Showcard INT0
1=Mexican, Mexican American, Mexicano or Chicano
2=Puerto Rican
3=Central American
4=South American
5=Cuban or Cuban American
6=Dominican (from Dominican Republic)
7=Spanish (from Spain)
8=Other Latin American, Hispanic, Latino or Spanish origin
Showcard INT1
1=White
2=Black or African American
3=American Indian or Alaska native (American Indian includes North American, Central American, and South American Indians)
4=Native Hawaiian
5=Guamanian or Chamorro
6=Samoan
7=Tongan
8=Marshallese
9=Asian Indian
10=Chinese
11=Filipino
12=Japanese
13=Korean
14=Vietnamese
15=Other Asian
16=Other Native American/American Indian
17=Other Pacific Islander
Showcard MED1
1=Could not afford care
2=Insurance company wouldn’t approve, cover, or pay for care
3=Doctor refused to accept family’s insurance plan
4=Problems getting to doctor’s office / transportation
5=Different language from doctors or nurses
6=Couldn’t get time off work
7=Didn’t know where to go to get care
8=Was refused services
9=Couldn’t get childcare
10=Didn’t have time or took too long
11=VA does not provide coverage for my condition
12=Concern about contracting Coronavirus (COVID-19)
13=Appointment cancelled / rescheduled due to Coronavirus (COVID-19)
14=Other
Showcard MED4
Select all that apply
1=Needed a diagnostic procedure
2=Care for a chronic condition
3=Needed to see a medical specialist
4=Needed to obtain prescription medication
5=Care to address pain
6=Mental health related issue
7=Some other reason
Showcard ROU1
1=Did not think it was important
2=Afraid of the side effects of the immunization
3=Child was sick and could not have immunizations at that time
4=I don’t trust the shots/ I don’t believe in shots
5=Couldn’t afford care
6=Problems getting to doctor's office / transportation
7=Different language from doctors or nurses
8=Couldn’t get time off work
9=Didn’t know where to go to get care
10=Didn’t have time or took too long
11=Other
Showcard ROU2
1=Could not afford care
2=Insurance company wouldn’t approve, cover, or pay for care
3=Doctor refused to accept family’s insurance plan
4=Problems getting to doctor’s office / transportation
5=Different language from doctors or nurses
6=Couldn’t get time off work
7=Didn’t know where to go to get care
8=Was refused services
9=Couldn’t get childcare
10=Didn’t have time or took too long
11=VA does not provide coverage for my condition
12=Concern about contracting Coronavirus (COVID-19)
13=Appointment cancelled / rescheduled due to Coronavirus (COVID-19)
14=Other
Showcard CON1
Select all that apply
1=Changed what I ate or how much I ate or when I ate
2=Exercised
3=Joined a weight loss program
4=Took diet pills prescribed by a doctor
5=Took other pills, medicines, herbs, or supplements not needing a prescription
6=Started to smoke or began to smoke again
7=Took laxatives or vomited
8=Drank a lot of water
9=Changed what I drank/reduced or gave up soft drinks/ beverages with sugar
10=Other
Showcard CON2
Select up to 3 kinds of cancer
1=Bladder
2=Blood
3=Bone
4=Brain
5=Breast
6=Cervix
7=Colon
8=Esophagus
9=Gallbladder
10=Kidney
11=Larynx-windpipe
12=Leukemia
13=Liver
14=Lung
15=Lymphoma
16=Melanoma
17=Mouth/Tongue/Lip
18=Ovary
19=Pancreas
20=Prostate
21=Rectum
22=Skin (non-Melanoma)
23=Skin (don’t know what kind)
24=Soft tissue (muscle or fat)
25=Stomach
26=Testis
27=Throat - pharynx
28=Thyroid
29=Uterus
30=Other
Showcard CAN1
1=Could not afford care
2=Insurance company wouldn’t approve, cover, or pay for care
3=Doctor refused to accept family’s insurance plan
4=Problems getting to doctor’s office / transportation
5=Different language from doctors or nurses
6=Couldn’t get time off work
7=Didn’t know where to go to get care
8=Was refused services
9=Couldn’t get childcare
10=Didn’t have time or took too long
11=VA does not provide coverage for my condition
12=Other
Showcard HEA1
1=Could not afford care
2=Insurance company wouldn’t approve, cover, or pay for care
3=Doctor refused to accept family’s insurance plan
4=Problems getting to doctor’s office/ transportation
5=Different language from doctors or nurses
6=Couldn’t get time off work
7=Didn’t know where to go to get care
8=Was refused services
9=Couldn’t get childcare
10=Didn’t have time or took too long
11=Do not have health insurance
12=Medicaid would not cover care
13=VA does not provide coverage for my condition
14=Other
Showcard HEA2
1=Friend/family member/neighbor told me
2=Family took you/him/her here
3=Advertisement in community
4=At a meeting
5=Contacted by someone from health center
6=Through your/his/her insurance
7=Social services
8=A doctor or the emergency room
9=You found out that the health center accepts uninsured patients
10=You found out that the health center accepts patients with your insurance.
11=Other
Showcard HEA3-a
You may select one or more locations
1=This health center
2=Clinic or health center offering a discount to low income or uninsured
people
3=Other clinic or health center
4=Doctor's office or HMO
5=Hospital emergency room
6=Hospital outpatient department
7=Facility operated by the Veteran’s Administration
8=Other
9=There is no usual place
Showcard HEA3-b
1=Never
2=Sometimes
3=Usually
4=Always
1=Convenient location
2=Convenient hours
3=You can afford it
4= You can be seen without an appointment or get an appointment right away
5=After you get there, you don't have to wait long to be seen
6=They provide childcare
7=They provide transportation or transportation vouchers
8=They have someone who speaks your language
9=Quality of care
10=It's the only medical care in the area
11=The health center accepts uninsured patients
12=The health center accepts patients with my insurance
13=Other
Showcard HEA5
Select all that apply
1=Called to remind {you/him/her} of appointment
2=Sending you reminders of appointments or prescription refills by emails or texts
3=Providing a website that allows you to manage your healthcare needs, such as making appointments and checking your test results
4=Providing a mobile app that allows you to manage your healthcare needs, such as making appointments and checking your test results
5=Using social media to provide service information and healthcare advice
6=Another form of communication [excluding telephone calls, in-person communication, or through U.S. mail
7=This health center does not provide any of these services
Showcard INS1
1=Lost job or working less hours
2=Got a job or working more hours
3=Changed jobs
4=Got married
5=Got divorced
6=Had a child
7=Got sick or injured
8=Costs too much
9=Became eligible for other coverage
10=Became ineligible for coverage
11=Other
Showcard INS2
1=Insurance from employer or union
2=Insurance through a state HIE plan from a state/federal agency
3=Insurance purchased directly from an insurance company or agent
4=Medicare
5=Medicaid, SCHIP, CHIP, or some other public coverage
6=Champus, Tricare, Champ-VA, VA or some other military health care
7=Some other coverage
8=Have never had insurance
Showcard PRS1
1=Could not afford prescription medicines
2=Insurance company wouldn’t approve, cover, or pay for prescription medicines
3=Pharmacy refused to accept family’s insurance plan
4=Problems getting to pharmacy / transportation
5=Didn’t know where to go to get prescription medicines
6=Pharmacy did not have in stock
7=VA does not provide coverage for medication
8=Did not have safe or suitable location to store my medication
9=Unaware of prescription mail-order services
10=Prescription mail-order services were unavailable
11=Unable to obtain prescription or refill authorization from prescribers
12=Insurance company does not reimburse prescription mail-order / mail-delivery services
13=Concern about contracting Coronavirus (COVID-19)
14=Could not get prescriptions filled due to Coronavirus (COVID-19)
15=Other
Showcard DEN1
1=Could not afford care
2=Insurance company wouldn’t approve, cover, or pay for care
3=Dentist refused to accept family’s insurance plan
4=Couldn’t get time off work
5=Didn’t know where to get care
6=Was refused care
7=Couldn’t get childcare
8=Afraid of going to the dentist/having dental work done
9=VA does not provide coverage for my condition
10=Concern about contracting Coronavirus (COVID-19)
11=Appointment cancelled / rescheduled due to Coronavirus (COVID-19)
12=Other
Showcard DEN2
Select all that apply
1=X-rays taken
2=Cleaning teeth
3=Examination
4=Fillings
5=Extractions
6=Root canals
7=Crowns or caps
8=Bridges, dentures, plates, etc. -- either new ones or repair work
9=Orthodontia -- bite adjustment, braces, retainers, etc.
10=Periodontia -- e.g., of gum disease treatment
11=Bonding
12=Surgery
13=Other
Showcard MEN1
1=All of the time
2=Most of the time
3=Some of the time
4=A little of the time
5=None of the time
Showcard MEN3
1=Could not afford care
2=Insurance company wouldn’t approve, cover, or pay for care
3=Doctor refused to accept family’s insurance plan
4=Problems getting to doctor’s office/transportation
5=Different language from doctors or nurses
6=Couldn’t get time off work
7=Didn’t know where to go to get care
8=Was refused services
9=Couldn’t get childcare
10=Didn’t have time or took too long
11=Was embarrassed/did not feel comfortable asking for help/ did not want other people to know about problem
12=VA does not provide coverage for my condition
13=Concern about contracting Coronavirus (COVID-19)
14=Appointment cancelled / rescheduled due to Coronavirus (COVID-19)
15=Other
Showcard SUB1_ecig
1=I have never tried an e-cigarette
2=Friend or family member used them
3=To try to quit using other tobacco products, such as cigarettes
4=They cost less than other tobacco products, such as cigarettes
5=They are easier to get than other tobacco products, such as cigarettes
6=Famous people on TV or in movies use them
7=They are less harmful than other forms of tobacco, such as cigarettes
8=They are available in flavors, such as mint, candy, fruit, or chocolate
9=They can be used in areas where other tobacco products, such as cigarettes, are not allowed
10=They can be used with marijuana, THC or hash oil, or THC wax
11=I used them for some other reason
Showcard SUB1
Alcoholic beverages such as beer, wine, or spirits?
Cannabis or marijuana? We are asking about non-medical use. these may be known as marijuana, pot, grass or hash.
Cocaine? This may be known as coke or crack.
Amphetamine-type stimulants? These may be known as speed, ecstasy, crystal meth or diet pills.
Inhalants? These may be known as nitrous, glue, petrol or paint thinner.
Sedatives or sleeping pills? We are asking about non-medical use. these may be known as Valium, Serepax or Rohypnol.
Hallucinogens? These may be known as LSD, acid, mushrooms, PCP or Special K.
Opioids? we are asking about non-medical use. These may be known as heroin, morphine, methadone, codeine, vicodin, hydrocodone, hydromorphone, oxymorphone, methadone, tramadol, and fentanyl.
Showcard SUB2
1=No way to pay for it
2=Did not know of or could not get into a treatment program
3=Did not have time for a program or a way to get there, or program not convenient enough
4=You didn’t want people to find out that you had a problem (at work, in community, etc...)
5=You didn’t really think the treatment would help
6=Other
Showcard PRG1
1=A birth control method or prescription
2=A check-up or medical test related to using a birth control method
3=Counseling about birth control
4=Counseling about getting sterilized
5=Emergency contraception or the “morning-after pill”
6=Counseling or information about emergency contraception or the “morning-after pill”
7=A sterilizing operation
8=Other
9=None of the above
Showcard PRG2
1=A birth control method or prescription
2=A check-up or medical test related to using a birth control method
3=Counseling about birth control
4=Counseling about getting sterilized
5=Emergency contraception or the "morning-after pill"
6=Counseling or information about emergency contraception or the "morning-after pill"
7=A sterilizing operation
8=No, there wasn’t a time when i needed a service but couldn't get it
9=Other
10=None of the above
Showcard HTG1
1=It's unlikely I’ve been exposed to HIV
2=I didn't know where to get tested
3=I was afraid of losing a job, insurance, housing, friends, family, if people knew i was positive for aids infection
4=I’m tested when i give blood
5=No particular reason
6=Some other reason
Showcard LIV1
1=A house, townhouse, or mobile home
2=An apartment or condo
3=A room other than a hotel or motel
4=An emergency shelter
5=A transitional shelter includes transitional housing
6=A church or chapel
7=An abandoned building
8=A place of business
9=A car or other vehicle
10=Anywhere outside
11=A hotel or motel (a place with separate rooms you pay for yourself)
12=A family member or friend’s room, apartment, or house without payment or rent
13=Some other place
Showcard INC1
When answering this next question, we would like you to:
Include your income plus the income of all family members living in your household
Include all types of income, including:
income from child support or alimony;
rental income;
any cash assistance from a state or county welfare program;
income from worker’s compensation or unemployment compensation;
any retirement, disability or survivor pension; and
any interest or investment income.
OMB# 0915-036879 Expiration Date 03/31/2023
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | swicegood |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |