CMS-10900.Applicant Screener Survey (7-9-24)

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IVaaS Applicant Screener Survey
Draft: 7/9/2024


Draft Screener Sections / Questions

Section 1. Introduction
Thank you for your interest in participating in customer experience research for federal benefits programs like Medicaid, SNAP and TANF. This survey helps the research team understand a little bit about your experiences related to these programs so we can connect with a diverse group of participants in future research. 

Your privacy is protected. What you have to say is private and will be used only for this study. Your answers will be part of a pool of information. We will not share your name or answers with anyone, except if required by law.

Your Participation is Voluntary. You do not have to answer any questions that you do not want to answer. If you choose not to answer, it will not affect the benefits you receive.

PRA Disclosure: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1382.  The expiration date is (12/31/2026). The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. This is a voluntary information collection request. The following information is being collected to help the research team connect with a diverse set of people who have experienced applying for government benefits. While we cannot pledge confidentiality based on the questions asked, we will protect your privacy to the extent allowed by law. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. 

CMS Disclosure: Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office.  Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact [email protected].




Survey Introduction
Note: * denotes required questions

Q1. What is your age?*
    • 17 or younger à Does not qualify
    • 18 - 24
    • 25-34
    • 35-44
    • 45-54
    • 55-64
    • 65 and over

Q2. Where do you live?*
City: [Open-ended short text box]
State: [Drop-down with state / territory abbreviations]

Q3. Do you have access to a computer or tablet with reliable Internet access?*
    • No  à Does not qualify
    • Yes

Q4. Which of the following government programs have you applied to in the past year?*
Please select all that apply.
[Randomize with None of the above and other at the bottom]
1	SNAP (EBT): Food assistance that helps pay for groceries
2	TANF: Cash Assistance
3	Medicaid: Health care coverage
4	WIC: Nutrition assistance for pregnant and breastfeeding women and children
5	LIHEAP: Assistance with energy costs
6	Rental assistance
7	None of the above
8	Other programs(open text field)



Q5. Which of the following government programs are you currently receiving benefits from?*
Please select all that apply.
[Randomize with None of the above and other at the bottom]
1	SNAP (EBT): Food assistance that helps pay for groceries 
2	TANF: Cash Assistance
3	Medicaid: Health care coverage
4	WIC: Nutrition assistance for pregnant and breastfeeding women and children
5	LIHEAP: Assistance with energy costs
6	Rental assistance
7	None of the above
8	Other programs (open text field)


If respondent answers "None of the above" to both Q4 and Q5, they do not qualify for this research.


Your Application Experience
Q6. How did you submit your most recent application or renewal for government benefits?*
[Randomize with Other: at the bottom]
1	Online
2	Paper application
3	Over the phone
4	Email
5	Other: _________________

Q7. Tell us about your most recent experience applying for government benefits, such as SNAP or Medicaid.







Work
Q8. This survey defines work as inclusive of all employment, jobs, etc. Are you currently working?*
Please answer 'yes' if you work an hourly or salaried job, or if you were paid for services or goods as a freelancer, independent contractor, or other kinds of self-employment.
    • Yes  à Skip to Q10
    • No

Q9. When was the last time you worked?*
A rough estimate is fine.
    • In the last 30 days
    • In the last 90 days
    • In the last 6 months
    • In the last year
    • Over a year ago

Q10. Please describe your current or most recent work. What type of work do you do?
__________________________________________________________

Q11. If you currently work, how are you getting paid? If you do not currently work, how did you get paid most recently?*
[Randomized with Other at the end]
1	Direct deposit
2	Invoices
3	Via a payment app (Zell, Venmo, etc.)
4	Cash
5	Paper check
6	Other: _________________

Q12. Can you view your pay information using an online payroll system for your current or most recent work?*
    • Yes
    • No
    • I don’t know

Q13. When you get paid, how often does or did the amount you make vary from one payment to the next?*
Please select the one that best applies.
[Likert scale]
    1. Never - My income is very steady from one paycheck to the next
    2. Rarely
    3. Sometimes
    4. Often
    5. Always - My income always varies from one paycheck to the next


Submitted
Thank you. Our research team will be in touch if you are a good fit for a research study. If you have questions, please reach out to