TSSB Survey 2024-05-01

A world-wide survey of beneficiaries eligible for health care coverage through the military health system

TRICARE Select Survey of Beneficiaries

SURVEY INSTRUCTIONS

RCS: DD-HA(A) 1942

SURVEY STARTS HERE

As an eligible TRICARE beneficiary, please complete this survey even if you did not receive your health care from a military facility.

Please recognize that some specific questions about TRICARE benefits may not apply to you, depending on your entitlement and particular TRICARE program.

This survey is about the health care of the person whose name appears on the cover letter. The survey should be completed by that person. If you are not the addressee, please give this survey to that person.

1. Are you the person whose name appears on the cover letter?

• Yes 4 Go to Question 2 on the next page

• No 4 Please give this questionnaire to the person addressed on the cover letter.

745-01 01 DKT

Providing information in this survey is voluntary. There is no penalty nor will your benefits be affected if you choose not to respond, although maximum participation is encouraged so that the data will be complete and representative.

The survey was written so that answers should not require you to provide any personally identifiable information (PII), but please be assured that any PII provided will be treated as confidential. Your responses are collected via a secure system which does not collect any information that could be used to determine your identity.

Answering the questions is voluntary; you may stop the survey at any time.

Answer all the questions by filling in the circle to the left of your answer. You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:

• Yes 4 Go to Question 12

• No

Please return the completed questionnaire in the enclosed postage-paid envelope within seven days. If the envelope is missing, please send to:

Office of the Assistant Secretary of Defense (Health Affairs)

DHA, Analytics and Evaluation Division

c/o DataStat, Inc.

3975 Research Park Dr.

Ann Arbor, MI 48108

PRIVACY ADVISORY

OMB CONTROL NUMBER: XXXX-XXXX

OMB EXPIRATION DATE: XX/XX/XXXX

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, [Insert OMB Control Number], is estimated to average 15 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. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

March 2024

2. By which of the following health plans are you

currently covered?

MARK ALL THAT APPLY.
Military Health Plans

• TRICARE Prime (including most Active Duty, TRICARE Prime Remote and TRICARE Overseas)

• TRICARE Select (previously known as TRICARE Extra or Standard (CHAMPUS))

• TRICARE Plus

• TRICARE for Life

• TRICARE Supplemental Insurance

• TRICARE Reserve Select

• TRICARE Retired Reserve

• TRICARE Young Adult Prime

• TRICARE Young Adult Select

• Continued Health Care Benefit Program (CHCBP) (a COBRA-like premium-based health care program)

Other Health Plans

• Medicare

• Federal Employees Health Benefit Program (FEHBP)

• Medicaid or other state health insurance

• A civilian HMO (such as Kaiser)

• Other civilian health insurance (such as Blue Cross)

• The Veterans Administration (VA)

• Government health insurance from a country other than the US

• Not sure

3. Which health plan did you use for all or most of your health care in the last 12 months?

MARK ONLY ONE.
Military Health Plans

• TRICARE Prime (including most Active Duty, TRICARE Prime Remote and TRICARE Overseas)

• TRICARE Select (previously known as TRICARE Extra or Standard (CHAMPUS))

• TRICARE Plus

• TRICARE Reserve Select

• TRICARE Retired Reserve

• TRICARE Young Adult

• Continued Health Care Benefit Program (CHCBP) (a COBRA-like premium-based health care program)

Other Health Plans

• Medicare

• Federal Employees Health Benefit Program (FEHBP)

• Medicaid or other state health insurance

• A civilian HMO (such as Kaiser)

• Other civilian health insurance (such as Blue Cross)

• Uniformed Services Family Health Plan (USFHP)

• The Veterans Administration (VA)

• Government health insurance from a country other than the US

• Not sure 4 Go to Question 5

• Did not use any health plan in the last 12 months 4 Go to Question 5

For the remainder of this questionnaire, the term health plan refers to the plan you indicated in Question 3.

4. How many months or years in a row have you been in this health plan?

• Less than 6 months

• 6 up to 12 months

• 12 up to 24 months

• 2 up to 5 years

• 5 up to 10 years

• 10 or more years

5. Are you covered by the same health plan beginning January 1, 2024 as the one you selected in Question 3?

• Yes

• No

• Don't know

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6. Many beneficiaries who are eligible for TRICARE

also have the opportunity to obtain other civilian health insurance through their job or a family member's job, through COBRA, or through retirement coverage from a previous job, or from some other group. COBRA lets beneficiaries pay to keep their coverage temporarily when they leave their job.

Do you have the opportunity to obtain civilian health insurance coverage for yourself through some civilian group?

• Yes

• No 4 Go to Question 10

7. What options do you have for obtaining civilian coverage?

MARK ALL THAT APPLY.

• Through my current employer

• Through COBRA from my previous employer

• Through retirement coverage from my previous employer

• Through a family member's current employer

• Through COBRA from a family member's previous employer

• Through retirement coverage from a family member's previous employer

• Through another organization

• Through a government program

• Insurance sold by insurance health exchanges (healthcare.gov)

• Don't Know

8. Are you now covered by a civilian health insurance policy?

• Yes

• No 4 Go to Question 10

9. Are you alone covered or are you and others in

your household covered by the civilian health insurance policy?

• I alone am covered

• I and at least one other person in my household are covered

10. Have you used TRICARE for any health care (not including for prescription drugs) in the past 12 months?

• Yes 4 Go to Question 12

• No

11. Why haven't you used TRICARE?
MARK ALL THAT APPLY.

• I have a greater choice of doctors with my civilian plan

• My personal doctor is not available to me through TRICARE

• My TRICARE regular doctor is no longer available to me

• My TRICARE specialist is no longer available to me

• My preferred doctors do not accept TRICARE

• I prefer civilian hospitals

• There are no military facilities near me

• I have to travel too far to see my TRICARE doctor

• I get better customer service with civilian plans

• TRICARE benefits are poor compared to my civilian plan

• It is easier for me to get care through my civilian plan

• I do not want to pay the premium for TRICARE

• I pay less for civilian care than I would for TRICARE

• I have not needed health care

• Another reason

TRICARE SELECT ENROLLMENT

12. Are you a retired member of a uniformed service or the spouse or child of a retired member who was covered by TRICARE Select in 2023?

• Yes

• No 4 Go to Question 17

13. Have you, your spouse, or parent arranged to pay a monthly enrollment fee for TRICARE Select?

• Yes 4 Go to Question 15

• No

• Don't Know 4 Go to Question 15

14. What is the main reason you don't pay a monthly enrollment fee for TRICARE Select?

MARK ONLY ONE.

• I was not aware that fees must be paid for Tricare Select

• Did not know how to set up payments

• I thought TRICARE was responsible for setting up payments

• I expected the requirement to be waived or delayed

• I dropped my TRICARE Select coverage

• My enrollment fee is paid on an annual or
  quarterly basis 4 Go to Question 16

• Don't Know

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15. Do you plan to re-enroll or apply for reinstatement in TRICARE Select?

• Yes

• No

16. Where did you get information about arranging to pay TRICARE Select premiums?

MARK ALL THAT APPLY.

• The TRICARE website

• Friends or colleagues

• Military or retiree news media

• My TRICARE regional contractor

• My benefits counselor

• Civilian news media

• A service members' professional organization

• Other

YOUR PERSONAL DOCTOR

17. A personal doctor is the one you would see if you need a checkup, want advice about a health problem, or get sick or hurt. Do you have a personal doctor?

• Yes

• No 4 Go to Question 25

18. In the last 12 months, how often did your personal doctor listen carefully to you?

• Never

• Sometimes

• Usually

• Always

• I had no visits in the last 12 months.

19. In the last 12 months, how often did your personal doctor explain things in a way that was easy to understand?

• Never

• Sometimes

• Usually

• Always

• I had no visits in the last 12 months.

20. In the last 12 months, how often did your

personal doctor show respect for what you had to say?

• Never

• Sometimes

• Usually

• Always

• I had no visits in the last 12 months.

21. In the last 12 months, how often did your personal doctor spend enough time with you?

• Never

• Sometimes

• Usually

• Always

• I had no visits in the last 12 months.

22. Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you use to rate your personal doctor?

Worst Best

possible possible

0	0	0	0	0	0	0	0	0	0	0
0	1	2	3	4	5	6	7	8	9	10

• I don't have a personal doctor.

23. How long does it take you to travel to your personal doctor?

• Less than 15 minutes

• 15 to 30 minutes

• 31 minutes to 60 minutes (1 hour)

• 61 minutes to 90 minutes

• 91 minutes to 120 minutes (2 hours)

• More than 120 minutes (2 hours)

24. Did you have the same personal doctor before you joined this health plan?

• Yes 4 Go to Question 26

• No

25. Since you joined your health plan, how much of a problem, if any, was it to get a personal doctor you are happy with?

• A big problem

• A small problem

• Not a problem

26. Where is your personal doctor located? MARK ONLY ONE.

• A military facility - This includes: Military clinic, Military hospital, PRIMUS clinic, NAVCARE clinic 4 Go to Question 28

• A civilian facility - This includes: Doctor's office, Clinic, Hospital, Civilian TRICARE contractor

• Uniformed Services Family Health Plan facility (USFHP)

• Veterans Affairs (VA) clinic or hospital

• I do not have a personal doctor

27. In the last 12 months, did you try to find a

personal doctor who was located at a military treatment facility?

• Yes

• No 4 Go to Question 30

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28. How much of a problem, if any, was it to find an available personal doctor at a military treatment facility?

• A big problem

• A small problem

• Not a problem 4 Go to Question 30

29. What is the biggest problem you encountered trying to find a personal doctor at a military treatment facility?

MARK ONLY ONE.

• The military facilities near me have downsized or closed

• The wait for an appointment at the military treatment facilities near me is too long

• The waiting rooms at the military facilities near me are crowded or uncomfortable

• The staff at the military treatment facilities near me are not helpful or courteous

• I have had problems communicating with doctor(s) at the military treatment facilities

• Another reason

30. Is your personal doctor a civilian?

• Yes

• No 4 Go to Question 35

• I do not have a personal doctor or
  nurse 4 Go to Question 35

31. The TRICARE civilian provider network is made up of the doctors, clinics, hospitals and other health care providers who are part of DoD's preferred provider pool.

Is your personal doctor part of the TRICARE civilian provider network?

• Yes

• No

• Don't Know

32. What is the specialty of your personal doctor? MARK ONLY ONE.

• Family Medicine or General Practitioner

• Internist

• Pediatrician

• OB-GYN

• Geriatrician or Geriatric Nurse

• Preventive Medicine

• Nurse Practitioner or Physician's Assistant

• Other Specialty

33. In the last 12 months, how much of a problem was it to find a personal doctor who would accept TRICARE?

• A big problem

• A small problem

• Not a problem 4 Go to Question 35

34. What problems did you encounter in finding a personal doctor who would accept TRICARE?

MARK ALL THAT APPLY.

• Travel distance too long

• Problems communicating with doctor

• Doctor(s) not taking any new patients

• Doctor(s) not taking new TRICARE patients

• Doctor(s) not accepting TRICARE payments

• Could not find the specialty I wanted

• Did not like doctor(s)

• Wait for an appointment was too long

• Could not find information about doctors

• Other

GETTING HEALTH CARE
FROM A SPECIALIST

When you answer the next questions, do not include dental visits or care you got when you stayed overnight in a hospital.

35. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care.

In the last 12 months, did you make any appointments to see a specialist?

• Yes

• No 4 Go to Question 37

36. In the last 12 months, how often did you get an appointment to see a specialist as soon as you needed?

• Never

• Sometimes

• Usually

• Always

• I didn't need a specialist in the last 12 months.

37. How many specialists have you seen in the last 12 months?

• None 4 Go to Question 46

• 1 specialist

• 2

• 3

• 4

• 5 or more specialists

38. We want to know your rating of the specialist you saw most often in the last 12 months. Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate the specialist?

Worst Best

possible possible

0	0	0	0	0	0	0	0	0	0	0
0	1	2	3	4	5	6	7	8	9	10

• I didn't see a specialist in the last 12 months.

39. How long does it take you to travel to the specialist you saw most in the past 12 months?

• Less than 15 minutes

• 15 to 30 minutes

• 31 minutes to 60 minutes (1 hour)

• 61 minutes to 90 minutes

• 91 minutes to 120 minutes (2 hours)

• More than 120 minutes (2 hours)

40. In the last 12 months, did you see a civilian specialist?

• Yes

• No 4 Go to Question 46

41. In the last 12 months, was the civilian specialist you saw most the same doctor as your personal doctor?

• Yes

• No

42. In the last 12 months, was the civilian specialist you saw most part of the TRICARE civilian provider network?

• Yes

• No

• Don't know

43. In the last 12 months, what was the specialty of the civilian specialist you saw most?

MARK ONLY ONE.

• Surgeon

• Cardiologist (heart doctor)

• Allergist

• Dermatologist (skin doctor)

• Rheumatologist (specialist of the joints)

• Endocrinologist (thyroid, hormone and diabetes specialist)

• Urologist (specialist of the urinary tract and male reproductive system)

• Oncologist (cancer specialist)

• Orthopedist (specialist of the bones, muscles and their connected tissues)

• Ear, nose and throat specialist

• Obstetrician/Gynecologist

• Ophthalmologist

• Other

please do not include personally identifying information

44. In the last 12 months, how much of a problem

was it to find a doctor with this specialty who would accept TRICARE?

• A big problem

• A small problem

• Not a problem 4 Go to Question 46

45. What problems did you encounter in finding a specialist who would accept TRICARE?

MARK ALL THAT APPLY.

• Travel distance too long

• Problems communicating with doctor

• Doctor(s) not taking any new patients

• Doctor(s) not taking new TRICARE patients

• Doctor(s) not accepting TRICARE payments

• Could not find the specialty I wanted

• Did not like doctor(s)

• Wait for an appointment was too long

• Could not find information about doctors

• Other

CALLING DOCTORS' OFFICES

46. In the last 12 months, did you call a doctor's office or clinic during regular office hours to get help or advice for yourself?

• Yes

• No 4 Go to Question 48

47. In the last 12 months, when you called during regular office hours, how often did you get the help or advice you needed?

• Never

• Sometimes

• Usually

• Always

• 

  

  

  I didn't call for help or advice during regular office hours in the last 12 months

YOUR HEALTH CARE IN
THE LAST 12 MONTHS

These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits.

48. In the last 12 months, did you have an illness, injury, or condition that needed care right away in

a clinic, emergency room, or doctor's office?

• Yes

• No 4 Go to Question 51

49. In the last 12 months, when you needed care right away, how often did you get care as soon as you needed?

• Never

• Sometimes

• Usually

• Always

• I didn't need care right away for an illness,
  injury or condition in the last 12 months.

50. In the last 12 months, when you needed care right away for an illness, injury, or condition, how long did you usually have to wait between trying to get care and actually seeing a provider?

• Same day

• 1 day

• 2 days

• 3 days

• 4-7 days

• 8-14 days

• 15 days or longer

• I didn't need care right away for an illness,
  injury or condition in the last 12 months.

51. In the last 12 months, did you make any appointments for a check-up or routine care at a doctor's office or clinic?

• Yes

• No 4 Go to Question 54

52. In the last 12 months, how often did you get an appointment for a check-up or routine care at a doctor's office or clinic as soon as you needed?

• Never

• Sometimes

• Usually

• Always

• I had no appointments in the last 12 months.

53. In the last 12 months, not counting the times you needed health care right away, how many days did you usually have to wait between making an appointment and actually seeing a provider?

• Same day

• 1 day

• 2-3 days

• 4-7 days

• 8-14 days

• 15-30 days

• 31 days or longer

• I had no appointments in the last 12 months.

54. In the last 12 months, how many times did you go to an emergency room to get care for yourself?

• None

• 1 time

• 2

• 3

• 4

• 5 to 9

• 10 or more times

55. In the last 12 months, not counting the times you went to an emergency room, how many times did you go to a doctor's office or clinic to get health care for yourself?

• None

• 1 time

• 2

• 3

• 4

• 5 to 9

• 10 or more times

Telehealth is phone call or video conference that links you to a provider at another location in order to assess, treat, and provide care to you remotely. When you answer the next questions, do not include dental visits.

56. In the last 12 months, did you have a telehealth appointment?

• Yes

• No 4 Go to Question 63

57. What type of telehealth appointment(s) did you have?

MARK ALL THAT APPLY.

• Phone call

• Video conference

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58. What type of provider did you meet with during your telehealth appointment(s)? Please mark all of the different providers you have met with using telehealth in the last 12 months.

MARK ALL THAT APPLY.

• Primary care doctor

• Nurse Practitioner or Physician Assistant

• Specialist (Such as heart, allergy, OB-GYN, and skin doctors)

• Mental health provider (Counselor, psychologist, psychiatrist)

• Other doctor or provider

• Don't know

Please indicate how much you agree or disagree with the following statements.

59. Thinking about your most recent telehealth appointment, the provider...

	Strongly agree	Agree	Disagree	Strongly Disagree
Listened carefully to me.	0	0	0	0
Explained things in a way that was easy to understand.	0	0	0	0
Spent enough time with me.	0	0	0	0
Met with me within 15 minutes of my appointment time.	0	0	0	0

60. Thinking about your most recent telehealth appointment...

	Strongly agree	Agree	Disagree	Strongly Disagree
I felt comfortable with the process (such as navigating the video or phone technology).	0	0	0	0
I was able to hear the provider clearly.	0	0	0	0
It allowed me to see a provider sooner.	0	0	0	0

61. Using any number from 0 to 10, where 0 is the worst care possible and 10 is the best care possible, what number would you use to rate the care you received via telehealth in the last 12 months?

Worst Best

possible possible

0	0	0		0	0	0	0	0	0	0	0
0	1	2		3	4	5	6	7	8	9	10

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62. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care in the last 12 months?

Worst Best

possible possible

0	0	0	0	0	0	0	0	0	0	0
0	1	2	3	4	5	6	7	8	9	10

• I had no visits in the last 12 months.

63. In the last 12 months, how often was it easy to

get the care, tests, or treatment you needed?

• Never

• Sometimes

• Usually

• Always

• I didn't need care, tests, or treatment in the last 12 months.

64. In the last 12 months, where did you go most often for your health care?

MARK ONLY ONE.

• A military facility - This includes: Military clinic, Military hospital, PRIMUS clinic, NAVCARE clinic

• A civilian facility - This includes: Doctor's office, Clinic, Hospital, Civilian TRICARE contractor

• Uniformed Services Family Health Plan facility (USFHP)

• Veterans Affairs (VA) clinic or hospital

• I went to none of the listed types of facilities in the last 12 months.

TREATMENT OR COUNSELING

65. In the last 12 months, did you need any treatment or counseling for a personal or family problem?

• Yes

• No 4 Go to Question 80

66. In the last 12 months, what type of provider did you want to see most for this treatment or counseling?

MARK ONLY ONE.

• Psychologist

• Psychiatrist

• Psychotherapist

• Social worker

• Mental health counselor

• Marriage or family therapist

• Your personal doctor or nurse

• Other

please do not include personally identifying information

• Don't know

67. In the last 12 months, did you receive treatment or counseling for a personal or family problem?

• Yes

• No 4 Go to Question 71

68. In the last 12 months, did you receive this treatment or counseling from a civilian provider?

• Yes

• No 4 Go to Question 70

69. In the last 12 months, did you receive this treatment or counseling from a provider in TRICARE's civilian network?

• Yes

• No

• Don't know

70. In the last 12 months, what type of provider did you see most often for this treatment or counseling?

MARK ONLY ONE.

• Psychologist

• Psychiatrist

• Psychotherapist

• Social worker

• Mental health counselor

• Marriage or family therapist

• Your personal doctor or nurse

• Other

please do not include personally identifying information

• Don't know

71. In the last 12 months, how much of a problem, if any, was it to get the treatment or counseling you needed through your health plan?

• A big problem

• A small problem

• Not a problem 4 Go to Question 73

72. In the last 12 months, what problems did you

encounter in finding treatment or counseling?

MARK ALL THAT APPLY.

• Travel distance too long

• Problems communicating with doctor

• Doctor(s) or counselor(s) not taking new patients

• Doctor(s) or counselor(s) not taking new TRICARE patients

• Doctor(s) or counselor(s) not accepting TRICARE payments

• Could not find the specialty I wanted

• Did not like doctor(s) or counselor(s)

• Wait for an appointment was too long

• Could not find information about doctors or counselors

• Other

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73. In the last 12 months, did you need treatment or counseling right away?

• Yes

• No 4 Go to Question 75

74. In the last 12 months, when you needed treatment or counseling right away, how often did you see someone as soon as you wanted?

• Never

• Sometimes

• Usually

• Always

75. In the last 12 months, did you need approval for any treatment or counseling?

• Yes

• No 4 Go to Question 77

76. In the last 12 months, how much of a problem, if any, were delays in treatment or counseling while you waited for approval?

• A big problem

• A small problem

• Not a problem

77. In the last 12 months, did you call customer service to get information or help about treatment or counseling?

• Yes

• No 4 Go to Question 79

78. In the last 12 months, how often did your health plan's customer service give you the information or help you needed?

• Never

• Sometimes

• Usually

• Always

79. Using any number from 0 to 10, where 0 is the worst treatment or counseling possible and 10 is the best treatment or counseling possible, what number would you use to rate all your treatment or counseling in the last 12 months?

Worst Best

possible possible

0	0	0	0	0	0	0	0	0	0	0
0	1	2	3	4	5	6	7	8	9	10

• I didn't receive treatment or counseling in the last 12 months.

80. Would you say that in general your mental or

emotional health is excellent, very good, good, fair, or poor?

• Excellent

• Very good

• Good

• Fair

• Poor

YOUR HEALTH PLAN

The next question asks about your experience with your health plan. By your health plan, we mean the health plan you marked in Question 3.

81. Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your health plan?

Worst Best

possible possible

0	0	0	0	0	0	0	0	0	0	0
0	1	2	3	4	5	6	7	8	9	10

Even if you do not use TRICARE Select, we'd like to know what you like and dislike about these plans compared to civilian plans.

82. What do you like about TRICARE Select (including Standard/Extra, TRICARE Reserve Select, or TRICARE Retired Reserve)?

MARK ALL THAT APPLY.

• I have a better choice of doctors with TRICARE than with a civilian plan

• My preferred personal doctor is only available to me through TRICARE

• I want to be sure I can always use military health care

• I get better customer service with TRICARE than with civilian plans

• It is easier to get care through TRICARE than a civilian plan

• The premium for TRICARE is lower than the premium for civilian coverage

• Copays or cost-shares cost less through TRICARE than a civilian plan

• Deductibles cost less through TRICARE than a civilian plan

• Civilian benefits are poor compared to TRICARE

• Other:

please do not include personally identifying information

745-10 10 DKT

83. What do you dislike about TRICARE Select? MARK ALL THAT APPLY.

• I have a better choice of doctors with a civilian plan than with TRICARE

• My preferred personal doctor is not available to me through TRICARE

• I worry about losing access to civilian coverage

• I get better customer service with civilian plans than with TRICARE

• It is easier to get care through a civilian plan than TRICARE

• The premium for TRICARE is too high

• Copays or cost-shares cost more through TRICARE than a civilian plan

• Deductibles cost more through TRICARE than a civilian plan

• TRICARE benefits are poor compared to a civilian plan

• Other:

please do not include personally identifying information

84. Using any number from 0 to 10, where 0 is not at all likely and 10 is extremely likely, how likely is it that you would recommend your healthcare plan to a friend or family member?

Not at Extremely

all likely likely

0	0	0	0	0	0	0	0	0	0	0
0	1	2	3	4	5	6	7	8	9	10

PREVENTIVE CARE

Preventive care is medical care you receive that is intended to maintain your good health or prevent a future medical problem. A physical or blood pressure screening are examples of preventive care.

85. When did you last have a blood pressure reading?

• Less than 12 months ago

• 1 to 2 years ago

• More than 2 years ago

86. Do you know if your blood pressure is too high?

• Yes, it is too high

• No, it is not too high

• Don't know

87. Have you ever smoked at least 100 cigarettes in your entire life?

• Yes

• No 4 Go to Question 90

• Don't know 4 Go to Question 90

88. Do you now smoke cigarettes or use tobacco every day, some days, or not at all?

• Every day

• Some days

• Not at all 4 Go to Question 91

• Don't know 4 Go to Question 91

89. In the last 12 months, how often were you

advised to quit smoking or using tobacco by a doctor or other health provider in your plan?

• Never

• Sometimes

• Usually

• Always

90. When did you last have a cholesterol screening, that is, a test to determine the level of cholesterol in your blood?

• Less than 12 months ago

• 1 to 2 years ago

• More than 2 but less than 5 years ago

• 5 or more years ago

• Never had a cholesterol screening

91. When did you last have a flu shot?

• Less than 12 months ago

• 1-2 years ago

• More than 2 years ago

• Never had a flu shot

92. Are you male or female?

• Male 4 Go to Question 95

• Female

93. If you are over 40 years of age, when was the last time your breasts were checked by mammography?

• Within the last 12 months

• 1 to 2 years ago

• More than 2 but less than 5 years ago

• 5 or more years ago

• Never had a mammogram

• I am under 40 years of age

745-11 11 D

ABOUT YOU

94. Would you say that in general your health is excellent, very good, good, fair or poor?

• Excellent

• Very good

• Good

• Fair

• Poor

95. Are you limited in any way in any activities because of any impairment or health problem?

• Yes

• No

96. What is the highest grade or level of school that you have completed?

• 8th grade or less

• Some high school, but did not graduate

• High school graduate or GED

• Some college or 2-year degree

• 4-year college graduate

• More than 4-year college degree

97. What is your race and/or ethnicity?

Select all that apply and enter additional details in the spaces below.

• American Indian or Alaska Native –
  Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

• Asian – Provide details below.

m Chinese m Asian Indian m Filipino

Enter, for example, Pakistani, Hmong, Afghan, etc.

m Vietnamese m Korean m Japanese

• Black or African American – Provide details below.

m African American m Jamaican m Haitian

Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc.

m Nigerian m Ethiopian m Somali

12

• Hispanic or Latino – Provide details below.

m Mexican m Puerto Rican m Salvadoran

Enter, for example, Colombian, Honduran, Spaniard, etc.

m Cuban m Dominican m Guatemalan

• Middle Eastern or North African – Provide details below.

m Lebanese m Iranian m Egyptian

Enter, for example, Moroccan, Yemeni, Kurdish, etc.

m Syrian m Iraqi m Israeli

• Native Hawaiian or Pacific Islander – Provide details below.

m Native Hawaiian m Samoan m Chamorro

Enter, for example, Chuukese, Palauan, Tahitian, etc.

m Tongan m Fijian m Marshallese

• White – Provide details below.

m English m German m Irish

Enter, for example, French, Swedish, Norwegian, etc.

m Italian m Polish m Scottish

98. What is your age now?

• 18 to 24

• 25 to 34

• 35 to 44

• 45 to 54

• 55 to 64

• 65 to 74

• 75 or older

99. Which of the following income ranges is closest
to your family's (2023) total income from all
sources? Your best estimate would be fine.

• Less than $10,000

• $10,000 to $24,999

• $25,000 to $49,999

• $50,000 to $74,999

• $75,000 to $99,999

• $100,000 to $124,999

• $125,000 to $149,999

• $150,000 and above

• Don't Know

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