Attachment A_Disability_Questionnaire

Attachment A CPS Disability Supplement Questions
Question number	Question wording	Response options	Who will receive the question
Intro	This month we would like to learn more about how people in different circumstances deal with work-related challenges.
1	(Do you/Does NAME) have a health condition or difficulty that limits the KIND or AMOUNT of paid work (you/he/she) could do?	1. Yes 2. No 3. Don't Know 4. Refused	Employed and Unemployed
1a	Although (you are/NAME is) not currently working, (do you/does he/she) have a health condition or difficulty that limits the KIND or AMOUNT of paid work (you/he/she) could do?	1. Yes 2. No 3. Don't Know 4. Refused	Persons who are not in the Labor Force
2	Which of the following MOST limits the kind or amount of paid work (you/NAME) could do? (select all that apply) Read if necessary: Category 2: Mobility impairments may cause serious difficulty walking or climbing stairs and may require the use of a wheelchair or other support. Examples include missing limbs, paralysis, osteoarthritis, spina bifida, or scoliosis. Category 3: Examples include depression, anxiety, or post-traumatic stress disorder. Category 4: Examples include down syndrome, a speech impairment, cerebral palsy, ADD (attention deficit disorder), dyslexia, dementia, or Alzheimer's disease. Category 5: Examples include heart problems, asthma, diabetes, or autoimmune diseases.	1. A visual or hearing impairment 2. A mobility impairment 3. A mental health condition 4. A cognitive, intellectual, or learning disability 5. Other health condition or difficulty 6. Don’t know 7. Refused	1. Q1 = 1 OR Q1a = 1
2_New	Of the categories you just selected, which one MOST limits the kind or amount of paid work you/NAME could do? (Select one; read items selected in Q2 only)	1. A visual or hearing impairment 2. A mobility impairment 3. A mental health condition 4. A cognitive, intellectual, or learning disability 5. Other health condition or difficulty 6. <do not read> Cannot decide/all equal 7. Don't Know 8. Refused	Those who selected multiple categories in Q2.
2a	You indicated that (you have/NAME has) difficulty in [fill: hearing/seeing/concentrating, remembering, or making decisions/walking or climbing stairs/dressing or bathing/doing errands alone]. Which of the following causes (you/NAME) the MOST difficulty? (select all that apply, if only one is selected, skip 2a New) Read if necessary: Category 2: Mobility impairments may cause serious difficulty walking or climbing stairs and may require use of a wheelchair or other support. Examples include missing limbs, paralysis, osteoarthritis, spina bifida, or scoliosis. Category 3: Examples include depression, anxiety, or post-traumatic stress disorder. Category 4: Examples include down syndrome, a speech impairment, cerebral palsy, ADD (attention deficit disorder), dyslexia, dementia, or Alzheimer's disease. Category 5: Examples include heart problems, asthma, diabetes, or autoimmune diseases. Fills are singular if person has one disability. Fills are plural if person has multiple disabilities. (As identified by the 6 disability questions.)	1. A visual or hearing impairment 2. A mobility impairment 3. A mental health condition 4. A cognitive, intellectual, or learning disability 5. Other health condition or difficulty 6. Don't Know 7. Refused	Q1/1a=2 and Yes to any of the six disability questions
2a_new	Of the categories you just selected, which one causes you the most difficulty? (Select one; read items selected in Q2a only.)	1. A visual or hearing impairment 2. A mobility impairment 3. A mental health condition 4. A cognitive, intellectual, or learning disability 5. Other health condition or difficulty 6. <do not read> Cannot decide/all equal 7. Don't Know 8. Refused	Those who selected multiple categories in Q2a.
2b	(Is/Are any of) the health condition(s) or difficulty(ies) related to autism, or autism spectrum disorder? Fills are singular if only one condition was selected in Q2/2a. Fills are plural if more than one condition was selected in Q2/2a.	1. Yes 2. No 3. Don't Know 4. Refused	Q2/2a in (3,4,5,6,7)
2c	(Is/Are any of) the health condition(s) or difficulty(ies) related to long-term COVID-19 symptoms lasting 3 months or longer? Read if necessary: Long-term symptoms may include: Tiredness or fatigue, difficulty thinking, concentrating, forgetfulness, or memory problems (sometimes referred to as “brain fog”), difficulty breathing or shortness of breath, joint or muscle pain, fast-beating or pounding heart (also known as heart palpitations), chest pain, dizziness on standing, menstrual changes, changes to taste/smell, or inability to exercise. Read if necessary: Only include symptoms that you did not have prior to having COVID-19, or that are not explained by something else. Fills are singular if only one condition was selected in Q2/2a. Fills are plural if more than one condition was selected in Q2/2a.	1. Yes 2. No 3. Don't Know 4. Refused	Q2/2a in (1,2,3,4,5,6,7)
3a	Is this health condition or difficulty a temporary one that is expected to last for LESS than three months?	1. Yes 2. No 3. Don't Know 4. Refused	Respondents who selected one condition in Q2/2a
3b	Are any of these health conditions or difficulties expected to last for MORE than three months?	1. Yes 2. No 3. Don't Know 4. Refused	Respondents who selected more than condition in Q2/2a
4a	(Have you/Has NAME) ever requested any change in (your/his/her) [fill: current job/main job] to help do (your/his/her) job better? For example, changes in work tasks, equipment, or schedule. Read if necessary: Answer about your MAIN job, that is, the one at which you usually work the most hours	1. Yes 2. No 3. Don't Know 4. Refused	Wage and salary workers, unpaid workers in a family business, and those whose class of worker status is unknown (those with and without a disability), but excluding the self-employed MLR in (1,2) AND IO1COW in (1,2,3,4,5,8,9,10)
5a	What change(s) did (you/NAME) request? (Interviewers read each response category aloud.) Read if necessary: Facilities may include: Entrance doors, corridors, toilet rooms, drinking fountains, visible and audible alarms, signage, wheelchair seating, service counters, and ramps or elevators where changes in level are necessary. [Instruction to interviewer: respondents can select multiple responses]	1. Changes in schedule 2. Changes in work tasks 3. Training to learn new job skills 4. Working from home (also known as telework) 5. Increased access to workplace or building facilities 6. Getting new or modified equipment 7. Arranging special transportation 8. Other changes 9. Don’t know 10. Refused	Q4a=1
6a	[Instruction to Interviewer: For each of the changes requested, ask:] Was the request for [fill response from 5a] granted fully, partially, or not at all?	1. Yes, fully 2. Yes, partially 3. Not at all 4. Don’t know 5. Refused	Q5a in (1,2,3,4,5,6,7,8)
4b	(Have you/Has NAME) ever made any change in (your/his/her) [fill: current job/main job] to help do (your/his/her) job better? For example, changes in work tasks, equipment, or schedule. Read if necessary: Answer about your MAIN job, that is, the one at which you usually work the most hours	1. Yes 2. No 3. Don't Know 4. Refused	Self-employed (those with and without a disability) MLR in (1,2) AND IO1COW in (6,7,11)
5b	What change(s) did (you/NAME) make? Read if necessary: Facilities may include: Entrance doors, corridors, toilet rooms, drinking fountains, visible and audible alarms, signage, wheelchair seating, service counters, and ramps or elevators where changes in level are necessary. [Instruction to interviewer: respondents can select multiple responses]	1. Changes in schedule 2. Changes in work tasks 3. Training to learn new job skills 4. Working from home (also known as telework) 5. Increased access to workplace or building facilities 6. Getting new or modified equipment 7. Arranging special transportation 8. Other changes 9. Don’t know 10. Refused	Q4b=1
7a	(Are you/Is NAME) facing challenges that COULD make it difficult for (you/him/her) to FIND a job? Read if necessary: Even if (you do NOT/NAME does NOT) currently want a job, (are you/is NAME) facing challenges that could make it difficult to find a job?	1. Yes 2. No 3. Don't Know 4. Refused	Persons who are not employed (those with and without a disability) MLR in (3,4,5,6,7)
8a	Is the challenge related to [Instruction to interviewer: Read response options; respondents can select multiple challenges] Read if necessary: In-home personal CARE services refer to things like help getting out of bed, bathing, or getting dressed. Public assistance refers to government programs that provide benefits to individuals and families such as Supplemental Nutrition Assistance Program, Supplemental Security Income, Medicaid, public housing, Workers Compensation, Social Security Disability Insurance, Veterans Disability compensation, or other disability benefits.	1. Own health condition or difficulty 2. Limited education or training 3. Gap in work history 4. Inaccessible websites 5. Lack of transportation 6. Lack of child care 7. Lack of in-home personal care services 8. Potential loss of public assistance 9. Employer or co-worker attitudes 10. Discrimination 11. Other 12. Don’t know 13. Refused	Q7a=1
7b	(Are you/Is NAME) facing challenges that make it difficult for (you/him/her) to DO (your/his/her) [fill: current job/main job? Interviewer instruction: Record NO if the respondent was granted accommodations and no longer faces challenges doing their job. Read if necessary: Answer about your MAIN job, that is, the one at which you usually work the most hours.	1. Yes 2. No 3. Don't Know 4. Refused	Employed MLR in (1,2)
8b	Is the challenge related to [Instruction to interviewer: respondents can select multiple challenges] Read if necessary: In-home personal CARE services refer to things like help getting out of bed, bathing, or getting dressed. Public assistance refers to government programs that provide benefits to individuals and families such as Supplemental Nutrition Assistance Program, Supplemental Security Income, Medicaid, public housing, Workers Compensation, Social Security Disability Insurance, Veterans Disability compensation, or other disability benefits.	1. Own health condition or difficulty 2. Limited education or training 3. Inaccessible websites 4. Lack of transportation 5. Lack of child care 6. Lack of in-home personal care services 7. Potential loss of public assistance 8. Employer or co-worker attitudes 9. Discrimination 10. Other 11. Don’t know 12. Refused	Q7b=1

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