VRFD 12-Month Follow-up Survey

SECTION A: RESPONDENT SCREENER AND INTRODUCTION
ALL
A1.
SampMemb

We are conducting a study for the Social Security Administration to find out more about
the experiences of people who have spinal cord injuries or brain injuries.
The purpose of this interview is to learn more about the experiences that people like you
may have, including job experience, job training, school, and other things.
The survey takes about 20 minutes to complete. At the end of the interview, we will mail
you a gift card for $25 to thank you for your time. You should receive it within 2 weeks.
CODE ONE ONLY
BEGIN INTERVIEW ................................................................................................1

A2

DID NOT RECEIVE OR DOES NOT RECALL LETTER .......................................2

NoLetter

NOT A GOOD TIME ................................................................................................3

Callback

HUNG UP DURING INTRODUCTION ...................................................................4

HUDI

SUPERVISOR REVIEW ..........................................................................................5

SUP REV

WILL CALL MPR BACK ..........................................................................................6

RCB

REFUSED ................................................................................................................r

REF

A1=1
A2.

Your participation in this study is completely voluntary. It will in no way affect your current
or future receipt of benefits. You can stop the interview at any time. If any question makes
you feel uncomfortable, you can refuse to answer that question.
If you get tired or need a break at any time, please tell me and we can take a break, or I will
call back later to finish the interview.
Let’s start the interview now.
CODE ONE ONLY
CONTINUE ..............................................................................................................1
CALLBACK ..............................................................................................................2

Callback

SUPERVISOR REVIEW ..........................................................................................3

sup rev

REFUSED ................................................................................................................r

ref

DRAFT Kessler Foundation/Mathematica

1

Date

SECTION B: EDUCATION AND TRAINING
The first few questions are about your education and training experiences.
ALL
B1.

Are you currently enrolled in school or taking any classes?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

B1=1
B2.

Are you a full-time or part-time student?
CODE ONE ONLY
FULL-TIME ..............................................................................................................1
PART-TIME..............................................................................................................2
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

ALL
B3.

Now I would like to ask you about any [other] training you may have had in the past 12
months. In the past 12 months, have you participated in any of the following training
program that was designed to help you find a job, improve your job skills, or learn a new
job?
CODE ALL THAT APPLY
Vocational rehabilitation services .......................................................................1
Job search assistance, job finding, orientation to the world of work............2
Vocational education apart from college ...........................................................3
Non-vocational adult education not directed toward a degree .......................4
Work Incentives Planning and Assistance (WIPA) services ...........................5
OTHER (SPECIFY) .................................................................................................99
_____________________________________________________ (STRING 100)
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

DRAFT Kessler Foundation/Mathematica

2

Date

ALL
B4.

Do your personal goals include completing a certificate, earning a degree, or an industrycertified credential?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

DRAFT Kessler Foundation/Mathematica

3

Date

SECTION C: SATISFACTION WITH EMPLOYMENT SERVICES
ALL
C1.

In the past 12 months, have you worked with anyone to determine your needs and help
connect you to services and supports related to education, employment, health, housing,
or anything else? This person could be a case manager, employment specialist, or a
resource facilitator, for example.
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

C1=1
C2.

In the past 12 months, how many times did you meet with this person or people?
1-2 times .................................................................................................................1
3-6 times .................................................................................................................2
7 or more times ......................................................................................................3
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

ALL
C3.

In the past 12 months, did you receive any of the following employment services?
CODE ONE PER ROW
YES

NO

DON’T
KNOW

REF

a. Help developing a return to work or education plan.

1

0

d

r

b. Help identifying potential barriers to work or school ..

1

0

d

r

c.

1

0

d

r

d. Coaching on disclosing your disability to an employer or co-workers

1

0

d

r

e. Information on disability rights, laws, or legislation ...

1

0

d

r

f.

Referral to non-employment community-based service

1

0

d

r

g. Advocacy and support for inclusion or access to resources

1

0

d

r

h. Help completing medical documentation or paperwork

1

0

d

r

Help identifying accommodations to overcome barriers to work or school

DRAFT Kessler Foundation/Mathematica

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Date

ALL
C4.

In the past 12 months, have you had help with learning about or getting into a school or
training program, including help with an application, entrance exam, or interview?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

ALL
C5.

In the past 12 months, have you had any training to help you learn new job skills? Please
do not include any training you had on the job directly from an employer.
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

ALL
C6.

In the past 12 months, have you had help in finding or applying for a job, such as help
finding jobs available, filling out an application, writing a resume, or going for an
interview?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

ALL
C7.

In the past 12 months, have you received any help while working at a job, such as help
with job accommodations or learning job duties? This could include help from a job
coach. Please do not include any help given by an employer.
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

DRAFT Kessler Foundation/Mathematica

5

Date

ALL
C8.

In the past 12 months, have you received any help with learning about, getting, or using
assistive technology?
This could include help with special tools or equipment, software, or devices that help you
perform school or work activities that are difficult to do because of your disability.
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

ALL
C9.

In the past 12 months, have you had help with transportation to or from any workplace
activity?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

ALL
C10.

In the past 12 months, have you had help in understanding or applying for state or federal
disability benefits, such as Social Security, SSI, SSDI, NJ Temporary Disability, Division of
Developmental Disabilities (DDD), Personal Preference Program (PPP), Personal
Assistance Service Program (PASP), or NJ WorkAbility? This is sometimes called benefits
counseling or benefits planning?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

ALL
C11.

In the past 12 months, have you received any other services to help you work, go to
school, or help your family in other ways?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

DRAFT Kessler Foundation/Mathematica

6

Date

C11=1
C11a. What kind of other services did you receive?
RECORD VERBATIM
_____________________________________________________ (STRING 100)
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r
ALL
C12.

In the past 12 months, have you needed any [other] help or services preparing for work or
school that you did not receive?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

C12=1
C12a. What help or other services did you need that you did not get?
DISCOVERING JOB INTERESTS/SKILLS ............................................................1
CAREER COUNSELING.........................................................................................2
HELP FINDING A JOB ............................................................................................3
SUPPORT ON THE JOB (JOB COACHING) ........................................................4
HELP GETTING INTO SCHOOL/TRAINING .........................................................5
UNDERSTANDING SSA/OTHER BENEFITS ........................................................6
COMPUTER LITERACY CLASSES .......................................................................7
FINANCIAL LITERACY/MONEY MANAGEMENT TRAINING ..............................8
REFERRAL TO ANOTHER AGENCY ....................................................................9
TRANSPORTATION SERVICES ............................................................................10
CASE MANAGEMENT ............................................................................................11
HELP WITH MEDICAL ISSUES OR SECONDARY COMPLICATIONS...............12
OTHER (SPECIFY) ................................................................................................13
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

DRAFT Kessler Foundation/Mathematica

7

Date

ALL
C13.

How satisfied are you with the services you received to help you prepare for a job or
school?
Very satisfied, ........................................................................................................1
Somewhat satisfied, ..............................................................................................2
Not very satisfied, or .............................................................................................3
Not at all satisfied?................................................................................................4
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

ALL
C14.

In the past 12 months, how successful do you think you have been in reaching your
goals?
Very successful, ....................................................................................................1
Somewhat successful, ..........................................................................................2
Not very successful, or .........................................................................................3
Not at all successful? ...........................................................................................4
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

DRAFT Kessler Foundation/Mathematica

8

Date

SECTION D: CURRENT EMPLOYMENT STATUS
ALL
The next questions are about your work activities.
D1.

In the past 12 months, have you worked at a job, organization, or business for pay or
profit? This includes work you may do for a business that you own.
IF NEEDED READ:

By ‘working at a job for pay or profit’ we mean at a job where you
get paid money for the work you do.

[INTERVIEWER: IF R IS SELF-EMPLOYED, CODE RESPONSE AS YES]
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r
ALL
D2.

In the past 12 months, have you done any volunteer work for an organization?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

D1=0
D3.

In the past 12 months, have you been looking for work?
IF NEEDED READ:

By looking for work, I mean looking for a job, either full-time or parttime, for which you will be paid.

YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

IF D1=0, D, R (NOT EMPLOYED), SKIP TO SECTION E

DRAFT Kessler Foundation/Mathematica

9

Date

D1=1
D4.
NBS
Modified

Now please think about all the jobs you have had in the past 12 months. When answering
these questions, please include both part-time and full-time jobs, but only include jobs
you worked at for pay or profit. This could be work you do for a business that you own.
How many jobs for pay or profit have you had in the past 12 months?
PROBE:

Please include any job that you worked at in the past 12 months for a week or
more. Count a job that you started, stopped and started again as separate jobs.

| | | NUMBER OF JOBS
(1-99)
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r
D1=1
D4a.

Are you currently working at a job for pay or profit?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

D1=1
D5.

Did you return to work at your former employer or job prior to your injury?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

D1=1
D6.

Is the kind of business or industry of your current/last job different than the one where you
worked prior to your injury?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

D1=1
D7.

Are your tasks or the kind of work you do/did different from the kind of work you did prior
to your injury?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

DRAFT Kessler Foundation/Mathematica

10

Date

D1=1
D8.

[Are/Were] you self-employed at this job?
PROBE:

NBS

Self-employed means that you [work/worked] for yourself or [own/owned] your
own business.

YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r
D1=1
D9.

Is/Was this job a temporary or seasonal job?
PROBE:

A Temporary job is one in which a person is hired to meet the short-term
and/or project needs of an employer. Temporary help has come to be used
across a broad range of skills and occupations to substitute for employees on
leave, on vacation, or in emergencies, or to provide supplemental support
where there are temporary skills shortages or specific projects or peak load
needs.

PROBE:

A seasonal job is one in which a person is hired to support existing staff
during a busy season—such as holiday help or summer work.

YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

D1=1
D10.

How many hours per week [do/did] you typically work at this job?
| | |
(0-99)

HOURS PER WEEK

DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r
D1=1
D11.

How much [do/did] you typically earn, before taxes or other deductions, on this job?
Please include tips and bonuses.
PROBE:
$|

|

Your best estimate is fine.

| |,| | |
($0-999,999.99)

|.|

|

|

DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

DRAFT Kessler Foundation/Mathematica

11

Date

D1=1
D12.

Is/Was that hourly, daily, weekly, bi-weekly, twice a month, monthly, or annually?
CODE ONE ONLY
HOURLY ..................................................................................................................1
DAILY .......................................................................................................................2
WEEKLY ..................................................................................................................3
BI-WEEKLY .............................................................................................................4
TWICE A MONTH....................................................................................................5
MONTHLY ...............................................................................................................6
ANNUALLY ..............................................................................................................7
PER UNIT OR PIECE..............................................................................................8
OTHER (SPECIFY) .................................................................................................9
_____________________________________________________ (STRING 100)
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

D1=1
D13.
NBS
Modified

Please indicate if your [main/current/last] employer [offers/offered] you any of the
following benefits.
IF NECESSARY, READ: Please answer ‘yes’ if you are eligible for the benefit even if you
haven’t started to receive it yet.
CODE ONE PER ROW
YES

NO

DON’T
KNOW

REFUSED

a. Health care insurance? (IF NECESSARY: medical and/or hospital)

1

0

d

r

b. Dental benefits?

1

0

d

r

c.

1

0

d

r

d. Paid vacation?

1

0

d

r

e. Free or low-cost childcare?

1

0

d

r

1

0

d

r

g. Long-term disability benefits?

1

0

d

r

h. Pension or retirement benefits?

1

0

d

r

i.

Short-term disability benefits?

1

0

d

r

j.

Flexible health or dependent care spending accounts?

1

0

d

r

f.

Sick days with pay?

Transportation, a transportation allowance, or transportation
discounts?

DRAFT Kessler Foundation/Mathematica

12

Date

D1=1
D14.

Has your [main/current/last] employer made any accommodations because of your
physical or mental condition. For example, provided you with any special equipment or
assistive technology or kept your job available to you, even though you have to go out on
disability from time to time.
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

D1=1
D15.

Taking all things into account, how satisfied (are/were) you with your [main/current/last]
job?
CODE ONE ONLY
Very satisfied, ........................................................................................................1
Somewhat satisfied, ..............................................................................................2
Not very satisfied, or .............................................................................................3
Not at all satisfied?................................................................................................4
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

D1=1
D16.

The next questions are about any expenses you may have had for services or other
support related to your condition that you need in order to work.
In the past month, did you have any of the following expenses related to your condition that
help you to work?
[PROBE:] Please think about any expenses you paid out of pocket.
CODE ONE PER ROW
YES

NO

DK

R

a.

Transportation costs, such as vehicle modifications or paratransit

1

0

d

r

b.

Attendant care costs, such as services performed to help prepare for work

1

0

d

r

c.

Medical exam or prescription drug costs

1

0

d

r

d.

Physical device costs, such as wheelchairs, dialysis equipment, or pacemakers

1

0

d

r

e.

Residential modification costs, such as exterior ramps, railings, pathways, or
enlarging a doorway

1

0

d

r

f.

Other costs

1

0

d

r

DRAFT Kessler Foundation/Mathematica

13

Date

IF D16A, D16B, D16C, D16D, D16E, OR D16F = 1
REPEAT FOR EACH YES AT D16
D17.

In the past month, how much did you spend on expenses for [FILL SERVICE FROM D16]?
$|

|,|

| | |.|
(0-9,999.99)

|

| AMOUNT

DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r
GO TO D17 FOR NEXT EXPENSE OR E1 IF NO OTHER EXPENSES

IF CANNOT PROVIDE AN AMOUNT AT D17, ASK FOR EACH
D18.

Was it …
Less than $100? .....................................................................................................1
Between $100 and $199? ......................................................................................2
Between $200 and $299? ......................................................................................3
$300 or more? .........................................................................................................4
Don’t know..............................................................................................................d
REFUSED ................................................................................................................r

ALL
IF D1=0, FILL “GETTING A JOB,” ELSE DO NOT FILL
D19.

Do your personal goals include [getting a job,] moving up in a job or learning new job skills?
YES .........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

ALL
D20.

How likely do you think it is that you will be working at a paid job in about a year?
Very likely ...............................................................................................................1
Somewhat likely .....................................................................................................2
Not very likely ........................................................................................................3
Not at all likely ........................................................................................................4
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

DRAFT Kessler Foundation/Mathematica

14

Date

ALL
D21.

The following are some reasons why it might be difficult to work following a Spinal Cord
Injury (SCI) or Brain Injury (BI). To what extent do you experience the following barriers to
work.
CODE ONE PER ROW
A LOT

A LITTLE

NOT AT
ALL

a.

I am limited in my ability to work because my injury is too severe.

1

2

3

b.

I am worried that my injury will get worse if I work.

1

2

3

c.

I am limited in my ability to work because I do not have reliable
transportation to and from work.

1

2

3

d.

I am limited in my ability to work because I do not have help for daily
living activities, such as dressing or bathing.

1

2

3

e.

I am limited in my ability to work because I am caring for children or
others.

1

2

3

f.

I am limited in my ability to work because I am finishing a school or
training program.

1

2

3

g.

I don’t have the skills or training I need to return to work.

1

2

3

h.

Employers will not provide supports, accommodations, or the
flexibility I need because of my injury.

1

2

3

i.

Work is not available.

1

2

3

j.

Other reason not listed (SPECIFY) ___________________

1

2

3

DRAFT Kessler Foundation/Mathematica

15

Date

SECTION E: INCOME
I’m going to ask you about the income you personally received last month, that is, in [INSERT LAST
MONTH, THIS YEAR]. This includes income and benefits from different programs. When answering
these questions, please think only about your own earnings and benefits, and don’t include
earnings or benefits that other family members may have received.
ALL
E1.

Last month did you receive any income from…
INTERVIEWER:

READ EACH SOURCE. IF RESPONDENT VOLUNTEERS ‘I ONLY GET
SSDI OR SOCIAL SECURITY,’ CONFIRM A “NO” RESPONSE FOR A-I,
THEN ENTER “1” FOR E1M.
CODE ONE PER ROW
YES

NO

DON’T
KNOW

REFUSED

a. Veterans’ benefits?

1

0

d

r

b. Public assistance or welfare payments?

1

0

d

r

c.

Workers’ compensation?

1

0

d

r

d. Private disability insurance?

1

0

d

r

e. Unemployment benefits?

1

0

d

r

f.

1

0

d

r

g. Disability insurance for a disabled adult child?

1

0

d

r

h. SNAP benefits or food stamps?

1

0

d

r

i.

Government energy assistance?

1

0

d

r

j.

Government childcare assistance?

1

0

d

r

k.

Other sources on a regular basis but not from jobs or
Social Security?

1

0

d

r

l.

Other sources not on a regular basis? (SPECIFY)
________________ (STRING 100)

1

0

d

r

m. IF VOLUNTEERED BY RESPONDENT: SSDI ONLY

1

0

d

r

Private pensions or government employee pensions?

INTERVIEWER: IF NOT VOLUNTEERED, ENTER “0”.
IF OTHER SPECIFY (99): What other sources of income were received?

DRAFT Kessler Foundation/Mathematica

16

Date

E1A, E1B, E1C, E1D, E1E, E1F, E1G, E1H, OR E1I=1. IF E1J=1, SKIP.
FILL WITH INCOME SOURCE FROM E1 (FOR E1I, FILL VERBATIM RESPONSE)
E2[1] SHOULD CORRELATE TO E1A; E2[2] SHOULD CORRELATE TO E1B , ETC.
E2.

How much income did you receive last month from [SOURCE FROM E1]?
INTERVIEWER:
$|

ROUND TO NEAREST DOLLAR

|,| | | |.|
(0-9,999.99)

|

| AMOUNT

SKIP TO E4

DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r
GO TO E2 FOR NEXT INCOME SOURCE OR E4 IF NO OTHER SOURCES OF INCOME

IF CANNOT PROVIDE AN AMOUNT AT E2, ASK FOR EACH
E3.

Was it…
Less than $150, ......................................................................................................1
$150 to less than $300, .........................................................................................2
$300 to less than $500, or .....................................................................................3
$500 or more? ........................................................................................................4
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

ALL
E4.
HOPE VI,
MTO

Do you currently receive any governmental housing assistance in paying rent, such as
through public housing or Section 8 or a Housing Choice Voucher?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

DRAFT Kessler Foundation/Mathematica

17

Date

ALL
Now I’d like you to think about the income of all members in your household.
E5.
Effects of
Housing
Choice
Vouchers on
Welfare
Families

What was the total combined income of all members of this household during [LAST
CALENDAR YEAR]? Please include money from jobs, work on the side, welfare, SSI, help
from your family and friends, and any other money income received by you or any other
household member.
Your best estimate is fine.
$|

|

|

|,| | |
($0-999,999)

| AMOUNT

DON’T KNOW ..........................................................................................................d
E5=D, R
E6.

Would you say the total combined income of all members of your household during
[CALENDAR YEAR] was…
CODE ONE ONLY
Less than $10,000, .................................................................................................1
$10,000 to less than $20,000, ...............................................................................2
$20,000 to less than $30,000, ...............................................................................3
$30,000 to less than $40,000, ...............................................................................4
$40,000 to less than $50,000, or ..........................................................................5
$50,000 or more? ...................................................................................................6
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

ALL
E7.

In about a year, how likely do you think it is that you will earn enough to support yourself
without financial help from your family or government benefit programs?
CODE ONE ONLY
Very likely ...............................................................................................................1
Somewhat likely .....................................................................................................2
Not very likely ........................................................................................................3
Not at all likely ........................................................................................................4
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

DRAFT Kessler Foundation/Mathematica

18

Date

SECTION F: HEALTH
The next few questions ask about your health.
ALL
F1.

In general, how would you rate your health?

CODE ONE ONLY

Excellent, ................................................................................................................1
Very good, ..............................................................................................................2
Good, .......................................................................................................................3
Fair, or .....................................................................................................................4
Poor? .......................................................................................................................5
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r
ALL
F2.

Since your initial discharge from a Kessler Institute for Rehabilitation inpatient facility,
have you stayed overnight in a hospital?
CODE ONE ONLY
YES .........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

ALL
F3.

What kinds of health coverage do you have?
PROBE:

Any other kind?

PROBE:

Medicare is health insurance coverage provided nationally to certain disabled
people under age 65, including Social Security Disability Insurance
beneficiaries that have been receiving benefits for more than 24 months.

PROBE:

Medicaid is state medical assistance program that serves low-income people
and Social Security Income recipients with disabilities.
CODE ALL THAT APPLY

PRIVATE INSURANCE ...........................................................................................1
MEDICAID ...............................................................................................................2
MEDICARE ..............................................................................................................3
OTHER PLAN (SPECIFY).......................................................................................99
_____________________________________________________ (STRING 100)
NO INSURANCE ______________________________________

4

DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

DRAFT Kessler Foundation/Mathematica

19

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SECTION H: DEMOGRAPHICS AND CONTACT INFORMATION
We are almost done. The next questions are about you and your background.
ALL
H1.

What is your marital status?
Single/never married, ............................................................................................1
Married, ...................................................................................................................2
Separated, ...............................................................................................................3
Divorced ..................................................................................................................4
Widowed .................................................................................................................5
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

ALL
H2.

How many adults (age 18 or older) currently live in your household?
|

|

|

ADULTS

DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r
ALL
H3.

What is your gender?
CODE ALL THAT APPLY
Man ..........................................................................................................................1
Woman ....................................................................................................................2
Non-binary ..............................................................................................................3
Transgender ...........................................................................................................4
Not listed (SPECIFY) .............................................................................................99
_____________________________________________________ (STRING 100)
DON’T KNOW ..........................................................................................................d
Prefer not to answer ..............................................................................................r

ALL
H4.

Are you Hispanic or Latino?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

DRAFT Kessler Foundation/Mathematica

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ALL
H5.

What is your race?
CODE ALL THAT APPLY
American Indian or Alaskan Native .....................................................................1
Asian .......................................................................................................................2
Black or African American ...................................................................................3
Native Hawaiian or other Pacific Islander ..........................................................4
White .......................................................................................................................5
Not listed (SPECIFY) .............................................................................................99
_____________________________________________________ (STRING 100)
DON’T KNOW ..........................................................................................................d
Prefer not to answer ..............................................................................................r

Please confirm the following information about you. This information will ensure that your gift card
is sent to the correct address.
ALL
H6.

Is this the correct spelling of your name? [READ FIRST MIDDLE LAST SUFFIX]. Is that
correct?
YES, ALL CORRECT ..............................................................................................1
NO, NAME NOT CORRECT ...................................................................................0
REFUSED ................................................................................................................r

H6=0
H7.

What is the correct spelling of your name?
_____________________________________________________ (STRING 50)
FIRST NAME
_____________________________________________________ (STRING 50)
MIDDLE INITIAL/NAME
_____________________________________________________ (STRING 50)
LAST NAME
_____________________________________________________ (STRING 25)
SUFFIX
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

DRAFT Kessler Foundation/Mathematica

21

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ALL
H8.

Our records show that your current address is (FILL FROM PRELOADS). Is this correct?
YES, ADDRESS IS CORRECT ..............................................................................1
NO, ADDRESS NOT CORRECT ............................................................................0
REFUSED ................................................................................................................r

H8=0
H9.

What is [your/his/her] current address?
_____________________________________________________
STREET 1
_____________________________________________________
STREET 2
_____________________________________________________
STREET 3
_____________________________________________________
CITY
_____________________________________________________
STATE
_____________________________________________________
ZIP
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

ALL
H10.

We have your telephone number as: [AREA CODE/PHONE NUMBER]. Is still the best
telephone number to use to reach you?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

H10=0
H10a. What is your telephone number, starting with area code?
|

| | |-| | | |-| | | | |
201-989)
(200-999)
(0000-9999)

NO HOME NUMBER ...............................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

DRAFT Kessler Foundation/Mathematica

22

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IF HAVE EMAIL ADDRESS ON FILE
H11.

We have your email address as [EMAIL ADDRESS]. Is this still the best email address to
reach you at?
YES ..........................................................................................................................1
NO ............................................................................................................................0
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r

IF DO NOT HAVE EMAIL ADDRESS ON FILE OR H7=0 OR D
H11a. What is your email address?
_____________________________________________________ (STRING 100)
DON’T KNOW ..........................................................................................................d
REFUSED ................................................................................................................r
ALL
END.

Thank you very much for your time today. You can expect to receive your $25 gift card
within 2 weeks.

DRAFT Kessler Foundation/Mathematica

23

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