Instrument 12b_COVID-19_CohortShortTermSurvey_Critical Items_Revised 12-9-21

H POG 2.0 COVID-19 Cohort Short-term Survey-Critical Items OMB Control No. 0970-0462

Expiration Date: xx/xx/xxxx

Reviewer Notes:

This is a shortened version of the full HPOG 2.0 COVID-19 Short-Term Follow-up Survey (CTS). It will be administered to reluctant respondents in an effort to maximize response rates for critical items only. In most sections of the survey we reduced the length of the section by dropping several questions. In other sections, we dropped all of the questions. The questionnaire overview indicates whether the section reduced the number of questions asked or was dropped entirely.

Variable names are noted in RED brackets e.g. _{<DOBMM>, <DOBDD>, <DOBYY>}

Questionnaire overview:

This survey instrument has nine sections. The content of each section is as follows:

1. Section A: training experiences and employment history from the point of random assignment through the interview date.—REDUCED.

2. Section B: school experiences—DROPPED.

3. Section C: credential attainment.—REDUCED.

4. Section D: conditions of current (or most recent) employment-REDUCED.

5. Section E: household composition—REDUCED.

6. Section F: income and financial well-being—REDUCED.

7. Section G: 21^st century and cognitive skills—DROPPED.

8. Section I: COVID-19 experiences—REDUCED.

9. Section H: respondent and secondary contact information—REDUCED.

Defining text substitutions

Throughout the instrument, there are places where the CAPI software will insert text to customize the question for the respondent. A couple of key text inserts are defined here:

[RAD]: This is the random assignment date for all participants. The random assignment date indicates the date that the person became a participant in the HPOG 2.0 National Evaluation.

General notes

CAPI notes, which begin with CAPI: are instructions for the programmers. They are noted in bold font and the skip logic for CAPI is noted with numeric values, for example: CAPI: IF B2≠6 SKIP TO B7.

Refused and Don’t Know responses are valued at -1 and -2 if the field is numeric; otherwise the values are 7 and 8 or 97 and 98 depending on how many other precoded responses there are. For example, in a yes, no, refused, don’t know response set, refused and don’t know have values of 7 and 8. If the question asks for total hours worked, refused and don’t know would be -1 and -2 respectively. If the question asked about highest grade obtained, there would be more than 6 responses—thus, the refused and don’t know values would become two-digit values of 97 and 98 respectively.

Plain text descriptions of who is asked each question are noted in bold font in orange text boxes. Skip logic for plain text descriptions are noted with alpha values, for example: Ask B6 if they were self-employed (B2=Self-employed).

Contents

Reviewer Notes: 1

Questionnaire overview: 1

INTRODUCTION 3

SCREENER /VERIFICATION: 4

A. TRAINING AND EMPLOYMENT HISTORY 5

C. CREDENTIALS 6

D. CURRENT/MOST RECENT JOB 10

E. HOUSEHOLD COMPOSITION 11

F. INCOME AND ADULT WELL-BEING 12

I. COVID-19 Module 13

H. CONTACT INFORMATION 15

INTRODUCTION

Hello, my name is [ ]. May I please speak with _____?

IF RESPONDENT COMES TO THE PHONE: I’m calling on behalf of the [PROGRAM NAME].

IF PHONE OR IN-PERSON: I work for Abt Associates, or Abt, which is an independent research company. Abt is helping the Administration for Children and Families (ACF) in the U.S. Department of Health and Human Services (HHS) with its evaluation of the Health Profession Opportunity Grants (HPOG) program. We are conducting interviews with people like you who agreed to be in a study about a program offered at [PARENT GRANTEE SITE] called [PROGRAM NAME]. Thank you for taking the time to talk with me today.

This interview will include questions on your employment and education activities, your use of services, and your overall well-being. This interview will take about 20 minutes to complete. When we are done, we will send you a link to access a $40 gift certificate to a store of your choice, as a token of appreciation. You agreed to be part of the study around [RAD] when you signed a consent form to let researchers collect information from you. We need to talk with people who got into the program and those who did not. Your participation in this study will help policymakers and program operators better understand how to help people attain educational credentials and find and keep jobs.

Before we begin the survey, I would like to assure you that all of your responses on this survey will be kept private and only used for studies about the different types of education and employment trainings and services that are the focus of this study. Any data sets that are developed for sharing with other researchers will be stripped of information that would make it possible to identify you. Your name will not appear in any written reports we produce. Your responses to these questions are completely voluntary. That means you may choose not to answer any question, or you may stop the interview if you wish, but we hope you don’t. Your responses to these questions will in no way affect your participation in any programs or your receipt of any kinds of public benefits or services. By participating in this study, you will help the government learn if and how programs like [PROGRAM NAME] make a difference in people’s lives and how to improve programs in the future. As we mentioned at the time of enrollment, we will continue to collect information from data sources such as the National Directory of New Hires and the National Student Clearinghouse so researchers can learn more about your future employment, earnings, and post-secondary education until the end of HHS’s research on HPOG grants, or when you choose to withdraw permission.

According to the Paperwork Reduction Act (PRA), an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information without approval from the Office of Management and Budget or OMB. This approval is called an OMB control number. The OMB control number for this collection is 0970-0462 and it expires 07/31/2024. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, please send them to Radha Roy, Abt Associates, Inc., 6130 Executive Boulevard, Rockville, MD 20852; Attn: OMB-PRA 0970-0462. Do you have any questions before we begin?

Let’s begin now.

SCREENER /VERIFICATION:

First I just need to verify that I am speaking with the correct person.

Read the following text and ask Q1 of everyone.

1. What is your date of birth? ___________ (MM/DD/YYYY)

INTERVIEWER: ENTER DATE USING FORMAT BELOW. ENTER DOB EVEN IF IT MATCHES THE SAMPLE INFO. REPEAT BACK TO RESPONDENT.

CAPI NOTE: DISPLAY DOB FROM SAMPLE.

Respondent’s Birthday: ________ / ________ / ____________

<SC1_MM>, <SC1_DD>, <SC1_YY> MM DD YYYY

<SC1_REF> REFUSED  ₇

<SC1_DK> DON’T KNOW  ₈

Ask Q2 only if the DOB in Q1 does not match what is in our records.

CAPI: IF DOB AGREES WITH THE BIRTH DATE ON THE FILE, SKIP TO SECTION A. ELSE, CONTINUE.

2. What are the last 4 digits of your Social Security Number?

INTERVIEWER – ENTER LAST 4 DIGITS OF SSN. REPEAT BACK TO RESPONDENT.

CAPI NOTE: DISPLAY LAST 4 DIGITS SSN FROM SAMPLE

<SC2_4SSN> RECORD LAST 4 DIGITS: ___ ___ ___ ___

<SC2_REF> REFUSED q ₇

<SC2_DK> DON’T KNOW q ₈

CAPI: IF THE 4 DIGITS GIVEN BY RESPONDENT AGREE WITH THE NUMBER ON THE FILE, SKIP TO A3.

IF SSN IS MISSING IN THE SAMPLE OR IS A MISMATCH WITH WHAT IS ENTERED AND THERE IS A MISMATCH IN DOB, DISPLAY DISCONTINUED TEXT:

DISCONTINUED TEXT: I’m sorry. I was unable to pull up the correct questionnaire. I will need to check with my supervisor to look into the problem. I will re-contact you when the problem is resolved. Thank you for your time.

1. TRAINING AND EMPLOYMENT HISTORY

CAPI: Stamp date and time [repeat at start of each section (B-H) and at end].

[A1_INTRO] I’d first like to get a general idea of some of the things you may have done between [RAD] and today. I will start with what you were doing on [RAD], when you applied to be part of a program offered at [PARENT GRANTEE SITE] called [PROGRAM NAME]. I’m interested in whether you were enrolled in school or training programs, working at a job for pay, and/or involved in other activities during this time. In answering the questions, please include any full- or part-time jobs or classes that have lasted at least one week or more.

<A3>. Since [RAD], have you worked at a job for pay, OR taken any classes, OR both worked at a job for pay and taken classes, OR neither worked at a job for pay nor taken any classes? (DO NOT READ RESPONSES)

1. WORKED AT A JOB FOR PAY [CONTINUE]

2. TAKEN CLASSES [CONTINUE]

3. BOTH WORKED AT A JOB FOR PAY AND TAKEN CLASSES [CONTINUE]

4. NO, NEITHER WORKED AT A JOB FOR PAY NOR TOOK CLASSES [GO TO C_INTRO]

7. REFUSED [GO TO C_INTRO]

8. DON’T KNOW [GO TO C_INTRO]

<A3A>. Are you currently working at a job for pay, taking classes, both working and taking classes, or neither working nor taking classes? (DO NOT READ RESPONSES)

1. WORKING AT A JOB FOR PAY

2. TAKING CLASSES

3. BOTH WORKING AT A JOB FOR PAY AND TAKING CLASSES

4. NO, NEITHER WORKING AT A JOB FOR PAY NOR TAKING CLASSES

7. REFUSED

8. DON’T KNOW

3. CREDENTIALS

IF R has not worked or taken classes since RAD (A3=4, 7, OR 8), skip to C4_INTRO.

Otherwise read the following text and ask C1.

[C1_INTRO] Now I’m going to ask you questions about the results of your overall training experience since [RAD].

<C1> Thinking about all the classes you have taken since [RAD], would you say that you took them to prepare for work in a particular occupation?

1. YES

2. NO [SKIP TO C2_INTRO]

3. IF VOL: NO CLASSES SINCE RAD [SKIP TO C4_INTRO]

7. REFUSED [SKIP TO C2_INTRO]

8. DON’T KNOW [SKIP TO C2_INTRO]

Read the following text and ask C1a if respondent has taken classes to prepare for a particular occupation (C1=YES).

<C1A>. Is that occupation in the field of healthcare?

1. YES

2. NO

7. REFUSED

8. DON’T KNOW

Read the following text and ask C2 of everyone with any training since randomization (A3=2 or 3).

[C2_INTRO] Now I’m going to ask you questions about any diplomas or academic degrees you may have received since [RAD]. I will ask you about any vocational certificates, professional certifications, and state or industry licenses you may have received later in this survey.

College diplomas or academic degrees

<C2> Since [RAD], have you received a diploma or academic degree for completing any regular college classes?

1. YES

2. NO [SKIP TO C3_INTRO]

7. REFUSED [SKIP TO C3_INTRO]

8. DON’T KNOW [SKIP TO C3_INTRO]

Ask C2a if they have received a diploma or academic degree from college classes since RAD (C2=YES).

<C2A>. How many diplomas or academic degrees did you receive since [RAD]?

#__________________ (MAX=4)

-1 REFUSED [SKIP TO C3_INTRO]

-2 DON’T KNOW [SKIP TO C3_INTRO]

Ask C2b if they have received at least 1 diploma or academic degree from college classes since RAD (C2a≥1).

CAPI: IF C2a>1 DIPLOMA OR ACADEMIC DEGREE, ASK ABOUT THE HIGHEST DIPLOMA OR ACADEMIC DEGREERECEIVED SINCE [RAD]

<C2B_1>. [CAPI: IF C2a=1] What kind of diploma or academic degree have you received?

[CAPI: IF C2a>=2 ASK] Now think about the highest diploma or academic degree you received since [RAD], what type of diploma or academic degree did you receive?

1. A diploma or academic degree requiring less than a full year’s worth of credit,

2. A diploma or academic degree requiring a full year or more worth of credit (but less than an Associate’s Degree),

3. An Associate’s Degree, or

4. Bachelor’s degree or higher?

95. VOL: OTHER (SPECIFY: <C2B_95_OTHER_X> [X = 1-4] ____)

97. REFUSED

98. DON’T KNOW

Ask C2E if they have received at least one diploma from college classes requiring less than an Associate’s Degree since RAD (C2B_1=a diploma or academic degree requiring less than a full year’s worth of credit or a diploma or academic degree that requires a year or more of credit, but less than an Associate’s Degree; C2B_1=1 OR 2).

<C2E_X>. Is this diploma or degree related to working in the field of healthcare?

1. YES

2. NO

7. REFUSED

8. DON’T KNOW

Ask C3 of everyone.

Certificates

[C3_INTRO] The next set of questions asks about any certificates you may have earned. People sometimes earn certificates from an education or training program. An educational certificate is one that can be awarded by a training provider or an educational institution. An educational certificate is awarded based on completion of all course requirements. These educational certificates are different from professional certifications or state or industry licenses. Some people get both a certificate from a school or other training institute and a related license from the state.

As we go through this next set of questions, please answer only about school- and institute-issued vocational certificates you may have received. Please do not include any school-issued diplomas or academic degrees that you already told me about. Also, please do not include professional certifications or state or industry licenses yet. We will talk about those in the next section.

<C3A> Since [RAD], have you received a certificate for completing a training program from an employer, employment agency, union, software or equipment manufacturer, or other training provider?

1. YES

2. NO

7. REFUSED

8. DON’T KNOW

<C3B>.Since [RAD], have you received a certificate for completing a vocational training program at a high school?

1. YES

2. NO

7. REFUSED

8. DON’T KNOW

<C3C>.Since [RAD], have you received a certificate—not a degree—for completing a program at a community or technical college, or other school after high school? Do not include teaching certificates or college degrees.

1. YES

2. NO

7. REFUSED

8. DON’T KNOW

CAPI: IF NO CERTIFICATES (C3a, C3b, AND C3c ARE ALL NO) SKIP TO C4_INTRO

Ask C3D if they have received any certificate since RAD (C3a, b or c=Yes).

<C3D> How many certificates have you received since [RAD]?

# _________________ (MAX=4)

-1. REFUSED [SKIP TO C4_INTRO]

-2. DON’T KNOW [SKIP TO C4_INTRO]

<C3G_X> [IF C3d=1: Is this certificate/ IF C3d>1:are any of these certificates] related to working in the field of healthcare?

1. YES

2. NO

7. REFUSED

8. DON’T KNOW

Ask C4 of everyone.

Certifications and Licenses

[C4_INTRO] This next set of questions asks about any professional certifications or state or industry licenses you may have received since [RAD].

A professional certification or license shows you are qualified to perform a specific job like Licensed Realtor, Certified Medical Assistant, Certified Construction Manager, or an IT certification. A certification is awarded by an organization; a state or industry license is awarded by a licensing agency. Both professional certifications and state or industry licenses need to be renewed periodically.

<C4> Since [RAD], have you received any professional certifications, or state or industry licenses? Please do not include any commercial licenses such as a liquor license or vending license.

1. YES

2. NO [SKIP TO C8]

7. REFUSED [SKIP TO C8]

8. DON’T KNOW [SKIP TO C8]

Ask C4a if they have received a professional certification, or state or industry license since RAD (C4=Yes).

<C4A>. How many professional certifications or state or industry licenses have you received since [RAD]?

#___________________ (RANGE=1-4)

-1. REFUSED [SKIP TO C8]

-2. DON’T KNOW [SKIP TO C8]

CAPI: DISPLAY “VERIFICATION SCREEN: DO NOT READ TO RESPONDENT. WE HAVE RECORDED __ CERTIFICATION(S) OR LICENSE(S). IF THIS IS NOT CORRECT PLEASE GO BACK AND ADJUST.”

<C4C_X> [X = 1-4] [IF C4a=1:Is [this professional certification / IF C4a>1:are any of these professional certifications], or state or industry license, related to working in the field of healthcare?

1. YES

2. NO

7. REFUSED

8. DON’T KNOW

Ask C8a-C8c of everyone.

<C8_X> [X = 1-3] I am going to read you three statements. Please tell me whether you would say you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with the following statements:

	Strongly Agree	Somewhat Agree	Somewhat Disagree	Strongly Disagree	REFUSED	DON’T KNOW
<C8_1> I am making progress towards my long-range educational goals. Would you say you:	1	2	3	4	7	8
<C8_2> I am making progress towards my long-range employment goals. Would you say you:	1	2	3	4	7	8
<C8_3> I see myself on a career path. Would you say you:	1	2	3	4	7	8

4. CURRENT/MOST RECENT JOB

CAPI: THIS SECTION IS ASKED FOR THE CURRENT OR MOST RECENT JOB. IF CURRENT JOB (A3a=1 or 3) USE WORDING 1 (PRESENT TENSE); OTHERWISE USE WORDING 2 (PAST TENSE).

Read the following text and ask D6 of any respondent who has worked since RAD (A3=1 or 3).

[D1_INTRO] This next question is about your [current job/most recent job].

<D6> [Is/Was] this occupation in the field of healthcare?

1. YES

2. NO

7. REFUSED

8. DON’T KNOW

Job Benefits

<D10_X> [Are/Were] any of the following benefits available to you [at that employer]? That is, if you [had] wanted it, [can you receive/could you have received]:

	YES	NO	REFUSED	DON’T KNOW
<D10_1> Health insurance?	1	2	7	8

5. HOUSEHOLD COMPOSITION

Read the following text and ask E1a of everyone.

[E1_INTRO] Now I’d like to talk to you about your family and current household.

1. Besides you, who among the following live in your household at least half the time?

<E1A>. Your spouse?

1. YES [SKIP TO E1c]

2. NO

7. REFUSED

8. DON’T KNOW

Ask E1b if they do NOT live with a spouse (E1a=No, Refused OR Don’t know).

<E1B>. Your unmarried romantic partner?

1. YES

2. NO

7. REFUSED

8. DON’T KNOW

Ask E3 always.

<E3_1> How many adults, aged 18 or over live with you at least half the time?

______ (0-15) number of persons aged 18 or over

-1. REFUSED

-2. DON’T KNOW

CAPI: DISPLAY “VERIFICATION SCREEN: DO NOT READ TO RESPONDENT. WE HAVE RECORDED __ ADULTS LIVING WITH YOU. IF THIS IS NOT CORRECT PLEASE GO BACK AND ADJUST.”

Ask E4 always.

<E4_1> How many persons aged 17 or younger live with you at least half the time? Include biological, adopted, foster, step, and any other children, as well as younger siblings.

______ (0-15) number of persons aged 17 or younger

-1. REFUSED [SKIP TO E6]

-2. DON’T KNOW [SKIP TO E6]

CAPI: DISPLAY “VERIFICATION SCREEN: DO NOT READ TO RESPONDENT. WE HAVE RECORDED __ PEOPLE UNDER 18 LIVING WITH YOU. IF THIS IS NOT CORRECT PLEASE GO BACK AND ADJUST.”

5. INCOME AND ADULT WELL-BEING

Income and Receipt of Public Assistance

Read the following text and ask F1 of everyone.

[F1_INTRO] Now, I am going to ask you some questions about your household income in [PRIOR MONTH]. I will only ask about other sources of income. Again,] I want to assure you that none of your answers will be discussed with anyone.

<F1_X> [X = 1-12] Did you or other members of the household have income or benefits from any of the following sources in [PRIOR MONTH]?

	YES	NO	REFUSED	DON’T KNOW
<F1_1> Temporary Assistance for Needy Families or TANF (“tan-eff”)	1	2	7	8
<F1_2> In [PRIOR MONTH] did you or other members of your household have income or benefits from Supplemental Nutrition Assistance Program also known as SNAP (“snap”) or Food Stamps	1	2	7	8
<F1_5> Medicaid	1	2	7	8

Ask F10 of everyone.

Financial Resilience

<F10> Think again over the past 12 months. Generally, at the end of the month do you end up with: more than enough money left over, some money left over, just enough to make ends meet, or not enough to make ends meet? (DO NOT READ RESPONSES)

1. MORE THAN ENOUGH MONEY LEFT OVER

2. SOME MONEY LEFT OVER

3. JUST ENOUGH TO MAKE ENDS MEET

4. NOT ENOUGH TO MAKE ENDS MEET

7. REFUSED

8. DON’T KNOW

I. COVID-19 Module

[I1_INTRO] The outbreak of a novel Coronavirus ((kuh-roh-nuh-veye-ruhs), also called COVID-19, has been impacting communities worldwide. These next few questions ask about your experiences during the outbreak. Please remember these questions are voluntary and you can choose not to answer them if you don’t want to.

When answering these next questions, please think specifically about the time since early 2020; that is, since the start of the Coronavirus outbreak.

CAPI: ASK OF ALL RESPONDENTS

[I4_INTRO] Now I will ask you some questions about how the Coronavirus has impacted your work at any of the jobs you reported.

<I4>. Since early 2020, have you provided direct care to people with Coronavirus (e.g., as a nurse, patient care assistant, home health aide, x-ray technician, or dental hygienist)?

1. YES

2. NO [SKIP TO SECTION H]

7. REFUSED [SKIP TO SECTION H]

8. DON’T KNOW [SKIP TO SECTION H]

<I4A>. In which of the following healthcare settings did you provide direct care to people with Coronavirus: a hospital, a doctor’s office or clinic, a long-term care facility, home health care, or another type of healthcare setting? (CHECK ALL THAT APPLY)

INTERVIEWER: READ FULL LIST AND SELECT ALL THAT APPLY. SELECT “NO OTHER MENTIONS” AFTER ALL RELEVANT ANSWER OPTIONS ARE SELECTED.

1. HOSPITAL

2. DOCTOR’S OFFICE OR CLINIC

3. A LONG-TERM CARE FACILITY

4. HOME HEALTH CARE

5. ANOTHER TYPE OF HEALTHCARE SETTING (SPECIFY_______________)

6. NO OTHER MENTIONS

7. VOL: DID NOT WORK IN A HEALTHCARE SETTING

97. REFUSED

98. DON’T KNOW

[I5_INTRO] Now I will ask you some questions about how Coronavirus may have effected your life overall.

<I5 >. For each item that I read, please tell me if the Coronavirus outbreak has had a very negative effect, a somewhat negative effect, or no negative effect at all on:

	VERY NEGATIVE EFFECT	SOMEWHAT NEGATIVE EFFECT	NO NEGATIVE EFFECT AT ALL	NOT APPLICABLE	REFUSED	DON’T KNOW
your ability to pay your expenses?	1	2	3	4	7	8
did the Coronavirus outbreak have a very negative effect, a somewhat negative effect, or no negative effect at all on your ability to attend classes?	1	2	3	4	7	8
did the Coronavirus outbreak have a very negative effect, a somewhat negative effect, or no negative effect at all on your ability to work?	1	2	3	4	7	8

H. CONTACT INFORMATION

Respondent Information

[H1_INTRO] Before we complete the interview, I would also like to make sure I have your contact information recorded correctly. This information will help us to reach you for future survey efforts, and to ensure that we send your link to access your token of appreciation to the correct email address. We may also use this information to call you and ask how your interview experience was.

<H1> I have your name recorded as [FIRST MI LAST]. Is this correct?

1. YES, STILL CORRECT (SKIP TO H2)

2. NO, NOT CORRECT

<H1A_1> What is your first name? [IF POSSIBLE, PREFILL FROM FIRST]

<H1B_1> What is your middle initial? [IF POSSIBLE, PREFILL FROM MIDDLE]

<H1C_1> What is your last name? [IF POSSIBLE, PREFILL FROM LAST]

<H2> I have your address recorded as [STREET, APT, CITY, STATE, ZIP]. Is this correct?

1. YES, STILL CORRECT (SKIP TO H3)

2. NO, NOT CORRECT

<H2A_1> What is your street address or PO box number? [IF POSSIBLE, PREFILL FROM ADDRESS1]

<H2B_1> Is there a complex or building name?

<H2C_1> Is there an apartment number? [IF POSSIBLE, PREFILL FROM ADDRESS1]

<H2D_1> In what city? [IF POSSIBLE, PREFILL FROM ADDRESS1]

<H2E_1> In what state? [IF POSSIBLE, PREFILL FROM ADDRESS1]

<H2F_1> What is the zip code? [IF POSSIBLE, PREFILL FROM ADDRESS1]

<H3> I have your primary phone number recorded as [xxx-xxx-xxxx]. Is this correct?

1. YES, STILL CORRECT (SKIP TO H3b)

2. NO, NOT CORRECT

1. What is the number, starting with the area code? <H3A_1>,<H3A_2>, < H3A_3>

___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___ [IF POSSIBLE, PREFILL FROM PHONE1]

<H3B> Is that a home, cell, work, or other number?

1. Home

2. Cell

3. Work

4. Other

97. REFUSED

98. DON’T KNOW

<H3C> IF CELL PHONE NUMBER AND PERMISSION TO TEXT=MISSING: Do we have your permission to contact you via text message to your cell phone?

1. YES

2. NO

7. REFUSED

8. DON’T KNOW

<H3D> IF CELL PHONE NUMBER AND PERMISSION TO TEXT=MISSING: Do we have your permission to contact you on that number via automated text message? An automated text message is a prewritten message that is sent at a later date. Examples of an automated text message may be one that reminds you to complete a form or call to set up an appointment.

1. YES

2. NO

7. REFUSED

8. DON’T KNOW

<H4> [IF MISSING, SKIP TO H5. IF ≠ MISSING:] I have your secondary phone number recorded as [xxx-xxx-xxxx]. Is this correct?

1. YES, STILL CORRECT (SKIP TO H4b)

2. NO, NOT CORRECT

1. What is the number, starting with the area code? <H4A_1>, H4A_3, <H4A_5>

___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

2. Is that a home, cell, work, or other number? <H4B>

1. Home

2. Cell

3. Work

4. Other

7. REFUSED

8. DON’T KNOW

<H4C> IF CELL PHONE NUMBER AND PERMISSION TO TEXT=MISSING: Do we have your permission to contact you via text message to your cell phone?

1. YES

2. NO

7. REFUSED

8. DON’T KNOW

<H4D> IF CELL PHONE NUMBER AND PERMISSION TO TEXT=MISSING: Do we have your permission to contact you on that number via automated text message? An automated text message is a prewritten message that is sent at a later date. Examples of an automated text message may be one that reminds you to complete a form or call to set up an appointment.

1. YES

2. NO

7. REFUSED

8. DON’T KNOW

<H5_1> Do you have another phone number where we can reach you?

1. YES, ADDITIONAL PHONE NUMBERS AVAILABLE

2. NO (SKIP TO H6)

1. What is the number, starting with the area code? <H5A_1_1>,<H5A_3_1>, <H5A_5_1>

___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

<H5B_1> Is that a home, cell, work, or other number?

1. Home

2. Cell

3. Work

4. Other

7. REFUSED

8. DON’T KNOW

<H5C_1> IF CELL PHONE NUMBER AND PERMISSION TO TEXT=MISSING: Do we have your permission to contact you via text message to your cell phone?

1. YES

2. NO

7. REFUSED

8. DON’T KNOW

<H5D_1> IF CELL PHONE NUMBER AND PERMISSION TO TEXT=MISSING: Do we have your permission to contact you on that number via automated text message? An automated text message is a prewritten message that is sent at a later date. Examples of an automated text message may be one that reminds you to complete a form or call to set up an appointment.

1. YES

2. NO

7. REFUSED

8. DON’T KNOW

[REPEAT H5 UNTIL ALL PHONE NUMBERS ARE RECORDED]

<H6> [IF EMAIL=MISSING, SKIP TO H7. IF EMAIL≠ MISSING:] I have your email address recorded as [[email protected]]. Is this correct?

1. YES, STILL CORRECT (SKIP TO H7)

2. NO, NOT CORRECT

3. NO LONGER HAVE ANY WORKING EMAIL ADDRESSES (SKIP TO H8_INTRO)

<H6A> What is your email address? [IF POSSIBLE, PREFILL FROM EMAIL]

<H7_1> Do you have [IF EMAIL=MISSING: an email address / IF EMAIL≠MISSING: any other email addresses]?

1. YES, ADDITIONAL EMAIL ADDRESSES ARE AVAILABLE

2. NO (SKIP TO H8_INTRO)

7. REFUSED

8. DON’T KNOW

1. What is the [IF EMAIL≠MISSING: additional] email address? < H7A_1>, <H7A_2> , <H7A_3>,<H7A_4>

[REPEAT H7 UNTIL ALL EMAIL ADDRESSES ARE LISTED]

[H8_INTRO] To help us be able to get back in touch with you in the future, we would like to review the names, telephone numbers and addresses of one person you provided when you became part of the study who will always know how to reach you. This information will be kept strictly private and will only be used if we are unable to contact you.

<H8> [IF CONTACT #1≠MISSING] When you became part of the study in [RAD] you said that [CONTACT #1] was a person who would always know where you are and how to reach you. Is [CONTACT#1] still a person who does not live with you and will always know how to contact you?

1. YES (VERIFY CONTACT #1 INFORMATION THEN GO TO H9)

2. NO

7. REFUSED

8. DON’T KNOW

<H8A_1_X> [X = 1- 11]. [IF CONTACT #1=MISSING OR IF H8=NO]: Could you please tell me the name of a person who does not live with you and will always know how to contact you?

1. YES

2. NO [SKIP TO CLOSING SCRIPT]

7. REFUSED [SKIP TO CLOSING SCRIPT]

8. DON’T KNOW [SKIP TO CLOSING SCRIPT]

H8a. [IF H8 OR H8a=YES]:

	CONFIRM INFO BELOW	Check if correct	ENTER/CHANGE INFO
first name	[DISPLAY FIRST NAME]	□	<H8A_2_A>
middle name	[DISPLAY MIDDLE NAME]	□
Last name	[DISPLAY LAST NAME]	□	<H8A_2_C>
Suffix	[DISPLAY SUFFIX]	□
Street Address/PO Box	[DISPLAY STREET ADDRESS]	□	<H8A_2_E>
Complex or Building Name	[DISPLAY COMPLEX NAME]	□	<H8A_2_F>
Apartment Number	[DISPLAY APT NUMBER]	□	<H8A_2_G>
City	[DISPLAY CITY]	□	<H8A_2_H>
State	[DISPLAY STATE]	□	<H8A_2_I>
Zip	[DISPLAY ZIP]	□	<H8A_2_J>
Home Phone	[DISPLAY HOME PHONE]	□	<H8A_2_K>
Cell Phone	[DISPLAY CELL PHONE]	□	<H8A_2_L>
Email (enter NA if no working email address)	[DISPLAY EMAIL]	□	<H8A_2_M>
Relationship	[DISPLAY RELATIONSHIP]	□	1. Friend 2. Relative 3. Other Specify <H8AN2_3_OTHER> 7. REFUSED 8. DON’T KNOW

Thank you very much for your time today.

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