Download:
pdf |
pdfAPPENDIX E
RETAIN ENROLLEE SURVEY INSTRUMENTS (R1, R2)
This page has been left blank for double-sided copying.
OMB No.: XXX
Expiration Date: X/XX/XX
Retaining Employment and Talent After Injury/Illness Network (RETAIN) Enrollee Round 1 Survey:
questionnaire and programming specifications
Version 12.17.19 (Deliverable 9.2C – R1)
Programming and operational assumptions:
Modes. The enrollee survey will be administered in three modes – web, telephone, and paper. These
specifications are for the computer-assisted versions only (web, telephone).
Population. Enrollees in RETAIN evaluation who have undergone random assignment and have
been randomly selected for the survey. These are individuals who have had an injury (likely
musculoskeletal) and may be at risk of exit from the labor force and / or long-term reliance on longterm injury or illness programs, such as SSDI and SSI. Respondents will include self-reporting
enrollees as well as proxies who are answering on enrollees’ behalf.
Target respondent. Enrollees in RETAIN who have enrolled during Phase 2. The subset of phase 2
state are not yet determined, but could include: CA, KS, MN, VT, CT, KY, OH, or WA.
Length. The questionnaire is designed to take about 12 minutes to complete.
Language. The questionnaire is available in English and Spanish only.
Administration and design specifications. Each item in the web questionnaire specifications
includes: which respondents receive the item; dynamic fills, designated by text [in brackets];
emphasis text, designated by underlined font; soft checks that help improve data quality (designated
in boxes below applicable items); response options shown with boxes indicate “check all that apply”
response format, whereas those shown in circles denote “check one” response format. The web
survey will be optimized to deploy on mobile devices, tablets, and/ or personal computers.
Login. Respondents will login to the survey homepage and input their username and password.
Critical items have soft checks added throughout the instrument. Cases will be designated as
qualified partials that have provided responses up to item C1 (receipt of employment services).
Questionnaire sections:
A
B
C
D
E
Introduction
Employment
Training and services
Health and well-being
General information about you
PROGRAMMING FILLS BY STATE:
PROGRAM
STATE
CA
State Name for RETAIN
RETAIN-California
Medi-Cal
CT
RETAIN-Connecticut
HUSKYHealth
KY
Retaining Kentucky's Workforce
through Universal Design (RKW-UD)
Kentucky Medicaid
KS
RETAIN-Kansas
KanCare Medical Assistance Program
MN
RETAIN-Minnesota
Medical Assistance (MA) / MinnesotaCare
OH
RETAIN-Ohio
Ohio Medicaid
VT
RETAIN-Vermont
Green Mountain Care
WA
RETAIN-Washington
Healthy Families
State name for Medicaid
WEB PROGRAMMING NOTES:
Include section header titles, but no logos on each page. Logo appears on intro and closing pages
only.
Do not employ a progress bar on the page; do not display item numbers on screen.
All items presented in grid format will be optimized for presentation on mobile devices.
Forward, back, and save buttons appear in the same locations on each page. One item presented per
page unless otherwise specified.
CATI PROGRAMMING NOTE:
Ensure that it is possible for an interviewer to toggle to proxy administration at any point in the
interview.
2
RETAIN Enrollee Round 1 Survey: LOGIN SCREEN - WEB / INTRO CATI
OMB No.: XXX
Expiration Date: X/XX/XX
WEB SURVEY LOGIN SCREEN:
Welcome to the Retaining Employment and Talent After Injury/Illness Network (RETAIN) Enrollee
Survey!
To begin, please enter your survey username and password below:
Username:
Password:
CLICK THE “NEXT” BUTTON TO CONTINUE …
If you have questions or difficulty logging in, we are here to help! Please call XXX-XXX-XXXX (toll
free).
Public reporting burden for this collection of information is estimated to average 18 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. The OMB number for this information collection
is XXX and the expiration date is XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to: XXXX. Do not return the completed form to this
address.
3
RETAIN Enrollee Round 1 Survey: LOGIN SCREEN - WEB / INTRO CATI
CATI VERSION
Hello . Hi, my name is [INTERVIEWER]. May I please speak to [ENROLLEE FULLNAME]?
I’m calling on behalf of the Social Security Administration for an important national study.
CODE ONE ONLY
SPEAKING TO [FIRSTNAME] ........................................................................................... 1
GO TO A1
[FIRSTNAME] COMES TO THE PHONE .......................................................................... 2
GO TO A1
NEED TO CALLBACK (NO APPT) .................................................................................... 3
TERMINATE
NEED TO CALLBACK (SET APPT) .................................................................................. 4
SETAPPT
[FIRSTNAME] HAS A HEALTH PROBLEM....................................................................... 5
SEEK PROXY
[FIRSTNAME] IS IN AN INSTITUTION (HOSPITAL, GROUP HOME, JAIL) .................... 6
SEEK PROXY
[FIRSTNAME] HAS MOVED/HAS NEW NUMBER ........................................................... 7
TERMINATE
[FIRSTNAME] DOES NOT SPEAK ENGLISH................................................................... 8
SEEK PROXY
NEVER HEARD OF [FULLNAME]/WRONG NUMBER ..................................................... 9
TERMINATE
HUNG UP DURING INTRODUCTION (HUDI) .................................................................. 10
TERMINATE
[FIRSTNAME] IS DECEASED ........................................................................................... 11
TERMINATE
PROXY TO COMPLETE INTERVIEW ............................................................................... 12
GO TO A1
4
RETAIN Enrollee Round 1 Survey: Section A. Introduction
SECTION A. INTRODUCTION
ALL
A1.
This survey is part of a national study for the “Retaining Employment and Talent After
Injury/Illness Network” (RETAIN) program. It is paid for by the Social Security
Administration (SSA). The survey asks about employment, services received, your wellbeing, and some general information about you.
You’ll get $25 for completing this voluntary survey. It takes about 12 minutes to complete.
Your answers will be kept private and will be grouped together with everyone else who
responds.
How will you be completing this survey? [NEW]
PROGRAMMER: DO NOT ALLOW MISSING VALUES ON THIS ITEM
I am completing on my own .................................................................................. 1
GO TO A2
Another person is answering on my behalf .......................................................... 2
GO TO A2
I do not agree to take part .................................................................................... 3
TERMINATE
HARD CHECK: IF A1=NO RESPONSE;
Your answer to this question is important. It shows that you agree to take part in the survey. It
also helps us ensure you receive only questions that apply. If you have any questions about the
survey, please call 1-xxx-xxx-xxxx.
CATI VERSION
A1.
This survey is part of a national study for the “Retaining Employment and Talent After
Injury/Illness Network” (RETAIN) program. It is paid for by the Social Security
Administration (SSA). The survey asks about employment, services received, your wellbeing, and some general information about you. You’ll get $25 for completing this
voluntary survey. It takes about 12 minutes to complete. Your answers will be kept private
and will be grouped together with everyone else who responds.
Do you have any questions for me before we begin?
How will you be completing this survey?
IF NEEDED: Will you be completing it on your own or is someone completing it on your
behalf?
CODE ONE ONLY
I am completing on my own ....................................................................... 1 GO TO A2
Another person is answering on my behalf ................................................. 2 GO TO A2
I DO NOT AGREE TO TAKE PART .......................................................... r TERMINATE-REF
PROGRAMMER DO NOT POPULATE DON’T KNOW RESPONSE IN A1
5
RETAIN Enrollee Round 1 Survey: Section A. Introduction
PROGRAMMER BOX 1
PROGRAMMER IF A1=2, POPULATE ALL FILLS HERE FORWARD WITH PROXY TEXT. IF A1=1, POPULATE
FILLS FOR SELF-REPORT. IF A1=REFUSED (3 OR R), ROUTE TO REFUSAL PATH AND TERMINATE.
ALL CONSENTING (A1=1 OR 2)
[Do you/ Does ENROLLEE]
A2.
[Do you/ Does ENROLLEE] have an injury or illness that limits the kind or amount of work
you can do now? (RETAIN Enrollment form, Q10)
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
A2.
[Do you/ Does ENROLLEE] have an injury or illness that limits the kind or amount of work
you can do now?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
6
RETAIN Enrollee Round 1 Survey: Section B. Employment
SECTION B. EMPLOYMENT
ALL CONSENTING (A1=1 OR 2)
[Are you/Is ENROLLEE] [you/(he/she)] [you own/(he/she) owns] [you are/(he/she) is]
B1.
The next set of questions ask about employment.
[Are you/Is ENROLLEE] now employed at a job, organization, or business for pay or
profit? This includes work [you/ (he/she)] may do for a business that [you own/ (he/she)
owns]. If [you are/ (he/she) is] self-employed, select “yes” below. [POD, C1, rev]
Yes – employed and working now ........................................................................ 1 GO TO B2
Yes – employed but out on medical leave right now ............................................ 2 GO TO B2
No ......................................................................................................................... 0 GO TO B9
NO RESPONSE .......................................................................................................... M GO TO C1
SOFT CHECK: IF B1=NO RESPONSE;
Your answer to this question helps make sure you only receive questions that apply to you.
CATI VERSION:
B1.
The next set of questions ask about employment.
[Are you/Is ENROLLEE] now employed at a job, organization, or business for pay or
profit? This includes work [you/ (he/she)] may do for a business that [you own/ (he/she)
owns].
IF EMPLOYED – PROBE IF WORKING NOW OR ON MEDICAL LEAVE NOW.
YES – EMPLOYED AND WORKING NOW ......................................................... 1 GO TO B2
YES – EMPLOYED BUT OUT ON MEDICAL LEAVE RIGHT NOW ................... 2 GO TO B2
No .......................................................................................................................... 0 GO TO B9
DON’T KNOW ..................................................................................................... d GO TO C1
REFUSED ............................................................................................................. r GO TO C1
SOFT CHECK: IF B1= D OR R;
Your answer to this question helps make sure you only receive questions that apply to you.
7
RETAIN Enrollee Round 1 Survey: Section B. Employment
ENROLLEE EMPLOYED (B1=1 OR 2)
[you/ (he/she)] [work/works] [your/ (his/her]] [have you/ has ENROLLEE]
B2.
If [you/ (he/she)] currently [work/works] more than one job, please answer about [your/
(his/her)] main job.
How long [have you/ has ENROLLEE] been employed at this job, organization, or
business? Has it been … [NEW]
Less than 2 months .............................................................................................. 1
2 to 12 months ..................................................................................................... 2
More than 12 months ........................................................................................... 3
No Response ........................................................................................................ M
CATI VERSION
B2.
If [you/ (he/she)] currently [work/works] more than one job, please answer about [your/
(his/her)] main job.
How long [have you/ has ENROLLEE] been employed at this job, organization, or
business? Has it been …
Less than 2 months, .................................................................................................... 1
2 to 12 months, or ....................................................................................................... 2
More than 12 months .................................................................................................. 3
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
PROGRAMMER: IF EMPLOYED BUT ON MEDICAL LEAVE (B1=2) ROUTE TO B8.
8
RETAIN Enrollee Round 1 Survey: Section B. Employment
ENROLLEE EMPLOYED, WORKING NOW (B1=1)
[you/(he/she)] [work/works] [your/ (his/her)] [you work/ (he/she) works]
B3.
How many hours per week [do you/does ENROLLEE] typically work at this job?
If [you/ (he/she)] currently [work/works] more than one job, please answer about [your/
(his/her)] main job.
[POD, C10, rev]
HOURS PER WEEK
GO TO B4
(RANGE 0-168)
NO RESPONSE ..................................................................................... M
GO TO B3a
SOFT CHECK: IF B3 IS>50 ;
If [you work/ (he/she) works] more than one job, please answer about [your/ (his/her)] main job.
SOFT CHECK: IF B3=NO RESPONSE;
Please provide an answer to this question. Your best guess is fine.
CATI VERSION
B3.
How many hours per week [do you/does ENROLLEE] typically work at this job?
IF NEEDED: If [you/ (he/she)] currently [work/works] more than one job, please answer
about [your/ (his/her)] main job.
|
|
|
HOURS PER WEEK
GO TO B4
DON’T KNOW ....................................................................................................... d
GO TO B3a
REFUSED ............................................................................................................. r
GO TO B3a
SOFT CHECK: IF B3= D;
Your best guess is fine.
SOFT CHECK: IF B3>50;
If [you work/ (he/she) works] more than one job, please answer about [your/ (his/her)] main job.
9
RETAIN Enrollee Round 1 Survey: Section B. Employment
ENROLLEE EMPLOYED, WORKING NOW (B1=1) AND N HOURS PER WEEK NOT PROVIDED
(B3=M, D, OR R)
[you typically work/ ENROLLEE typically works]
B3a.
We understand you may not have an exact answer.
What is your best guess as to how many hours a week [you typically work/ ENROLLEE
typically works] at this job?
Would you say it is … [NEW]
Less than 10 hours per week ............................................................................... 1
10 to 20 hours per week ....................................................................................... 2
21 to 30 hours per week ...................................................................................... 3
31 to 35 hours per week ....................................................................................... 4
35 or more hours per week ................................................................................... 5
CATI VERSION
B3a.
We understand you may not have an exact answer.
What is your best guess as to how many hours a week [you typically work/ ENROLLEE
typically works] at this job? Would you say it is …
CODE ONE ONLY
Less than 10 hours per week ...................................................................................... 1
10 to 20 hours per week.............................................................................................. 2
21 to 30 hours per week.............................................................................................. 3
31 to 35 hours per week.............................................................................................. 4
35 or more hours per week ......................................................................................... 5
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
10
RETAIN Enrollee Round 1 Survey: Section B. Employment
ENROLLEE EMPLOYED, WORKING NOW (B1=1)
[do you/does ENROLLEE]
B4.
How much [do you/does ENROLLEE] typically earn, before taxes or other deductions, on
this job? Please include tips and bonuses. [POD, C11]
Your best estimate is fine.
PROGRAMMER: INSERT COMMA FIELD MASK
$
GO TO B4a
(0-200,000)
NO RESPONSE ................................................................................................... M GO TO B5
SOFT CHECK: IF B4=NO RESPONSE;
Earnings are an important topic for this survey. Please provide an answer to this question.
Your best guess is fine.
CATI VERSION
B4.
How much [do you/does ENROLLEE] typically earn, before taxes or other deductions, on
this job? Please include tips and bonuses.
PROBE:
$|
|
Your best estimate is fine.
|
|,|
|
|
|.|
|
|
GO TO B4a
(0-200,000)
DON’T KNOW ....................................................................................................... d GO TO B5
REFUSED ............................................................................................................. r GO TO B5
SOFT CHECK: IF B4=D OR R:
Earnings are an important topic for this survey.
Do you have questions or concerns about answering this question that I could help address?
PROGRAMMER: PLACE ITEMS B4 AND B4A ON THE SAME SCREEN IN BOTH WEB AND CATI
11
RETAIN Enrollee Round 1 Survey: Section B. Employment
ENROLLEE EMPLOYED, REPORTED A WAGE (B4 >0 AND NE OR D OR R)
$[FILL B4] per [FILL B4a] [you earn/ ENROLLEE earns]
B4a.
Is that hourly, daily, weekly, bi-weekly, twice a month, monthly, or annually? [POD, C12]
Hourly ................................................................................................................... 1
Daily ...................................................................................................................... 2
Weekly .................................................................................................................. 3
Bi-weekly .............................................................................................................. 4
Twice a month ...................................................................................................... 5
Monthly ................................................................................................................. 6
Annually ................................................................................................................ 7
Other ..................................................................................................................... 99
Specify
(STRING 100)
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF B4a=NO RESPONSE;
Please provide an answer to this question. Your best guess is fine.
CATI VERSION
B4a.
Is that hourly, daily, weekly, bi-weekly, twice a month, monthly, annually, or some other
way?
CODE ONE ONLY
HOURLY ............................................................................................................... 1
DAILY .................................................................................................................... 2
WEEKLY ............................................................................................................... 3
BI-WEEKLY ........................................................................................................... 4
TWICE A MONTH ................................................................................................. 5
MONTHLY ............................................................................................................. 6
ANNUALLY .......................................................................................................... 7
OTHER (SPECIFY) ............................................................................................... 99
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF (B4 NE D OR R) AND (B4a NE D OR R);
May I confirm I have recorded correctly that [you earn/ ENROLLEE earns] $[FILL B4] [FILL B4a
or B4a_specify]?
12
RETAIN Enrollee Round 1 Survey: Section B. Employment
ENROLLEE EMPLOYED, WORKING NOW (B1=1)
[your/ENROLLEE’s] [you/ENROLLEE] [you do/(he/she) does] [you/ (he/she)] [work/works] [your/
(his/her)] [me/ENROLLEE] if [you are/ (he/she) is]
B5.
Here are benefits some employers offer their employees. Does [your/ENROLLEE’s]
employer offer [you/ENROLLEE] any of these benefits?
Please answer ‘yes’ if the benefit was offered to [you/ENROLLEE] - even if [you do/ (he/she)
does] not use or receive it. [POD, C13, rev]
PROGRAMMER: HYPERLINK FROM “EMPLOYER” TO READ: If [you/ (he/she)] currently [work/works]
more than one job, please answer about [your/ (his/her)] main job.
PROGRAMMER: FORMAT FOR WEB USING BANKED FORMAT TO OPTIMIZE FOR MOBILE DEVICES.
a. Health care insurance (such as medical and/or hospital)?
Yes, employer
offers to
[me/ENROLLEE]
No, not offered to
[me/ENROLLEE]
Do not know if
offered
N/A
Self-employed
1
0
D
2
b. Any paid leave (such as sick time or vacation)?
Yes, employer
offers to
[me/ENROLLEE]
No, not offered to
[me/ENROLLEE]
Do not know if
offered
N/A
Self-employed
1
0
D
2
CATI VERSION
B5.
I’m going to read a list of benefits that some employers offer their employees.
Please answer ‘yes’ if the benefit was offered to [you/ENROLLEE] – even if [you do/ (he/she)
does] not use or receive it. If you do not know if it was offered, or if [you are/ (he/she) is] selfemployed, please let me know.
IF NEEDED: If [you/ (he/she)] currently [work/works] more than one job, please answer about
[your/ (his/her)] main job.
CODE ONE PER ROW
YES,
EMPLOYER
OFFERS
TO
ENROLLEE
NO, NOT
OFFERED
TO
ENROLLEE
DO NOT
KNOW IF
OFFERED
N/A –
SELFEMPLOYED
REF
a. Health care insurance (such as medical
and/or hospital)?
1
0
D
2
R
b. Any paid leave (such as sick time or
vacation)?
1
0
D
2
R
13
RETAIN Enrollee Round 1 Survey: Section B. Employment
ENROLLEE EMPLOYED, WORKING NOW (B1=1)
[have you/has ENROLLEE] [your/(his/her)]
B6.
In the past 2 months, [have you/has ENROLLEE] received any advice about modifying
[your/ (his/her)] job or workplace?
This advice could come from an employer, as well as from staff at other organizations.
Please do not include advice from friends or family. [BOND 12-mo, C28d rev]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
B6.
In the past 2 months, [have you/has ENROLLEE] received any advice about modifying
[your/ (his/her)] job or workplace?
This advice could come from an employer, as well as from staff at other organizations.
Please do not include advice from friends or family.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
14
RETAIN Enrollee Round 1 Survey: Section B. Employment
ENROLLEE EMPLOYED, WORKING NOW (B1=1)
[your/ENROLLEE’s] [your/(his/her)] [you/ENROLLEE]
B7.
After [your/ ENROLLEE’s] injury or illness, did [your/ (his/her)] employer offer [you/
(him/her)] the chance to return to work with any of the following temporary changes in
[your/ (his/her)] work duties or work environment? [WCRI Injured Worker Survey 2019, rev]
a. A reduction in work hours or a shorter work-week?
Yes
No
Not needed
N/A
Self-Employed
1
0
2
3
b. A telecommuting arrangement such as working from home?
Yes
No
Not needed
N/A
Self-Employed
1
0
2
3
c. Additional breaks from work?
Yes
No
Not needed
N/A
Self-Employed
1
0
2
3
d. A change in [your/ ENROLLEE’s] job duties
Yes
No
Not needed
N/A
Self-Employed
1
0
2
3
e. Changes to [your/ ENROLLEE’s] work space or equipment or
work location or work environment?
Yes
No
Not needed
N/A
Self-Employed
1
0
2
3
f. Some other temporary change?
Yes
No
Not needed
N/A
Self-Employed
99
0
2
3
IF OTHER SPECIFY (B7f=99):
B7f_other: What other accommodations has [your/ENROLLEE’s] employer made because of
[your/ (his/her)] injury or illness?
Specify
(STRING 150)
15
RETAIN Enrollee Round 1 Survey: Section B. Employment
CATI VERSION
B7.
After [your/ ENROLLEE’s] injury or illness, did [your/ (his/her)] employer offer [you/
(him/her)] the chance to return to work with any of the following temporary changes in
[your/ (his/her)] work duties or work environment?
For each, please tell me if [your/ENROLLEE’s] employer offered it or not, if it was not
needed, or if it does not apply because [you are/ (he/she) is] self-employed.
IF NEEDED:
After [your/ ENROLLEE’s] injury or illness, did [your/ (his/her)] employer offer [you/
(him/her)] the chance to return to work with …
CODE ONE PER ROW
YES
NO
NOT
NEEDED
N/A –
SELFEMPLOYED
DK
REF
a. A reduction in work hours or a shorter
work-week?
1
0
2
3
d
r
b. A telecommuting arrangement such as
working from home?
1
0
2
3
d
r
c. Additional breaks from work?
1
0
2
3
d
r
d. A change in your job duties?
1
0
2
3
d
r
e. Changes to your work space or
equipment or work location or work
environment?
1
0
2
3
d
r
f. Some other temporary change?
(SPECIFY)
99
0
2
3
d
r
IF OTHER SPECIFY (B7f=99):
B7f_other: What other accommodations has [your/ENROLLEE’s] employer made because of
[your/ (his/her)] injury or illness?
Specify
(STRING 150)
16
RETAIN Enrollee Round 1 Survey: Section B. Employment
ENROLLEE ON MEDICAL LEAVE NOW (B1=2)
[you are/ ENROLLEE is] [You/ENROLLEE] [Your/ENROLLEE’s] [you are/ENROLLEE is]
B8.
Below is a list of reasons why some people are out on medical leave. For each, select “yes” if
it is a reason [you are/ENROLLEE is] out on leave or “no” if it is not. [NBS-17, B25, REV]
a. [You are/ ENROLLEE is] worried [your/ (his/her)] illness/injury
will get worse if [you/ (him/her)] return to work.
Yes
No
1
0
b. [Your/ENROLLEE’s] injury or illness or is too severe.
Yes
No
1
0
c. [Your/ENROLLEE’s] doctor does not think [you are / (he/she) is]
ready to work.
Yes
No
1
0
d. [Your/ENROLLEE’s] employer will not provide needed support,
accommodation, or flexibility.
Yes
No
1
0
e. [You do/ ENROLLEE does] not have a way to get to and from
work.
Yes
No
1
0
f. [You/ENROLLEE] cannot get help needed with daily living
activities, such as dressing or bathing.
Yes
No
1
0
g. Other reason on medical leave – not listed above.
Yes
No
99
0
NO RESPONSE ................................................................................................... M
IF OTHER SPECIFY (B8g=99):
B8g_other: What is the reason [you are/ENROLLEE is] out on medical leave at this time?
17
RETAIN Enrollee Round 1 Survey: Section B. Employment
CATI VERSION
B8.
Next I’ll read some reasons why some people are out on medical leave. For each, say
“yes” if it is a reason [you are/ENROLLEE is] out on leave or “no” if it is not.
CODE ONE PER ROW
YES
NO
DK
REF
a. [You are/ ENROLLEE is] worried [your/ (his/her)] illness/injury
will get worse if [you/ (him/her)] return to work.
1
0
d
r
b. [Your/ENROLLEE’s] injury or illness is too severe.
1
0
d
r
c. [Your/ENROLLEE’s] doctor does not think [you are / (he/she) is]
ready to work.
1
0
d
r
d. [Your/ ENROLLEE’s] employer will not provide needed support,
accommodation, or flexibility.
1
0
d
r
e. [You do/ ENROLLEE does] not have a way to get to and from
work.
1
0
d
r
1
0
d
r
99
0
d
r
f.
[You/ENROLLEE] cannot get help needed with daily living
activities, such as dressing or bathing.
g. Other reason on medical leave, not listed. (SPECIFY)
IF OTHER SPECIFY (B8g=99):
B8g_other: What is the reason [you are/ENROLLEE is] out on medical leave at this time?
18
RETAIN Enrollee Round 1 Survey: Section B. Employment
ENROLLEE NOT WORKING NOW – NOT ON MEDICAL LEAVE (B1=0)
[are you / is ENROLLEE is] [I go/ ENROLLEE goes] [my/ (his/her)]
B9.
Below is a list of reasons why some people are not working now. For each, select “yes” if it
is a reason [you are/ENROLLEE is] not working now or “no” if it is not. [NBS-17, B25, REV]
a. Worried that if [I go/ ENROLLEE goes] back to work [my/
(his/her)] injury or illness will get worse.
Yes
No
1
0
b. Doctor does not want [me/ (him/her)] to work.
Yes
No
1
0
c. Employer will not provide needed supports, accommodation, or
flexibility.
Yes
No
1
0
d. Injury or illness is too severe.
Yes
No
1
0
e. In school or training program.
Yes
No
1
0
f. No work available/ laid off.
Yes
No
1
0
g. Was fired or terminated from job.
Yes
No
1
0
h. Cannot get help needed with daily living activities such as
dressing or bathing.
Yes
No
1
0
19
RETAIN Enrollee Round 1 Survey: Section B. Employment
B9.
CONTINUED: Below is a list of reasons why some people are not working now. For each,
select “yes” if it is a reason [you are/ENROLLEE is] not working now or “no” if it is not.
i. Other reason, not listed.
Yes
No
99
0
NO RESPONSE ................................................................................................... M
IF OTHER SPECIFY (B9i=99): B9i_other: What is the reason [you are/ENROLLEE is] not working
now?
(STRING 250)
CATI VERSION
B9.
I’m going to read a list of reasons why some people are not working now. For each, say “yes” if
it is a reason [you are/ENROLLEE is] not working now or “no” if it is not.
CODE ONE PER ROW
YES
NO
DK
REF
a. Worried that if [I go/ ENROLLEE goes] back to work [my/
(his/her)] injury or illness will get worse.
1
0
d
r
b. Doctor does not want [me/ (him/her)] to work.
1
0
d
r
c. Employer will not provide needed supports,
accommodation, or flexibility.
1
0
d
r
d. Injury or illness is too severe.
1
0
d
r
e. In school or training program.
1
0
d
r
f. No work available or laid off.
1
0
d
r
g. Was fired or terminated from job?
1
0
d
r
h. Cannot get help needed with daily living activities such as
dressing or bathing.
1
0
d
r
i. Other reason, not listed (SPECIFY).
99
0
d
r
IF OTHER SPECIFY (B9j=99):
B9i_other: What is the reason [you are/ENROLLEE is] not working now?
(STRING 250)
20
RETAIN Enrollee Round 1 Survey: Section B. Employment
ENROLLEE NOT WORKING NOW, NOT ON MEDICAL LEAVE (B1=0)
[you/ENROLLEE] [Have you/Has ENROLLEE]
B10.
Looking for work includes looking for a full-time or part-time job, for which
[you/ENROLLEE] will be paid. [Have you/Has ENROLLEE] been looking for work during the
last two months? [BOND 36-mo, C2 rev]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
B10.
Looking for work includes looking for a full-time or part-time job, for which
[you/ENROLLEE] will be paid. [Have you/Has ENROLLEE] been looking for work during the
last two months?
YES ............................................................................................................................. 1
NO .............................................................................................................................. 0
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
ENROLLEE NOT WORKING NOW (B1=0) OR IS ON MEDICAL LEAVE (B1= 2)
[Do you/ Does ENROLLEE]
B11.
[Do you/ Does ENROLLEE] plan to return to work in the future? [NEW]
Yes ........................................................................................................................ 1 GO TO B12
No ......................................................................................................................... 0 GO TO C1
NO RESPONSE ................................................................................................... M GO TO C1
CATI VERSION
B11.
[Do you/ Does ENROLLEE] plan to return to work in the future?
Yes ........................................................................................................................ 1 GO TO B12
No ......................................................................................................................... 0 GO TO C1
DON’T KNOW....................................................................................................... d GO TO C1
REFUSED............................................................................................................. r GO TO C1
21
RETAIN Enrollee Round 1 Survey: Section B. Employment
ENROLLEE PLANS TO RETURN TO WORK (B11=1)
[ARE YOU/IS ENROLLEE]
B12.
[Are you/Is ENROLLEE] planning to return to work in the next 90 days? [NEW]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
B12.
[Are you/Is ENROLLEE] planning to return to work in the next 90 days?
YES ............................................................................................................................. 1
NO .............................................................................................................................. 0
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
22
RETAIN Enrollee Round 1 Survey: Section B. Employment
ALL CONSENTING (A1=1 OR 2)
[you/ENROLLEE] [have you/ has ENROLLEE] [you only do/ ENROLLEE only does] [your/ (his/her)]
B13.
The next questions ask about other activities [you/ENROLLEE] may have done to earn
money.
In the past month, [have you/ has ENROLLEE] been paid for any of the following
occasional work activities or side jobs, such as: babysitting, house cleaning, yard work,
or other personal services, such as running errands, etc.?
Do not include activities that [you only do/ ENROLLEE only does] as part of [your/
(his/her)] main job. [Survey of Household Economics and Decision making, G1 REV]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
B13.
The next questions ask about other activities [you/ENROLLEE] may have done to earn
money.
In the past month, [have you/ has ENROLLEE] been paid for any of the following
occasional work activities or side jobs, such as: babysitting, house cleaning, yard work, or
other personal services, such as running errands, etc.?
Do not include activities that [you only do/ ENROLLEE only does] as part of [your/
(his/her)] main job.
YES ............................................................................................................................. 1
NO .............................................................................................................................. 0
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
23
RETAIN Enrollee Round 1 Survey: Section B. Employment
ALL CONSENTING (A1=1 OR 2)
[have you/ has ENROLLEE] [your/ (his/her)] [your/ (his/her)] [you only do/ ENROLLEE only does] [your/
(his/her)]
B14.
In the past month, [have you/ has ENROLLEE] been paid for any of the following online
occasional work activities or side jobs, such as: completing paid online tasks, renting out
property online; selling goods on-line, or driving using a ride-sharing app?
Do not include activities that [you only do/ ENROLLEE only does] as part of [your/
(his/her)] main job. [Survey of Household Economics and Decision making, G2 REV]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
B14.
In the past month, [have you/ has ENROLLEE] been paid for any of the following online
occasional work activities or side jobs, such as: completing paid online tasks, renting out
property online; selling goods on-line, or driving using a ride-sharing app?
Do not include activities that [you only do/ ENROLLEE only does] as part
of [your/ (his/her)] main job.
YES ............................................................................................................................. 1
NO .............................................................................................................................. 0
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
24
RETAIN Enrollee Round 1 Survey: Section B. Employment
ALL CONSENTING (A1=1 OR 2)
[have you/ has ENROLLEE] [you only do/ ENROLLEE only does] [your/ (his/her)]
B15.
In the past month, [have you/ has ENROLLEE] been paid for any other occasional work
activities or side jobs such as: selling goods at flea markets, garage sales or thrift stores?
[Survey of Household Economics and Decision making, G3, REV]
Do not include activities that [you only do/ ENROLLEE only does] as part
of [your/ (his/her)] main job.
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
B15.
In the past month, [have you/ has ENROLLEE] been paid for any other occasional work
activities or side jobs such as: selling goods at flea markets, garage sales, or thrift stores?
Do not include activities that [you only do/ ENROLLEE only does] as part of [your/
(his/her)] main job.
YES ............................................................................................................................. 1
NO .............................................................................................................................. 0
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
25
RETAIN Enrollee Round 1 Survey: Section B. Employment
REPORTS OCCASSIONAL WORK (B13=1 OR B14=1 OR B15=1)
B16.
About how much of last month’s income came from all occasional paid work activities or
side jobs?
Would you say it was… [Survey of Household Economics and Decision making, G20.2 REV]
Less than 25% ...................................................................................................... 1
26 to 50% .............................................................................................................. 2
51 to 75% .............................................................................................................. 3
More than 75% ..................................................................................................... 4
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF B16 = M; Please provide an answer to this question. Your best guess is fine.
B16.
About how much of last month’s income came from all occasional paid work activities or side
jobs?
Would you say it was….
CODE ONE ONLYCODE
ONE ONLY
Less than 25% ........................................................................................................... 1
26 to 50% .................................................................................................................... 2
51 to 75% .................................................................................................................... 3
More than 75% ........................................................................................................... 4
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
SOFT CHECK: IF B16=d OR r; Your best guess is fine.
26
RETAIN Enrollee Round 1 Survey Section C. Training and services
SECTION C. TRAINING AND SERVICES RECEIVED
ALL CONSENTING (A1= 1 OR 2)
[have you/has ENROLLEE]
C1.
The next set of questions ask about training and other services.
Employment-related services can include help searching for work, referrals to jobs or
employers, help with a resume, information on how to change careers, and information on
education or job training programs.
In the past 2 months, [have you/has ENROLLEE] received any employment-related support
services? Do not include supports provided by friends or family. [NEW]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF C1=NO RESPONSE;
Please provide an answer to this question. This helps us make sure you only receive questions
that apply to you.
CATI VERSION:
C1.
The next set of questions ask about training and other services.
Employment-related services can include help searching for work, referrals to jobs or
employers, help with a resume, information on how to change careers, and information on
education or job training programs.
In the past 2 months, [have you/has ENROLLEE] received any employment-related support
services? Do not include supports provided by friends or family.
YES ............................................................................................................................. 1
NO .............................................................................................................................. 0
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
SOFT CHECK: IF C1=D OR R;
Employment-related services are an important topic for this study. Are there any concerns you
have about answering this question that I could help address?
PROGRAMMER: IF C1=1, 0, D OR R – CASE HAS MET STUDY CRITERIA FOR A QUALIFIED
PARTIAL (INCLUSION IN ANALYSIS FILE AND FACTORED INTO SURVEY RESPONSE RATE
ACCORDINGLY).
27
RETAIN Enrollee Round 1 Survey Section C. Training and services
ALL CONSENTING (A1=1 OR 2)
[Are you/Is ENROLLEE]
C2.
[Are you/Is ENROLLEE] currently enrolled in school or taking any classes? [POD, B1, rev]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
C2.
[Are you/Is ENROLLEE] currently enrolled in school or taking any classes?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL CONSENTING (A1=1 OR 2)
[have you/has ENROLLEE] [you/(him/her)] [your/(his/her)]
C3.
In the past 2 months, [have you/has ENROLLEE] participated in any training program that
lasted at least one week and that was designed to help [you/(him/her)] find a job, improve
[your/(his/her)] job skills, or learn a new job? [POD, B3]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
C3.
In the past 2 months, [have you/has ENROLLEE] participated in any training program that lasted
at least one week and that was designed to help [you/(him/her)] find a job, improve
[your/(his/her)] job skills, or learn a new job?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
28
RETAIN Enrollee Round 1 Survey Section C. Training and services
ALL CONSENTING (A1=1 OR 2)
[have you/has ENROLLEE]
C4.
A care or other service coordinator helps people with support services after injury or
illness. They might coordinate medical services, work with employers/supervisors to
develop alternative job duties or help people find temporary employment.
In the last 2 months, [have you/has ENROLLEE] worked with a care or other service
coordinator? [NEW]
Yes ........................................................................................................................ 1 GO TO C5
No ......................................................................................................................... 0 GO TO C6
NO RESPONSE ................................................................................................... M GO TO C6
CATI VERSION
C4.
A care or other service coordinator helps people with support services after injury or
illness. They might coordinate medical services, work with employers/supervisors to
develop alternative job duties or help people find temporary employment.
In the last 2 months, [have you/has ENROLLEE] worked with a care or other service
coordinator?
YES ............................................................................................................................. 1
GO TO C5
NO ............................................................................................................................... 0
GO TO C6
DON’T KNOW ............................................................................................................. d
GO TO C6
REFUSED ................................................................................................................... r
GO TO C6
REPORTS USE OF COORDINATOR SERVICES (C4=1)
C5.
How useful were the services the care or other service coordinator provided? [NEW]
Very useful ............................................................................................................ 1
Somewhat useful .................................................................................................. 2
Not very useful ...................................................................................................... 3
Not at all useful ..................................................................................................... 4
NO RESPONSE ................................................................................................... M
CATI VERSION
C5.
How useful were the services the care or other service coordinator provided?
CODE ONE ONLY
Very useful .................................................................................................................. 1
Somewhat useful ......................................................................................................... 2
Not very useful ............................................................................................................ 3
Not at all useful ........................................................................................................... 4
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
29
RETAIN Enrollee Round 1 Survey Section C. Training and services
ALL CONSENTING (A1=1 or 2)
[you have/has ENROLLEE] [your/(his/her)] [your/ (his/her)]
C6.
In the past 2 months, [have you/ has ENROLLEE] talked with your doctor or other
healthcare providers about how [your/ (his/her)] injury or illness affects [your/ (his/her)]
ability to work? [NEW]
Yes ........................................................................................................................ 1 GO TO C7
No ......................................................................................................................... 0 GO TO C7
Have not seen doctor or other health care providers in past 2 months ............... 2 GO TO D1
NO RESPONSE ................................................................................................... M GO TO D1
CATI VERSION
C6.
In the past 2 months, [have you/ has ENROLLEE] talked with your doctor or other
healthcare providers about how [your/ (his/her)] injury or illness affects [your/ (his/her)]
ability to work?
IF NEEDED: If [you have/ ENROLLEE has] not seen [your/ (his/her)] doctor or other
healthcare providers in the past 2 months, just let me know.
YES ....................................................................................................................... 1 GO TO C7
NO ........................................................................................................................ 0 GO TO C7
HAVE NOT SEEN DOCTOR OR OTHER HEALTH CARE PROVIDERS IN
PAST 2 MONTHS ................................................................................................. 2 GO TO D1
DON’T KNOW....................................................................................................... d GO TO D1
REFUSED............................................................................................................. r
GO TO D1
30
RETAIN Enrollee Round 1 Survey Section C. Training and services
ENROLLEE HAD CONTACT WITH PROVIDER IN PAST 2 MONTHS (C6=1,0)
[you have/ENROLLEE has] [your/ (his/her)] [you need/ENROLLEE needs] [your/ (his/her)]
C7.
Please think about the care [you have/ENROLLEE has] received from [your/ (his/her)]
doctor or other healthcare providers in the past two months.
How helpful have these providers been in providing all the services [you need/ENROLLEE
needs] to help return to work or stay at work after [your/ (his/her)] injury or illness? [NEW]
Extremely helpful .................................................................................................. 1
Somewhat helpful ................................................................................................. 2
Not very helpful ..................................................................................................... 3
Not at all helpful .................................................................................................... 4
NO RESPONSE ................................................................................................... M
CATI VERSION:
C7.
Please think about the care [you have/ENROLLEE has] received from [your/ (his/her)]
doctor or other healthcare providers in the past two months.
How helpful have these providers been in providing all the services [you need/ENROLLEE
needs] to help return to work or stay at work after [your/ (his/her)] injury or illness?
CODE ONE ONLY
Extremely helpful......................................................................................................... 1
Somewhat helpful........................................................................................................ 2
Not very helpful .......................................................................................................... 3
Not at all helpful .......................................................................................................... 4
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
31
RETAIN Enrollee Round 1 Survey: Section D. Health and well-being
SECTION D. HEALTH AND WELL-BEING
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s]
D1.
The next set of questions ask about your health and well-being. There are no right or
wrong answers, as everyone’s experience is different.
In general, how would you rate [your/ENROLLEE’s] health? [POD, F1]
Excellent ............................................................................................................... 1
Very good ............................................................................................................. 2
Good ..................................................................................................................... 3
Fair ........................................................................................................................ 4
Poor ...................................................................................................................... 5
NO RESPONSE ................................................................................................... M
CATI VERSION:
D1.
The next set of questions ask about your health and well-being. There are no right or
wrong answers, as everyone’s experience is different.
In general, how would you rate [your/ENROLLEE’s] health?
CODE ONE ONLY
Excellent ................................................................................................................ 1
Very good .............................................................................................................. 2
Good...................................................................................................................... 3
Fair ........................................................................................................................ 4
Poor ....................................................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
32
RETAIN Enrollee Round 1 Survey: Section D. Health and well-being
ALL CONSENTING (A1=1 OR 2)
[are you/is (he/she)] [your/ (his/her)] [you/(he/she)] [you are/(he/she) is] [State name for Medicaid]
D2.
[Do you/Does ENROLLEE] have health insurance coverage now?
For instance, [are you/is (he/she)] covered by a plan that someone else in [your/ (his/her)]
family has, or through a health plan [your/ (his/her)] employer provides, or Medicare,
Medicaid [or State name for Medicaid], or a plan [you/ (he/she)] bought on [your/ (his/her)]
own? [BOND 36mo, G1]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF D2=0;
So, [you are/ (he/she) is] uninsured, is that correct? This means no Medicaid coverage or any
other government sponsored health insurance coverage. [BOND 36mo, G2]
CATI VERSION:
D2.
[Do you/Does ENROLLEE] have health insurance coverage now?
PROBE: For instance, [are you/is (he/she] covered by a plan that someone else in [your/
(his/her)] family has, or through a health plan [your/ (his/her)] employer provides, or
Medicare, Medicaid [or State name for Medicaid], or a plan [you/ (he/she)] bought on [your/
(his/her)] own?
YES ............................................................................................................................. 1
NO .............................................................................................................................. 0
DON’T KNOW ............................................................................................................. d
REFUSED ............................................................................................................. …...r
SOFT CHECK: IF D2=0;
So, [you are/ (he/she) is] uninsured, is that correct? This means no Medicaid coverage or any
other government sponsored health insurance coverage.
33
RETAIN Enrollee Round 1 Survey: Section D. Health and well-being
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s]
D3.
Now thinking about [your/ENROLLEE’s] physical health, which includes physical illness
and injury, for how many days during the past 30 days was [your/ENROLLEE’s] physical
health not good? [BRFSS 2018, PHYSHLTH]
|
|
| DAYS IN PAST 30 WHERE PHYSICAL HEALTH NOT GOOD
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF D3=M; Please select a number between 0 and 30.
CATI VERSION:
D3.
Now thinking about [your/ENROLLEE’s] physical health, which includes physical illness
and injury, for how many days during the past 30 days was [your/ENROLLEE’s] physical
health not good?
|
|
| DAYS IN PAST 30 WHERE PHYSICAL HEALTH NOT GOOD
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF D3>30; PLEASE ENTER A NUMBER BETWEEN 0 AND 30.
34
RETAIN Enrollee Round 1 Survey: Section D. Health and well-being
ALL CONSENTING SELF REPORTING ENROLLEES (A=1 OR CURRENT MODE = SELFREPORTING)
INSERT FILL CONDITION OR DELETE ROW
D4.
Using a scale of 0-10 with 0 being no pain and 10 being the worst imaginable pain, how
would you rate your pain on average in the past 7 days? [NHIS Supplement on Cancer
Screenings & Survivorship]
| | | PAIN ON AVERAGE IN PAST 7 DAYS
(0-10)
(RANGE 0-10)
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF D4>10; Please enter a number between 0 and 10.
CATI VERSION:
D4.
Using a scale of 0-10 with 0 being no pain and 10 being the worst imaginable pain, how
would you rate your pain on average in the past 7 days?
| | | PAIN ON AVERAGE IN PAST 7 DAYS
(0-10)
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
SOFT CHECK: IF D4>10; PLEASE ENTER A NUMBER BETWEEN 0 AND 10.
35
RETAIN Enrollee Round 1 Survey: Section D. Health and well-being
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s]
D5.
During the past 2 months, how much did pain interfere with [your/ENROLLEE’s] normal
work, including both work outside the home and housework? [POD, F8]
All of the time ........................................................................................................ 1
Most of the time .................................................................................................... 2
A little of the time .................................................................................................. 3
None of the time ................................................................................................... 4
NO RESPONSE ................................................................................................... M
CATI VERSION:
D5.
During the past 2 months, how much did pain interfere with [your/ENROLLEE’s] normal
work, including both work outside the home and housework?
CODE ONE ONLY
All of the time ........................................................................................................ 1
Most of the time..................................................................................................... 2
A little of the time ................................................................................................... 3
None of the time .................................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
36
RETAIN Enrollee Round 1 Survey: Section D. Health and well-being
ALL CONSENTING (A1=1 OR 2)
[you/ENROLLEE]
D6.
Opioid pain relievers are drugs used to treat moderate-to-severe pain. They are often
prescribed following surgery or injury, or for health conditions.
In the past 2 months, has a doctor or other health professional given [you/ENROLLEE] a
prescription for opioid pain relievers? [SAMHSA - Alcohol, Tobacco, and Other Drugs
Survey, REV; CDC - Opioid Overdose Survey, REV]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION:
D6.
Opioid pain relievers are drugs used to treat moderate-to-severe pain. They are often
prescribed following surgery or injury, or for health conditions.
In the past 2 months, has a doctor or other health professional given [you/ENROLLEE] a
prescription for opioid pain relievers?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
37
RETAIN Enrollee Round 1 Survey: Section D. Health and well-being
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s] [your/(his/her)]
D7.
Now thinking about [your/ENROLLEE’s] mental health, which includes stress, depression,
and problems with emotions, for how many days during the past 30 days was [your/
(his/her)] mental health not good? [BRFSS 2018, MENTHLTH]
| | | DAYS IN PAST 30 WHERE MENTAL HEALTH NOT GOOD
(RANGE 0-30)
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF D7=M OR >30; Please record a number between 0 and 30.
CATI VERSION:
D7.
Now thinking about [your/ENROLLEE’s] mental health, which includes stress, depression,
and problems with emotions, for how many days during the past 30 days was [your/
(his/her)] mental health not good?
| | | DAYS IN PAST 30 WHERE MENTAL HEALTH NOT GOOD
(RANGE 0-30)
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
SOFT CHECK: IF D7>30: INTERVIEWER – RECORD A NUMBER BETWEEN 0-30.
38
RETAIN Enrollee Round 1 Survey: Section E. General information about you
SECTION E. GENERAL INFORMATION ABOUT YOU
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s] [Your/ (His/Her)]
E_INTRO.
The last set of questions ask for some general information about [you/ENROLLEE]. This
helps researchers better understand the experiences of different groups of people.
CONTINUE ........................................................................................................... 1
NO RESPONSE ................................................................................................... M
CATI VERSION:
E_INTRO.
The last set of questions ask for some general information about [you/ENROLLEE]. This
helps researchers better understand the experiences of different groups of people.
CONTINUE ........................................................................................................... 1
39
RETAIN Enrollee Round 1 Survey: Section E. General information about you
ALL CONSENTING (A1=1 OR 2)
[Are you/Is ENROLLEE]
E1.
[Are you/Is ENROLLEE] … [PROMISE, P2_A_Q2, REV]
Married .................................................................................................................. 1
In a marriage-like relationship .............................................................................. 2
Divorced................................................................................................................ 3
Separated ............................................................................................................. 4
Widowed ............................................................................................................... 5
Single, never married ........................................................................................... 6
NO RESPONSE ................................................................................................... M
CATI VERSION:
E1.
[Are you/Is ENROLLEE]…
INTERVIEWER:
PROBE, FOR CURRENT MARITAL STATUS. IF ONCE DIVORCED, BUT
NOW REMARRIED, THE STATUS WOULD BE “MARRIED.”
CODE ONE ONLY
Married, .......................................................................................................... 1
In a marriage-like relationship,.................................................................... 2
Divorced, ....................................................................................................... 3
Separated, ..................................................................................................... 4
Widowed, or .................................................................................................. 5
Single, never married? ................................................................................. 6
DON’T KNOW................................................................................................. d
REFUSED....................................................................................................... r
40
RETAIN Enrollee Round 1 Survey: Section E. General information about you
ALL CONSENTING (A1=1 OR 2)
[you/ENROLLEE] [your/ENROLLEE’s] [ENROLLEE MAILING ADDRESS] [ENROLLEE CITY],
[ENROLLEE STATE] [ENROLLEE ZIPCODE]
E2.
Thanks for answering these questions.
We will send [you/ENROLLEE] a check for $25 for taking part in this survey. Our records
show [your/ENROLLEE’s] mailing address is:
[ENROLLEE MAILING ADDRESS]
[ENROLLEE CITY], [ENROLLEE STATE] [ENROLLEE ZIPCODE]
Is this correct? If not, please select “not correct” to update this information.
This is correct ...................................................................................................... 1
GO TO E4
Not correct – need to update ................................................................................ 0
GO TO E3
NO RESPONSE .......................................................................................................... M GO TO E4
PROGRAMMER: IF VALUES FOR FILLS ARE MISSING, THEN POPULATE FILL WITH “NOT ON
FILE”. THIS WOULD NOT NECESSARILY APPLY TO ADDRESS2 AS THAT’S ACCEPTABLE TO HAVE
DATA FOR.
CATI VERSION:
E2.
Thanks for answering these questions. We will send [you/ENROLLEE] a check for $25 for
taking part in this survey. Our records show [your/ENROLLEE’s] mailing address is:
[ENROLLEE MAILING ADDRESS]
[ENROLLEE CITY], [ENROLLEE STATE] [ENROLLEE ZIPCODE]
Is this correct?
This is correct ................................................................................................. 1 GO TO E4
Not correct – need to update .......................................................................... 0 GO TO E3
DON’T KNOW................................................................................................. d GO TO E4
REFUSED....................................................................................................... r
GO TO E4
41
RETAIN Enrollee Round 1 Survey: Section E. General information about you
MAILING ADDRESS NEEDS UPDATE (E2=0)
[your/ENROLLEE’s] [you/enrollee]
E3.
What is [your/ENROLLEE’s] mailing address?
Street address / PO Box:
(STRING 150)
City:
STRING 100)
State:
USE DROP DOWN MENU
Zip code:
(STRING 5)
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF E3=NO RESPONSE ALL CELLS;
Please provide an address. This helps us keep in touch with [you/enrollee] and ensures we mail
the $25 check to the correct address.
CATI VERSION:
E3.
What is [your/ENROLLEE’s] mailing address?
___________________________________________________
STREET 1 OR P.O. BOX NUMBER
___________________________________________________
STREET 2
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF E3= D OR R:
This helps us keep in touch with [you/enrollee] and ensures we mail the $25 check to the
correct address.
42
RETAIN Enrollee Round 1 Survey: Section E. General information about you
ALL CONSENTING (A1=1 OR 2)
[you/ ENROLLEE] [ENROLLEE TELEPHONE NUMBER]
E4.
What is the best telephone number to reach [you/ ENROLLEE] at? Our records show it as:
[ENROLLEE TELEPHONE NUMBER]
Is this correct? If not, please select “no” to update this information.
This is correct .......................................................................... 1
GO TO E6
Not correct – need to update ................................................... 0
GO TO E5
NO RESPONSE ............................................................................. M GO TO E7
SOFT CHECK: IF E4=M;
Please provide a telephone number. This helps us reach [you/enrollee] for the next survey.
CATI VERSION:
E4.
What is the best telephone number to reach [you/ENROLLEE] at? Our records show it as:
[ENROLLEE TELEPHONE NUMBER]
Is this correct?
THIS IS CORRECT ........................................................................ 1 GO TO E6
NOT CORRECT – NEED TO UPDATE ........................................ 0 GO TO E5
DON’T KNOW ................................................................................ d GO TO E6
REFUSED ...................................................................................... r GO TO E7
SOFT CHECK: IF E4=D OR R; This helps us reach [you/enrollee] for the next survey.
43
RETAIN Enrollee Round 1 Survey: Section E. General information about you
BEST PHONE NEEDS UPDATE (E4=0)
[you/ENROLLEE]
E5.
What is the best telephone number to reach [you/ENROLLEE] at?
TELEPHONE
(STRING 10)
GO TO E6
NO RESPONSE ............................................................................. M
GO TO E7
SOFT CHECK: IF E5=D OR R;
Providing a telephone number helps us reach [you/ENROLLEE] for the next survey.
CATI VERSION:
E5.
What is the best telephone number to reach [you/ENROLLEE] at?
|
|
|
|-|
|
|
|-|
|
|
|
|
GO TO E6
DON’T KNOW ................................................................................ d
GO TO E7
REFUSED ...................................................................................... r
GO TO E7
SOFT CHECK: IF E5=D OR R;
Providing a telephone number helps us reach [you/ENROLLEE] for the next survey.
44
RETAIN Enrollee Round 1 Survey: Section E. General information about you
PHONE CORRECT (E4=1) OR PHONE PROVIDED (E5 NE M)
[you/ENROLLEE]
E6.
Would it be ok for us to send a text message when we try to contact [you/ENROLLEE] for the
next survey? Please note that standard text message rates may apply. (NLTS2012, J11b)
Ok to send a text to that number ......................................................................... 1
Not ok to text that number .................................................................................... 0
Phone number does not accept text messages .................................................. 2
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF E6=M; This helps us reach [you/ENROLLEE] you for the next survey.
CATI VERSION:
E6.
Would it be ok for us to send a text message when we try to contact [you/ENROLLEE] for the
next survey? Please note that standard text message rates may apply.
CODE ONE ONLY
OK TO SEND A TEXT TO THAT NUMBER ............................................................... 1
NOT OK TO TEXT THAT NUMBER ........................................................................... 0
PHONE NUMBER DOES NOT ACCEPT TEXT MESSAGES.................................... 2
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
SOFT CHECK: IF E6= D OR R; This helps us reach [you/ENROLLEE] for the next survey.
45
RETAIN Enrollee Round 1 Survey: Section E. General information about you
ALL CONSENTING (A1=1 OR 2)
E7.
That is the end of the survey - thank you for completing it!
Your efforts help make the evaluation of RETAIN a success. If you have any questions, or
if your contact information changes, please call us at xxx-xxx-xxxx (toll free).
We look forward to hearing from you in the next survey about one year from now.
CATI VERSION:
E7.
That is the end of the survey - thank you for completing it! Your efforts help make the
evaluation of RETAIN a success.
If you have any questions, or if your contact information changes, please call xxx-xxxxxxx. We look forward to hearing from you in the next survey about one year from now.
46
OMB Control No.: XXXX-XXXX
Expiration date: XX/XX/XXXX
Retaining Employment and Talent After
Injury/Illness Network (RETAIN)
Enrollee Survey
This survey should be completed by:
Please return this survey by:
[Name (MPRID)]
[DATE]
Your input matters!
Public reporting burden for this collection of information is estimated to average 18 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays
a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to: xxxxx. Do not return the completed form to this address.
ABOUT THIS SURVEY
This survey is part of a national study for the “Retaining Employment and Talent After
Injury/Illness Network” (RETAIN) program. The study is paid for by the Social Security
Administration (SSA).
The survey asks about your employment, services received, your well-being, and some
general information about you. It takes about 12 minutes to answer these questions.
You will get $25 for completing this voluntary survey. Your answers will be kept private
and will be grouped together with everyone else who responds. This information will be4
used for research purposes only. Your decision to take part will not affect any benefits
that you, or your household members, receive now or in the future.
INSTRUCTIONS
Please record your answers as clearly as possible.
Mark checkboxes with a check () or X mark.
Continue to the next question in the survey unless instructed to go elsewhere.
RETURNING THIS FORM
Thank you for completing this survey!
Please return it to:
RETAIN Survey Team
Mathematica
P.O. Box 2393
Princeton, NJ 08540
If you have any questions about the survey, contact Mathematica at XXX-XXX-XXXX.
BEGIN HERE
Q1.
How will you be completing this survey?
1
2
Q2.
□ I am completing on my own
□ Another person is answering on my behalf
Do you have an injury or illness that limits the kind or amount of work you can do
now?
1
0
□ Yes
□ No
EMPLOYMENT
The next set of questions asks about employment.
Q3.
Are you now employed at a job, organization, or business for pay or profit?
This includes work you may do for a business that you own. If you are self-employed,
select “yes” below.
MARK ONE ONLY
1
2
0
Q4.
□ Yes – employed and working now
□ Yes – employed but out on leave right now
□ No GO TO Q14 ON PAGE 5
How long have you been employed at this job, organization or business? If you
currently work more than one job, please answer about your main job.
1
2
3
□ Less than 2 months
□ 2 to 12 months
□ More than 12 months
IF EMPLOYED AND WORKING NOW, CONTINUE TO Q5 ON PAGE 2.
IF EMPLOYED AND ON LEAVE NOW, GO TO Q11 ON PAGE 4.
1
Q5.
How many hours per week do you typically work at this job?
If you currently work more than one job, please answer about your main job.
Your best guess is fine.
|
Q6.
|
| HOURS PER WEEK
How much do you typically earn, before taxes or other deductions, on this job?
Please include tips and bonuses.
Your best estimate is fine.
$|
Q7.
|
|
|,|
|
|
|.|
|
| EARNINGS
Is that hourly, daily, weekly, bi-weekly, twice a month, monthly, or annually?
1
2
3
4
5
6
7
□ Hourly
□ Daily
□ Weekly
□ Bi-Weekly
□ Twice a month
□ Monthly
□ Annually
□ Other (specify): _________________________________________________
99
Q8.
Here are benefits some employers offer their employees. Does your employer offer
you any of these benefits? Please answer ‘yes’ if the benefit was offered to you, even
if you do not use or receive it.
MARK ONE PER ROW
Yes,
employer
offers to me
No, not
offered to
me
Do not
know if
offered
N/A
Selfemployed
a. Health care insurance (such as medical
and/or hospital)?
1
□
0
□
D
□
2
□
b. Any paid leave (such as sick time or
vacation)?
1
□
0
□
D
□
2
□
2
Q9.
In the past 2 months, have you received any advice about modifying your job or
workplace?
This advice could come from an employer, as well as from staff at other
organizations. Please do not include advice from friends or family.
1
0
□ Yes
□ No
Q10. Here are some temporary changes in your work duties or environment.
After your injury or illness, did your employer offer you the chance to return to work
with any of the following temporary changes in your work duties or work
environment?
MARK ONE PER ROW
Yes
a. A reduction in work hours or a shorter work-week.
b. A telecommuting arrangement such as working from
home.
c. Additional breaks from work.
1
1
1
d. A change in your job duties.
1
e. Changes to your work space or equipment or work
location or work environment.
f. Some other temporary change?
1
1
(specify):
____________________________________________
IF EMPLOYED AND WORKING NOW GO TO Q18 ON PAGE 6.
3
□
□
□
□
□
□
No
0
0
0
0
0
0
□
□
□
□
□
□
Not
needed
2
2
2
2
2
2
□
□
□
□
□
□
N/A
SelfEmployed
3
3
3
3
3
3
□
□
□
□
□
□
IF EMPLOYED AND ON LEAVE NOW, CONTINUE TO Q11.
Q11.
Below is a list of reasons why some people are out on medical leave. For each, select
“yes” if it is a reason you are out on leave or “no” if it is not.
MARK ONE PER
ROW
Yes
□
□
□
a. You are worried your illness/injury will get worse if you return to work.
1
b. Your injury or illness is too severe.
1
c. Your doctor does not think you are ready to work.
1
d. Your employer will not provide needed support, accommodation, or
flexibility.
1
e. You do not have a way to get to and from work.
1
□
□
f. You cannot get help needed with daily living activities, such as
dressing or bathing.
1
1
No
0
0
0
□
□
□
0
□
□
□
0
□
□
0
□
0
g. Other reason on medical leave – not listed above.
(specify): ________________________
Q12. Do you plan to return to work in the future?
1
0
□ Yes
□ No
GO TO Q18
Q13. Do you plan to return to work in the next 90 days?
1
0
□ Yes
□ No
IF EMPLOYED AND ON LEAVE NOW, GO TO Q18 ON PAGE 6.
4
IF NOT EMPLOYED NOW, CONTINUE TO Q14.
Q14.
Below is a list of reasons why some people are not working now. For each, select
“yes” if it is a reason you are not working now or “no” if it is not.
MARK ONE PER ROW
Yes
a. Worried if I go back to work my illness/injury will get worse.
b. Doctor does not want me to work.
1
c. Employer will not provide needed supports, accommodation,
or flexibility.
d. Injury or illness is too severe.
1
f. No work available or was laid off.
1
g. Was fired or terminated from job.
1
h. Cannot get help needed with daily living activities, such as
dressing or bathing.
Q15.
1
1
e. In school or training program.
i.
1
Other reason – not listed above.
(specify): _________________________________________
1
1
□
□
□
□
□
□
□
□
□
No
0
0
0
0
0
0
0
0
0
□
□
□
□
□
□
□
□
□
Looking for work includes looking for a full-time or part-time job, for which you will
be paid.
Have you been looking for work during the last two months?
1
0
□ Yes
□ No
Q16. Do you plan to return to work in the future?
1
0
□ Yes
□ No
GO TO Q18
Q17. Do you plan to return to work in the next 90 days?
1
0
□ Yes
□ No
GO TO Q18
5
The next questions ask about other activities you may have done to earn money.
Q18. In the past month, have you been paid for any of the following occasional work
activities or side jobs, such as babysitting, house cleaning or yard work, or
providing other personal services, such as running errands, etc.?
Do not include activities that you only do as part of your main job.
1
0
□ Yes
□ No
Q19. In the past month, have you been paid for any of the following online occasional
work activities or side jobs, such as: completing paid online tasks, renting out
property online, selling goods on-line, or driving using a ride-sharing app?
Do not include activities that you only do as part of your main job.
1
0
□ Yes
□ No
Q20. In the past month, have you been paid for any other occasional work activities or
side jobs such as selling goods at flea markets, garage sales, or thrift stores?
Do not include activities that you only do as part of your main job.
1
0
□ Yes
□ No
IF YOU EARN INCOME THROUGH OCCASIONAL WORK ACTIVITIES, GO TO Q21.
IF YOU DO NOT EARN INCOME THROUGH OCCASIONAL WORK ACTIVITIES, GO TO Q22.
Q21.
About how much of last month’s income did you get from occasional paid activities
or side jobs?
1
2
3
4
□ Less than 25%
□ 26 to 50%
□ 51 to 75%
□ More than 75%
6
TRAINING AND SERVICES
The next set of questions ask about training and other services.
Q22. Employment-related services can include help searching for work, referrals to job or
employers, help with a resume, information on how to change careers, and
information on education or job training programs.
In the past 2 months, have you received any employment-related support services?
Do not include supports provided by friends or family.
1
0
Q23.
Are you currently enrolled in school or taking any classes?
1
0
Q24.
□ Yes
□ No
In the past 2 months, have you participated in any training program that lasted at
least one week and that was designed to help you find a job, improve your job skills,
or learn a new job?
1
0
Q25.
□ Yes
□ No
□ Yes
□ No
A care or other service coordinator helps people with support services after injury or
illness. They might coordinate medical services, work with employers/supervisors to
develop alternative job duties or help people find temporary employment.
In the last 2 months, have you worked with a care or other service coordinator?
1
0
□ Yes
□ No
GO TO Q27
Q26. How useful were the services the care or other service coordinator provided?
1
2
3
4
□ Very useful
□ Somewhat useful
□ Not very useful
□ Not at all useful
7
Q27. In the past two months, have you talked with your doctor or other health care
providers about how your injury or illness affects your ability to work?
MARK ONE ONLY
1
0
2
□ Yes
□ No
□ Does not apply—I have not seen a health care
GO TO Q29
provider in past two months
Q28. Please think about the care you have received from your doctor or other healthcare
providers in the past two months.
How helpful have these providers been in providing all the services you need to help
return to work or stay at work after your injury or illness?
MARK ONE ONLY
1
2
3
4
□ Extremely helpful
□ Somewhat helpful
□ Not very helpful
□ Not at all helpful
HEALTH AND WELL BEING
The next set of questions ask about your health and well-being. There are no right or wrong
answers, as everyone’s experience is different.
Q29. In general, how would you rate your health?
1
2
3
4
5
□ Excellent
□ Very good
□ Good
□ Fair
□ Poor
8
Q30. Do you have health insurance coverage now?
For instance, are you covered by a plan that some else in your family has, or through
a health plan your employer provides, or Medicare, Medicaid, or a plan you bought on
your own?
1
0
Q31
Now thinking about your physical health, which includes physical illness and injury,
for how many days during the past 30 days was your physical health not good?
|
Q32.
|
| DAYS IN PAST 30 WHERE PHYSICAL HEALTH NOT GOOD
Using a scale of 0-10 with 0 being no pain and 10 being the worst imaginable pain,
how would you rate your pain on average in the past 7 days?
|
Q33.
□ Yes
□ No
|
| PAIN ON AVERAGE IN PAST 7 DAYS
During the past 2 months, how much did pain interfere with your normal work,
including both work outside the home and housework?
MARK ONE ONLY
1
2
3
4
Q34.
□ All of the time
□ Most of the time
□ A little of the time
□ None of the time
Opioid pain relievers are drugs used to treat moderate-to-severe pain. They are often
prescribed following surgery or injury, or for health conditions.
In the past 2 months, has a doctor or other health professional given you a
prescription for opioid pain relievers?
1
0
Q35.
□ Yes
□ No
Now thinking about your mental health, which includes stress, depression, and
problems with emotions, for how many days during the past 30 days was your mental
health not good?
|
|
| DAYS IN PAST 30 WHERE MENTAL HEALTH NOT GOOD
9
GENERAL INFORMATION ABOUT YOU
The last set of questions ask for some general information about you. This helps
researchers better understand the experiences of different groups of people.
Q36. Are you…
MARK ONE ONLY
1
2
3
4
5
6
□ Married
□ In a marriage-like relationship
□ Divorced
□ Separated
□ Widowed
□ Single, never married
Q37. What is your mailing address? This helps us keep in touch with you and ensures we
mail your $25 check to the correct address.
________________________________________________________________________
STREET OR P.O. BOX NUMBER
________________________________________________________________________
CITY
STATE
ZIP CODE
Q38. What is the best telephone number to reach you at? This helps us reach you for the
next survey.
|
|
|
|-|
AREA CODE
|
|
|-|
|
|
|
|
PHONE NUMBER
Q39. Would it be ok for us to send a text message when we try to contact you for the next
survey? Please note that standard text message rates will apply.
MARK ONE ONLY
1
0
2
□ Ok to send a text to that number
□ Not ok to text that number
□ Phone number does not accept text messages
Thanks for completing this survey! Please return it in the envelope provided. If you have
any questions about the survey, contact Mathematica at XXX-XXX-XXXX. We look forward
to hearing from you in the next survey about one year from now.
10
Retaining Employment and Talent After Injury/Illness Network (RETAIN) Enrollee Round 2 Survey:
questionnaire and programming specifications
12.17.19 (Deliverable 9.2C – R2)
Programming and operational assumptions:
Modes. The enrollee survey will be administered in three modes – web, telephone, and paper. These
specifications are for the computer-assisted versions only (web, telephone).
Population. Enrollees in RETAIN evaluation who have undergone random assignment and have
been randomly selected for the survey. These are individuals who have had an injury (likely
musculoskeletal) and may be at risk of exit from the labor force and / or long-term reliance on longterm injury or illness programs, such as SSDI and SSI. Respondents will include self-reporting
enrollees as well as proxies answering on enrollees’ behalf.
Target respondent. Enrollees in RETAIN who have enrolled during Phase 2. The subset of phase 2
states are not yet determined, but could include: CA, KS, MN, VT, CT, KY, OH, or WA. All eligible
sample members will be included in the R2 survey, regardless of participation in the R1 survey.
Length. The questionnaire is designed to take about 18 minutes to complete.
Language. The questionnaire is available in English and Spanish only.
Administration and design specifications. Each item in the web questionnaire specifications
includes: which respondents receive the item; dynamic fills, designated by text [in brackets];
emphasis text, designated by underlined font; soft checks that help improve data quality (designated
in boxes below applicable items); response options shown with boxes indicate “check all that apply”
response format, whereas those shown in circles denote “check one” response format. The web
survey will be optimized to deploy on mobile devices, tablets, and/ or personal computers.
Web survey login. Respondents will login to the homepage and input their username and password.
Critical items have soft checks added throughout the instrument. Cases will be designated as
qualified partials that have provided responses up to item D1 (receipt of employment services).
Questionnaire sections:
A
B
C
D
E
F
Introduction
Employment
Household Income
Training and services
Health and well-being
General information about you
PROGRAMMING FILLS BY STATE:
PROGRAM
STATE
State Name for RETAIN
State Name for Medicaid
State Name for TANF
State Name for SNAP
CA
RETAIN-California
Medi-Cal
CALWORKS (California Work
Opportunity and Responsibility to Kids)
CalFresh
CT
RETAIN-Connecticut
HUSKYHealth
JOBS First
SNAP
KY
Retaining Kentucky's Workforce
through Universal Design (RKW-UD)
Kentucky Medicaid
K-TAP (Kentucky Transitional
Assistance Program)
SNAP
KS
RETAIN-Kansas
KanCare Medical Assistance
Program
Kansas Works
Food Assistance
Program
MN
RETAIN-Minnesota
Medical Assistance (MA) /
MinnesotaCare
MFIP (Minnesota Family Investment
Program)
SNAP
OH
RETAIN-Ohio
Ohio Medicaid
OWF (Ohio Works First)
SNAP
VT
RETAIN-Vermont
Green Mountain Care
ANFC (Aid to Needy Families with
Children), Reach Up, TANF work
program
3SquaresVT
WA
RETAIN-Washington
Healthy Families
Work First
Basic Food
WEB PROGRAMMING NOTES:
Include section header titles, but no logos on each page. Logo appears on intro and closing pages only.
Do not employ a progress bar on the page; do not display item numbers on screen.
All items presented in grid format will be optimized for presentation on mobile devices.
Forward, back, and save buttons appear in the same locations on each page. One item presented per page unless otherwise specified.
CATI PROGRAMMING NOTE:
Ensure that it is possible for an interviewer to toggle to proxy administration at any point in the interview.
2
RETAIN Enrollee Questionnaire R2: LOGIN SCREEN - WEB
WEB ONLY: LOGIN SCREEN:
OMB No.:
Expiration Date:
Welcome to the RETAIN Enrollee Survey!
To begin, please enter your survey username and password below:
Username:
Password:
PLEASE CLICK THE “NEXT” BUTTON BELOW TO CONTINUE …
If you have any questions, or are having difficulty logging in, we are here to help.
Please call the study team xxx-xxx-xxxx (toll free).
Public reporting burden for this collection of information is estimated to average 24 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to: xxxx.
3
RETAIN Enrollee Questionnaire R2: LOGIN SCREEN - WEB
CATI VERSION
Hello.
Hi, my name is [INTERVIEWER]. May I please speak to [ENROLLEE FULLNAME]?
I’m calling to follow up on a letter we sent about an important study for the Social Security
Administration.
CODE ONE ONLYCODE
ONE ONLY
SPEAKING TO [FIRSTNAME] ........................................................................................... 1
GO TO A1
[FIRSTNAME] COMES TO THE PHONE .......................................................................... 2
GO TO A1
NEED TO CALLBACK (NO APPT) .................................................................................... 3
TERMINATE
NEED TO CALLBACK (SET APPT) .................................................................................. 4
SETAPPT
[FIRSTNAME] HAS A HEALTH PROBLEM....................................................................... 5
SEEK PROXY
[FIRSTNAME] IS IN AN INSTITUTION (HOSPITAL, GROUP HOME, JAIL) .................... 6
SEEK PROXY
[FIRSTNAME] HAS MOVED/HAS NEW NUMBER ........................................................... 7
TERMINATE
[FIRSTNAME] DOES NOT SPEAK ENGLISH................................................................... 8
SEEK PROXY
NEVER HEARD OF [FULLNAME]/WRONG NUMBER ..................................................... 9
TERMINATE
HUNG UP DURING INTRODUCTION (HUDI) .................................................................. 10
TERMINATE
[FIRSTNAME] IS DECEASED ........................................................................................... 11
TERMINATE
PROXY TO COMPLETE INTERVIEW ............................................................................... 12
GO TO A1
4
RETAIN Enrollee Questionnaire R2: Section A. Introduction
SECTION A. INTRODUCTION
ALL
A1.
This survey is part of a national study for the “Retaining Employment and Talent After
Injury/Illness Network” (RETAIN) program. It is paid for by the Social Security
Administration (SSA). The survey asks about employment, services received, your wellbeing, and some general information about you.
You’ll get $25 for completing this voluntary survey. It takes about 18 minutes to complete.
Your answers will be kept private and will be grouped together with everyone else who
responds. How will you be completing this survey? [NEW]
PROGRAMMER: DO NOT ALLOW MISSING VALUES ON THIS ITEM
I am completing on my own .................................................................................. 1
GO TO A2
Another person is answering on my behalf .......................................................... 2
GO TO A2
I do not agree to take part .................................................................................... 3
TERMINATE
HARD CHECK: IF A1=NO RESPONSE;
Your answer to this question is important to the study. It tells us that you have agreed to take
part in the survey. It also helps us ensure you receive only questions that apply to you. If you
have any questions about the survey, please call xxx-xxx-xxxx.
CATI VERSION
A1.
This survey is part of a national study for the “Retaining Employment and Talent After
Injury/Illness Network” (RETAIN) program. It is paid for by the Social Security
Administration (SSA). The survey asks about employment, services received, your wellbeing, and some general information about you.
You’ll get $25 for completing this voluntary survey. It takes about 18 minutes to complete.
Your answers will be kept private and will be grouped together with everyone else who
responds. Do you have any questions for me before we begin?
How will you be completing this survey?
IF NEEDED: Will you be completing it on your own or is someone completing it on your
behalf?
CODE ONE ONLYCODE
ONE ONLY
I am completing on my own ....................................................................... 1 GO TO A2
Another person is answering on my behalf ................................................. 2 GO TO A2
I DO NOT AGREE TO TAKE PART .......................................................... r TERMINATE-REF
PROGRAMMER DO NOT POPULATE DON’T KNOW RESPONSE IN A1
5
RETAIN Enrollee Questionnaire R2: Section A. Introduction
PROGRAMMER BOX 1
PROGRAMMER IF A1=2, POPULATE ALL FILLS HERE FORWARD WITH PROXY TEXT. IF A1=1, POPULATE
FILLS FOR SELF-REPORT. IF A1=REFUSED (3 OR R), ROUTE TO REFUSAL PATH AND TERMINATE.
ALL CONSENTING (A1=1 OR 2)
[Do you/ Does ENROLLEE]
A2.
[Do you/ Does ENROLLEE] have an injury or illness that limits the kind or amount of work
you can do now? [RETAIN Enrollment form, Q10]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
A2.
[Do you/ Does ENROLLEE] have an injury or illness that limits the kind or amount of work
you can do now?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
6
RETAIN Enrollee Questionnaire R2: Section B. Employment
SECTION B. EMPLOYMENT
ALL CONSENTING (A1=1 OR 2)
[Are you/Is ENROLLEE] [you/(he/she)] [you own/(he/she) owns] [you are/(he/she) is]
B1.
The next set of questions ask about employment.
[Are you/Is ENROLLEE] now employed at a job, organization, or business for pay or
profit? This includes work [you/ (he/she)] may do for a business that [you own/ (he/she)
owns]. If [you are/ (he/she) is] self-employed, select “yes” below. [POD, C1, rev]
Yes – employed and working now ........................................................................ 1 GO TO B2
Yes – employed but out on medical leave right now ............................................ 2 GO TO B2
No ......................................................................................................................... 0 GO TO B9
NO RESPONSE .......................................................................................................... M GO TO C1
SOFT CHECK: IF B1=NO RESPONSE;
Your answer to this question helps make sure you only receive questions that apply to you.
CATI VERSION:
B1.
The next set of questions ask about employment.
[Are you/Is ENROLLEE] now employed at a job, organization, or business for pay or
profit? This includes work [you/ (he/she)] may do for a business that [you own/ (he/she)
owns].
IF EMPLOYED – PROBE IF WORKING NOW OR ON MEDICAL LEAVE NOW.
YES – EMPLOYED AND WORKING NOW ......................................................... 1 GO TO B2
YES – EMPLOYED BUT OUT ON MEDICAL LEAVE RIGHT NOW ................... 2 GO TO B2
NO ......................................................................................................................... 0 GO TO B9
DON’T KNOW ..................................................................................................... d GO TO C1
REFUSED ............................................................................................................. r GO TO C1
SOFT CHECK: IF B1= D OR R;
Your answer to this question helps make sure you only receive questions that apply to you.
7
RETAIN Enrollee Questionnaire R2: Section B. Employment
ENROLLEE EMPLOYED (B1=1 OR 2)
[you/ (he/she)] [work/works] [your/ (his/her]] [have you/ has ENROLLEE]
B2.
If [you/ (he/she)] currently [work/works] more than one job, please answer about [your/
(his/her)] main job.
How long [have you/ has ENROLLEE] been employed at this job, organization, or
business? Has it been … [New]
Less than 2 months .............................................................................................. 1
2 to 12 months ..................................................................................................... 2
More than 12 months ........................................................................................... 3
No Response ........................................................................................................ M
CATI VERSION
B2.
If [you/ (he/she)] currently [work/works] more than one job, please answer about [your/
(his/her)] main job.
How long [have you/ has ENROLLEE] been employed at this job, organization, or
business? Has it been …
Less than 2 months, ................................................................................................. 1
2 to 12 months, or ..................................................................................................... 2
More than 12 months ................................................................................................ 3
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
PROGRAMMER: IF EMPLOYED BUT ON MEDICAL LEAVE (B1=2) ROUTE TO B8.
8
RETAIN Enrollee Questionnaire R2: Section B. Employment
ENROLLEE EMPLOYED, WORKING NOW (B1=1)
[you/(he/she)] [work/works] [your/ (his/her)] [you work/ (he/she) works]
B3.
How many hours per week [do you/does ENROLLEE] typically work at this job?
If [you/ (he/she)] currently [work/works] more than one job, please answer about [your/
(his/her)] main job.
[POD, C10, rev]
HOURS PER WEEK
GO TO B4
(RANGE 0-168)
NO RESPONSE ..................................................................................... M
GO TO B3a
SOFT CHECK: IF B3 IS>50 ;
If [you work/ (he/she) works] more than one job, please answer about [your/ (his/her)] main job.
SOFT CHECK: IF B3=NO RESPONSE;
Please provide an answer to this question. Your best guess is fine.
CATI VERSION
B3.
How many hours per week [do you/does ENROLLEE] typically work at this job?
IF NEEDED: If [you/ (he/she)] currently [work/works] more than one job, please answer
about [your/ (his/her)] main job.
|
|
|
HOURS PER WEEK
GO TO B4
DON’T KNOW ....................................................................................................... d
GO TO B3a
REFUSED ............................................................................................................. r
GO TO B3a
SOFT CHECK: IF B3= D;
Your best guess is fine.
SOFT CHECK: IF B3>50;
If [you work/ (he/she) works] more than one job, please answer about [your/ (his/her)] main job.
9
RETAIN Enrollee Questionnaire R2: Section B. Employment
ENROLLEE EMPLOYED, WORKING NOW (B1=1) AND N HOURS PER WEEK NOT PROVIDED
(B3=M, D, OR R)
[you typically work/ ENROLLEE typically works]
B3a.
We understand you may not have an exact answer.
What is your best guess as to how many hours a week [you typically work/ ENROLLEE
typically works] at this job?
Would you say it is … [NEW]
Less than 10 hours per week ............................................................................... 1
10 to 20 hours per week ....................................................................................... 2
21 to 30 hours per week ...................................................................................... 3
31 to 35 hours per week ....................................................................................... 4
35 or more hours per week ................................................................................... 5
NO RESPONSE ................................................................................................... M
CATI VERSION
B3a.
We understand you may not have an exact answer. What is your best guess as to how
many hours a week [you typically work/ ENROLLEE typically works] at this job? Would
you say it is …
CODE ONE ONLY
Less than 10 hours per week ................................................................................... 1
10 to 20 hours per week ........................................................................................... 2
21 to 30 hours per week ........................................................................................... 3
31 to 35 hours per week ........................................................................................... 4
35 or more hours per week ...................................................................................... 5
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
10
RETAIN Enrollee Questionnaire R2: Section B. Employment
ENROLLEE EMPLOYED, WORKING NOW (B1=1)
[do you/does ENROLLEE]
B4.
How much [do you/does ENROLLEE] typically earn, before taxes or other deductions, on
this job? Please include tips and bonuses. [POD, C11]
Your best estimate is fine.
PROGRAMMER: INSERT COMMA FIELD MASK
$
GO TO B4a
(0-200,000)
NO RESPONSE ................................................................................................... M GO TO B5
SOFT CHECK: IF B4=NO RESPONSE;
Earnings are an important topic for this survey. Please provide an answer to this question.
Your best guess is fine.
CATI VERSION
B4.
How much [do you/does ENROLLEE] typically earn, before taxes or other deductions, on
this job? Please include tips and bonuses.
PROBE:
$|
|
Your best estimate is fine.
|
|,|
|
|
|.|
|
|
GO TO B4a
(0-200,000)
DON’T KNOW ....................................................................................................... d GO TO B5
REFUSED ............................................................................................................. r GO TO B5
SOFT CHECK: IF B4=D OR R:
Earnings are an important topic for this survey.
Do you have questions or concerns about answering this question that I could help address?
PROGRAMMER: PLACE ITEMS B4 AND B4A ON THE SAME SCREEN IN BOTH WEB AND CATI
11
RETAIN Enrollee Questionnaire R2: Section B. Employment
ENROLLEE EMPLOYED, REPORTED A WAGE (B4 >0 AND NE OR D OR R)
$[FILL B4] per [FILL B4a] [you earn/ ENROLLEE earns]
B4a.
Is that hourly, daily, weekly, bi-weekly, twice a month, monthly, or annually? [POD, C12]
Hourly ................................................................................................................... 1
Daily ...................................................................................................................... 2
Weekly .................................................................................................................. 3
Bi-weekly .............................................................................................................. 4
Twice a month ...................................................................................................... 5
Monthly ................................................................................................................. 6
Annually ................................................................................................................ 7
Other ..................................................................................................................... 99
Specify
(STRING 100)
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF B4a=NO RESPONSE;
Please provide an answer to this question. Your best guess is fine.
CATI VERSION
B4a.
Is that hourly, daily, weekly, bi-weekly, twice a month, monthly, annually, or some other
way?
CODE ONE ONLYCODE ONE ONLY
HOURLY ............................................................................................................... 1
DAILY .................................................................................................................... 2
WEEKLY ............................................................................................................... 3
BI-WEEKLY ........................................................................................................... 4
TWICE A MONTH ................................................................................................. 5
MONTHLY ............................................................................................................. 6
ANNUALLY .......................................................................................................... 7
OTHER (SPECIFY) ............................................................................................... 99
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF (B4 NE D OR R) AND (B4a NE D OR R);
May I confirm I have recorded correctly that [you earn/ ENROLLEE earns] $[FILL B4] [FILL B4a
or B4a_specify]?
12
RETAIN Enrollee Questionnaire R2: Section B. Employment
ENROLLEE EMPLOYED, WORKING NOW (B1=1)
[your/ENROLLEE’s] [you/ENROLLEE] [you do/(he/she) does] [work/works] [your/ (his/her)]
[me/ENROLLEE] [you are/ (he/she) is]
B5.
Here are benefits some employers offer their employees. Does [your/ENROLLEE’s]
employer offer [you/ENROLLEE] any of these benefits?
Please answer ‘yes’ if the benefit was offered to [you/ENROLLEE] - even if [you do/ (he/she)
does] not use or receive it. [POD, C13, rev]
PROGRAMMER: HYPERLINK FROM “EMPLOYER” TO READ: If [you/ (he/she)] currently [work/works]
more than one job, please answer about [your/ (his/her)] main job.
PROGRAMMER: FORMAT FOR WEB USING BANKED FORMAT TO OPTIMIZE FOR MOBILE DEVICES.
a. Health care insurance (such as medical and/or hospital)?
Yes, employer
offers to
[me/ENROLLEE]
No, not offered to
[me/ENROLLEE]
Do not know if
offered to
[me/ENROLLEE]
N/A
Self- employed
1
0
D
2
b. Any paid leave (such as sick time or vacation)?
Yes, employer
offers to
[me/ENROLLEE]
No, not offered to
[me/ENROLLEE]
1
Do not know if
offered to
[me/ENROLLEE]
N/A
Self employed
D
2
0
CATI VERSION
B5.
I’m going to read a list of benefits that some employers offer their employees.
Please answer ‘yes’ if the benefit was offered to [you/ENROLLEE] - even if [you do/ (he/she)
does] not use or receive it. If you do not know if it was offered, or if [you are/ (he/she) is] selfemployed, please let me know.
IF NEEDED: If [you/ (he/she)] currently [work/works] more than one job, please answer about
[your/ (his/her)] main job.
CODE ONE PER ROW
YES,
EMPLOYER
OFFERS TO
ENROLLEE
NO, NOT
OFFERED
TO
ENROLLEE
DO NOT
KNOW IF
OFFERED
N/A – SELFEMPLOYED
RE
F
a. Health care insurance, such as
medical and/or hospital?
1
0
D
2
R
b. Any paid leave (such as sick time
or vacation)?
1
0
D
2
R
13
RETAIN Enrollee Questionnaire R2: Section B. Employment
ENROLLEE EMPLOYED, WORKING NOW (B1=1)
[have you/has ENROLLEE] [your/(his/her)]
B6.
In the past 2 months, [have you/has ENROLLEE] received any advice about modifying
[your/ (his/her)] job or workplace?
This advice could come from an employer, as well as from staff at other organizations.
Please do not include advice from friends or family. [BOND 12-mo, C28d rev]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
B6.
In the past 2 months, [have you/has ENROLLEE] received any advice about modifying
[your/ (his/her)] job or workplace?
This advice could come from an employer, as well as from staff at other organizations.
Please do not include advice from friends or family.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
14
RETAIN Enrollee Questionnaire R2: Section B. Employment
ENROLLEE EMPLOYED, WORKING NOW (B1=1)
[your/ENROLLEE’s] [your/(his/her)] [you/ENROLLEE]
B7.
After [your/ ENROLLEE’s] injury or illness, did [your/ (his/her)] employer offer [you/
(him/her)] the chance to return to work with any of the following temporary changes in
[your/ (his/her)] work duties or work environment? [WCRI Injured Worker Survey 2019, rev]
a. A reduction in work hours or a shorter work-week?
Yes
No
Not needed
N/A
Self-Employed
1
0
2
3
b. A telecommuting arrangement such as working from
home?
Yes
No
Not needed
N/A
Self-Employed
1
0
2
3
c. Additional breaks from work?
Yes
No
Not needed
N/A
Self-Employed
1
0
2
3
d. A change in [your/ ENROLLEE’s] job duties?
Yes
No
Not needed
N/A
Self-Employed
1
0
2
3
e. Changes to [your/ ENROLLEE’s] work space or
equipment or work location or work environment?
Yes
No
Not needed
N/A
Self-Employed
1
0
2
3
f. Some other temporary change?
Yes
No
Not needed
N/A
Self-Employed
99
0
2
3
IF OTHER SPECIFY (B7f=99):
B7f_other: What other accommodations has [your/ENROLLEE’s] employer made because of
[your/ (his/her)] injury or illness?
Specify
(STRING 150)
15
RETAIN Enrollee Questionnaire R2: Section B. Employment
CATI VERSION
B7.
After [your/ ENROLLEE’s] injury or illness, did [your/ (his/her)] employer offer [you/
(him/her)] the chance to return to work with any of the following temporary changes in
[your/ (his/her)] work duties or work environment?
For each, please tell me if your employer offered it or not, if it was not needed, or if it does
not apply because you are self-employed..
IF NEEDED: After [your/ ENROLLEE’s] injury or illness, did [your/ (his/her)] employer offer
[you/ (him/her)] the chance to return to work with …
CODE ONE PER ROW
YES
NO
NOT
NEEDED
N/A SELFEMPLOYED
DK
REF
a. A reduction in work hours or a
shorter work-week?
1
0
2
3
d
r
b. A telecommuting arrangement such
as working from home?
1
0
2
3
d
r
c. Additional breaks from work?
1
0
2
3
d
r
d. A change in [your/ENROLLEE’s] job
duties?
1
0
2
3
d
r
e. Changes to [your/ENROLLEE’s] work
space or equipment or work location
or work environment?
1
0
2
3
d
r
f. Some other temporary change?
(SPECIFY)
99
0
2
3
d
r
IF OTHER SPECIFY (B7f=99):
B7f_other: What other accommodations has [your/ENROLLEE’s] employer made because of
[your/ (his/her)] injury or illness?
Specify
(STRING 150)
16
RETAIN Enrollee Questionnaire R2: Section B. Employment
ENROLLEE ON MEDICAL LEAVE NOW (B1=2)
[you are/ ENROLLEE is] [You/ENROLLEE] [Your/ENROLLEE’s] [you are/ENROLLEE is]
B8.
Below is a list of reasons why some people are out on medical leave. For each, select “yes” if
it is a reason [you are/ENROLLEE is] out on leave or “no” if it is not. [NBS-17, B25, REV]
a. [You are/ ENROLLEE is] worried [your/ (his/her)] illness/injury
will get worse if [you/ (him/her)] return to work.
Yes
No
1
0
b. [Your/ENROLLEE’s] injury or illness or is too severe.
Yes
No
1
0
c. [Your/ENROLLEE’s] doctor does not think [you are / (he/she) is]
ready to work.
Yes
No
1
0
d. [Your/ENROLLEE’s] employer will not provide needed support,
accommodation, or flexibility.
Yes
No
1
0
e. [You do/ ENROLLEE does] not have a way to get to and from
work.
Yes
No
1
0
f. [You/ENROLLEE] cannot get help needed with daily living
activities, such as dressing or bathing.
Yes
No
1
0
g. Other reason on medical leave – not listed above.
Yes
No
99
0
NO RESPONSE ................................................................................................... M
IF OTHER SPECIFY (B8g=99):
B8g_other: What is the reason [you are/ENROLLEE is] out on medical leave at this time?
17
RETAIN Enrollee Questionnaire R2: Section B. Employment
CATI VERSION
B8.
Next I’ll read some reasons why some people are out on medical leave. For each, say
“yes” if it is a reason [you are/ENROLLEE is] out on leave or “no” if it is not.
CODE ONE PER ROW
YES
NO
DK
REF
a. [You are/ ENROLLEE is] worried [your/ (his/her)]
illness/injury will get worse if [you/ (him/her)] return to
work.
1
0
d
r
b. [Your/ENROLLEE’s] injury or illness is too severe.
1
0
d
r
c. [Your/ENROLLEE’s] doctor does not think [you are /
(he/she) is] ready to work.
1
0
d
r
d. [Your/ ENROLLEE’s] employer will not provide needed
support, accommodation, or flexibility.
1
0
d
r
e. [You do/ ENROLLEE does] not have a way to get to and
from work.
1
0
d
r
1
0
d
r
99
0
d
r
f.
[You/ENROLLEE] cannot get help needed with daily living
activities, such as dressing or bathing.
g. Other reason on medical leave, not listed. (SPECIFY)
IF OTHER SPECIFY (B8g=99):
B8g_other: What is the reason [you are/ENROLLEE is] out on medical leave at this time?
18
RETAIN Enrollee Questionnaire R2: Section B. Employment
ENROLLEE NOT WORKING NOW – NOT ON MEDICAL LEAVE (B1=0)
[are you / is ENROLLEE is] [I go/ ENROLLEE goes] [my/ (his/her)]
B9.
Below is a list of reasons why some people are not working now. For each, select “yes” if it
is a reason [you are/ENROLLEE is] not working now or “no” if it is not. [NBS-17, B25, REV]
a. Worried that if [I go/ ENROLLEE goes] back to work [my/
(his/her)] injury or illness will get worse.
Yes
No
1
0
b. Doctor does not want [me/ (him/her)] to work.
Yes
No
1
0
c. Employer will not provide needed supports, accommodation, or
flexibility.
Yes
No
1
0
d. Injury or illness is too severe.
Yes
No
1
0
e. In school or training program.
Yes
No
1
0
f. No work available/ laid off.
Yes
No
1
0
g. Was fired or terminated from job.
Yes
No
1
0
h. Cannot get help needed with daily living activities such as
dressing or bathing.
Yes
No
1
0
19
RETAIN Enrollee Questionnaire R2: Section B. Employment
B9.
CONTINUED:
Below is a list of reasons why some people are not working now. For each, select “yes” if
it is a reason [you are/ENROLLEE is] not working now or “no” if it is not.
i. Other reason, not listed.
Yes
No
99
0
NO RESPONSE ................................................................................................... M
IF OTHER SPECIFY (B9i=99):
B9i_other: What is the reason [you are/ENROLLEE is] not working now?
(STRING 250)
CATI VERSION
B9.
I’m going to read a list of reasons why some people are not working now. For each, say “yes” if
it is a reason [you are/ENROLLEE is] not working now or “no” if it is not.
CODE ONE PER ROW
YES
NO
DK
REF
a. Worried that if [I go/ ENROLLEE goes] back to work [my/
(his/her)] injury or illness will get worse.
1
0
d
r
b. Doctor does not want [me/ (him/her)] to work.
1
0
d
r
c. Employer will not provide needed supports,
accommodation, or flexibility.
1
0
d
r
d. Injury or illness is too severe.
1
0
d
r
e. In school or training program.
1
0
d
r
f. No work available/ laid off.
1
0
d
r
g. Was fired or terminated from job?
1
0
d
r
h. Cannot get help needed with daily living activities such as
dressing or bathing.
1
0
d
r
i. Other reason, not listed (SPECIFY).
99
0
d
r
IF OTHER SPECIFY (B9j=99):
B9i_other: What is the reason [you are/ENROLLEE is] not working now?
(STRING 250)
20
RETAIN Enrollee Questionnaire R2: Section B. Employment
ENROLLEE NOT WORKING NOW, NOT ON MEDICAL LEAVE (B1=0)
[you/ENROLLEE] [Have you/Has ENROLLEE]
B10.
Looking for work includes looking for a full-time or part-time job, for which
[you/ENROLLEE] will be paid.
[Have you/Has ENROLLEE] been looking for work during the last two months? [BOND 36mo, C2 rev]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
B10.
Looking for work includes looking for a full-time or part-time job, for which
[you/ENROLLEE] will be paid.
[Have you/Has ENROLLEE] been looking for work during the last two months?
YES ............................................................................................................................. 1
NO .............................................................................................................................. 0
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
21
RETAIN Enrollee Questionnaire R2: Section B. Employment
ENROLLEE NOT WORKING NOW (B1=0) OR IS ON MEDICAL LEAVE (B1= 2)
[Do you/ Does ENROLLEE]
B11.
[Do you/ Does ENROLLEE] plan to return to work in the future? [NEW]
Yes ........................................................................................................................ 1 GO TO B12
No ......................................................................................................................... 0 GO TO C1
NO RESPONSE ................................................................................................... M GO TO C1
CATI VERSION
B11.
[Do you/ Does ENROLLEE] plan to return to work in the future?
Yes ........................................................................................................................ 1 GO TO B12
No ......................................................................................................................... 0 GO TO C1
DON’T KNOW....................................................................................................... d GO TO C1
REFUSED............................................................................................................. r GO TO C1
ENROLLEE PLANS TO RETURN TO WORK (B11=1)
[ARE YOU/IS ENROLLEE]
B12.
[Are you/Is ENROLLEE] planning to return to work in the next 90 days? [NEW]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
B12.
[Are you/Is ENROLLEE] planning to return to work in the next 90 days?
YES ............................................................................................................................. 1
NO .............................................................................................................................. 0
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
22
RETAIN Enrollee Questionnaire R2: Section B. Employment
ALL CONSENTING (A1=1 OR 2)
[you/ENROLLEE] [have you/ has ENROLLEE] [you only do/ ENROLLEE only does] [your/ (his/her)]
B13.
The next questions ask about other activities [you/ENROLLEE] may have done to earn
money.
In the past month, [have you/ has ENROLLEE] been paid for any of the following occasional
work activities or side jobs, such as: babysitting, house cleaning, yard work, or other personal
services, such as running errands, etc.?
Do not include activities that [you only do/ ENROLLEE only does] as part of [your/
(his/her)] main job. [Survey of Household Economics and Decision making, G1 REV]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
B13.
The next questions ask about other activities [you/ENROLLEE] may have done to earn
money.
In the past month, [have you/ has ENROLLEE] been paid for any of the following
occasional work activities or side jobs, such as: babysitting, house cleaning, yard work, or
other personal services, such as running errands, etc.?
Do not include activities that [you only do/ ENROLLEE only does] as part of [your/
(his/her)] main job.
YES ............................................................................................................................. 1
NO .............................................................................................................................. 0
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
23
RETAIN Enrollee Questionnaire R2: Section B. Employment
ALL CONSENTING (A1=1 OR 2)
[have you/ has ENROLLEE] [your/ (his/her)] [your/ (his/her)] [you only do/ ENROLLEE only does] [your/
(his/her)]
B14.
In the past month, [have you/ has ENROLLEE] been paid for any of the following online
occasional work activities or side jobs, such as: completing paid online tasks, renting out
property online; selling goods on-line, or driving using a ride-sharing app?
Do not include activities that [you only do/ ENROLLEE only does] as part of [your/
(his/her)] main job. [Survey of Household Economics and Decision making, G2 REV]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
B14.
In the past month, [have you/ has ENROLLEE] been paid for any of the following online
occasional work activities or side jobs, such as: completing paid online tasks, renting out
property online; selling goods on-line, or driving using a ride-sharing app?
Do not include activities that [you only do/ ENROLLEE only does] as part
of [your/ (his/her)] main job.
YES ............................................................................................................................. 1
NO .............................................................................................................................. 0
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
24
RETAIN Enrollee Questionnaire R2: Section B. Employment
ALL CONSENTING (A1=1 OR 2)
[have you/ has ENROLLEE] [you only do/ ENROLLEE only does] [your/ (his/her)]
B15.
In the past month, [have you/ has ENROLLEE] been paid for any other occasional work
activities or side jobs such as: selling goods at flea markets, garage sales or thrift stores?
[Survey of Household Economics and Decision making, G3, REV]
Do not include activities that [you only do/ ENROLLEE only does] as part
of [your/ (his/her)] main job.
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
B15.
In the past month, [have you/ has ENROLLEE] been paid for any other occasional work
activities or side jobs such as: selling goods at flea markets, garage sales, or thrift stores?
Do not include activities that [you only do/ ENROLLEE only does] as part of [your/
(his/her)] main job.
YES ............................................................................................................................. 1
NO .............................................................................................................................. 0
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
25
RETAIN Enrollee Questionnaire R2: Section B. Employment
REPORTS OCCASSIONAL WORK (B13=1 OR B14=1 OR B15=1)
B16.
About how much of last month’s income came from all occasional paid work activities or
side jobs?
Would you say it was… [Survey of Household Economics and Decision making, G20.2 REV]
Less than 25% ...................................................................................................... 1
26 to 50% .............................................................................................................. 2
51 to 75% .............................................................................................................. 3
More than 75% ..................................................................................................... 4
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF B16 = M; Please provide an answer to this question. Your best guess is fine.
B16.
About how much of last month’s income came from all occasional paid work activities or side
jobs?
Would you say it was….
CODE ONE ONLYCODE
ONE ONLY
Less than 25% ........................................................................................................... 1
26 to 50% .................................................................................................................... 2
51 to 75% .................................................................................................................... 3
More than 75% ........................................................................................................... 4
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
SOFT CHECK: IF B16=d OR r; Your best guess is fine.
26
RETAIN Enrollee Questionnaire R2: Section C. Household income
SECTION C. HOUSEHOLD INCOME
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s] [Your/ (His/Her)]
C_INTRO.
The next section asks about benefits [your/ENROLLEE’s] household may receive, as well
as household income. This information helps researchers better understand how family
finances impact people’s lives. [Your/ (His/Her)] answers are important to the success of
this study and will be grouped together with everyone else who takes part.
CONTINUE ........................................................................................................... 1
NO RESPONSE ................................................................................................... M
CATI VERSION:
C_INTRO.
The next section asks about benefits [your/ENROLLEE’s] household may receive, as well as
household income. This information helps researchers better understand how family finances
impact people’s lives. [Your/ (His/Her)] answers are important to the success of this study and
will be grouped together with everyone else who takes part.
CONTINUE ........................................................................................................... 1
27
RETAIN Enrollee Questionnaire R2: Section C. Household income
ALL CONSENTING (A1=1 OR 2)
[Do you/Does ENROLLEE] [your/ENROLLEE’s] [or STATE NAME FOR SNAP]
C1.
[Do you/Does ENROLLEE] or does anyone in [your/ENROLLEE’s] household receive
assistance from SNAP, the Supplemental Nutrition Assistance Program [or STATE NAME
FOR SNAP]? This program was formerly known as “food stamps.” [PROMISE, P2_C_B2]
PROGRAMMER: HYPERLINK FROM “SNAP” TO READ: SNAP provides a monthly
supplement for purchasing nutritious food. Benefits are provided on an electronic card,
called an EBT card that is used like an ATM card and accepted at most grocery stores.
Yes ...............................................................................................................1
No ................................................................................................................0 GO TO C3
NO RESPONSE .................................................................................................M GO TO C3
SOFT CHECK: IF C1=NO RESPONSE;
Benefits are an important topic for this survey. Please provide an answer to this question.
CATI VERSION:
C1.
[Do you/Does ENROLLEE] or does anyone in [your/ENROLLEE’s] household receive
assistance from SNAP, the Supplemental Nutrition Assistance Program [or STATE NAME
FOR SNAP]? This program was formerly known as “food stamps.”
IF NEEDED:
SNAP provides a monthly supplement for purchasing nutritious food. Benefits are
provided on an electronic card, called an EBT card that is used like an ATM card and
accepted at most grocery stores.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
GO TO C3
DON’T KNOW ....................................................................................................... d
GO TO C3
REFUSED ............................................................................................................. r
GO TO C3
SOFT CHECK: IF C1=D OR R;
Benefits are an important topic for this survey. Do you have concerns about answering this
question that I could help address?
28
RETAIN Enrollee Questionnaire R2: Section C. Household income
RECEIVES SNAP BENEFITS (C1=1)
[your/ENROLLEE’s] [or STATE NAME FOR SNAP]
C2.
How much did [your/ENROLLEE’s] household get from the SNAP program [or STATE
NAME FOR SNAP] last month? [PROMISE, P2_C_B2a]
Your best guess is fine.
PROGRAMMER: INSERT COMMA FIELD MASK
$
(0-1,500)
HOUSEHOLD $ FROM SNAP LAST MONTH
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF C2=NO RESPONSE;
Please provide an answer to this question. Your best guess is fine.
CATI VERSION:
C2.
How much did [your/ENROLLEE’s] household get from the SNAP program [or STATE
NAME FOR SNAP] last month?
PROBE:
This program was formerly known as “food stamps.”/Your best guess is fine.
INTERVIEWER:
$| |,| |
(0-1,500)
|
RECORD IN WHOLE DOLLARS
| HOUSEHOLD $ FROM SNAP LAST MONTH
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
SOFT CHECK: IF C2> $500:
May I confirm I have correctly recorded last month’s SNAP benefit as $[C2]?
29
RETAIN Enrollee Questionnaire R2: Section C. Household income
ALL CONSENTING (A1=1 OR 2)
[Do you/Does ENROLLEE] [your/ENROLLEE’s]
C3.
Do you/Does ENROLLEE] or does anyone in [your/ENROLLEE’s] household receive any
government housing assistance in paying rent, such as through public housing or Section
8? [PROMISE, P2_C_B3]
PROGRAMMER: HYPERLINK FROM “HOUSING ASSISTANCE” TO READ: This is also
known as the Housing Choice Voucher Program. Section 8 provides funding to help
people pay their rent.
Yes ...............................................................................................................1
No ................................................................................................................0 GO TO C5
NO RESPONSE .................................................................................................M GO TO C5
SOFT CHECK: IF C3=NO RESPONSE;
Benefits are an important topic for this survey. Please provide an answer to this question.
CATI VERSION:
C3.
[Do you/Does ENROLLEE] or does anyone in [your/ENROLLEE’s] household receive any
government housing assistance in paying rent, such as through public housing or Section
8?
IF NEEDED: This is also known as the Housing Choice Voucher Program. Section 8
provides funding to help people pay their rent.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
GO TO C5
DON’T KNOW ....................................................................................................... d
GO TO C5
REFUSED ............................................................................................................. r
GO TO C5
SOFT CHECK: IF C3=NO RESPONSE;
Benefits are an important topic for this survey. Do you have concerns about answering this
question that I could help address?
30
RETAIN Enrollee Questionnaire R2: Section C. Household income
HOUSEHOLD RECEIVES INCOME FROM PUBLIC-HOUSING OR SECTION 8 (C3=1)
[your/ENROLLEE’s]
C4.
How much did [your/ENROLLEE’s] household receive from housing assistance in paying
rent (such as through public housing or Section 8) last month? [PROMISE, P2_C_B3A]
Your best guess is fine.
PROGRAMMER: INSERT COMMA FIELD MASK
$
(0-5,000)
HOUSEHOLD $ FROM HOUSING ASSISTANCE LAST MONTH
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF C4=NO RESPONSE;
Please provide an answer to this question. Your best guess is fine.
CATI VERSION:
C4.
How much did [your/ENROLLEE’s] household receive from housing assistance in paying
rent (such as through public housing or Section 8) last month?
PROBE:
Your best guess is fine.
INTERVIEWER:
$| |,| |
(0-5,000)
|
RECORD IN WHOLE DOLLARS.
| HOUSEHOLD $ FROM HOUSING ASSISTANCE LAST MONTH
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C4> $1500:
May I confirm I have correctly recorded last month’s housing benefit as $[C4]?
31
RETAIN Enrollee Questionnaire R2: Section C. Household income
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s] [Do you/ Does ENROLLEE]
C5.
Does anyone in [your/ENROLLEE’s] household receive any income from Supplemental
Security Income (SSI) or Social Security Disability Insurance (SSDI) because of a
disability? [PROMISE, P2_C_B4]
PROGRAMMER: HYPERLINK FROM “SSI or SSDI” TO READ: SSI and SSDI provides
payments to aged, blind, and disabled persons (including children).
Yes ...............................................................................................................1
No ................................................................................................................0 GO TO C7
NO RESPONSE .................................................................................................M GO TO C7
SOFT CHECK: IF C5=NO RESPONSE;
Benefits are an important topic to this survey. Please provide an answer to this question.
CATI VERSION:
C5.
Does anyone in [your/ENROLLEE’s] household receive any income from Supplemental
Security Income (SSI) or Social Security Disability Insurance (SSDI) because of a
disability?
IF NEEDED: SSI and SSDI provides payments to aged, blind, and disabled persons
(including children).
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
GO TO C7
DON’T KNOW ....................................................................................................... d
GO TO C7
REFUSED ............................................................................................................. r
GO TO C7
SOFT CHECK: IF C5=D OR R;
Benefits are an important topic to this survey. Do you have questions or concerns about
answering this question that I could help to address?
32
RETAIN Enrollee Questionnaire R2: Section C. Household income
RECEIVES INCOME FROM SSI OR SSDI (C5=1)
[your/ENROLLEE’s]
C6.
How much did [your/ENROLLEE’s] household receive from SSI or SSDI last month?
Your best guess is fine. [PROMISE, _C_B4a]
PROGRAMMER: INSERT COMMA FIELD MASK
$
(0-9,999)
HOUSEHOLD $ FROM SSI/ SSDI LAST MONTH
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF E6=NO RESPONSE;
Benefits are an important topic to this survey. Please provide an answer to this question. Your
best guess is fine.
CATI VERSION:
C6.
How much did [your/ENROLLEE’s] household receive from SSI or SSDI last month?
PROBE:
Your best guess is fine.
INTERVIEWER:
$| |,| |
(0-9,999)
|
RECORD IN WHOLE DOLLARS
| HOUSEHOLD $ FROM SSI/ SSDI LAST MONTH
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C6> $1,000:
May I confirm I have correctly recorded last month’s SSI/SSDI benefit as $[C6]?
33
RETAIN Enrollee Questionnaire R2: Section C. Household income
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s] [Do you/ Does ENROLLEE]
C7.
Does anyone in [your/ENROLLEE’s] household receive any unemployment compensation
or unemployment benefits? [CPS, Q51A1 REVISED]
Yes .................................................................................................................. 1
No ................................................................................................................... 0 GO TO C9
NO RESPONSE .................................................................................................... M GO TO C9
SOFT CHECK: IF C7=NO RESPONSE;
Benefits are an important topic for this survey. Please provide an answer to this question.
CATI VERSION:
C7.
Does anyone in [your/ENROLLEE’s] household receive any unemployment compensation
or unemployment benefits?
PROBE: Your best estimate is fine.
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0 GO TO C9
DON’T KNOW ....................................................................................................... d GO TO C9
REFUSED ............................................................................................................. r GO TO C9
SOFT CHECK: IF C7= D OR R;
Benefits are an important topic for this survey. Do you have questions or concerns about
answering this question that I could help to address?
34
RETAIN Enrollee Questionnaire R2: Section C. Household income
RECEIVES INCOME UNEMPLOYMENT (C7=1)
[your/ENROLLEE’s]
C8.
How much did [your/ENROLLEE’s] household receive last month in unemployment
compensation? [CPS, Q51A11 REVISED]
Your best guess is fine.
PROGRAMMER: INSERT COMMA FIELD MASK
$=
(0-9,999)
HOUSEHOLD $ FROM UNEMPLOYMENT LAST MONTH
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF C8=NO RESPONSE;
Please provide an answer to this question. Your best guess is fine.
CATI VERSION:
C8.
How much did [your/ENROLLEE’s] household receive last month in unemployment
compensation?
PROBE:
Your best guess is fine.
INTERVIEWER:
$| |,| |
(0-9,999)
|
RECORD IN WHOLE DOLLARS
| HOUSEHOLD $ FROM UNEMPLOYMENT LAST MONTH
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C8> $1,000:
May I confirm I have correctly recorded last month’s unemployment compensation as $[C8]?
35
RETAIN Enrollee Questionnaire R2: Section C. Household income
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s]
C9.
Does anyone in [your/ENROLLEE’s] household receive Worker's Compensation payments
or other payments as a result of a job related injury or illness? [CPS, Q52a-REV]
Please include State Worker’s Compensation, employer or employer’s insurance worker’s
compensation, or own insurance worker’s compensation.
Exclude sick pay and/or disability retirement.
Yes .......................................................................................................... 1
No ........................................................................................................... 0 GO TO C11
NO RESPONSE ............................................................................................ M GO TO C11
SOFT CHECK: IFC9=NO RESPONSE;
Benefits are an important topic for this survey. Please provide an answer to this question.
CATI VERSION:
C9.
Does anyone in [your/ENROLLEE’s] household receive Worker's Compensation payments
or other payments as a result of a job related injury or illness?
Please include State Worker’s Compensation, employer or employer’s insurance worker’s
compensation, or own insurance worker’s compensation. Exclude sick pay and/or
disability retirement.
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0 GO TO C11
DON’T KNOW ....................................................................................................... d GO TO C11
REFUSED ............................................................................................................. r GO TO C11
SOFT CHECK: IF C9= D OR R;
Benefits are an important topic for this survey. Do you have questions or concerns about
answering this question that I could help to address?
36
RETAIN Enrollee Questionnaire R2: Section C. Household income
RECEIVES INCOME WORKER’S COMPENSATION C9=1
[your/ENROLLEE’s]
C10.
How much did [your/ENROLLEE’s] household receive last month from worker’s
compensation payments or other payments as a result of a job related injury or illness?
[NEW]
Your best guess is fine.
PROGRAMMER: INSERT COMMA FIELD MASK
$
HOUSEHOLD $ FROM WORKER’S COMPENSATION OR OTHER PAYMENTS
FOR DISABILITY LAST MONTH
(0-9,999)
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF C10=NO RESPONSE;
Please provide an answer to this question. Your best guess is fine.
CATI VERSION:
C10.
How much did [your/ENROLLEE’s] household receive last month from worker’s
compensation payments or other payments as a result of a job related injury or illness?
PROBE:
Your best guess is fine.
INTERVIEWER:
RECORD IN WHOLE DOLLARS
$|
|,| | | | HOUSEHOLD $ FROM WORKER’S COMPENSATION OR OTHER PAYMENTS FOR
DISABILITY LAST MONTH
(0-9,999)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C10> $1,000:
May I confirm I have correctly recorded last month’s worker’s compensation payment as
$[C10]?
37
RETAIN Enrollee Questionnaire R2: Section C. Household income
ALL CONSENTING (A1=1 OR 2)
[Do you/Does ENROLLEE] [your/ENROLLEE’s] [Do you/ Does ENROLLEE]
C11.
[Do you/Does ENROLLEE] or does anyone in [your/ENROLLEE’s] household receive
retirement income from social security, a retirement plan, pension, 401k, or any other
source of retirement income? [Promise, P2_C_B3A]
PROGRAMMER: HYPERLINK TEXT BELOW OFF OF “RETIREMENT INCOME.”
When you work and pay Social Security taxes, you earn “credits” toward Social Security
benefits. A Social Security benefit payment is based earnings during a career and age of
retirement. Survivors’ benefits pay out benefits of a deceased individual to their surviving
spouse or dependent children.
Under a retirement plan, an employee contributes a percentage of his/her earnings
annually. These contributions are then invested. The employee receives the balance
following retirement.
A pension plan promises a specified monthly benefit at retirement. This may be a specific
dollar amount or may be calculated based on salary and years of service.
Yes ............................................................................................................. 1
No .............................................................................................................. 0 GO TO C13
NO RESPONSE ............................................................................................... M GO TO C13
SOFT CHECK: IF C11=NO RESPONSE;
Income is an important topic in this survey. Please provide an answer to this question.
CATI VERSION:
C11.
[Do you/Does ENROLLEE] or does anyone in [your/ENROLLEE’s] household receive
retirement income from social security, a retirement plan, pension, 401k, or any other
source of retirement income?
IF NEEDED:
When you work and pay Social Security taxes, you earn “credits” toward
Social Security benefits. A Social Security benefit payment is based earnings during a
career and age of retirement. Survivors’ benefits pay out benefits of a deceased individual
to their surviving spouse or dependent children.
Under a retirement plan, an employee contributes a percentage of his/her earnings
annually. These contributions are then invested. The employee receives the balance
following retirement.
A pension plan promises a specified monthly benefit at retirement. This may be a specific
dollar amount or may be calculated based on salary and years of service.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
GO TO C13
DON’T KNOW ....................................................................................................... d
GO TO C13
REFUSED ............................................................................................................. r
GO TO C13
SOFT CHECK: IF C11=NO RESPONSE; Income is an important topic in this survey. Do you have
questions or concerns about answering this question that I could help to address?
38
RETAIN Enrollee Questionnaire R2: Section C. Household income
RECEIVES RETIREMENT INCOME (C11=1)
[your/ENROLLEES’s]
C12.
How much did [your/ENROLLEE’s] household receive in retirement income from all
sources last month? [Promise 60mnth, P2_C_B4a.]
Your best guess is fine.
PROGRAMMER: INSERT COMMA FIELD MASK
$
(RANGE 0-9,999)
HOUSEHOLD $ FROM RETIREMENT INCOME LAST MONTH
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF C12=NO RESPONSE;
Please provide an answer to this question. Your best guess is fine.
CATI VERSION:
C12.
How much did [your/ENROLLEE’s] household receive in retirement income from all
sources last month?
PROBE:
Your best guess is fine.
INTERVIEWER:
RECORD IN WHOLE DOLLARS
$| || |, |
(0-9,999)
||
||
| HOUSEHOLD $ FROM RETIREMENT INCOME LAST MONTH
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C12> $1,500: May I confirm I have correctly recorded last month’s retirement
income as $[C12]?
39
RETAIN Enrollee Questionnaire R2: Section C. Household income
ALL CONSENTING (A1=1 OR 2)
[Do you/Does ENROLLEE] [your/ENROLLEE’s]
C13.
[Do you/Does ENROLLEE] or does anyone in [your/ENROLLEE’s] household receive
income from short- or long-term disability payments? [NEW]
Yes ............................................................................................................. 1
No .............................................................................................................. 0 GO TO C15
NO RESPONSE ............................................................................................... M GO TO C15
SOFT CHECK: IF C13=NO RESPONSE;
Income is an important topic in this survey. Please provide an answer to this question.
CATI VERSION:
C13.
[Do you/Does ENROLLEE] or does anyone in [your/ENROLLEE’s] household receive
income from short- or long-term disability payments?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
GO TO C15
DON’T KNOW ....................................................................................................... d
GO TO C15
REFUSED ............................................................................................................. r
GO TO C15
SOFT CHECK: IF C15=NO RESPONSE;
Income is an important topic in this survey. Do you have questions or concerns about
answering this question that I could help to address?
40
RETAIN Enrollee Questionnaire R2: Section C. Household income
RECEIVES SHORT OR LONG TERM DISABILITY INCOME (C13=1)
[your/ENROLLEES’s]
C14.
How much did [your/ENROLLEE’s] household receive in short- or long-term disability
payments last month? [NEW]
Your best guess is fine.
PROGRAMMER: INSERT COMMA FIELD MASK
$
(RANGE 0-9,999)
HOUSEHOLD $ FROM SHORT OR LT DISABILITY LAST MONTH
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF C14=NO RESPONSE;
Please provide an answer to this question. Your best guess is fine.
CATI VERSION:
C14.
How much did [your/ENROLLEE’s] household receive in short- or long-term disability
payments last month?
PROBE:
Your best guess is fine.
INTERVIEWER:
RECORD IN WHOLE DOLLARS
$| || |, |
(0-9,999)
||
||
| HOUSEHOLD $ FROM SHORT OR LT DISABILITY LAST MONTH
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C14> $1,500:
May I confirm I have correctly recorded last month’s income from short- or long-term disability
as $[C14]?
41
RETAIN Enrollee Questionnaire R2: Section C. Household income
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s][CURRENT MONTH – 1 MONTH] [your/ENROLLEE’s] [Do you/ Does ENROLLEE]
C15.
What were the total earnings of all persons in [your/ENROLLEE’s] household last month,
that is, in [CURRENT MONTH – 1 MONTH]?
Please include wages, salary, commissions, bonuses and tips from all jobs that all
household members worked before taxes. Do not include retirement earnings, public
benefits or other sources of income [your/ENROLLEE’s] household may have received.
[PROMISE, P2_C_B6]
PROGRAMMER: INSERT COMMA FIELD MASK
$
(0-99,000)
TOTAL HOUSEHOLD EARNINGS LAST MONTH
GO TO C17
NO RESPONSE ........................................................................................ M GO TO C16
SOFT CHECK: IF C15=NO RESPONSE;
Income is an important topic in this survey. Please provide an answer to this question. Your
best guess is fine.
CATI VERSION:
C15.
What were the total earnings of all persons in [your/ ENROLLEE’s] household last month,
that is, in [CURRENT MONTH – 1 MONTH]? Please include wages, salary, commissions,
bonuses and tips from all jobs that all household members worked before taxes. Do not
include retirement earnings, public benefits or other sources of income
[your/ENROLLEE’s] household may have received.
PROBE:
Your best guess is fine.
INTERVIEWER:
$|
|
|,|
|
IF NO INCOME LAST MONTH, RECORD “0.”
|
| (ALLOWABLE RANGE: 0-99,999) GO TO C15
DON’T KNOW ............................................................................................. d
GO TO C17
REFUSED ................................................................................................... r
GO TO C16
SOFT CHECK: IF C15> $5,000:
May I confirm I have correctly recorded total earnings from last month’s as $[C15]?
SOFT CHECK: IF C15=D OR R:
Income is an important topic in this survey. Do you have questions or concerns about
answering this question that I could help to address?
42
RETAIN Enrollee Questionnaire R2: Section C. Household income
REFUSED OR DON’T KNOW HOUSEHOLD INCOME FOR LAST MONTH (C15=M, D OR R)
[your/ENROLLEE’s][PRIOR CALENDAR MONTH] [your/ENROLLEE’s]
C16.
We understand you may not be able to provide an exact number. Which of the following
ranges best describes the total earnings of all persons in [your/ENROLLEE’s] household
last month, that is, in [PRIOR CALENDAR MONTH]?
Please include wages, salary, commissions, bonuses and tips from all jobs that all
household members worked before taxes. Do not include retirement earnings, public
benefits or other sources of income [your/ENROLLEE’s] household may have received.
[PROMISE, P2_C_B6]
Select one only
Less than $500 ..................................................................................................... 1
$500 to less than $1,500 ...................................................................................... 2
$1,500 to less than $2,500 ................................................................................... 3
$2,500 to less than $3,500 ................................................................................... 4
$3,500 to less than $4,500 ................................................................................... 5
$4,500 to less than $5,500 ................................................................................... 6
$5,500 to less than $6,500 ................................................................................... 7
$6,500 or more ..................................................................................................... 8
NO RESPONSE ................................................................................................... M
CATI VERSION:
C16.
We understand you may not be able to provide an exact number.
Which of the following ranges best describes the total earnings of all persons in your
household last month, that is, in [PRIOR CALENDAR MONTH]?
Please include wages, salary, commissions, bonuses and tips from all jobs that all
household members worked before taxes. Do not include retirement earnings, public
benefits or other sources of income [your/ENROLLEE’s] household may have received.
CODE ONE ONLYCODE ONE ONLY
Less than $500, ................................................................................................... 1
$500 to less than $1,500, .................................................................................... 2
$1,500 to less than $2,500, ................................................................................. 3
$2,500 to less than $3,500, ................................................................................. 4
$3,500 to less than $4,500, ................................................................................. 5
$4,500 to less than $5,500, ................................................................................ 6
$5,500 to less than $6,500 or ............................................................................. 7
$6,500 or more? ................................................................................................... 8
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
43
RETAIN Enrollee Questionnaire R2: Section C. Household income
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s] [you have/ (he/she) has]
C17.
Does anyone in [your/ENROLLEE’s] household receive money from any source [you have/
(he/she) has] not already told me about - such as other kinds of public assistance (such as
TANF or [STATE NAME TANF]), money from child support or alimony, interest, dividends,
or money from friends and family? [PROMISE, P2_C_B7 REV]
Please do not include wages, salary, commissions, bonuses and tips from all jobs that all
household members worked.
Yes ........................................................................................................ 1
No ......................................................................................................... 0 GO TO D1
NO RESPONSE .......................................................................................... M GO TO D1
CATI VERSION:
C17.
Does anyone in [your/ENROLLEE’s] household receive money from any source [you have/
(he/she) has] not already told me about - such as other kinds of public assistance (such as
TANF or [STATE NAME TANF]), money from child support or alimony, interest, dividends, or
money from friends and family?
Please do not include wages, salary, commissions, bonuses and tips from all jobs that all
household members worked.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
GO TO D1
DON’T KNOW ....................................................................................................... d
GO TO D1
REFUSED ............................................................................................................. r
GO TO D1
44
RETAIN Enrollee Questionnaire R2: Section C. Household income
REPORTS INCOME FROM OTHER SOURCES (C17=1)
[your/ENROLLEE’s]
C18.
How much money did [your/ENROLLEE’s] household receive from these other sources
last month? Please do not include wages, salary, commissions, bonuses and tips from all
jobs that all household members worked. [PROMISE, P2_C_B7a]
Your best guess is fine.
PROGRAMMER: INSERT COMMA FIELD MASK
$
(0-50,000)
HOUSEHOLD $ FROM OTHER SOURCES LAST MONTH
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF C18> $10,000:
To confirm, your household received $[C18] last month?
If that is not correct, please update your answer. If it is, please continue to the next question.
CATI VERSION:
C18.
How much money did [your/ENROLLEE’s] household receive from these other sources
last month?
Please do not include wages, salary, commissions, bonuses and tips from all jobs that all
household members worked.
PROBE:
Your best guess is fine.
INTERVIEWER:
RECORD IN WHOLE DOLLARS
$|__||__|, |__|__|__| HOUSEHOLD $ FROM OTHER SOURCES LAST MONTH
(0-50,000)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C18> $1500: May I confirm I have correctly recorded $[C18]?
SOFT CHECK: IF C18> $10,000: To confirm, your household received $[C18] last month?
45
RETAIN Enrollee Questionnaire R2: Section D. Training and services
SECTION D. TRAINING AND SERVICES RECEIVED
ALL CONSENTING (A1= 1 OR 2)
[have you/has ENROLLEE] [you have/ (he/she) has]
D1.
The next set of questions ask about training and other services.
Employment-related services can include help searching for work, referrals to jobs or
employers, help with a resume, information on how to change careers, and information on
education or job training programs.
In the past 2 months, [have you/has ENROLLEE] received any employment-related support
services? Do not include supports provided by friends or family. [NEW]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF D1=M: This is an important topic for this survey. Please provide an answer to
this question.
PROGRAMMER – IF D1 IS POPULATED (WEB OR CATI) THE CASE SHOULD BE SET AS A
QUALIFIED PARTIAL FOR INCLUSION IN THE FINAL DATASET, SHOULD THE INTERVIEW NOT BE
COMPLETED BY THE END OF THE FIELD PERIOD.
CATI VERSION:
D1.
The next set of questions ask about training and other services.
Employment-related services can include help searching for work, referrals to jobs or
employers, help with a resume, information on how to change careers, and information on
education or job training programs.
In the past 2 months, [have you/has ENROLLEE] received any employment-related support
services? Do not include supports provided by friends or family.
YES ............................................................................................................................. 1
NO .............................................................................................................................. 0
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
SOFT CHECK: IF D1=D OR R:
This is an important topic for this survey. Are there any concerns [you have/ (he/she)] about
answering this question that I can help address?
PROGRAMMER: IF D1=1, 0, D, OR 3 – THE CASE HAS REACHED THRESHOLD TO BE SET AS A
QUALIFIED PARTIAL COMPLETE.
46
RETAIN Enrollee Questionnaire R2: Section D. Training and services
ALL CONSENTING (A1=1 OR 2)
[Are you/Is ENROLLEE]
D2.
[Are you/Is ENROLLEE] currently enrolled in school or taking any classes? [POD, B1, rev]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
D2.
[Are you/Is ENROLLEE] currently enrolled in school or taking any classes?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL CONSENTING (A1=1 OR 2)
[have you/has ENROLLEE] [you/(him/her)] [your/(his/her)]
D3.
In the past 2 months, [have you/has ENROLLEE] participated in any training program that
lasted at least one week and that was designed to help [you/(him/her)] find a job, improve
[your/(his/her)] job skills, or learn a new job? [POD, B3]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION
D3.
In the past 2 months, [have you/has ENROLLEE] participated in any training program that
lasted at least one week and that was designed to help [you/(him/her)] find a job, improve
[your/(his/her)] job skills, or learn a new job?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
47
RETAIN Enrollee Questionnaire R2: Section D. Training and services
ALL CONSENTING (A1=1 OR 2)
[have you/has ENROLLEE]
D4.
A care or other service coordinator helps people with support services after injury or
illness. They might coordinate medical services, work with employers/supervisors to
develop alternative job duties or help people find temporary employment.
In the last 2 months, [have you/has ENROLLEE] worked with a care or other service
coordinator? [NEW]
Yes ........................................................................................................................ 1 GO TO D5
No ......................................................................................................................... 0 GO TO D6
NO RESPONSE ................................................................................................... M GO TO D6
CATI VERSION
D4.
A care or other service coordinator helps people with support services after injury or
illness. They might coordinate medical services, work with employers/supervisors to
develop alternative job duties or help people find temporary employment.
In the last 2 months, [have you/has ENROLLEE] worked with a care or other service
coordinator?
YES ............................................................................................................................. 1
GO TO D5
NO ............................................................................................................................... 0
GO TO D6
DON’T KNOW ............................................................................................................. d
GO TO D6
REFUSED ................................................................................................................... r
GO TO D6
REPORTS USE OF COORDINATOR SERVICES (D4=1)
D5.
How useful were the services the care or other service coordinator provided? [NEW]
Very useful ............................................................................................................ 1
Somewhat useful .................................................................................................. 2
Not very useful ...................................................................................................... 3
Not at all useful ..................................................................................................... 4
NO RESPONSE ................................................................................................... M
CATI VERSION
D5.
How useful were the services the care or other service coordinator provided?
CODE ONE ONLYCODE
ONE ONLY
Very useful ................................................................................................................. 1
Somewhat useful....................................................................................................... 2
Not very useful .......................................................................................................... 3
Not at all useful ......................................................................................................... 4
DON’T KNOW ............................................................................................................. d
48
RETAIN Enrollee Questionnaire R2: Section D. Training and services
REFUSED ................................................................................................................... r
ALL CONSENTING (A1=1 or 2)
[you have/has ENROLLEE] [your/(his/her)] [your/ (his/her)]
D6.
In the past 2 months, [have you/ has ENROLLEE] talked with your doctor or other
healthcare providers about how [your/ (his/her)] injury or illness affects [your/ (his/her)]
ability to work? [NEW]
Yes ........................................................................................................................ 1 GO TO D7
No ......................................................................................................................... 0 GO TO E1
Have not seen doctor or other health care providers in past 2 months ............... 2 GO TO E1
NO RESPONSE ................................................................................................... M GO TO E1
CATI VERSION
D6.
In the past 2 months, [have you/ has ENROLLEE] talked with your doctor or other
healthcare providers about how [your/ (his/her)] injury or illness affects [your/ (his/her)]
ability to work?
IF NEEDED: If [you have/ ENROLLEE has] not seen [your/ (his/her)] doctor or other
healthcare providers in the past 2 months, just let me know.
YES ....................................................................................................................... 1 GO TO D7
NO ........................................................................................................................ 0 GO TO E1
HAVE NOT SEEN DOCTOR OR OTHER HEALTH CARE PROVIDERS IN
PAST 2 MONTHS ................................................................................................. 2 GO TO E1
DON’T KNOW....................................................................................................... d GO TO E1
REFUSED............................................................................................................. r
GO TO E1
49
RETAIN Enrollee Questionnaire R2: Section D. Training and services
ENROLLEE HAD CONTACT WITH PROVIDER IN PAST 2 MONTHS (D6=1,0)
[you have/ENROLLEE has] [your/ (his/her)] [you need/ENROLLEE needs] [your/ (his/her)]
D7.
Please think about the care [you have/ENROLLEE has] received from [your/ (his/her)]
doctor or other healthcare providers in the past two months.
How helpful have these providers been in providing all the services [you need/ENROLLEE
needs] to help return to work or stay at work after [your/ (his/her)] injury or illness? [NEW]
Extremely helpful .................................................................................................. 1
Somewhat helpful ................................................................................................. 2
Not very helpful ..................................................................................................... 3
Not at all helpful .................................................................................................... 4
NO RESPONSE ................................................................................................... M
CATI VERSION:
D7.
Please think about the care [you have/ENROLLEE has] received from [your/ (his/her)]
doctor or other healthcare providers in the past two months.
How helpful have these providers been in providing all the services [you need/ENROLLEE
needs] to help return to work or stay at work after [your/ (his/her)] injury or illness?
CODE ONE ONLY
Extremely helpful ...................................................................................................... 1
Somewhat helpful ..................................................................................................... 2
Not very helpful ........................................................................................................ 3
Not at all helpful ........................................................................................................ 4
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
50
RETAIN Enrollee Questionnaire R2: Section E. Health and well-being
SECTION E. HEALTH AND WELL-BEING
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s] [you/ENROLLEE] [your/ (his/her)]
E1.
The next set of questions ask about [your/ENROLLEE’s] health and well-being. There are
no right or wrong answers, as everyone’s experience is different.
In general, how would [you/ENROLLEE] rate [your/ (his/her)] health? [POD, F1]
Excellent ............................................................................................................... 1
Very good ............................................................................................................. 2
Good ..................................................................................................................... 3
Fair ........................................................................................................................ 4
Poor ...................................................................................................................... 5
NO RESPONSE ................................................................................................... M
CATI VERSION:
E1.
The next set of questions ask about [your/ENROLLEE’s] health and well-being. There are
no right or wrong answers, as everyone’s experience is different.
In general, how would [you/ENROLLEE] rate [your/ (his/her)] health?
CODE ONE ONLYCODE
ONE ONLY
Excellent .............................................................................................................. 1
Very good ............................................................................................................. 2
Good ..................................................................................................................... 3
Fair ........................................................................................................................ 4
Poor ...................................................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
51
RETAIN Enrollee Questionnaire R2: Section E. Health and well-being
ALL CONSENTING (A1=1 OR 2)
[Do you/ Does ENROLLEE] [are you/is (he/she)] [your/ (his/her)] [your/ (his/her)] [State name for
Medicaid] [you/(he/she)] [your/(his/her)] [you are/ (he/she) is]
E2.
[Do you/Does ENROLLEE] have health insurance coverage now?
For instance, [are you/is (he/she)] covered by a plan that someone else in [your/ (his/her)]
family has, or through a health plan [your/ (his/her)] employer provides, or Medicare,
Medicaid [or State name for Medicaid], or a plan [you/ (he/she)] bought on [your/ (his/her)]
own? [BOND 36-mo, G1]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF E2=0;
So, [you are/ (he/she) is] uninsured, is that correct? This means no Medicaid coverage or any
other government sponsored health insurance coverage. [BOND 36-mo, G2]
CATI VERSION:
E2.
[Do you/Does ENROLLEE] have health insurance coverage now?
PROBE: For instance, [are you/is (he/she] covered by a plan that someone else in [your/
(his/her)] family has, or through a health plan [your/ (his/her)] employer provides, or
Medicare, Medicaid [or State name for Medicaid], or a plan [you/ (he/she)] bought on [your/
(his/her)] own?
YES ............................................................................................................................. 1
NO .............................................................................................................................. 0
DON’T KNOW ............................................................................................................. d
REFUSED ............................................................................................................. …...r
SOFT CHECK: IF E2=0;
So, [you are/ (he/she) is] uninsured, is that correct? This means no Medicaid coverage or any
other government sponsored health insurance coverage.
52
RETAIN Enrollee Questionnaire R2: Section E. Health and well-being
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s]
E3.
Now thinking about [your/ENROLLEE’s] physical health, which includes physical illness
and injury, for how many days during the past 30 days was [your/ENROLLEE’s] physical
health not good? [BRFSS 2018, PHYSHLTH]
|
|
| DAYS IN PAST 30 WHERE PHYSICAL HEALTH NOT GOOD
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF E3=M; Please select a number between 0 and 30.
CATI VERSION:
E3.
Now thinking about [your/ENROLLEE’s] physical health, which includes physical illness
and injury, for how many days during the past 30 days was [your/ENROLLEE’s] physical
health not good?
|
|
| DAYS IN PAST 30 WHERE PHYSICAL HEALTH NOT GOOD
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF E3>30; PLEASE ENTER A NUMBER BETWEEN 0 AND 30.
53
RETAIN Enrollee Questionnaire R2: Section E. Health and well-being
ALL CONSENTING SELF REPORTING ENROLLEES (A=1 OR CURRENT MODE = SELFREPORTING)
E4.
Using a scale of 0-10 with 0 being no pain and 10 being the worst imaginable pain, how
would you rate your pain on average in the past 7 days? [NHIS Supplement on Cancer
Screenings & Survivorship]
| | | PAIN ON AVERAGE IN PAST 7 DAYS
(0-10)
(RANGE 0-10)
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF E4>10; Please enter a number between 0 and 10.
CATI VERSION:
E4.
Using a scale of 0-10 with 0 being no pain and 10 being the worst imaginable pain, how
would you rate your pain on average in the past 7 days?
| | | PAIN ON AVERAGE IN PAST 7 DAYS
(0-10)
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
SOFT CHECK: IF E4>10; PLEASE ENTER A NUMBER BETWEEN 0 AND 10.
54
RETAIN Enrollee Questionnaire R2: Section E. Health and well-being
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s]
E5.
During the past 2 months, how much did pain interfere with [your/ENROLLEE’s] normal
work, including both work outside the home and housework? [POD, F8]
All of the time ........................................................................................................ 1
Most of the time .................................................................................................... 2
A little of the time .................................................................................................. 3
None of the time ................................................................................................... 4
NO RESPONSE ................................................................................................... M
CATI VERSION:
E5.
During the past 2 months, how much did pain interfere with [your/ENROLLEE’s] normal
work, including both work outside the home and housework?
CODE ONE ONLYCODE
ONE ONLY
All of the time ...................................................................................................... 1
Most of the time................................................................................................... 2
A little of the time ................................................................................................ 3
None of the time .................................................................................................. 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
55
RETAIN Enrollee Questionnaire R2: Section E. Health and well-being
ALL CONSENTING (A1=1 OR 2)
[you/ENROLLEE]
E6.
Opioid pain relievers are drugs used to treat moderate-to-severe pain. They are often
prescribed following surgery or injury, or for health conditions.
In the past 2 months, has a doctor or other health professional given [you/ENROLLEE] a
prescription for opioid pain relievers? [SAMHSA - Alcohol, Tobacco, and Other Drugs
Survey, REV; CDC - Opioid Overdose Survey, rev]
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
NO RESPONSE ................................................................................................... M
CATI VERSION:
E6.
Opioid pain relievers are drugs used to treat moderate-to-severe pain. They are often
prescribed following surgery or injury, or for health conditions.
In the past 2 months, has a doctor or other health professional given [you/ENROLLEE] a
prescription for opioid pain relievers?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
56
RETAIN Enrollee Questionnaire R2: Section E. Health and well-being
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s] [your/(his/her)]
E7.
Now thinking about [your/ENROLLEE’s] mental health, which includes stress, depression,
and problems with emotions, for how many days during the past 30 days was [your/
(his/her)] mental health not good? [BRFSS 2018, MENTHLTH]
| | | DAYS IN PAST 30 WHERE MENTAL HEALTH NOT GOOD
(RANGE 0-30)
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF E7=M OR >30; Please record a number between 0 and 30.
CATI VERSION:
E7.
Now thinking about [your/ENROLLEE’s] mental health, which includes stress, depression,
and problems with emotions, for how many days during the past 30 days was [your/
(his/her)] mental health not good?
| | | DAYS IN PAST 30 WHERE MENTAL HEALTH NOT GOOD
(RANGE 0-30)
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
SOFT CHECK: IF E7>30: INTERVIEWER – RECORD A NUMBER BETWEEN 0-30.
57
RETAIN Enrollee Questionnaire R2: Section F. General information about you
SECTION F. GENERAL INFORMATION ABOUT YOU
ALL CONSENTING (A1=1 OR 2)
[your/ENROLLEE’s] [Your/ (His/Her)]
F_INTRO.
The last set of questions ask for some general information about [you/ENROLLEE]. This
helps researchers better understand the experiences of different groups of people.
CONTINUE ........................................................................................................... 1
NO RESPONSE ................................................................................................... M
CATI VERSION:
F_INTRO.
The last set of questions ask for some general information about [you/ENROLLEE]. This
helps researchers better understand the experiences of different groups of people.
CONTINUE ........................................................................................................... 1
58
RETAIN Enrollee Questionnaire R2: Section F. General information about you
ALL CONSENTING (A1=1 OR 2)
[Are you/Is ENROLLEE]
F1.
[Are you/Is ENROLLEE]… [PROMISE, P2_A_Q2, REV]
Married .................................................................................................................. 1
In a marriage-like relationship .............................................................................. 2
Divorced................................................................................................................ 3
Separated ............................................................................................................. 4
Widowed ............................................................................................................... 5
Single, never married ........................................................................................... 6
NO RESPONSE ................................................................................................... M
CATI VERSION:
F1.
[Are you/Is ENROLLEE]…
INTERVIEWER:
PROBE, FOR CURRENT MARITAL STATUS. IF ONCE DIVORCED, BUT
NOW REMARRIED, THE STATUS WOULD BE “MARRIED.”
CODE ONE ONLYCODE
ONE ONLY
Married, .......................................................................................................... 1
In a marriage-like relationship,.................................................................... 2
Divorced, ....................................................................................................... 3
Separated, ..................................................................................................... 4
Widowed, or .................................................................................................. 5
Single, never married? ................................................................................. 6
DON’T KNOW................................................................................................. d
REFUSED....................................................................................................... r
59
RETAIN Enrollee Questionnaire R2: Section F. General information about you
ALL CONSENTING (A1=1 OR 2)
[yourself/ENROLLEE] [you/(him/her)] [yourself/ENROLLEE] [you/ (him/her)] [yourself/ENROLLEE]
[yourself/ENROLLEE] [you live / ENROLLEE lives]
F2.
Including [yourself/ENROLLEE], how many people currently live with [you/ (him/her)]?
Please include babies, small children, people who are not related to [you/ (him/her)], and
people who are temporarily away. [WIA, E8, REV]
NUMBER OF PEOPLE IN HOUSEHOLD, INCLUDING ENROLLEE
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF F2>1;
Please confirm that you have included [yourself/ENROLLEE] in the count.
SOFT CHECK: IF F2=0;
Please include [yourself/ENROLLEE] in the count. If [you live / ENROLLEE lives] alone, please
record a “1” for this item.
CATI VERSION:
F2.
Including [yourself/ENROLLEE], how many people currently live with [you/ (him/her)]?
Please include babies, small children, people who are not related to [you/ (him/her)], and
people who are temporarily away.
INTERVIEWER: IF NUMBER PROVIDED IS >1, CONFIRM THE R HAS INCLUDED
HIM/HERSELF IN THE COUNT.
|
|
| NUMBER OF PEOPLE IN HOUSEHOLD, INCLUDING ENROLLEE
DON’T KNOW ............................................................................................................. d
REFUSED ............................................................................................................. r
SOFT CHECK: IF F2=0;
Please include [yourself/ENROLLEE] in the count. If [you live/ ENROLLEE lives] alone, please
record a “1” for this item.
60
RETAIN Enrollee Questionnaire R2: Section F. General information about you
N PEOPLE IN ENROLLEE HOUSEHOLD >1 ( F2>1)
[you/ENROLLEE]
F3.
How many of these people are children under 18 who are financially dependent on
[you/ENROLLEE]?
If there are no children under 18 living with you, record “0”. [WIA E9, rev]
NUMBER OF CHILDREN LIVING IN HOUSEHOLD
NO RESPONSE ................................................................................................... M
SOFT CHECK: IF F3=NO RESPONSE;
If there are no children under 18 living with you, please record “0”.
CATI VERSION:
F3.
How many of these people are children under 18 who are financially dependent on
[you/ENROLLEE]?
INTERVIEWER:
|
|
IF THERE ARE NO APPLICABLE CHILDREN UNDER 18, RECORD “0”.
| NUMBER OF CHILDREN LIVING IN HOUSEHOLD
DON’T KNOW ............................................................................................................. d
REFUSED ................................................................................................................... r
61
RETAIN Enrollee Questionnaire R2: Section F. General information about you
ALL CONSENTING (A1=1 OR 2)
[you/ENROLLEE] [your/ENROLLEE’s] [ENROLLEE MAILING ADDRESS] [ENROLLEE CITY],
[ENROLLEE STATE] [ENROLLEE ZIPCODE]
F4.
Thanks for answering these questions.
We will send [you/ENROLLEE] a check for $25 for taking part in this survey. Our records
show [your/ENROLLEE’s] mailing address is:
[ENROLLEE MAILING ADDRESS]
[ENROLLEE CITY], [ENROLLEE STATE] [ENROLLEE ZIPCODE]
Is this correct? If not, please select “not correct” to update this information.
This is correct ...................................................................................................... 1
GO TO F6
Not correct – need to update ................................................................................ 0
GO TO F5
NO RESPONSE .......................................................................................................... M GO TO F6
PROGRAMMER: IF VALUES FOR FILLS ARE MISSING, THEN POPULATE FILL WITH “NOT ON
FILE”. THIS WOULD NOT NECESSARILY APPLY TO ADDRESS2 AS THAT’S ACCEPTABLE TO HAVE
DATA FOR.
CATI VERSION:
F4.
Thanks for answering these questions. We will send [you/ENROLLEE] a check for $25 for
taking part in this survey. Our records show [your/ENROLLEE’s] mailing address is:
[ENROLLEE MAILING ADDRESS]
[ENROLLEE CITY], [ENROLLEE STATE] [ENROLLEE ZIPCODE]
Is this correct?
THIS IS CORRECT ........................................................................................ 1 GO TO F6
NOT CORRECT – NEED TO UPDATE ......................................................... 0 GO TO F5
DON’T KNOW................................................................................................. d GO TO F6
REFUSED....................................................................................................... r
GO TO F6
62
RETAIN Enrollee Questionnaire R2: Section F. General information about you
MAILING ADDRESS NEEDS UPDATE (F4=0)
[your/ENROLLEE’s] [you/enrollee]
F5.
What is [your/ENROLLEE’s] mailing address?
Street address / PO Box:
(STRING 150)
City:
STRING 100)
State:
USE DROP DOWN MENU
Zip code:
(STRING 5)
NO RESPONSE ................................................................................................... M
CATI VERSION:
F5.
What is [your/ENROLLEE’s] mailing address?
___________________________________________________
STREET 1 OR P.O. BOX NUMBER
___________________________________________________
STREET 2
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
63
RETAIN Enrollee Questionnaire R2: Section F. General information about you
ALL CONSENTING (A1=1 OR 2)
[you/ ENROLLEE] [ENROLLEE TELEPHONE NUMBER]
F6.
What is the best telephone number to reach [you/ ENROLLEE] at? Our records show it as:
[ENROLLEE TELEPHONE NUMBER]
Is this correct? If not, please select “no” to update this information.
This is correct .......................................................................... 1
GO TO F8
Not correct – need to update ................................................... 0
GO TO F7
NO RESPONSE ............................................................................. M GO TO F8
SOFT CHECK: IF F6=M;
Please provide a telephone number. This helps us reach [you/ENROLLEE] if your mailed payment
is returned to us.
CATI VERSION:
F6.
What is the best telephone number to reach [you/ENROLLEE] at? Our records show it as:
[ENROLLEE TELEPHONE NUMBER]
Is this correct?
THIS IS CORRECT ........................................................................ 1 GO TO F8
NOT CORRECT – NEED TO UPDATE ........................................ 0 GO TO F7
DON’T KNOW ................................................................................ d GO TO F8
REFUSED ...................................................................................... r GO TO F8
SOFT CHECK: IF F6=D OR R;
This helps us reach [you/ENROLLEE] if your mailed payment is returned to us.
64
RETAIN Enrollee Questionnaire R2: Section F. General information about you
PHONE NEEDS UPDATE (F4=0)
[you/ENROLLEE]
F7.
What is the best telephone number to reach [you/ENROLLEE] at?
TELEPHONE
(STRING 10)
NO RESPONSE ............................................................................. M
CATI VERSION:
F7.
What is the best telephone number to reach [you/ENROLLEE] at?
|
|
|
|-|
|
|
|-|
|
|
|
|
DON’T KNOW ................................................................................ d
REFUSED ...................................................................................... r
ALL CONSENTING (A1=1 OR 2)
F8.
That is the end of the survey - thank you for completing it! Your efforts help make the
evaluation of RETAIN a success. If you have any questions, please call us at xxx-xxx-xxxx.
CATI VERSION:
F8.
That is the end of the survey - thank you for completing it! Your efforts help make the
evaluation of RETAIN a success. If you have any questions, please call xxx-xxx-xxxx.
65
OMB Control No.: XXXX-XXXX
Expiration date: XX/XX/XXXX
Retaining Employment and Talent After
Injury/Illness Network (RETAIN)
Enrollee Survey
Your input matters!
This survey should be completed by:
Please return this survey by:
[Name (MPRID)]
[DATE]
Public reporting burden for this collection of information is estimated to average 24 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays
a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to: xxxxx. Do not return the completed form to this address.
ABOUT THIS SURVEY
This survey is part of a national study for the “Retaining Employment and Talent After
Injury/Illness Network” (RETAIN) program. The study is paid for by the Social Security
Administration (SSA).
The survey asks about your employment, services received, your well-being, household
income, and some general information about you. It takes about 18 minutes to answer
these questions.
You will get $25 for completing this voluntary survey. Your answers will be kept private
and will be grouped together with everyone else who responds. Your decision to take
part will not affect any benefits that you, or your household members, receive now or in
the future.
INSTRUCTIONS
Please record your answers as clearly as possible.
Mark checkboxes with a check () or X mark.
Continue to the next question in the survey unless instructed to go elsewhere.
RETURNING THIS FORM
Thank you for completing this survey!
Please return it to:
RETAIN Survey Team
Mathematica
P.O. Box 2393
Princeton, NJ 08540
If you have any questions about the survey, contact Mathematica at XXX-XXX-XXXX.
BEGIN HERE
Q1.
How will you be completing this survey?
1
2
Q2.
□ I am completing on my own
□ Another person is answering on my behalf
Do you have an injury or illness that limits the kind or amount of work you can do
now?
1
0
□ Yes
□ No
EMPLOYMENT
The next set of questions asks about employment.
Q3.
Are you now employed at a job, organization, or business for pay or profit?
This includes work you may do for a business that you own. If you are self-employed,
select “yes” below.
MARK ONE ONLY
1
2
0
Q4.
□ Yes – employed and working now
□ Yes – employed but out on leave right now
□ No GO TO Q14 ON PAGE 7
How long have you been employed at this job, organization or business? If you
currently work more than one job, please answer about your main job.
1
2
3
□ Less than 2 months
□ 2 to 12 months
□ More than 12 months
IF EMPLOYED AND WORKING NOW, CONTINUE TO Q5 ON PAGE 2.
IF EMPLOYED AND ON LEAVE NOW, GO TO Q11 ON PAGE 4.
1
Q5.
How many hours per week do you typically work at this job?
If you currently work more than one job, please answer about your main job.
Your best guess is fine.
|
Q6.
|
| HOURS PER WEEK
How much do you typically earn, before taxes or other deductions, on this job?
Please include tips and bonuses.
Your best estimate is fine.
$|
Q7.
|
|
|,|
|
|
|.|
|
| EARNINGS
Is that hourly, daily, weekly, bi-weekly, twice a month, monthly, or annually?
1
2
3
4
5
6
7
□ Hourly
□ Daily
□ Weekly
□ Bi-Weekly
□ Twice a month
□ Monthly
□ Annually
□ Other (specify): _________________________________________________
99
Q8.
Here are benefits some employers offer their employees. Does your employer offer
you any of these benefits?
Please answer ‘yes’ if the benefit was offered to you, even if you do not use or
receive it.
MARK ONE PER ROW
Yes,
employer
offers to
me
No, not
offered to
me
Do not
know if
offered
N/A –
SelfEmployed
a. Health care insurance (such as medical
and/or hospital)?
1
□
0
□
D
□
2
□
b. Any paid leave (such as sick time or
vacation)?
1
□
0
□
D
□
2
□
2
Q9.
In the past 2 months, have you received any advice about modifying your job or
workplace?
This advice could come from an employer, as well as from staff at other
organizations. Please do not include advice from friends or family.
1
0
□ Yes
□ No
Q10. Here are some temporary changes in your work duties or environment.
After your injury or illness, did your employer offer you the chance to return to work
with any of the following temporary changes in your work duties or work
environment?
MARK ONE PER ROW
Yes
a. A reduction in work hours or a shorter work-week
b. A telecommuting arrangement such as working from
home
c. Additional breaks from work
1
1
1
d. A change in your job duties
1
e. Changes to your work space or equipment or work
location or work environment
f. Some other temporary change
1
1
(specify): _____________________________________
IF EMPLOYED AND WORKING NOW GO TO Q18 ON PAGE 6.
3
□
□
□
□
□
□
No
0
0
0
0
0
0
□
□
□
□
□
□
Not
needed
2
2
2
2
2
2
□
□
□
□
□
□
N/A –
Selfemployed
3
3
□
□
3
□
□
□
3
□
3
3
IF EMPLOYED AND ON LEAVE NOW, CONTINUE TO Q11.
Q11.
Below is a list of reasons why some people are out on medical leave. For each, select
“yes” if it is a reason you are out on leave or “no” if it is not.
MARK ONE
PER ROW
Yes
□
□
□
a. You are worried your illness/injury will get worse if you return to work.
1
b. Your injury or illness is too severe.
1
c. Your doctor does not think you are ready to work.
1
d. Your employer will not provide needed support, accommodation, or
flexibility.
1
e. You do not have a way to get to and from work.
1
□
□
f. You cannot get help needed with daily living activities, such as dressing
or bathing.
1
1
No
0
0
0
□
□
□
0
□
□
□
0
□
□
0
□
0
g. Other reason on medical leave – not listed above.
(specify): ________________________
Q12. Do you plan to return to work in the future?
1
0
□ Yes
□ No
GO TO Q18 ON PAGE 6
Q13. Do you plan to return to work in the next 90 days?
1
0
□ Yes
□ No
IF EMPLOYED AND ON LEAVE NOW, GO TO Q18 ON PAGE 6.
4
IF NOT EMPLOYED NOW, CONTINUE TO Q14.
Q14.
Below is a list of reasons why some people are not working now. For each, select
“yes” if it is a reason you are not working now or “no” if it is not.
MARK ONE PER ROW
Yes
a. Worried if I go back to work my illness/injury will get worse.
b. Doctor does not want me to work.
1
c. Employer will not provide needed supports, accommodation,
or flexibility.
d. Injury or illness is too severe.
1
f. No work available or was laid off.
1
g. Was fired or terminated from job.
1
h. Cannot get help needed with daily living activities, such as
dressing or bathing.
Q15.
1
1
e. In school or training program.
i.
1
Other reason – not listed above
(specify): _________________________________________
1
1
□
□
□
□
□
□
□
□
□
No
0
0
0
0
0
0
0
0
0
□
□
□
□
□
□
□
□
□
Looking for work includes looking for a full-time or part-time job, for which you will
be paid.
Have you been looking for work during the last two months?
1
0
□ Yes
□ No
Q16. Do you plan to return to work in the future?
1
0
□ Yes
□ No
GO TO Q18
Q17. Do you plan to return to work in the next 90 days?
1
0
□ Yes
□ No
The next questions ask about other activities you may have done to earn money.
5
Q18. In the past month, have you been paid for any of the following occasional work
activities or side jobs, such as: babysitting, house cleaning or yard work, or
providing other personal services, such as running errands, etc.?
Do not include activities that you only do as part of your main job.
1
0
□ Yes
□ No
Q19. In the past month, have you been paid for any of the following online occasional
work activities or side jobs, such as: completing paid online tasks, renting out
property online, selling goods on-line, or driving using a ride-sharing app?
Do not include activities that you only do as part of your main job.
1
0
□ Yes
□ No
Q20. In the past month, have you been paid for any other occasional work activities or
side jobs such as: selling goods at flea markets, garage sales, or thrift stores?
Do not include activities that you only do as part of your main job.
1
0
□ Yes
□ No
IF YOU EARN INCOME THROUGH OCCASIONAL WORK ACTIVITIES, GO TO Q21.
IF YOU DO NOT EARN INCOME THROUGH OCCASIONAL WORK ACTIVITIES, GO TO Q22.
Q21.
About how much of last month’s income did you get from occasional paid activities
or side jobs?
1
2
3
4
□ Less than 25%
□ 26 to 50%
□ 51 to 75%
□ More than 75%
6
HOUSEHOLD INCOME
The next section asks about benefits your household may receive, as well as household
income. This information helps researchers better understand how family finances impact
people’s lives. Your answers are important to the success of this study and will be grouped
together with everyone else who takes part.
Q22.
Do you or does anyone in your household receive assistance from SNAP, the
Supplemental Nutrition Assistance Program? This program was formerly known as
“food stamps.”
1
0
Q23.
□ Yes
□ No
GO TO Q24
How much did your household get from the SNAP program last month?
Your best guess is fine.
$|
Q24.
|
|
|.|
|
| HOUSEHOLD $ FROM SNAP LAST MONTH
Do you or does anyone in your household receive any government housing
assistance in paying rent, such as through public housing or Section 8?
1
0
Q25.
|
□ Yes
□ No
GO TO Q26
How much did your household receive from housing assistance in paying rent (such
as through public housing or Section 8) last month?
Your best guess is fine.
$|
|,|
|
|
|.|
|
| HOUSEHOLD $ FROM HOUSING ASSISTANCE LAST MONTH
Q26. Does anyone in your household receive any income from Supplemental Security
Income (SSI) or Social Security Disability Insurance (SSDI) because of a disability?
1
0
Q27.
□ Yes
□ No
GO TO Q28
How much did your household receive from SSI or SSDI last month?
Your best guess is fine.
$|
|
|
|
|.|
|
| HOUSEHOLD $ FROM SSI/SSDI LAST MONTH
7
Q28. Does anyone in your household receive any unemployment compensation or
unemployment benefits?
1
0
Q29.
□ Yes
□ No
GO TO Q30
How much did your household receive last month in unemployment compensation?
Your best guess is fine.
$|
|
|
|
|.|
|
| HOUSEHOLD $ FROM UNEMPLOYMENT LAST MONTH
Q30. Does anyone in your household receive Worker's Compensation payments or other
payments as a result of a job related injury or illness?
Please include State Worker’s Compensation, employer or employer’s insurance
worker’s compensation, or own insurance worker’s compensation.
Exclude sick pay and/or disability retirement.
1
0
Q31.
□ Yes
□ No
GO TO Q32
How much did your household receive last month from worker’s compensation
payments or other payments as a result of a job related injury or illness?
Your best guess is fine.
$ | | | | |.| | | HOUSEHOLD $ FROM WORKER’S COMPENSATION OR OTHER
PAYMENTS FOR DISABILITY LAST MONTH
Q32. Do you or does anyone in your household receive retirement income from social
security, a retirement plan, pension, 401k, or any other source of retirement
income?
1
0
Q33.
□ Yes
□ No
GO TO Q34
How much did your household receive in retirement income from all sources last
month?
Your best guess is fine.
$|
|
|
|
|.|
|
| HOUSEHOLD $ FROM RETIREMENT INCOME LAST MONTH
8
Q34. Do you or does anyone in your household receive income from short- or long-term
disability payments?
1
0
Q35.
□ Yes
□ No
GO TO Q36
How much did your household receive in short- or long-term disability payments last
month?
Your best guess is fine.
$|
|
|
|
|.|
|
| HOUSEHOLD $ FROM SHORT OR LT DISABILITY LAST MONTH
Q36. What were the total earnings of all persons in your household last month?
Please include wages, salary, commissions, bonuses and tips from all jobs that all
household members worked before taxes. Do not include retirement earnings, public
benefits or other sources of income your household may have received.
Your best guess is fine.
$|
|
|
|
|.|
|
| TOTAL HOUSEHOLD EARNINGS LAST MONTH
Q37. Does anyone in your household receive money from any source you have not already
recorded - such as other kinds of public assistance (such as TANF or [STATE NAME
TANF]), money from child support or alimony, interest, dividends, or money from
friends and family?
Please do not include wages, salary, commissions, bonuses and tips from all jobs
that all household members worked.
1
0
Q38.
□ Yes
□ No
GO TO Q39
How much money did your household receive from these other sources last month?
Please do not include wages, salary, commissions, bonuses and tips from all jobs
that all household members worked.
Your best guess is fine.
$|
|
|
|
|
|.|
|
| EARNINGS
9
TRAINING
AND
SERVICES
The next set of questions ask
about training
and other
services. RECEIVED
The next set of questions ask about training and other services.
Q39. Employment-related services can include help searching for work, referrals to job or
employers, help with a resume, information on how to change careers, and
information on education or job training programs.
In the past 2 months, have you received any employment-related support services?
Do not include supports provided by friends or family.
1
0
Q40.
Are you currently enrolled in school or taking any classes?
1
0
Q41.
□ Yes
□ No
In the past 2 months, have you participated in any training program that lasted at
least one week and that was designed to help you find a job, improve your job skills,
or learn a new job?
1
0
Q42.
□ Yes
□ No
□ Yes
□ No
A care or other service coordinator helps people with support services after injury or
illness. They might coordinate medical services, work with employers/supervisors to
develop alternative job duties or help people find temporary employment.
In the last 2 months, have you worked with a care or other service coordinator?
1
0
Q43.
□ Yes
□ No
GO TO Q44
How useful were the services the care or other service coordinator provided?
1
2
3
4
□ Very useful
□ Somewhat useful
□ Not very useful
□ Not at all useful
10
Q44. In the past two months, have you talked with your doctor or other health care
providers about how your injury or illness affects your ability to work?
MARK ONE ONLY
1
0
2
□ Yes
□ No
□ Does not apply—I have not seen a health care
GO TO Q46
provider in past two months
Q45. Please think about the care you have received from your doctor or other healthcare
providers in the past two months.
How helpful have these providers been in providing all the services you need to help
return to work or stay at work after your injury or illness?
MARK ONE ONLY
1
2
3
4
□ Extremely helpful
□ Somewhat helpful
□ Not very helpful
□ Not at all helpful
HEALTH AND WELL-BEING
The next set of questions ask about your health and well-being. There are no right or wrong
answers, as everyone’s experience is different.
Q46. In general, how would you rate your health?
1
2
3
4
5
□ Excellent
□ Very good
□ Good
□ Fair
□ Poor
Q47. Do you have health insurance coverage now?
For instance, are you covered by a plan that someone else in your family has, or
through a health plan your employer provides, or Medicare, Medicaid, or a plan you
bought on your own?
1
0
□ Yes
□ No
11
Q48. Now thinking about your physical health, which includes physical illness and injury,
for how many days during the past 30 days was your physical health not good?
|
Q49.
| DAYS IN PAST 30 WHERE PHYSICAL HEALTH NOT GOOD
Using a scale of 0-10 with 0 being no pain and 10 being the worst imaginable pain,
how would you rate your pain on average in the past 7 days?
|
Q50.
|
|
| PAIN ON AVERAGE IN PAST 7 DAYS
During the past 2 months, how much did pain interfere with your normal work,
including both work outside the home and housework?
MARK ONE ONLY
1
2
3
4
Q51.
□ All of the time
□ Most of the time
□ A little of the time
□ None of the time
Opioid pain relievers are drugs used to treat moderate-to-severe pain. They are often
prescribed following surgery or injury, or for health conditions.
In the past 2 months, has a doctor or other health professional given you a
prescription for opioid pain relievers?
1
0
Q52.
□ Yes
□ No
Now thinking about your mental health, which includes stress, depression, and
problems with emotions, for how many days during the past 30 days was your mental
health not good?
|
|
| DAYS IN PAST 30 WHERE MENTAL HEALTH NOT GOOD
12
GENERAL INFORMATION ABOUT YOU
The last set of questions ask for some general information about you. This helps
researchers better understand the experiences of different groups of people.
Q53. Are you…
MARK ONE ONLY
1
2
3
4
5
6
□ Married
□ In a marriage-like relationship
□ Divorced
□ Separated
□ Widowed
□ Single, never married
Q54. Including yourself how many people currently live with you?
Please include babies, small children, people who are not related to you, and people
who are temporarily away.
|
|
| NUMBER OF PEOPLE IN HOUSEHOLD INCLUDING YOURSELF
Q55. How many of these people are children under 18 who are financially dependent on you?
If there are no children under 18 living with you, record “0”.
|
|
| NUMBER OF CHILDREN LIVING IN HOUSEHOLD
Q56. What is your mailing address? This helps us keep in touch with you and ensures we
mail your $25 check to the correct address.
________________________________________________________________________
STREET OR P.O. BOX NUMBER
________________________________________________________________________
CITY
STATE
ZIP CODE
Q57. What is the best telephone number to reach you at? This helps us reach you if your
mailed payment is returned to us.
|
|
|
|-|
AREA CODE
|
|
|-|
|
|
|
|
PHONE NUMBER
Thanks for completing this survey! Please return it in the envelope provided. Your efforts
help make the evaluation of RETAIN a success. If you have any questions, please call
xxx-xxx-xxxx.
13
| File Type | application/pdf |
| File Modified | 2020-12-14 |
| File Created | 2020-02-28 |