomly select people across the country
until we reach a total of 3,000 people who agree to participate in the study.
What if I'm appealing my denial or reapplying for benefits?
You can still participate in the study if you are appealing your denial or reapplying for benefits, and
your participation will not affect your appeal or reapplication.
Do I have to participate in the Supported Employment Demonstration?
No. This is an important national study and we hope you will want to participate, but participation is
voluntary. You can choose not to participate in this study without penalty. The decision is up to
you.
3

6464 Supported Employment Demonstration Attachment D. Study Overview and FAQs 05-03-17

What do I have to do to join the study?
If you decide that you want to join the study, a Research Assistant will first ask you to answer some
questions to confirm your eligibility for the study. If you are eligible, we will ask you to carefully
read and sign the study consent form that describes how you will participate, the services you may
receive, what kinds of information we will collect about you, and how we will protect your privacy.
Do I have to sign the study consent form?
No. You can choose not to sign the study consent form. However, if you do not sign the consent
form, you cannot join the study.
What happens next after I sign the consent form?
After you sign the consent form, the Research Assistant will conduct a baseline interview with you
to collect information about topics such as your health, work history, and health care. The baseline
interview will last about 45 minutes and you will receive $50 for completing this interview. The
computer will then randomly assign you to one of three groups: the Full-Service Treatment Group,
the Basic-Service Treatment Group, or the Usual-Services Group (Control).
Within two weeks after you are assigned to one of the study groups, a study staff member will
contact you to participate in an interview by phone or in person about your mental and emotional
health. You will receive $45 for completing this interview, which will last about 40 minutes.
What happens if I am assigned to the Full-Service Treatment Group?
If you are assigned to the Full-Service Treatment Group, over the next three years you will be
provided with:





Supported employment services to help you find a job that fits your preferences, skills and
experiences.
Behavioral health and related services that will support you in your work efforts.
Assistance from a nurse care coordinator.
Reimbursement for out-of-pocket expenses associated with approved behavioral health services
and treatments not covered by insurance, and reimbursement for approved work-related
expenses.

As part of your participation, a study staff member will contact you every three months to complete
a telephone interview. These interviews will ask questions about your employment status, health
care and employment services you may have received, and how you are doing. You will receive $25
for completing each of nine quarterly interviews, which will take about 15 minutes each; and $40
for completing each of three annual interviews, which will take about 30 minutes each, for a total of
$345.

4

6464 Supported Employment Demonstration Attachment D. Study Overview and FAQs 05-03-17

If I am assigned to the Full-Service Group, will I pay for my medication and other services
that I receive by participating in the study?
The study will pay for out-of-pocket costs associated with approved behavioral health services and
treatments not already covered by insurance. You will also receive reimbursement for approved
work-related expenses.
If I am in the Full-Service Group, what happens to me at the end of the three-year study
period?
At the end of three years, the Supported Employment Demonstration will no longer pay for any
services you may have received as part of the study. However, study staff will work with you to
prepare a transition plan as you approach the end of the three-year study period. This transition plan
can help to ensure that after the study ends you can continue to receive the services you need
through other programs. However, there is no guarantee that all of your services will be continued.
What happens if I am assigned to the Basic-Service Treatment Group?
If you are assigned to the Basic-Service Treatment Group, over the next three years you will be
provided with:




Supported employment services to help you find a job that fits your preferences, skills and
experiences.
Behavioral health and related services that will support you in your work efforts.
Reimbursement for out-of-pocket expenses associated with approved behavioral health services
and treatments not covered by insurance, and reimbursement for approved work-related
expenses.

As part of your participation, a study staff member will contact you every three months to complete
a telephone interview. These interviews will ask questions about your employment status, health
care and employment services you may have received, and how you are doing. You will receive $25
for completing each of nine quarterly interviews, which will take about 15 minutes each; and $40
for completing each of three annual interviews, which will take about 30 minutes each, for a total of
$345.
If I am assigned to the Basic-Service Group, will I pay for the services that I receive by
participating in the study?
The study will pay for out-of-pocket costs associated with approved behavioral health services and
treatments not already covered by insurance. You will also receive reimbursement for approved
work-related expenses.

5

6464 Supported Employment Demonstration Attachment D. Study Overview and FAQs 05-03-17

If I am in the Basic-Service Group, what happens to me at the end of the three-year study
period?
At the end of three years, the Supported Employment Demonstration will no longer pay for any
services you may have received as part of the study. However, study staff will work with you to
prepare a transition plan as you approach the end of the three-year study period. This transition plan
can help to ensure that after the study ends you can continue to receive the services you need
through other programs. However, there is no guarantee that all of your services will be continued.
What happens if I am assigned to the Usual Services Group (Control Group)?
If you are assigned to the Usual Services Group (Control Group), we will provide you with a
manual describing behavioral health and employment services in the local area, as well as state and
national resources that may help you find and keep a job.
As part of your participation, a study staff member will contact you every three months to complete
a telephone interview. These interviews will ask questions about your employment status, health
care and employment services you may have received, and how you are doing. You will receive $25
for completing each of nine quarterly interviews, which will take about 15 minutes each; and $40
for completing each of three annual interviews, which will take about 30 minutes each, for a total of
$345.
What happens if I do not have health insurance when I join the study?
You can still participate in the Supported Employment Demonstration if you do not have health
insurance when you join the study. The study will pay for health insurance for you until you can
enroll in an insurance plan through your state’s Health Exchange.
What happens if I decide not to keep my health insurance after I join the study?
Whether to keep your health insurance is your decision. You can still participate in the Supported
Employment Demonstration if you discontinue your health insurance after you join the study.
However, if you do not keep your health insurance, the study might not pay for any services that
you receive as part of the study.
What information will you collect about me during the next three years?
If you agree to participate in the study, the study researchers will request personal information about
you, including information about your health and employment such as:






Information about jobs you have held
Records about treatment and services you received during the study
The diagnosis and treatment of mental health conditions
Information that you provide in the study interviews
Information contained in records about any medications you receive

6

6464 Supported Employment Demonstration Attachment D. Study Overview and FAQs 05-03-17

Will information about me be kept private?
SSA will protect your information in accordance with the Privacy Act and other Federal laws.
Section 1110 of the Social Security Act, as amended, allows information to be collected about you
for the study. Providing this information is voluntary. If you do not provide all or part of the
information, your eligibility for benefits now or in the future will not be affected and you may
continue to participate in this study.
How will my information be used?
SSA will use the information you provide for research purposes, to evaluate the Supported
Employment Demonstration. SSA may also share my information for the following purposes, called
routine uses:
1. To a contractor under contract to the Social Security Administration, subject to any restrictions
imposed by 26 U.S.C. 6103 of the Internal Revenue Code, for the performance of research and
statistical activities directly related to this system of records in conducting the demonstrations
and experiments and to provide a statistical database for research studies; and
2. To a congressional office in response to an inquiry from that office.
3. A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-218, entitled Disability Insurance and Supplemental Security Income
Demonstration Projects and Experiments System. Additional information and a full listing of all
our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.
Can I withdraw my permission and stop participating in the study?
Yes. You can withdraw your participation in the study at any time. There is no penalty for
withdrawing from the study whenever you choose. However, any services and other benefits offered
through the study will then stop. Information collected about you for this study prior to your
withdrawal date may be used for purposes of the Supported Employment Demonstration.
Can I ask questions about the study?
Yes. You may ask questions about the study at any time, and you have the right to receive answers
to your questions that you can understand. You may direct your questions about the study to the
Supported Employment Demonstration’s toll-free number at [insert toll-free number].
Can I ask questions about my rights as a research participant?
Yes. If you have questions about your rights and welfare as a research participant, please call the
Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your full
name, say that you are calling about the Supported Employment Demonstration, and provide a
phone number beginning with the area code. Someone will return your call as soon as possible.

7

6464 Supported Employment Demonstration Attachment E. Competency Screener 05-03-17
COMPETENCY SCREENER

A-1.

First, I need to briefly explain a few things about the study. I will then ask you some questions to be sure you
understand it. The interview includes questions about your previous work history; your health now; and any
health care services you might use. Can you repeat the topics to me so that I can confirm you know what this
interview is about?
LISTS ALL .....................................................
LISTS ANY 2 .................................................
LISTS ONLY 1 ...............................................
INCORRECT ANSWER(S) ............................

A-1a.

I need to briefly explain again a few things about the study. I will then ask you some questions to be sure you
understand it. The interview includes questions about your previous work history; your health now; and any
health care services you might use. Can you repeat the topics to me so that I can confirm you know what this
interview is about?
LISTS ALL .....................................................
LISTS ANY 2 .................................................
LISTS ONLY 1 ...............................................
INCORRECT ANSWER(S) ............................

A-2.

1 (A-2)
2 (A-2)
3
4

1
2
3 (INELIGIBLE)
4 (INELIGIBLE)

Now, I need to remind you that your participation in this study is fully voluntary. You can decide to participate
or not. Also, you can refuse to answer any questions during the interview or stop at any time if the questions
make you uncomfortable.
When I say your participation is fully voluntary, what does that mean to you?
[INTERVIEWER: IF RESPONDENT SAYS “It is voluntary,” THEN PROBE FOR AN EXPLANATION. AN
ACCURATE ANSWER IS: “It is my choice whether or not to participate; I don’t have to do this (participate); I
can do this (interview) if I want”; ETC.]
ACCURATE ANSWER ..................................
INACCURATE ANSWER...............................

A-3.

1
2 (INELIGIBLE)

All information you provide today will be kept confidential and used only for research purposes. Nobody other
than members of the research team will have access to the information we get from you.
When I say that all information will be kept confidential, what does that mean to you?
[INTERVIEWER: IF RESPONDENT SAYS “It is confidential,” THEN PROBE FOR AN EXPLANATION. AN
ACCURATE ANSWER IS: “It will be secret; Only authorized (some) people will see what I said; What I say
will be (kept) private; It will only be used for research”; ETC.]
ACCURATE ANSWER ..................................
INACCURATE ANSWER...............................

1 (ELIGIBLE)
2 (INELIGIBLE)

Ineligible Statement. Unfortunately, you are not eligible for the study. We appreciate your interest. Thank you for
your time.
Eligible Statement. Now we need to review the consent form for the study.

6464 Supported Employment Demonstration Attachment F. Study Consent 05-03-17

SUPPORTED EMPLOYMENT DEMONSTRATION
SOCIAL SECURITY ADMINISTRATION
CONSENT TO PARTICIPATE IN THE STUDY
I agree to participate in the Supported Employment Demonstration, a research study by the Social Security
Administration (SSA). SSA has contracted with Westat, a national research company, to carry out the
Supported Employment Demonstration on behalf of SSA. Westat has also contracted with an employment and
health agency in my local area to provide services to participants in the study.
PURPOSE
The purpose of this study is to find out if providing high quality employment services and behavioral health
services helps people who were recently denied Social Security disability benefits to find good jobs they want
and to function better overall in their daily lives. SSA also wants to know which services and treatments work
best and what they cost.
STUDY PROCEDURES
By consenting to participate in this study, I agree to participate in the following study activities over the next three
years:
 An in-person, baseline interview about my health, work history and health care at the beginning of the study.
I will receive $50 for completing the baseline interview, which will take about 45 minutes.
 An interview about my mental and emotional health to be conducted in-person or by telephone in the first two
weeks of the study. I will receive $45 for completing this interview, which will take about 40 minutes.
 A telephone interview about my health, work history and health care every three months until the end of the
study. I will receive $25 for completing each of nine quarterly interviews, which will take about 20 minutes
each; and $40 for completing each of three annual interviews, which will take about 30 minutes each, for a
total of $345.
I will receive a total of $440 if I complete all of the study interviews listed above.
After the baseline interview at the beginning of the study, I will be randomly assigned to one of three groups: the
Full-Service Treatment Group, the Basic-Service Treatment Group or the Usual Services Group (Control
Group).
If I am assigned to the Full-Service Treatment Group, over the next three years study, staff will provide me
with:
 Supported employment services to help me find a job that fits my preferences, skills, and experiences.
 Behavioral health and related services that will support me in my work efforts.
 Assistance from a nurse-care coordinator.
 Reimbursement for out-of-pocket expenses associated with approved behavioral health services and
treatments not covered by my insurance, and reimbursement for approved work-related expenses.
Page 1 of 4

6464 Supported Employment Demonstration Attachment F. Study Consent 05-03-17



If I do not have health insurance when I join the study, the study will pay for health insurance for me until I
can enroll in an insurance plan through my state’s Health Exchange. After I join the study, if I do not keep
my health insurance, the study might not pay for any services that I receive as part of the study.

If I am assigned to the Basic-Service Treatment Group, over the next three years, study staff will provide me
with:
 Supported employment services to help me find a job that fits my preferences, skills and experiences.
 Behavioral health and related services that will support me in my work efforts.
 Reimbursement for out-of-pocket expenses associated with approved behavioral health services and
treatments not covered by insurance, and reimbursement for approved work-related expenses.
 If I do not have health insurance when I join the study, the study will pay for health insurance for me until I
can enroll in an insurance plan through my state’s Health Exchange. After I join the study, if I do not keep
my health insurance, the study might not pay for any services that I receive as part of the study.
If I am assigned to the Usual Services (Control) Group, study staff will provide me with:
 A manual describing behavioral health and employment services in the local area, along with state and
national resources that may help me find and keep a job.
At the end of the three-year study period, the study will no longer pay for any of the services I may have received
as part of the study. However, study staff will work with me to prepare a transition plan as I approach the end of
the three-year study period. Although there is no guarantee that my services will be continued after the end of the
study, this transition plan can help to ensure that after the study ends I can continue to receive the services I need
through other programs.
VOLUNTARY PARTICIPATION
I was randomly selected to participate in the Supported Employment Demonstration from a list of names of
people who applied for disability benefits and recently received a denial of benefits. However, my participation
in this study is voluntary. If I choose not to participate in this study, there will be no penalty. If I am appealing
my denial or reapplying for SSA benefits, I can still participate in the study and my participation will not affect
my appeal or reapplication.
Some study interviews may be audio-recorded to help the researchers recall what was said. I will always be asked
to give permission for such recordings, and I can refuse to have anything audio-recorded and still participate in
the study interviews.
I can withdraw my participation in the study at any time without penalty. However, the services and other benefits
offered through the study will then stop. Information collected about me for this study before my withdrawal date
may be used for purposes of the Supported Employment Demonstration.

Page 2 of 4

6464 Supported Employment Demonstration Attachment F. Study Consent 05-03-17

RISKS
It is possible that my health may not improve and I may not find a job that I want as a result of participating in
this study. I may also experience anxiety, fatigue or frustration while completing study-related interviews. If this
happens, I can take a break, skip any section, or stop the interview. If I get upset during my participation in studyrelated activities, I may be offered a referral to crisis management services that I can use if I wish.
BENEFITS
By participating in this study, I will receive the services described under STUDY PROCEDURES as part of
my assigned study group. As a result of my study participation, my health may improve and this may lead to
better life functioning and work. My study participation will not affect any benefits that I may be currently
receiving, but if I begin working, this may affect my eligibility to receive benefits from SSA in the future. My
participation in this study will also help SSA improve their programs in order to help other people in similar
circumstances.
PRIVACY
SSA will protect my information in accordance with the Privacy Act and other Federal laws. Section 1110 of
the Social Security Act, as amended, allows information to be collected about me for the study. Providing this
information is voluntary. If I do not provide all or part of the information, my eligibility for benefits now or in
the future will not be affected and I may continue to participate in this study.
SSA will use the information I provide for research purposes, to evaluate the Supported Employment
Demonstration. SSA may also share my information for the following purposes, called routine uses:
1. To a contractor under contract to the Social Security Administration, subject to any restrictions imposed by
26 U.S.C. 6103 of the Internal Revenue Code, for the performance of research and statistical activities
directly related to this system of records in conducting the demonstrations and experiments and to provide a
statistical database for research studies; and
2. To a congressional office in response to an inquiry from that office.
3. A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-218,
entitled Disability Insurance and Supplemental Security Income Demonstration Projects and Experiments
System. Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.
QUESTIONS
For questions about the study, I can call the study’s toll-free number XXX-XXX-XXXX. For questions about my
rights and welfare as a research participant, I can call the Westat Human Subjects Protections office at 1-888920-7631 and leave a message with my full name, the name of the research study (Supported Employment
Demonstration), and a phone number beginning with the area code. Someone will return my call as soon as
possible.
Page 3 of 4

6464 Supported Employment Demonstration Attachment F. Study Consent 05-03-17

SIGNATURE OF INFORMED CONSENT
I have read and understand the above information about participation in the Supported Employment
Demonstration. By signing below, I consent to participate in this study. I understand that I will receive a copy of
this consent form to keep for my records.

Signature of Participant

Date

__________________________________________
Printed Name of Participant

Signature of Person Conducting Informed Consent Discussion

Date

Printed Name of Person Conducting Informed Consent Discussion

Use the following only if applicable
If this consent form is read to the participant because the participant is unable to read the form, an impartial
witness not affiliated with the research or investigator must be present for the consent and sign the statement
below. Note: This signature block cannot be used for translations into another language. A translated consent
form is necessary for enrolling participants who do not speak English.
I confirm that the information in the consent form and any other written information was accurately explained to
and apparently understood by the participant. The participant freely consented to participate in the study.
______________________________________________
Signature of Impartial Witness

_________________
Date

______________________________________________
Printed Name of Impartial Witness

The information we collect in this study is in accordance with the clearance requirements of Section 3507 of the
Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a
collection of information unless it displays a valid control number from the Office of Management and Budget
(OMB) in the Federal government. The OMB Control Number for this collection is XXXX-XXXX, expiration
date XX/XX/XXXX.
FOR OFFICE USE ONLY Study ID # ____________________
Page 4 of 4

6464 Supported Employment Demonstration Attachment G. Randomization Letters 05-03-17

[Date]
Dear [Participant]:
Thank you for agreeing to participate in the Supported Employment Demonstration. You have been randomly
assigned to the Full-Service Treatment Group.
As described in the information that you received, your participation in the Full-Service Treatment Group gives
you access to the following:






Supported employment services to help you find a job that fits your preferences, skills and experiences.
Behavioral health and related services that will support you in your work efforts.
Assistance from a nurse care coordinator.
Reimbursement for out-of-pocket expenses associated with approved behavioral health services and
treatments not covered by your insurance, and reimbursement for approved work-related expenses.
If you do not have health insurance, you can still participate in the Supported Employment Demonstration
and the study will pay for health insurance for you until you can enroll in an insurance plan through your
state’s Health Exchange. If you do not keep your health insurance, the study might not pay for any services
that you receive as part of the study.

Today you will receive $50 as a thank you for your time spent completing the baseline interview.
Within the next two weeks, a study staff member will contact you to participate in an interview about your
mental and emotional health. You will receive $45 as a thank you for your time spent completing this interview,
which will take about 40 minutes.
For the next three years, a study staff member will contact you every three months to participate in a telephone
interview. The interviewer will ask questions about your employment status, health care and employment
services you may have received, and how you are doing. You will receive $25 for completing each of nine
quarterly interviews, which will take about 20 minutes each; and $40 for completing each of three annual
interviews, which will take about 30 minutes each, for a total of $345.
Your nurse care coordinator, [NCC’s name], will call you in the coming week to discuss the next steps. In the
meantime, if you have any questions, please feel free to contact me at (XXX) XXX-XXXX.
We are delighted to have you as a study participant.
Sincerely,

Research Assistant
SSA Supported Employment Demonstration

6464 Supported Employment Demonstration Attachment G. Randomization Letters 05-03-17

[Date]
Dear [Participant]:

Thank you for agreeing to participate in the Supported Employment Demonstration. You have been randomly
assigned to the Basic-Service Treatment Group.
As described in the information that you received, your participation in the Basic-Service Treatment Group
gives you access to the following:





Supported employment services to help you find a job that fits your preferences, skills and experiences.
Behavioral health and related services that will support you in your work efforts.
Reimbursement for out-of-pocket expenses associated with approved behavioral health services and
treatments not covered by insurance, and reimbursement for approved essential work-related expenses.
If you do not have health insurance, you can still participate in the Supported Employment Demonstration
and the study will pay for health insurance for you until you can enroll in an insurance plan through your
state’s Health Exchange. If you do not keep your health insurance, the study might not pay for any services
that you receive as part of the study.

Today you will receive $50 as a thank you for your time spent completing the baseline interview.
Within the next two weeks, a study staff member will contact you to participate in an interview about your
mental and emotional health. You will receive $45 as a thank you for your time spent completing this interview,
which will take about 40 minutes.
For the next three years, a study staff member will contact you every three months to participate in a telephone
interview. The interviewer will ask questions about your employment status, health care and employment
services you may have received, and how you are doing. You will receive $25 for completing each of nine
quarterly interviews, which will take about 20 minutes each; and $40 for completing each of three annual
interviews, which will take about 30 minutes each, for a total of $345.
An employment specialist will call you in the coming week to discuss the next steps. [His/Her] name is
[Employment Specialist’s name]. In the meantime, if you have any questions, please feel free to contact me at
(XXX) XXX-XXXX.
We are delighted to have you as a study participant.
Sincerely,

Research Assistant
SSA Supported Employment Demonstration

6464 Supported Employment Demonstration Attachment G. Randomization Letters 05-03-17

[Date]
Dear [Participant]:

Thank you for agreeing to participate in the Supported Employment Demonstration. You have been randomly
assigned to the Usual Services Group.
As described in the information that you received, your participation in the Usual Services Group means:









We will provide you with a comprehensive manual describing employment services, behavioral health
services and related resources available in the local area, as well as state and national resources that may
help you find and keep a job.
You will receive a $50 today as a thank you for your time spent completing the baseline interview.
Within the next two weeks, a study staff member will contact you to participate in an interview about your
mental and emotional health. You will receive $45 as a thank you for your time spent completing this
interview, which will take about 40 minutes.
For the next three years, a study staff member will contact you every three months to participate in a
telephone interview. The interviewer will ask questions about your employment status, health care and
employment services you may have received, and how you are doing. You will receive $25 for completing
each of nine quarterly interviews, which will take about 20 minutes each; and $40 for completing each of
three annual interviews, which will take about 30 minutes each, for a total of $345.
You will help many people who share your circumstances because the Supported Employment
Demonstration will likely affect national policy on work and disability for many years.

A study staff member will call you within two weeks to complete the next interview. In the meantime, if you
have any questions, please feel free to contact me at (XXX) XXX-XXXX.
We are delighted to have you as a study participant.
Sincerely,

Research Assistant
SSA Supported Employment Demonstration

6464 Supported Employment Demonstration Attachment H. Reloadable Card FAQs 05-03-17

Reloadable MasterCard
Frequently Asked Questions
As a participant in the Supported Employment Demonstration, you will receive a total of $440 in
appreciation for your time spent completing study interviews over the next three years, as
follows:




Today when you enroll in the study, you will receive $50 for completing the baseline
interview about your health, work history and health care.
In the next two weeks, you will receive $45 for completing an interview about your mental
and emotional health. This interview will take about 45 minutes.
You will receive a total of $345 for completing a series of telephone interviews about your
health, work history and health care, occurring once every three months until the end of the
study. You will receive $25 for completing each of nine quarterly interviews, which will take
about 20 minutes each; and $40 for completing each of three annual interviews, which will
take about 30 minutes each.

We are giving you a reloadable MasterCard that we will use to make these payments to you. This
is similar to a debit card. Each time you complete a study interview, we will add to your card the
amount that you will receive as a thank you for completing the interview. We have added $50 to
your card for completing the baseline interview today.
Does my card have a Personal Identification Number (PIN)?
Yes. Your card has an assigned PIN. If you forget your PIN, please call the customer
support number on the back of the card for assistance with resetting the PIN.
Is my card accepted everywhere?
You can use your card to make purchases anywhere that accepts MasterCard. You will
need to select “credit” at the register and then sign for your purchase. Each time you
make purchases using your card, the amount you spent will be automatically deducted
from the card’s balance.
Can I withdraw money from my card?
You can access cash through a bank teller cash withdrawal or using PIN debit with cash
back. This card cannot be used to withdraw cash from an ATM.

1

6464 Supported Employment Demonstration Attachment H. Reloadable Card FAQs 05-03-17

Will I have to pay fees?
There is a $1.00 fee for each cash withdrawal that you make through a bank teller. There
is also a maintenance fee of $3.00 each month. This fee will be waived if you make at
least one purchase each month. The maintenance fee will not be charged if the card
balance is $0.00.
How can I find out my balance on my card?
To find out the card balance and transaction history, please call the customer support
number on the back of the card.
How much will be on my card?
In appreciation for completing the baseline interview today, we have added $50 to your
card. We will add $45 to your card after you complete the next study interview. After
that, each time you complete one of the nine quarterly telephone interviews, we will add
$25 to your card. Each time you complete one of the three annual telephone interviews,
we will add $40 to your card. You can access the money on the same day that you
complete each interview.
Do I have to keep the same card for the entire the study?
Yes. Every time you complete a study interview, we will add money to this specific card.
Therefore, it is important that you keep the card in a safe place and know where it is at all
times for the duration of the three-year study period.
What happens if I lose my card?
If your card becomes lost or stolen, please call the customer support number on the back
of the card to report this. After you report a card as lost or stolen, we will issue a new
card to you and transfer the remaining balance to the replacement card.
What if my card doesn’t work?
If your card does not work, please call the customer support number on the back of the
card for assistance.

2

6464 Supported Employment Demonstration Attachment I. Participant Dispute Resolution Letter 05-03-17

[Study Letterhead]
[Date]
Dear [Participant Name]:
As a treatment participant in the Supported Employment Demonstration, you have the
right at any time during your involvement in the study to:






Ask questions about the course of your treatment
Refuse to participate in any part of the treatment
Change your clinical provider
Request reconsideration of a denied payment reimbursement claim
Request reconsideration of a denied request for services

You may initiate a formal appeal to the Supported Employment Demonstration Dispute
Resolution Board if you feel that these rights have not been honored. You can do this in
one of two ways:
1. Call the Supported Employment Demonstration Help Desk at 1-XXX-XXXXXXX or email. Someone is available to take your call Monday through Friday
(9:00 am – 5:00 pm). If you call after business hours or if the help desk is
experiencing high call volumes, then please leave a voice message which includes
your name, telephone number (or best phone contact number on weekdays between
the hours of 9:00 am and 5:00 pm), and the nature of your call. We will return your
call no later than the next business day. If you prefer, you can also send an email to
[email protected].
2. Complete the Dispute Resolution Appeal Form. If you would prefer to submit a
written appeal, please use the attached Dispute Resolution Appeal Form and mail it to
Westat using the pre-paid envelope attached to this letter. Or you can submit your
appeal using the study’s Secure Fax line at: 1-XXX-XXX-XXXX. Please write “Attn:
Dispute Resolution Board” on the Fax coversheet.
Sincerely,

6464 Supported Employment Demonstration Attachment J1. Baseline Interview Computer
Assisted Personal Interview (CAPI) 05-03-17
BASELINE INTERVIEW

AUDIO RECORDING (AR)
AR-1. With your permission, I would like to record this interview to help us recall what was said. Is that okay?
YES ................................................ 1 (DISPLAY PERMISSION = YES, GO TO AR-2)
NO .................................................. 2 (DISPLAY PERMISSION = NO, GO TO CI-1)
PERMISSION = YES: Thank you. I’ll start the audio recording now.
PERMISSION = NO: That’s fine. The interview will not be recorded.
AR-2. For the purposes of the recording, do I have your permission to record this interview?
YES ................................................ 1 (DISPLAY RECORDED PERMISSION = YES, GO TO CI-1)
NO .................................................. 2 (DISPLAY RECORDED PERMISSION = NO, GO TO CI-1)
RECORDED PERMISSION = YES: Okay let’s get started.
RECORDED PERMISSION = NO: That’s fine. The interview will not be recorded.

BENEFICIARY CONTACT INFORMATION (CI)

CI-1.

Are you planning to move in the next 3 months?
YES .............................................................................
NO ..............................................................................

CI-2.

1
2 (C-6)

What will your new address be?
__________________________________________
STREET ADDRESS
__________________________________________
CITY
__________________________________________
STATE
__________________________________________
ZIP CODE

CI-3.

When will you move to this new address?
|__|__| / |__|__| / |__|__|__|__|
MONTH DAY
YEAR

CI-4.

Will you keep the same telephone number?
YES .............................................................................
NO ..............................................................................

1 (C-6)
2

1

6464 Supported Employment Demonstration Attachment J1. Baseline Interview Computer
Assisted Personal Interview (CAPI) 05-03-17
CI-5.

What will your new telephone number be?
|__|__|__| - |__|__|__| - |__|__|__|__|
TELEPHONE NUMBER

CI-6.

We’d like the names, addresses and phone numbers of two people who will know where you are if we have
trouble contacting you during this study. We will not contact these people except to have them help us
locate you to speak with you again, should that be necessary. If we do contact them, we will not discuss any
of your personal information with them.

__________________________________________
CONTACT 1 NAME
__________________________________________
STREET ADDRESS
__________________________________________
CITY
__________________________________________
STATE
__________________________________________
ZIP CODE
|__|__|__| - |__|__|__| - |__|__|__|__|
TELEPHONE NUMBER

__________________________________________
CONTACT 2 NAME
__________________________________________
STREET ADDRESS
__________________________________________
CITY
__________________________________________
STATE
__________________________________________
ZIP CODE
|__|__|__| - |__|__|__| - |__|__|__|__|
TELEPHONE NUMBER

2

6464 Supported Employment Demonstration Attachment J1. Baseline Interview Computer
Assisted Personal Interview (CAPI) 05-03-17
DEMOGRAPHICS (DM)

First, I would like to begin by asking you some questions about yourself.
DM-1.

What is your date of birth?
|__|__| / |__|__| / |__|__|__|__|

DM-2.

[INTERVIEWER: CODE GENDER.]
MALE ..........................................................................
FEMALE ......................................................................

DM-3.

Are you of Hispanic, Latino, or Spanish origin?
YES .............................................................................
NO ..............................................................................

DM-4.

1
2

1
2

What race do you consider yourself to be? Please select one or more of the following categories:
[INTERVIEWER: SELECT ALL THAT APPLY.]
White, .......................................................................... 1
Black or African-American, .......................................... 2
Asian, .......................................................................... 3
American Indian or Alaskan Native, or ......................... 4
Native Hawaiian or Pacific Islander? ........................... 5
OTHER (SPECIFY)____________ ______________ 91

DM-5.

What languages do you usually speak?
English only, ................................................................ 1
Spanish only, .............................................................. 2
Both English and Spanish, .......................................... 3
Both English and some other language, or ................. 4
Some other language only? (SPECIFY) __________ 91

DM-6.

What is your marital status?
Never married, ............................................................
Married, .......................................................................
Living as married, ........................................................
Separated, ..................................................................
Divorced, or..................................................................
Widowed? ....................................................................

1
2
3
4
5
6

3

6464 Supported Employment Demonstration Attachment J1. Baseline Interview Computer
Assisted Personal Interview (CAPI) 05-03-17
DM-7.

What is the highest grade in school that you completed?
NO FORMAL SCHOOLING ........................................
SOME ELEMENTARY SCHOOLING ..........................
COMPLETED 8TH GRADE ..........................................
SOME HIGH SCHOOL ...............................................
COMPLETED HIGH SCHOOL OR GED .....................
SOME COLLEGE OR TECHNICAL SCHOOL .............
COMPLETED ASSOCIATE’S DEGREE .....................
COMPLETED BACHELOR’S DEGREE ......................
SOME GRADUATE SCHOOL ....................................
COMPLETED MASTER’S DEGREE ..........................
COMPLETED DOCTORAL DEGREE .........................
OTHER (SPECIFY) __________________________

DM-8.

11
12
13
14
15
16
17
18
19
20
21
91

Which of following best describes where you have been living during the past 30 days? Would you say…

At one address in an apartment or house, .................. 1
At more than one address in apartments or houses, .. 2
In a homeless shelter or homeless with no
particular address, or ................................................ 3
Some other place? (SPECIFY) _________________ 91

DM-9.

Describe who you have been living with during the past 30 days.
LIVING ALONE ........................................................... 1 (DM-13)
LIVING WITH SPOUSE/SIGNIFICANT OTHER ONLY 2
LIVING WITH CHILDREN ONLY ................................ 3
LIVING WITH SPOUSE/SIGNIFICANT OTHER
AND CHILDREN ....................................................... 4
LIVING WITH PARENTS ............................................ 5
LIVING WITH OTHER RELATIVES (OTHER THAN
SPOUSE, CHILDREN, OR PARENTS) ................... 6
LIVING WITH FRIENDS ............................................. 7 (DM-13)
LIVING WITH OTHER NON-RELATED ADULTS
(NOT NECESSARILY FRIENDS) ............................ 8 (DM-13)
OTHER (SPECIFY) __________________________ 91

DM-10

How many people have you been living with during the past 30 days?
|__|
PEOPLE

DM-11 Starting with the oldest person in the household, please let me know each person’s age, gender, highest
level of education and relationship to you.
DM-11a. How old is the [oldest/next oldest/youngest] person in the household?

4

6464 Supported Employment Demonstration Attachment J1. Baseline Interview Computer
Assisted Personal Interview (CAPI) 05-03-17

DM-11b. And is this person male or female?
MALE ..........................................................................
FEMALE ......................................................................

1
2

DM-11c. And what is this person’s highest level of education?
NO FORMAL SCHOOLING ........................................
SOME ELEMENTARY SCHOOLING ..........................
COMPLETED 8TH GRADE ..........................................
SOME HIGH SCHOOL ...............................................
COMPLETED HIGH SCHOOL OR GED .....................
SOME COLLEGE OR TECHNICAL SCHOOL .............
COMPLETED ASSOCIATE’S DEGREE .....................
COMPLETED BACHELOR’S DEGREE ......................
SOME GRADUATE SCHOOL ....................................
COMPLETED MASTER’S DEGREE ..........................
COMPLETED DOCTORAL DEGREE .........................
DON’T KNOW .............................................................
OTHER (SPECIFY) __________________________

11
12
13
14
15
16
17
18
19
20
21
XX
91

DM-11d. And what is this person’s relationship to you?
SPOUSE .....................................................................
SON OR DAUGHTER .................................................
SIBLING ......................................................................
PARENT .....................................................................
GRANDCHILD .............................................................
PARENT-IN-LAW .........................................................
SON-IN-LAW OR DAUGHTER-IN-LAW .....................
OTHER RELATIVE .....................................................
ROOMER OR BOARDER ...........................................
HOUSEMATE OR ROOMMATE .................................
UNMARRIED PARTNER ............................................
FOSTER CHILD ..........................................................
OTHER NONRELATIVE .............................................

1
2
3
4
5
6
7
8
9
10
11
12
13

REPEAT 11A-11D FOR EACH HOUSEHOLD MEMBER, USING NEXT OLDEST
FOR EACH UNTIL LAST, WHICH IS YOUNGEST.

DM-12 [DISPLAY ROSTER] Just to confirm, there are XX people living with you – READ ROSTER. Is that correct?
IF YES – CONTINUE
IF NO – MAKE CORRECTIONS

DM-13 In the past 12 months, did you [or any member of this household] receive benefits from the Food Stamp
Program or SNAP (the Supplemental Nutrition Assistance Program)?
YES .............................................................................
NO ..............................................................................

1
2

5

6464 Supported Employment Demonstration Attachment J1. Baseline Interview Computer
Assisted Personal Interview (CAPI) 05-03-17

DM-14 In the past 12 months, did you [or any member of this household] receive benefits from TANF (Temporary
Assistance for Needy Families), also known as cash welfare?
YES .............................................................................
NO ..............................................................................

DM-15

1
2

Do you have access to reliable transportation when you need it?
YES .............................................................................
NO ..............................................................................

1
2

DM-16. In the past three months, how many days have you been…
Living in a shelter or on the street? .............................

|__|__|

6

6464 Supported Employment Demonstration Attachment J1. Baseline Interview Computer
Assisted Personal Interview (CAPI) 05-03-17
WORK HISTORY AND INCOME (WI)

A. WORK HISTORY
Now I’d like to ask you some questions about your work history.
WI-1.

Have you ever worked at a job or business for pay?
YES .............................................................................
NO ..............................................................................

WI-2.

Have you worked at a job or business for pay in the past 2 years?
YES .............................................................................
NO ..............................................................................

WI-3.

1
2 (WI-19)

1
2 (WI-19)

Are you currently working at a job or business for pay?
YES .............................................................................
NO ..............................................................................

1
2

Now, I am going to ask some questions about your work history in the past two years starting with your {current/ most
recent} job. If you {have/had} more than one job in the same time period, tell me about the main job first. Also, if you
have held more than one position within the same company, you should tell me about those positions as separate
jobs. You should include part-time and full-time jobs, but only include jobs or positions you have held for pay.

ASK WI-4 TO WI-18 FOR EACH JOB HELD IN THE PAST TWO YEARS

WI-4.

What {is/was} your job title?/ What job did you do before that?
[INTERVIEWER: PLEASE MAKE SURE EACH JOB TITLE IS UNIQUE.]
__________________________________________
NAME OF JOB/JOB TITLE

WI-5.

On what date did you begin that job?

WI-5A

|__|__| / |__|__| / |__|__|__|__|
DAY MONTH YEAR
(If R KNOWS DAY, WI-6, IF R UNSURE, CONTINUE WITH PROBES)
Was it closer to the beginning of the month, or the end of the month?
Let’s look at this calendar.

WI-6.

On what date did that job end?

7

6464 Supported Employment Demonstration Attachment J1. Baseline Interview Computer
Assisted Personal Interview (CAPI) 05-03-17
|__|__| / |__|__| / |__|__|__|__|
DAY MONTH YEAR
CURRENTLY WORKING MAIN JOB ........................... 95
CURRENTLY WORKING SECOND JOB ................... 96

WI-6A

(If R KNOWS DAY, WI-7, IF R UNSURE, CONTINUE WITH PROBES)
Was it closer to the beginning of the month, or the end of the month?
Let’s look at this calendar.

WI-7.

How many hours per day {do/did} you usually work at that job?
|__|__|
HOURS

WI-8.

How many days per week {do/did} you usually work at that job?
|__|
DAYS

WI-9.

How many weeks per month {do/did} you usually work at that job?
|__|
WEEKS

WI-10.

What {are/were} your main activities or duties on this job?
__________________________________________
JOB DUTIES

WI-11.

What {is/was} the name of the organization or company you {work/worked} for?
__________________________________________
NAME OF ORGANIZATION/COMPANY
CASUAL LABOR/SELF-EMPLOYED .......................... 95

WI-12.

What type of business {is/was} it, that is what type of product {is/was} made or what type of service {is/was}
provided?
__________________________________________
TYPE OF BUSINESS

WI-13.

What {is/was} your hourly wage?
$|___|___|___|.|__|__| HOURLY WAGE

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WI-14.

Is it possible that you {are/were} paid a piece rate? That is, your pay {is/was} not based on an hourly rate
but on the number of items that you {produce/produced}?
YES .............................................................................
NO ..............................................................................
CASUAL LABOR/SELF-EMPLOYED .........................

WI-15.

Is/was this a temporary position?
YES .............................................................................
NO ..............................................................................

1
2
3

1
2 (WI-16)

WI-15b If yes, when will/did you end the job?
|__|__| / |__|__| / |__|__|__|__|

WI-15c. Is/was this a seasonal job or a transitional job?
SEASONAL JOB ......................................................... 1
TRANSITIONAL JOB .................................................. 2
OTHER JOB (SPECIFY) ______________________ 91

WI-16 From whom do/did you receive your paycheck or cash payment?
Employer .....................................................................
Temporary agency .......................................................
Mental health or rehabilitation agency .........................
Self employment ..........................................................
Other ............................................................................

11
12
13
14
15

WI-17
WI-17
WI-17
WI-17

WI-16a. Are/were you part of a work crew consisting of clients at the agency? Examples of a work crew would be a
cleaning service or a group operating a snack bar. Or are/were you part of an agency-run business?
Work crew ................................................................... 11
Agency-run business ................................................... 12

WI-17.

About how much {do/did} you earn at this job?

$|___|___|___|___|___|___|___| |__|__|

UNIT1

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WI-18.

Is that before taxes and other deductions {are/were} taken out or after taxes and other deductions {are/were}
taken out?
BEFORE TAXES ........................................................
AFTER TAXES ...........................................................
UNIT
EVERY HOUR ......................................................................................................
EVERY DAY .........................................................................................................
EVERY WEEK ......................................................................................................
EVERY TWO WEEKS ...........................................................................................
TWICE A MONTH .................................................................................................
EVERY MONTH....................................................................................................
EVERY QUARTER ...............................................................................................
EVERY YEAR .......................................................................................................
OTHER (SPECIFY) ________________________________________________
CWSSpecifyUnitPayEarnedOther
“CWSSpecified Other Unit of Pay Earned”

WI-19.

1
2

10
11
12
13
14
15
16
17
91

Have you worked at a volunteer job in the past month?
YES .............................................................................
NO ..............................................................................

1
2

IF RESPONDENT IS CURRENTLY WORKING (WI-3 = 1) THEN GO TO WI-21.

WI-20.

Which of the following best describes your current work status? Would you say…
Have a job but currently not at work (for instance on
a leave of absence or suspended), .......................... 1
Looking for work, ......................................................... 2
Keeping house or caregiving, ...................................... 3
Going to school, .......................................................... 4
Doing volunteer work, ................................................. 5
In vocational training, .................................................. 6
Retired, ....................................................................... 7
Unable to work, or ....................................................... 8
Something else? (SPECIFY) ___________________ 91

B. CURRENT INCOME SOURCES
WI-21.

Please tell me how much money you received from the following sources during the past month.
Remember, everything you tell me will be kept private.
a.

Any earned income or money from all paid employment,
including tips or commissions. Please tell me the take
home amount ...............................................................
$|__|__|,|__|__|__|.|__|__|

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6464 Supported Employment Demonstration Attachment J1. Baseline Interview Computer
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b.
c.
d.

e.

f.

g.

h.
i.

j.
k.

WI-22.

Social Security Retirement or Survivors Benefits .........
$|__|__|,|__|__|__|.|__|__|
VA or other armed services disability benefits .............
$|__|__|,|__|__|__|.|__|__|
Other state or county social welfare benefits such as
general assistance or public aid ..................................
$|__|__|,|__|__|__|.|__|__|
Food Stamp Program or SNAP (the Supplemental
Nutritional Assistance Program)...................................
$|__|__|,|__|__|__|.|__|__|
Temporary Assistance for Needy Families (TANF),
also known as cash welfare .........................................
$|__|__|,|__|__|__|.|__|__|
Vocational program such as Vocational Rehabilitation,
the Job Training Partnership Act, or Easter Seal .........
$|__|__|,|__|__|__|.|__|__|
Unemployment compensation......................................
$|__|__|,|__|__|__|.|__|__|
Retirement, pension (including military), investing, or
savings income that you receive regular payments
from ..............................................................................
$|__|__|,|__|__|__|.|__|__|
Alimony and child support ............................................
$|__|__|,|__|__|__|.|__|__|
Money from family members including gifts, loans,
or bill payments ............................................................
$|__|__|,|__|__|__|.|__|__|

Sometimes people’s income is increased through other sources that are not reported to the government.
The kinds of things I’m referring to include money received by doing odd jobs such as babysitting or yard
work, helping in a business, or doing work “under the table.” Did you receive any income this way last
month that you have not already told me about? Remember, what you tell me will be kept private.
YES .............................................................................
NO ..............................................................................

WI-23.

1
2 (BOX WI-2)

How much did you receive that you have not already told me about?
$|__|__|,|__|__|__|.|__|__|

BOX WI-2
IF RESPONDENT LIVES WITH OTHER ADULTS IN A NON-SUPERVISED SETTING
{(DM-9 = 2, 3, 4, 5, OR 6) OR [(DM-9 = 9 OR 8)}
THEN ASK WI-24. OTHERWISE, GO TO NEXT SECTION.

WI-24.

About how much was your total household income last month? Household income means the total amount
of money that everyone in your household, including yourself, received during the past month.

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$|__|__|,|__|__|__|.|__|__|

IF DON’T KNOW:
WI-24a. Ok, let’s try to estimate your total household income last month. Was it…
[INTERVIEWER begin with category including sum of WI-22 and WI-23.
PROGAMMER – DISPLAY SUM]
Less than $500 ...........................................................
$500 to $999 ...............................................................
$1,000 to $1,499 .........................................................
$1,500 to $1,999 ..........................................................
$2,000 to $2,499 ..........................................................
$2,500 to $2,999 ..........................................................
$3,000 to $3,499 ..........................................................
$3,500 to $3,999 ..........................................................
$4,000 to $4,499 ..........................................................
$5,500 to $5,999 ..........................................................
$6,000 to $6,499 ..........................................................
$6,500 to $6,999 ..........................................................
$7,000 or more.............................................................

1
2
3
4
5
6
7
8
9
10
11
12
13

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HEALTH STATUS (HS)
SF-12

The next few questions ask about your health and how well you are able to do your usual activities. First I will ask
about your health now. Please try to answer the question as accurately as you can.
HS-1.

In general, would you say your health is…
Excellent, .....................................................................
Very good,....................................................................
Good, ...........................................................................
Fair, or .........................................................................
Poor? ...........................................................................

1
2
3
4
5

Now, I’m going to ask about activities that you might do during a typical day. 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.
HS-2.

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…
A lot, ............................................................................
A little, or .....................................................................
Not at all? .....................................................................

HS-3.

1
2
3

Does your health now limit you in climbing several flights of stairs? Does it limit you…
A lot, ............................................................................
A little, or .....................................................................
Not at all? .....................................................................

1
2
3

The next two questions ask about your physical health and your daily activities.
HS-4.

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…
[INTERVIEWER: SHOW HS CARD.]
All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

1
2
3
4
5

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HS-5.

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…
[INTERVIEWER: SHOW HS CARD.]
All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

1
2
3
4
5

Now I will ask about any emotional problems and your daily activities.
HS-6.

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…
[INTERVIEWER: SHOW HS CARD.]
All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

HS-7.

1
2
3
4
5

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…
[INTERVIEWER: SHOW HS CARD.]
All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

HS-8.

1
2
3
4
5

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.
Not at all, ......................................................................
A little bit, .....................................................................
Moderately, ..................................................................
Quite a bit, or ...............................................................
Extremely? ...................................................................

1
2
3
4
5

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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.

HS-9.

During the past 4 weeks, how much of the time have you felt calm and peaceful? Would you say…
[INTERVIEWER: SHOW HS CARD.]
All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

1
2
3
4
5

HS-10. During the past 4 weeks, how much of the time did you have a lot of energy? Would you say…
[INTERVIEWER: SHOW HS CARD.]
All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

1
2
3
4
5

HS-11. During the past 4 weeks, how much of the time have you felt downhearted and depressed? Would you say…
[INTERVIEWER: SHOW HS CARD.]
All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

1
2
3
4
5

HS-12. 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…
[INTERVIEWER: SHOW HS CARD.]
All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

1
2
3
4
5

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PAIN
This next question is about pain.
Please rate your current pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine.
You can use these faces to help. This smiley face on the left represents no pain, while the crying face on the right
represents the worst pain you can imagine. How would you rate your pain?
[INTERVIEWER: SHOW FACES SHOWCARD]
|__|__| ENTER NUMBER BETWEEN 0 AND 10

COLORADO SYMPTOM INDEX (CSI)
Now I am going to ask you some questions about any psychological or emotional difficulties that you may have had.
For these questions, I am going to ask you how often you experienced certain problems during the past month.
SOME OF THESE QUESTIONS MAY SOUND SIMILAR TO OTHER QUESTIONS I’VE ASKED YOU.
For each problem I mention, I’ll ask you to look at this list of choices and pick one that best describes how often you
have had the problem in the past month. The responses vary from “At least every day” to “Not at all.” If you have
experienced the problem at least once in the past month you would choose “Once during the month.” If you have
experienced the problem more often, you would choose “Several times during the month.” Do you have any
questions about what the choices mean?
CSI-1
In the past month, how often have you felt nervous, tense, worried, frustrated, or afraid?
[INTERVIEWER: SHOW CSI CARD.]
NOT AT ALL ................................................................ 1
ONCE DURING THE MONTH .................................... 2
SEVERAL TIMES DURING THE MONTH ................... 3
SEVERAL TIMES A WEEK.......................................... 4
AT LEAST EVERY DAY .............................................. 5

CSI-2
In the past month, how often have you felt depressed?
[INTERVIEWER: SHOW CSI CARD.]
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

1
2
3
4
5

CSI-3
In the past month, how often have you felt lonely?
[INTERVIEWER: SHOW CSI CARD.]
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

1
2
3
4
5

CSI-4
In the past month, how often have others told you that you acted “paranoid” or “suspicious”?
[INTERVIEWER: SHOW CSI CARD.]
NOT AT ALL ................................................................ 1
ONCE DURING THE MONTH .................................... 2
SEVERAL TIMES DURING THE MONTH ................... 3

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SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

4
5

CSI-5 In the past month, how often did you hear voices, or hear or see things that other people didn’t think were
there?
[INTERVIEWER: SHOW CSI CARD.]
NOT AT ALL ................................................................ 1
ONCE DURING THE MONTH .................................... 2
SEVERAL TIMES DURING THE MONTH ................... 3
SEVERAL TIMES A WEEK.......................................... 4
AT LEAST EVERY DAY .............................................. 5
CSI-6
(Read slowly) In the past month, how often did you have trouble making up your mind about something, like
deciding where you wanted to go or what you wanted to do, or how to solve a problem?
[INTERVIEWER: SHOW CSI CARD.]
NOT AT ALL ................................................................ 1
ONCE DURING THE MONTH .................................... 2
SEVERAL TIMES DURING THE MONTH ................... 3
SEVERAL TIMES A WEEK.......................................... 4
AT LEAST EVERY DAY .............................................. 5
CSI-7
(Read slowly) In the past month, how often did you have trouble thinking straight, or concentrating on
something you needed to do like worrying so much, or thinking about problems so much that you can’t remember or
focus on other things?
[INTERVIEWER: SHOW CSI CARD.]
NOT AT ALL ................................................................ 1
ONCE DURING THE MONTH .................................... 2
SEVERAL TIMES DURING THE MONTH ................... 3
SEVERAL TIMES A WEEK.......................................... 4
AT LEAST EVERY DAY .............................................. 5
CSI-8
In the past month, how often did you feel that your behavior or actions were strange or different from that of
other people?
[INTERVIEWER: SHOW CSI CARD.]
NOT AT ALL ................................................................ 1
ONCE DURING THE MONTH .................................... 2
SEVERAL TIMES DURING THE MONTH ................... 3
SEVERAL TIMES A WEEK.......................................... 4
AT LEAST EVERY DAY .............................................. 5
CSI-9 In the past month, how often did you feel out of place or like you did not fit in?
[INTERVIEWER: SHOW CSI CARD.]
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

1
2
3
4
5

CSI-10 In the past month, how often did you forget important things?
[INTERVIEWER: SHOW CSI CARD.]
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

1
2
3
4
5

CSI-11

In the past month, how often did you have problems with thinking too fast (thoughts racing)?

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[INTERVIEWER: SHOW CSI CARD.]
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

1
2
3
4
5

CSI-12 In the past month, how often did you feel suspicious or paranoid?
[INTERVIEWER: SHOW CSI CARD.]
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

1
2
3
4
5

CSI-13 In the past month, how often did you feel like hurting or killing yourself?
[INTERVIEWER: SHOW CSI CARD.]
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

1
2
3
4
5

CSI-14 In the past month, how often have you felt like seriously hurting someone else?
[INTERVIEWER: SHOW CSI CARD.]
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

1
2
3
4
5

BRIEF RESILIENCE SCALE (BR)
Next, I am going to read you a series of statements. Let me know how much you agree or disagree with each of the
statements.
BR-1.

I tend to bounce back quickly after hard times. Would you say you…

Strongly disagree .........................................................
Disagree ......................................................................
Neutral .........................................................................
Agree, or ......................................................................
Strongly agree? ...........................................................

BR-2.

1
2
3
4
5

I have a hard time making it through stressful events. Would you say you…

Strongly disagree .........................................................
Disagree ......................................................................

1
2

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Neutral .........................................................................
Agree, or ......................................................................
Strongly agree? ...........................................................
BR-3.

It does not take me long to recover from a stressful event. Would you say you…

Strongly disagree .........................................................
Disagree ......................................................................
Neutral .........................................................................
Agree, or ......................................................................
Strongly agree? ...........................................................
BR-4.

1
2
3
4
5

I usually come through difficult times with little trouble. Would you say you…

Strongly disagree .........................................................
Disagree ......................................................................
Neutral .........................................................................
Agree, or ......................................................................
Strongly agree? ...........................................................
BR-6.

1
2
3
4
5

It is hard for me to snap back when something bad happens. Would you say you…

Strongly disagree .........................................................
Disagree ......................................................................
Neutral .........................................................................
Agree, or ......................................................................
Strongly agree? ...........................................................

BR-5.

3
4
5

1
2
3
4
5

I tend to take a long time to get over set-backs in my life. Would you say you…

Strongly disagree .........................................................
Disagree ......................................................................
Neutral .........................................................................
Agree, or ......................................................................
Strongly agree? ...........................................................

1
2
3
4
5

SATISFACTION WITH LIFE (SL)
The next questions are about how you like your present life. For each question, please let me know which option best
reflects your feelings about your life at this time.
SL-1

How much do you like the place where you live?

Not at all .......................................................................

1

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Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-2

How satisfied are you with the amount of privacy you have in your current living situation?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-3

1
2
3
4
5

How satisfied are you with the number of friends you have?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-7

1
2
3
4
5

How satisfied are you with the way you spend your evenings and weekends?
Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

SL-6

1
2
3
4
5

How much do you like the food you usually eat?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-5

1
2
3
4
5

How satisfied are you with the amount of space you have in your current living situation?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-4

2
3
4
5

1
2
3
4
5

Do you feel as close to your friends as you would like to be?

Not at all .......................................................................

1

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Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-8

How satisfied are you with the kind and amount of contact you have with the opposite sex?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-9

1
2
3
4
5

How satisfied are you with the kind of work that you do?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-13

1
2
3
4
5

How satisfied are you with the way you spend your days?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

SL-12

1
2
3
4
5

How satisfied are you with the kinds of relationships you have with members of your family?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-11

1
2
3
4
5

How satisfied are you with your current social life?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

SL-10

2
3
4
5

1
2
3
4
5

Do you feel that you are working as much as you would like?

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Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

SL-14

How satisfied are you with your current psychological condition?
Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

SL-15

1
2
3
4
5

Do you feel you get as much enjoyment from life as most people do?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-18

1
2
3
4
5

How satisfied are you with yourself on the whole?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

SL-17

1
2
3
4
5

How satisfied are you with your present life?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

SL-16

1
2
3
4
5

1
2
3
4
5

Do you feel that you have as much freedom as you want?
Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

1
2
3
4
5

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ALCOHOL, DRUGS, AND TOBACCO USE (SA)

SA-1.

These next questions are about smoking and tobacco use. In the last week, how many days did you smoke
cigarettes or use tobacco in other forms such as cigars, pipes, hookahs, vaporizers, or chewing tobacco?
|__|__|
DAYS
(IF >0, CONTINUE TO SA-2, OTHERWISE SKIP TO SA-7)

What form or forms of tobacco did you use in the last week? Was it…
SA-2a.

Cigarettes?
YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

Pipes, hookahs, or vaporizers?
YES ..............................................................................
NO ..............................................................................

1
2

SA-2d. Chewing tobacco?
YES ..............................................................................
NO ..............................................................................

1
2

SA-2b. Cigars?

SA-2c.

IF SA-2A = YES, ASK SA-3; IF SA-2B = YES, ASK SA-4; IF SA-2C = YES, ASK SA-5; IF SA-2D = YES, ASK SA6

SA-3.

How many cigarettes did you smoke in a typical day in the past week?
|__|__|
CIGARETTES

SA-4.

How many cigars did you smoke in a typical day in the past week?
|__|__|
CIGARS

SA-5.

How many pipes full of tobacco did you smoke in a typical day in the past week?
|__|__|
PIPES

SA-6.

How many times did you use chewing tobacco in a typical day in the past week?

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|__|__|
TIMES
SA-7.

You just told me that in the past week you [SUMMARIZE SMOKING HABITS]. Now think about the past
three months. Was this past week typical of all the other weeks in the past three months, or were there
weeks you used more or used less than this?
[SHOW CALENDAR]
TYPICAL ......................................................................
SOME WEEKS MORE ................................................
SOME WEEKS LESS ..................................................

1
2
3

Now I am going to ask you about your use of alcohol and drugs in the past week. This includes any use of alcohol,
not just getting high or drunk, and this includes different types of alcohol such as beer, malt liquor, wine, wine coolers,
and hard liquor such as whisky, vodka, rum, and so forth. For drug use, this includes the use of any illegal drugs
such as marijuana and cocaine, and it includes abuse of prescription or over-the-counter medicines. Please look
over this list of alcohol and drug names so you can see the types of substances that I am asking about.
[INTERVIEWER: SHOW DRUG LIST]
SA-8.

In the last week, how many days did you drink any amount of alcohol?
|__|__|
DAYS
(IF >0, CONTINUE TO SA-9, OTHERWISE SKIP TO SA-10)

SA-9.

How many drinks did you have in a typical day in the past week?
|__|__|
DRINKS

SA-10. Now think about the past three months. Was this past week typical of all the other weeks in the past three
months, or were there weeks you drank more or drank less than this?
[SHOW CALENDAR]
TYPICAL ...................................................................... 1
SOME WEEKS MORE ................................................ 2
SOME WEEKS LESS .................................................. 3
SA-11. [INTERVIEWER, POINT TO DRUG LIST] In the last week, did you use any of these drugs?
YES .............................................................................. 1
NO .............................................................................. 2 (SA-14)
Which drug or drugs did you use?
SA-12a. Marijuana?
YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

SA-12b. Sedatives?

SA-12c. Cocaine?

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YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

SA-12d. Stimulants?

SA-12e. Hallucinogens?

SA-12f. Heroin?

SA-12g. Methadone?

SA-12h. Other opiates?

SA-12g. Inhalants?

SA-12h. Other?

[REPEAT SA-13 AND SA-14 FOR EACH DRUG]
SA-13. How many days in the last week did you use [DRUG]?
|__|__|
DAYS
SA-14. Now think about the past three months. Was this past week typical of all the other weeks in the past three
months, or were there weeks you used more or used less than this?
[SHOW CALENDAR]
TYPICAL ...................................................................... 1
SOME WEEKS MORE ................................................ 2
SOME WEEKS LESS .................................................. 3
SA-15. Now think about your prescribed medications. How many days in last week did you take more of your
medication than the doctor prescribed?
|__|__|
DAYS
SA-16. Now think about the past three months. Was this past week typical of all the other weeks in the past three
months, or were there weeks you took more medication that prescribed more or less often?
TYPICAL ...................................................................... 1

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SOME WEEKS MORE ................................................
SOME WEEKS LESS ..................................................

2
3

SA-17. How many days in last week did you take medication that was prescribed to someone else?
|__|__|
DAYS
SA-18. Now think about the past three months. Was this past week typical of all the other weeks in the past three
months, or were there weeks you took medication that was not prescribed to you more or less often?
TYPICAL ...................................................................... 1
SOME WEEKS MORE ................................................ 2
SOME WEEKS LESS .................................................. 3
BMI
BMI-1.

How tall are you without shoes?
|__| |__|__|
FEET INCHES

BMI-2.

How much do you weigh without shoes?
|__|__|__|
POUNDS

HEALTH CARE COVERAGE AND SERVICE UTILIZATION (HC)

A. HEALTH CARE COVERAGE
HC-1.

What types of health insurance or health coverage plans are you currently covered by?
INSURANCE THROUGH A CURRENT OR FORMER EMPLOYER OR UNION (OF YOURS OR ANOTHER
FAMILY MEMBER)
INSURANCE PURCHASED DIRECTLY FROM AN INSURANCE COMPANY (BY YOU OR ANOTHER
FAMILY MEMBER)
INSURANCE THROUGH HEALTHCARE.GOV OR A STATE EXCHANGE
MEDICARE, FOR PEOPLE 65 AND OLDER, OR PEOPLE WITH CERTAIN DISABILITIES
MEDICAID, MEDICAL ASSISTANCE, OR ANY KIND OF GOVERNMENT-ASSISTANCE PLAN FOR THOSE
WITH LOW INCOMES OR A DISABILITY
VA (INCLUDING THOSE WHO HAVE EVER USED OR ENROLLED FOR VA HEALTH CARE)
TRICARE, TRICARE FOR LIFE OR OTHER MILITARY HEALTH CARE
INDIAN HEALTH SERVICE
OTHER SPECIFY

HC-2. [IF NO INSURANCE] Just to confirm, you are not currently covered by Medicare, Medicaid, VA, TRICARE, or
any other health insurance. Is that correct?
YES .............................................................................
NO ..............................................................................

1
2

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B. HEALTH CARE SERVICE UTILIZATION
HC-3.

During the past 12 months, did you receive any care in an emergency room?
YES .............................................................................
NO ..............................................................................

1
2 (HC-10)

I would like to get more information about your emergency room visits. Let’s begin with the most recent time you
visited an emergency room and work backwards over the past 12 months.

ASK HC-4 TO HC-9 ABOUT EACH EMERGENCY ROOM VISIT IN PAST 12 MONTHS.

HC-4.

When did you go on your most recent visit?/When did you go before that?
[INTERVIEWER: ASK RESPONDENT ABOUT PREVIOUS EMERGENCY ROOM VISITS BY READING THE
DATE AND NAME OF THE LAST EMERGENCY ROOM VISIT ENTERED. VISITS MUST BE SINCE DATE
OF LAST INTERVIEW.]
|__|__| - |__|__|__|__|
MONTH
YEAR

HC-5.

Where did you go?
[INTERVIEWER: ENTER NAME OF EMERGENCY ROOM. IF RESPONDENT DOES NOT KNOW THE
NAME OR REFUSES TO GIVE IT, PLEASE ENTER A DESCRIPTION. ENTER THE WORD “DELETE” TO
INDICATE THIS ENTRY IS AN ERROR.]
__________________________________________
NAME OF EMERGENCY ROOM

HC-6.

There may be more than one reason for this visit. Please tell us all the reasons for this visit. Was it for…
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-4) AND NAME OF PLACE (RESPONSE TO HC5) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
A physical problem, .....................................................

1

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A mental health problem, ........................................... 2
An alcohol problem, .................................................... 3
A drug problem, or ...................................................... 4
Some other problem? (SPECIFY) ______________ 91

HC-7.

Were you admitted to the hospital following this emergency room visit?
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-4) AND NAME OF PLACE (RESPONSE TO HC5) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
YES .............................................................................
NO ..............................................................................
HC-10)

HC-8.

1
2 (NEXT VISIT OR

There may be more than one reason why you were admitted to the hospital following this emergency room
visit. Please tell us all the reasons for this admission into the hospital. Was it for…
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-21) AND NAME OF PLACE (RESPONSE TO HC22) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
A physical problem, ..................................................... 1
A mental health problem, ........................................... 2
An alcohol problem, .................................................... 3
A drug problem, or ...................................................... 4
Some other problem? (SPECIFY) ______________ 91

HC-9.

How many nights did you stay in the hospital?
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-21) AND NAME OF PLACE (RESPONSE TO HC22) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
|__|__| NIGHTS

HC-10. During the past 12 months, have you stayed overnight in a hospital [other than the ones you mentioned in
the previous questions]?
YES .............................................................................
NO ..............................................................................

1
2 (HC-15)

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I’d like to get more information about your hospital stays over the past 12 months other than the ones you mentioned
earlier. Let’s begin with the most recent time you were in the hospital and work backwards over the past year.

ASK HC-11 TO HC-14 ABOUT EACH HOSPITAL VISIT IN PAST 12 MONTHS.

HC-11. When did you stay in the hospital?/When did you stay before that?
|__|__| - |__|__|__|__|
MONTH
YEAR

HC-12. Where did you stay?
[INTERVIEWER: ENTER NAME OF HOSPITAL. IF RESPONDENT DOES NOT KNOW THE NAME OR
REFUSES TO GIVE IT, PLEASE ENTER A DESCRIPTION. ENTER THE WORD “DELETE” TO INDICATE
THIS ENTRY IS AN ERROR.]
__________________________________________
NAME OF HOSPITAL

HC-13. There may be more than one reason for this hospital stay. Please tell us all the reasons for your admission.
Was it for…
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-11) AND NAME OF PLACE (RESPONSE TO HC12) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
A physical problem, ..................................................... 1
A mental health problem, ........................................... 2
An alcohol problem, .................................................... 3
A drug problem, or ...................................................... 4
Some other problem? (SPECIFY) ______________ 91

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HC-14. How many nights did you stay in the hospital?
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-11) AND NAME OF PLACE (RESPONSE TO HC12) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
|__|__| NIGHTS
HC-15. During the past 12 months, have you had any outpatient visits for day surgeries or other serious non-routine
medical services?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-19)

I would like to get more information about those outpatient visits. Let’s begin with the most recent time visit and work
backwards over the past 12 months.

ASK HC-16 – HC-18 ABOUT EACH NON-ROUTINE OUTPATIENT VISIT

HC-16. When did you receive care?/When did you stay before that?
|__|__| - |__|__|__|__|
MONTH
YEAR

HC-17. Where did you receive care?
[INTERVIEWER: ENTER NAME OF OUTPATIENT CENTER/CLINIC. IF RESPONDENT DOES NOT KNOW
THE NAME OR REFUSES TO GIVE IT, PLEASE ENTER A DESCRIPTION. ENTER THE WORD “DELETE”
TO INDICATE THIS ENTRY IS AN ERROR.]
__________________________________________
NAME OF CENTER/CLINIC

HC-18. There may be more than one reason for this visit. Please tell us all the reasons for your visit. Was it for…
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-16) AND NAME OF PLACE (RESPONSE TO HC17) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
A physical problem, ..................................................... 1
A mental health problem, ........................................... 2
An alcohol problem, .................................................... 3
A drug problem, or ...................................................... 4
Some other problem? (SPECIFY) ______________ 91

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Next, I want to ask you about outpatient visits for help with drug or alcohol abuse, emotional or psychiatric problems.
BE SURE NOT TO COUNT THE SAME SERVICE IN TWO CAETGROIES (for example alcohol counseling and
community mental health center)—CHOSE THE ONE THAT FITS BEST IN YOUR OPINION.
Do not include visits exclusively for research data collection.

HC-19. In the past month, did you attend an outpatient visit to a psychiatrist for an emotional or psychiatric problem,
or for an alcohol or drug problem?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-20)
HC-19a How many outpatient visits did you attend?
|__|__| VISITIS
HC-19b On average, how long did each visit last?
|__|__| MINUTES

HC-20. In the past month, did you attend an outpatient visit to some other mental health professional (e.g., social
worker, psychologist, nurse, etc.) for an emotional or psychiatric problem, or for an alcohol or drug problem?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-21)
HC-20a How many outpatient visits did you attend?
|__|__| VISITIS
HC-20b On average, how long did each visit last?
|__|__| MINUTES
HC-21

In the past month, did you attend an outpatient visit to a Community Health Center for an emotional or
psychiatric problem, or for an alcohol or drug problem?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-22)

HC-21a How many outpatient visits did you attend?
|__|__| VISITIS
HC-21b On average, how long did each visit last?
|__|__| MINUTES

HC-22

In the past month, did you attend an outpatient visit to a Family Service or Child Guidance Agency?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-23)

HC-22a How many outpatient visits did you attend?

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|__|__| VISITIS
HC-22b On average, how long did each visit last?
|__|__| MINUTES
HC-23

In the past month, did you attend an outpatient for alcohol or drug counseling?
YES .............................................................................
NO ..............................................................................

1
2 (HC-24)

HC-23a How many outpatient visits did you attend?
|__|__| VISITIS
HC-23b On average, how long did each visit last?
|__|__| MINUTES
HC-24

In the past month, did you attend an outpatient visit to a self-help group for an emotional or psychiatric
problem, or for an alcohol or drug problem?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-25)

HC-24a How many outpatient visits did you attend?
|__|__| VISITIS
HC-24b On average, how long did each visit last?
|__|__| MINUTES
HC-25

In the past month, did you attend an outpatient visit to a day hospital or day treatment center for an
emotional or psychiatric problem, or for an alcohol or drug problem?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-26)

HC-25a How many outpatient visits did you attend?
|__|__| VISITIS
HC-25b On average, how long did each visit last?
|__|__| MINUTES
HC-26

In the past month, did you attend an outpatient visit to a VA clinic for an emotional or psychiatric problem, or
for an alcohol or drug problem?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-27)

HC-26a How many outpatient visits did you attend?
|__|__| VISITIS

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HC-26b On average, how long did each visit last?
|__|__| MINUTES
HC-27

In the past month, did you attend an outpatient visit to a Psychosocial Rehabilitation Program?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-28)

HC-27a How many outpatient visits did you attend?
|__|__| VISITIS
HC-27b On average, how long did each visit last?
|__|__| MINUTES
HC-28

In the past month, did you attend an outpatient visit for intensive case management/ACT for an emotional or
psychiatric problem, or for an alcohol or drug problem? (If case management services were included in
previous categories, do not count here.)
YES ............................................................................. 1
NO .............................................................................. 2 (HC-29)

HC-28a How many outpatient visits did you attend?
|__|__| VISITIS
HC-28b On average, how long did each visit last?
|__|__| MINUTES
HC-29

In the past month, did you attend an outpatient visit to any other professional for an emotional or psychiatric
problem, or for an alcohol or drug problem?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-30)

HC-29a How many outpatient visits did you attend?
|__|__| VISITIS
HC-29b On average, how long did each visit last?
|__|__| MINUTES
HC-30

In the past month, did you attend an outpatient visit for peer support/counseling (other than AA/CA/NA) for
an emotional or psychiatric problem, or for an alcohol or drug problem? (e.g., formal support/assistance
from other people who have personally experienced mental illness)
YES ............................................................................. 1
NO .............................................................................. 2 (HC-31)

HC-30a How many outpatient visits did you attend?
|__|__| VISITIS
HC-30b On average, how long did each visit last?

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|__|__| MINUTES
Now, I’m going to read a list of some places from which you may have received medical services.
In the past month, how many visits did you attend at these clinics for medical problems?
HC-31

In the past month, have you visited a private medical doctor for outpatient medical services?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-32)

HC-31a How many outpatient visits did you attend?
|__|__| VISITIS
HC-32

In the past month, have you visited a private health care practitioner (Non-M.D.) for outpatient medical
services?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-33)

HC-32a How many outpatient visits did you attend?
|__|__| VISITIS
HC-33

In the past month, have you visited an outpatient clinic for outpatient medical services?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-34)

HC-33a How many outpatient visits did you attend?
|__|__| VISITIS
HC-34

In the past month, have you visited a community health center for outpatient medical services?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-35)

HC-34a How many outpatient visits did you attend?
|__|__| VISITIS
HC-35

In the past month, have you visited anywhere else for outpatient medical services?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-36)

HC-35a How many outpatient visits did you attend?
|__|__| VISITIS

HC-36. In the past month, have you received any employment, vocational, job skills, or job finding services?
YES ............................................................................. 1
NO .............................................................................. 2 (NEXT SECTION)

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HC-36a How many times did you receive these services?
|__|__| TIMES
HC-36b Where did you receive these services?
|______|
HC-36a What kinds of services did you receive?
SUPPORTED EMPLOYMENT ....................................
JOB FINDING SERVICES ..........................................
JOB SKILLS TRAINING ..............................................
VOCATIONAL REHABILITATION ..............................
PREVOCATIONAL WORK CREW .............................
OTHER EMPLOYMENT OR
VOCATIONAL SERVICES ..........................................

1
2
3
4
5
6

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HEALTH CONDITIONS/COMORBIDITIES (CM)
The next questions are about different medical conditions you may have.
CM-1.

Have you ever been told by a doctor or other health professions that you had hypertension, also called high
blood pressure?
YES .............................................................................
NO ..............................................................................

CM-2.

1
2 (CM-3)

Were you told on 2 or more different visits that you had hypertension, also called high blood pressure?
YES .............................................................................
NO ..............................................................................

1
2

CM-2a. Do you receive treatment for hypertension?
YES .............................................................................
NO ..............................................................................

1
2

CM-2b. Does your hypertension limit any of your activities?
YES .............................................................................
NO ..............................................................................

CM-3.

1
2

Have you ever been told by a doctor or other health professional that you had diabetes or sugar diabetes?
YES .............................................................................
NO ..............................................................................
BORDERLINE OR PREDIABETES ............................

CM-3a. Do you receive treatment for diabetes?
YES .............................................................................
NO ..............................................................................

1
2 (CM-4)
3

1
2

CM-3b. Does your diabetes limit any of your activities?
YES .............................................................................
NO ..............................................................................
CM-4.

1
2

Have you ever been told by a doctor or other health professional that you had congestive heart failure?
YES .............................................................................
NO ..............................................................................

CM-4a. Do you receive treatment for congestive heart failure?
YES .............................................................................
NO ..............................................................................

1
2 (CM-5)

1
2

CM-4b. Does your congestive heart failure limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

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CM-5.

Have you ever been told by a doctor or other health professional that you had coronary heart disease?
YES .............................................................................
NO ..............................................................................

CM-5a. Do you receive treatment for your heart disease?
YES .............................................................................
NO ..............................................................................

1
2 (CM-6)

1
2

CM-5b. Does your heart disease limit any of your activities?
YES .............................................................................
NO ..............................................................................
CM-6.

1
2

Have you ever been told by a doctor or other health professional that you had a lung disease?
YES .............................................................................
NO ..............................................................................

CM-6a. Do you receive treatment for your lung disease?
YES .............................................................................
NO ..............................................................................

1
2 (CM-7)

1
2

CM-6b. Does your lung disease limit any of your activities?
YES .............................................................................
NO ..............................................................................
CM-7.

1
2

Have you ever been told by a doctor or other health professional that you had an ulcer or stomach disease?
YES .............................................................................
NO ..............................................................................

CM-7a. Do you receive treatment for your ulcer or stomach disease?
YES .............................................................................
NO ..............................................................................

1
2 (CM-8)

1
2

CM-7b. Does your ulcer or stomach disease limit any of your activities?
YES .............................................................................
NO ..............................................................................
CM-8.

1
2

Have you ever been told by a doctor or other health professional that you had anemia or other blood
disease?
YES .............................................................................
NO ..............................................................................

CM-8a. Do you receive treatment for your blood disease?
YES .............................................................................
NO ..............................................................................

1
2 (CM-9)

1
2

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CM-8b. Does your blood disease limit any of your activities?
YES .............................................................................
NO ..............................................................................

CM-9.

1
2

Have you ever been told by a doctor or other health professional that you had a stroke?
YES .............................................................................
NO ..............................................................................

CM-9a. Do you receive treatment for strokes?
YES .............................................................................
NO ..............................................................................

1
2 (CM-10)

1
2

CM-9b. Does your stroke history limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-10. Have you ever been told by a doctor or other health professional that you had asthma?
YES .............................................................................
NO ..............................................................................
CM-10a. Do you receive treatment for your asthma?
YES .............................................................................
NO ..............................................................................

1
2 (CM-11)

1
2

CM-10b. Does your asthma limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-11. Have you ever been told by a doctor or other health professional that you had emphysema?
YES .............................................................................
NO ..............................................................................
CM-11a. Do you receive treatment for your emphysema?
YES .............................................................................
NO ..............................................................................

1
2 (CM-12)

1
2

CM-11b. Does your emphysema limit any of your activities?
YES .............................................................................
NO ..............................................................................

CM-12

1
2

Have you ever been told by a doctor or other health professional that you had chronic bronchitis?

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6464 Supported Employment Demonstration Attachment J1. Baseline Interview Computer
Assisted Personal Interview (CAPI) 05-03-17
YES .............................................................................
NO ..............................................................................
CM-12a. Do you receive treatment for your chronic bronchitis?
YES .............................................................................
NO ..............................................................................

1
2 (CM-13)

1
2

CM-12b. Does your chronic bronchitis limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-13 Have you ever been told by a doctor or other health professional that you had COPD?
YES .............................................................................
NO ..............................................................................
CM-13a. Do you receive treatment for your COPD?
YES .............................................................................
NO ..............................................................................

1
2 (CM-14)

1
2

CM-13b. Does your COPD limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-14. Have you ever been told by a doctor or other health professional that you had a thyroid problem?
YES .............................................................................
NO ..............................................................................
CM-14a. Do you receive treatment for your thyroid problem?
YES .............................................................................
NO ..............................................................................

1
2 (CM-15)

1
2

CM-14b. Does your thyroid problem limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-15. Have you ever been told by a doctor or other health professional that you had a liver disease or any other
kind of liver problem?
YES .............................................................................
NO ..............................................................................
CM-15a. Do you receive treatment for your liver problem?
YES .............................................................................
NO ..............................................................................

1
2 (CM-16)

1
2

CM-15b. Does your liver problem limit any of your activities?

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6464 Supported Employment Demonstration Attachment J1. Baseline Interview Computer
Assisted Personal Interview (CAPI) 05-03-17
YES .............................................................................
NO ..............................................................................

1
2

CM-16. Have you ever been told by a doctor or other health professional that you had a kidney disease or weak or
failing kidneys? Do not include kidney stones, bladder infections, or incontinence.
YES .............................................................................
NO ..............................................................................
CM-17a. Do you receive treatment for your kidney problem?
YES .............................................................................
NO ..............................................................................

1
2 (CM-17)

1
2

CM-17b. Does your kidney problem limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-18. Have you ever been told by a doctor or other health professional that you had osteoarthritis or degenerative
arthritis?
YES .............................................................................
NO ..............................................................................
CM-18a. Do you receive treatment for your arthritis?
YES .............................................................................
NO ..............................................................................

1
2 (CM-19)

1
2

CM-18b. Does your arthritis limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-19. Have you ever been told by a doctor or other health professional that you had rheumatoid arthritis?
YES .............................................................................
NO ..............................................................................
CM-19a. Do you receive treatment for your arthritis?
YES .............................................................................
NO ..............................................................................

1
2 (CM-20)

1
2

CM-19b. Does your arthritis limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-20. Have you ever been told by a doctor or other health professional that you had cancer?
YES .............................................................................
NO ..............................................................................

1
2 (CM-21)

40

6464 Supported Employment Demonstration Attachment J1. Baseline Interview Computer
Assisted Personal Interview (CAPI) 05-03-17
CM-20a. Do you receive treatment for your cancer?
YES .............................................................................
NO ..............................................................................

1
2

CM-20b. Does your cancer limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-21. Have you ever been told by a doctor or other health professional that you had depression?
YES .............................................................................
NO ..............................................................................
CM-21a. Do you receive treatment for depression?
YES .............................................................................
NO ..............................................................................

1
2 (CM-22)

1
2

CM-21b. Does your depression limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-22. Have you ever been told by a doctor or other health professional that you had back pain?
YES .............................................................................
NO ..............................................................................
CM-22a. Do you receive treatment for your back pain?
YES .............................................................................
NO ..............................................................................

1
2 (CM-23)

1
2

CM-22b. Does your back pain limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-23. Have you ever been told by a doctor or other health professional that you had HIV?
YES .............................................................................
NO ..............................................................................
CM-23a. Do you receive treatment for your HIV?
YES .............................................................................
NO ..............................................................................

1
2 (CM-24)

1
2

CM-23b. Does your HIV limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-24. Do you have any other health conditions?

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6464 Supported Employment Demonstration Attachment J1. Baseline Interview Computer
Assisted Personal Interview (CAPI) 05-03-17
YES .............................................................................
NO ..............................................................................

1
2

(NEXT SECTION)

CM-24a. Please tell me about the other health conditions that you have.
[OPEN TEXT BOX]
CM-24b. Do you receive treatment for your [OTHER TEXT]?
YES .............................................................................
NO ..............................................................................

1
2

CM-24c. Does your [OTHER TEXT] limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

PRESCRIPTION MEDICATION (PM)
The next questions are about prescription medications.
PM-1

Have you obtained any prescription medicines in the last three months? For example, have you had any
new prescriptions or a refill of a prescription? Please include any on-line prescriptions
YES .............................................................................
NO ..............................................................................

PM-2

1
2 (PM-3)

What health problem are these medicines prescribed for?

PROBE: Any other health problems? IF CONDITION IS ALREADY LISTED, SELECT ENTRY ON ROSTER.
[1. Medical Condition]
[2. Medical Condition]
[3. Medical Condition]
PM-3

Have you obtained any prescription medicines in the three months before that ([MONTH] to [MONTH])? For
example, have you had any new prescriptions or a refill of a prescription? Please include any on-line
prescriptions
YES .............................................................................
NO ..............................................................................

PM-4

1
2 (PM-3)

What health problem are these medicines prescribed for?

PROBE: Any other health problems? IF CONDITION IS ALREADY LISTED, SELECT ENTRY ON ROSTER.
[1. Medical Condition]
[2. Medical Condition]
[3. Medical Condition]
JUSTICE INVOLVEMENT (JI)
These final questions are about your possible involvement with the justice system.

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6464 Supported Employment Demonstration Attachment J1. Baseline Interview Computer
Assisted Personal Interview (CAPI) 05-03-17
JI-1

Not counting minor traffic violations, have you ever been arrested and booked for breaking the law? Being
"booked" means that you were taken into custody and processed by the police or by someone connected
with the courts, even if you were then released.
YES .............................................................................
NO ..............................................................................

JI-2

1
2 (JI-6)

Not counting minor traffic violations, how many times during the past 12 months have you been arrested and
booked for breaking the law?
|______|

JI-3

Have you been convicted of any misdemeanors in the past 12 months?
YES .............................................................................
NO ..............................................................................

JI-4

Have you been convicted of any felonies in the past 12 months?
YES .............................................................................
NO ..............................................................................

JI-5

1
2 (JI-6)

1
2 (JI-6)

In the past 12 months, how many nights did you spend in jail, prison, or a correctional facility?
|______|

JI-6

Were you on probation at any time in the past 12 months?
YES .............................................................................
NO ..............................................................................

1
2

DIGIT SYMBOL TEST (DS)

[INTERVIEWER: ADMINISTER THE PAPER-PENCIL DIGIT SYMBOL TEST. SCORE THE TEST AFTER YOU HAVE
FINISHED INTERVIEWING THE RESPONDENT AND RECORD THE SCORE IN THE MANAGEMENT
INFORMATION SYSTEM.]

WORK DISABILITY FUNCTIONAL ASSESSMENT BATTERY (FAB)

[INTERVIEWER: ADMINISTER THE WORK DISABILITY FUNCTIONAL ASSESSMENT BATTERY2 USING THE
ONLINE COMPUTERIZED ADAPTIVE TESTING SOFTWARE.]

2

The WD-FAB is administered using computerized adaptive testing (CAT) methodology, where an item is initially presented from the mid-range of a
defined list of items and then selects subsequent items at an appropriate level based on the respondent’s previous answers. Typically, if the test-taker

43

6464 Supported Employment Demonstration Attachment J1. Baseline Interview Computer
Assisted Personal Interview (CAPI) 05-03-17

is answering the first questions correctly or in accordance with preset or expected response algorithms, the next questions will be more difficult until
the level appropriate for the examinee performance is best reached or the test is completed. If one does not answer the first questions correctly or as
typically expected, then easier questions would generally be presented to the test-taker. CAT estimates scores of the test-taker after each response to
a question and adjusts the administration of the next question accordingly. CAT software tailors an assessment by asking only the most informative
questions, based on a person’s response to previous questions, thus, fewer questions, in total, are needed to achieve an accurate and precise
assessment. Attachment J2 includes the full item pool for the WD-FAB.

44