Attachment c Updated

Attachment 2c. NHIS 2007 Flashcard

Booklet

54HIS-501(C) (2007)

NATIONAL

HEALTH

INTERVIEW

SURVEY

U.S. Department

of Commerce

BUREAU OF THE

CENSUS

Field

Representative=s

Flashcard and

Information

Booklet (CAPI)

CARD H1

You may choose more than one.

1. Puerto Rican

2. Cuban/Cuban American

3. Dominican (Republic)

4. Mexican

5. Mexican American

6. Central or South American

7. Other Latin American

8. Other Hispanic/Latino/Spanish

CARD H2

You may choose more than one.

1. White

2. Black/African American

3. Indian (American)

4. Alaska Native

5. Native Hawaiian

6. Guamanian

7. Samoan

8. Other Pacific Islander

9. Asian Indian

10. Chinese

11. Filipino

12. Japanese

13. Korean

14. Vietnamese

15. Other Asian

CARD H3

2. Spouse (husband/wife)

3. Unmarried Partner

4. Child (biological/adoptive/in-law/

step/foster)

5. Child of Partner

6. Grandchild

7. Parent (biological/adoptive/in-law/

step/foster)

8. Brother/Sister (biological/adoptive/in-law/

step/foster)

9. Grandparent (Grandmother/Grandfather)

10. Aunt/Uncle

11. Niece/Nephew

12. Other relative

13. Housemate/Roommate

14. Roomer/Boarder

15. Other non-relative

16. Legal Guardian

17. Ward

CARD F1

You may choose more than one.

1. Vision/problem seeing

2. Hearing problem

3. Speech problem

4. Asthma/breathing problem

5. Birth defect

6. Injury

7. Mental retardation

8. Other developmental problem

(e.g., cerebral palsy)

9. Other mental, emotional, or behavioral

problem

10. Bone, joint, or muscle problem

11. Epilepsy or seizures

12. Learning disability

13. Attention Deficit/Hyperactivity

Disorder (ADD/ADHD)

Other impairment/problem

CARD F2

You may choose more than one.

1. Vision/problem seeing

2. Hearing problem

3. Arthritis/rheumatism

4. Back or neck problem

5. Fracture, bone/joint injury

6. Other injury

7. Heart problem

8. Stroke problem

9. Hypertension/high blood pressure

10. Diabetes

11. Lung/breathing problem (e.g., asthma

and emphysema)

12. Cancer

13. Birth defect

14. Mental retardation

15. Other developmental problem (e.g., cerebral palsy)

16. Senility

17. Depression/anxiety/emotional problem

18. Weight problem

Other impairment/problem

CARD F3

Beginning

1	2	3	4	5	6	7
8	9	10

M Middle iddle Middle			11	12	13	14
15	16	17	18	19	20

End						21
22	23	24	25	26	27	28
29	30	31

CARD F4

You may choose up to four.

Insert drawing of injured body parts here

Insert drawing of face here.

CARD F5

You may choose up to two.

34600. Broken bone or fracture

2. Sprain, strain, or twist

3. Cut

4. Scrape

5. Bruise

6. Burn

7. Insect bite

8. Animal bite

9. Other (specify)

CARD F6

35116. Passenger car

35117. Passenger truck, such as a pickup truck, van, or SUV

35118. Bus

35119. Large commercial truck, such as a semi-truck, big rig, or 18-wheeler

35120. Motorcycle (including mopeds, minibikes)

35121. All terrain vehicle or ski/snow-mobile

35122. Farm equipment (such as a tractor)

35123. Industrial or construction vehicle

35124. Other

CARD F7

You may choose up to two.

On, down, from, or into:

1. Stairs, steps, or escalator

2. Floor or level ground

3. Curb (including sidewalk)

4. Ladder or scaffolding

5. Playground equipment

6. Sports field, court, or rink

7. Building or other structure

8. Chair, bed, sofa, or other furniture

9. Bathtub, shower, toilet, or commode

10. Hole or other opening

11. Other

CARD F8

36156. Slipping or tripping

36157. Jumping or diving

36158. Bumping into an object or another person

36159. Being shoved or pushed by another person

36160. Losing balance or having dizziness (becoming faint or having a seizure)

36161. Other

CARD F9

1. Swallowing a drug or medical substance mistakenly or in overdose

2. Swallowing or touching a harmful solid or liquid substance

3. Inhaling harmful gases or vapors

4. Eating a poisonous plant or other substance

mistaken for food

5. Being bitten by a poisonous animal

6. Other (specify)

CARD F10

You may choose up to two.

1. Driving or riding in a motor vehicle

2. Working at a paid job

3. Working around the house or yard

4. Attending school

5. Unpaid work (such as volunteer work)

6. Sports and exercise

7. Leisure activity (excluding sports)

8. Sleeping, resting, eating, or drinking

9. Cooking

10. Being cared for (hands-on care from other person)

11. Other (specify)

CARD F11

You may choose up to two.

1. Home (inside)

2. Home (outside)

3. School (not residential)

4. Child care center or preschool

5. Residential institution (excluding hospital)

6. Health care facility (including hospital)

7. Street or highway

8. Sidewalk

9. Parking lot

10. Sport facility, athletic field, or playground

11. Shopping center, restaurant, store, bank, gas station, or other place of business

12. Farm

13. Park or recreation area (including bike or jog path)

14. River, lake, stream, or ocean

15. Industrial or construction area

16. Other public building

17. Other

CARD F12

You may choose more than one.

1. Private health insurance*

2. Medicare

3. Medi-Gap

4. Medicaid

5. SCHIP (CHIP/Children=s Health

Insurance Program)

5. Military health care

(TRICARE/VA/CHAMP-VA)

5. Indian Health Service

8. State-sponsored health plan

9. Other government program

10. Single service plan (e.g., dental, vision, prescriptions)

10. No coverage of any type

*EXCLUDE private plans that only provide

extra cash while hospitalized.

CARD F13

Insert picture of Medicare card here.

CARD F14 – Each State Has Separate Card

STATE NAMES FOR MEDICAID, CHIP, STATE-/LOCAL-SPONSORED, AND OTHER HEALTH INSURANCE PROGRAMS

Please find your state.

Note: Some Medicaid programs are called “Medical Assistance Program”, “Title 19" or “{State} Medicaid”, such as “Alabama Medicaid”. CHIP or S-CHIP programs can also be under “Title XXI Program” or “{State} CHIP”, such as “Pennsylvania CHIP”. The names provided below offer additional names for the public health insurance programs for each state.

ALABAMA	ALASKA	ARIZONA
Medicaid: Patient 1st; SOBRA,	Medicaid: Alaska Medicaid	Medicaid: AHCCCS; Arizona Health Care Cost Containment System; Healthy Arizona; SOBRA
CHIP: AL-Kids, ALL KIDS	CHIP: Denali KidCare, AKChip	CHIP: KidsCare
State/Other: Children’s Rehabilitation Service (CRS), Alabama Child Caring Plan, Alabama Health Insurance Plan (AHIP); Alabama Health Plan	State/Other: Chronic and Acute Medical Assistance (CAMA); Health Care Program for Children with Special Health Care Needs (HCP-CSN); Alaska Comprehensive Health Insurance Association ACHIA)	State/Other: Medically Indigent - Medically Needy Program (MI/MN); Office for Children with Special Health Care Needs (CSHCN); Young Adults Transitional Insurance (YATI)
ARKANSAS	CALIFORNIA	COLORADO
Medicaid: ConnectCare ; Katie Beckett; TEFRA	Medicaid: Medi-Cal; Health Insurance Premium Payment Program (HIPP)	Medicaid: Primary Care Physician Program (PCPP); BabyCare / KidsCare
CHIP: ARKids First	CHIP: Healthy Families Program (HFP)	CHIP: Child Health Plan Plus (CHP+); Childrens Basic Health Plan
State/Other: Arkansas Comprehensive Health Insurance Plan; Children’s Medical Services (CMS)	State/Other: Access for Infants & Mothers (AIM); County Medical Services Program (CMSP); California Children’s Services (CCS); Major Risk Medical Insurance Program (MRMIP); CARE Health Insurance Premium Payment Program; California Major Risk Medical Insurance Program	State/Other: Health Care Program for Children with Special Needs (HCP); CUHIP - Colorado Uninsurable Health Insurance Plan; CoverColorado; Colorado Indigent Care Program (CICP)

CONNECTICUT	DELAWARE	DISTRICT OF COLUMBIA
Medicaid: Medical Assistance Program; HUSKY Part A	Medicaid: Diamond State Health Plan;	Medicaid: Medical Assistance
CHIP: The HUSKY Plan; HUSKY PLUS, HUSKY Part B	CHIP: Healthy Children The Delaware Healthy Children Program (DHCP)	CHIP: DC Healthy Families
State/Other: Refugee Medical Assistance; Children with Special Health Care Needs; Connecticut Health Reinsurance Association (HRA); Connecticut Insurance Assistance Program for AIDS Patients (CIAPAP); State-Administered General Assistance Medical Aid (SAGA); Family Health Services Division (BCH)	State/Other: Children with Special Health Care Needs (CSHCN)	State/Other: Medical Charities Program; Health Services for Children with Special Needs; DC Healthcare Alliance
FLORIDA	GEORGIA	HAWAII
Medicaid: MediPass	Medicaid: Georgia Better Health Care; Right from the Start (RSM); Health Insurance Premium Payment Program (HIPP); Katie Beckett / TEFRA	Medicaid: Hawaii-QUEST
CHIP: KidCare ; MediKids; Florida Healthy Kids	CHIP: PeachCare for Kids	CHIP: Hawaii CHIP
State/Other: AIDS Insurance Continuation Program (AICP); Florida Comprehensive Health Association; Children’s Medical Services (CMS)	State/Other: Children’s Medical Services (CMS); Indigent Care Trust Fund (ICTF)	State/Other: QUEST-Net; HCOBRA; Children with Special Health Needs

IDAHO	ILLINOIS	INDIANA
Medicaid: Healthy Connections; Medical Assistance	Medicaid: Medical Assistance; Healthy Start; Family Care; Parent Assist; Kidcare Assist; Kidcare Moms and Babies	Medicaid: Hoosier Healthwise; Primestep; Risk Based Managed Care; Medicaid Select
CHIP: Children’s Health Insurance Program; CHIP-A; CHIP-B; Access Card	CHIP: KidCare Share; KidCare Premium; Kidcare Rebate	CHIP: Hoosier Healthwise for Children; Children’s Health Plan; Benefit Package C
State/Other: Catastrophic Fund; Children’s Special Health Program (CSHP)	State/Other: Comprehensive Health Insurance Plan (ICHIP); Specialized Care for Children (DSCC); Health Care for workers with Disabilities (HBWD)	State/Other: Children’s Special Health Care Services (CSHCS); Indiana Comprehensive Health Insurance Association (ICHIA);
IOWA	KANSAS	KENTUCKY
Medicaid: Medical Assistance; Health Insurance Premium Payment (HIPP); MediPASS; Iowa Plan	Medicaid: HealthConnect; Healthwave 19	Medicaid: Kentucky Patient Access and Care System (KenPAC)
CHIP: Health and Well Kids in Iowa (HAWK-I)	CHIP: HealthWave 21	CHIP: Kentucky Children’s Health Insurance Program (KCHIP)
State/Other: Children’s Health Specialty Clinics (CHSC); Iowa Comprehensive Health Association ; AIDS/HIV Health Insurance Premium Payment	State/Other: Medi-KAN; Services for Children with Special Health Care Needs (CSHSN); Kansas Uninsurable Health Insurance Plan; Kansas Health Insurance Association (KHIA)	State/Other: Kentucky HIV Health Insurance Assistance Program; Commission for Children with Special Health Care Needs; Kentucky Access

LOUISIANA	MAINE	MARYLAND
Medicaid: CommunityCARE; LaMoms	Medicaid: PrimeCare; Maine Care	Medicaid: Medical Assistance Program; HealthChoice; REM Program
CHIP: LACHIP	CHIP: Cub Care	CHIP: Maryland Childrens Health Program (MCHP)
State/Other: Louisiana Health Plan; Children’s Special Health Services; Louisiana Health Insurance Association	State/Other: Children with Special Health Care Needs Program (CSHNP)	State/Other: AIDS Insurance Assistance Program (MAIAP); Maryland Primary Care (MPC); Children’s Medical Services (CMS)
MASSACHUSETTS	MICHIGAN	MINNESOTA
Medicaid: MassHealth;	Medicaid: Medical Assistance Program; Healthy Kids; MICHOICE	Medicaid: Medical Assistance (MA)
CHIP: MassHealth	CHIP: MIChild Program	CHIP: Children’s Health Insurance Program
State/Other: Children’s Medical Security Plan (CMSP); Commonhealth; Medical Security Plan (MSP); Special Kids / Special Care; Insurance Partnership; Division of Special Health Care Needs	State/Other: Children’s Special Health Care Services; Trust Fund for Children with Special Health Care Needs	State/Other: Minnesota Care; Minnesota General Assistance Medical Care Program (GAMC); HIV/AIDS Insurance Continuation Program; Minnesota Children with Special Health Care Needs (MCSHN); Minnesota Comprehensive Health Association (MCHA)

MISSISSIPPI	MISSOURI	MONTANA
Medicaid: Medicaid	Medicaid: Managed Care Plus (MC+); MCPlus; Sarah Lopez Waiver;	Medicaid: Passport to Health
CHIP: Mississippi Children’s Health Insurance Program (CHIP)	CHIP: MC+ for Kids	CHIP: Montana’s CHIP
State/Other: Mississippi Comprehensive Health Insurance Risk Pool Children with Special Health Care Needs	State/Other: General Relief Medical Assistance; Children with Special Health Care Needs; Missouri Health Insurance Pool (MHIP)	State/Other: Montana Comprehensive Health Insurance Association (MCHA); Health Insurance Continuum of Coverage Program (HICCP); Children’s Special Health Services (SHS)
NEBRASKA	NEVADA	NEW HAMPSHIRE
Medicaid: Medical Assistance Program; Nebraska Health Connection (NHC);	Medicaid: Nevada Medicaid; Child Assurance Program (CHAP)	Medicaid: New Hampshire Medicaid; Healthy Kids Gold
CHIP: Kids Connection	CHIP: Nevada Check Up	CHIP: Healthy Kids Silver
State/Other: Medically Handicapped Children’s Program (MHCP); Comprehensive Health Insurance Pool	State/Other: Family Health Services Bureau; Children with Special Health Care Needs	State/Other: Special Medical Services (SMSB); Healthy Kids Buy-in; Catastrophic Illness Program
NEW JERSEY	NEW MEXICO	NEW YORK
Medicaid: New Jersey Care 2000+; AIDS Community Care Alternatives (ACCAP);	Medicaid: SALUD!	Medicaid: The Partnership Plan; Medicaid; Child Health Plus A
CHIP: New Jersey Family Care/ New Jersey Kid Care	CHIP: New MexiKids	CHIP: Child Health Plus B
State/Other: Health Insurance Continuation Program (HICP); Special Child Adult and Early Intervention Services (SCAEIS)	State/Other: Insurance Assistance Program; Children’s Medical Services (CMS); New Mexico Medical Insurance Pool (NMMIP); New Mexico Health Insurance Alliance (NMHIA)	State/Other: Family Health Plus; FHPlus; Healthy New York; Physically Handicapped Children’s Program; Children with Special Health Care Needs Program (CSHCN); ADAP Plus Insurance continucation Program (APIC)

NORTH CAROLINA	NORTH DAKOTA	OHIO
Medicaid: Carolina Access; HealthCare Connection; Access II;	Medicaid: Primary Care Provider Program; Altrucare	Medicaid: Healthy Families, Healthy Start;
CHIP: NC CHIP program; NC Health Choice for Children (NCHC)	CHIP: Healthy Steps Program	CHIP: Healthy Start
State/Other: Title V Services for Children with Special Health Care Needs	State/Other: Comprehensive Health Association of North Dakota (CHAND); Children’s Special Health Services (CSHS)	State/Other: HIV Health Insurance Premium Payment Program (HIPP); Hemophilia Insurance Pilot Program; Bureau for Children with Medical Handicaps (BCMH);
OKLAHOMA	OREGON	PENNSYLVANIA
Medicaid: SoonerCare Plus; SoonerCare Choice	Medicaid: Oregon Health Plan (OHP)	Medicaid: Medical Assistance; Access Card; HealthChoices; Access Plus
CHIP: Oklahoma SCHIP	CHIP: Oregon SCHIP	CHIP: Pa CHIP
State/Other: Children with Special Health Care Needs (CSHCN); Oklahoma Health Insurance High Risk Pool	State/Other: CareAssist; Oregon Services for Children with Special Health Needs; Oregon Medical Insurance Pool (OMIP); Family Health Insurance Assistance Program (FHIAP); Insurance Purchasing Cooperative; Child Development and Rehabilitation Center	State/Other: Title V Program; Bureau of Family Health; Health Insurance Premium Payment Program; Adult Basic

RHODE ISLAND	SOUTH CAROLINA	SOUTH DAKOTA
Medicaid: RIte Care; RI Medical Assistance; Katie Beckett	Medicaid: Healthy Options Program (HOP); Physicians Enhanced Program (PEP); South Carolina Partners for Health	Medicaid: Medical Assistance; Medicaid
CHIP: RIte Care	CHIP: Partners for Healthy Children (PHC)	CHIP: CHIP-NM
State/Other: Subsidy for Health Insurance for Center-Based Child-Care Providers; Office of Children with Special Health Care Needs (OCSHN); RIte share Premium Assistance Program; Child Care Provider Rite Care Program (CCPRC)	State/Other: South Carolina Health Insurance Pool; Children’s Rehabilitative Services (CRS); Medically Indigent Assistance Program (MIAP)	State/Other: Catastrophic County-Poor Relief Program (CCPR); Continuation of Health Insurance; Children’s Special Health Services (CSHS); Refugee Medical Assistance; South Dakota Risk Pool; Disabled Children’s Program
TENNESSEE	TEXAS	UTAH
Medicaid: TennCare Medicaid;	Medicaid: State of Texas Access Reform (STAR); Star+Plus;	Medicaid: Medicaid
CHIP: TennCare Standard	CHIP: Texas CHIP	CHIP: Children’s Health Insurance Program
State/Other: Children’s Special Services (CSS); Tenncare Standard; Tenncare Assist	State/Other: Texas Health Insurance Risk Pool; State Kid Insurance Program (SKIP); Children with Special Health Care Needs (CSHCN)	State/Other: Utah’s Primary Care Network (PCN); Custody Medical Care Program; Children with Special Health Care Needs (CSHCN); Comprehensive Health Insurance Pool (HIPUtah); Health Insurance Continuation Program;

VERMONT	VIRGINIA	WASHINGTON
Medicaid: Medicaid; Primary Care Plus	Medicaid: Medicaid; Virginia Medallion. Medallion II	Medicaid: Childrens Medical; Family Medicaid; Healthy Options
CHIP: Dr. Dynasaur	CHIP: Family Access to Medical Insurance Security Plan (FAMIS)	CHIP: Children’s Health Insurance Program
State/Other: Vermont Health Access Plan (VHAP); HIV Insurance Continuation Program (ICAP); Children with Special Health Needs (CSHN)	State/Other: State and Local Hospitalization (SLH) Program; Children’s Specialty Services; Children with Special Health Care Needs (CSHCN)	State/Other: Basic Health; Children with Special Health Care Needs (CSHCN); Washington State Health Insurance Pool; Children’s Health Program (CHP); General Assistance Unemployable (GA-U)
WEST VIRGINIA	WISCONSIN	WYOMING
Medicaid: Medical Assistance; Mountain Health Trust (MHT); Physician Assured Access System (PAAS)	Medicaid: Medical Assistance MA, Wisconsin Medicaid, Healthy Start	Medicaid: Wyoming Medicaid;
CHIP: Children’s Health Insurance Program (CHIP); WVCHIP	CHIP: BadgerCare	CHIP: Wyoming Kid Care
State/Other: Children with Special Health Care Needs	State/Other: Health Insurance Risk Sharing Program (HIRSP); Wisconsin AIDS/HIV Health Insurance Premium Subsidy Program; Children with Special Health Needs (CSHN)	State/Other: Wyoming Health Insurance Pool (WHIP); Children’s Special Health Services (CSH), Caring Program for Children

CARD F15

You may choose more than one.

38804. Accidents

38805. AIDS care

38806. Cancer treatment

38807. Catastrophic care

38808. Dental care

38809. Disability insurance (cash payments

when unable to work for health reasons)

38810. Hospice care

38811. Hospitalization only

38812. Long-term care (nursing home care)

38813. Prescriptions

38814. Vision care

38815. Other (specify)

CARD F16

1. Through employer

2. Through union

3. Through workplace, but don=t know if

employer or union

4. Through workplace, self-employed or

professional association

5. Purchased directly

6. Through a state/local government or

community program

7. Other (specify)

CARD F17

1. 6 months or less

2. More than 6 months, but not more than 1 year ago

3. More than 1 year, but not more than 3

years ago

4. More than 3 years

5. Never

CARD F18

You may choose up to five.

1. Person in family with health insurance

lost job or changed employers

2. Got divorced or separated/death

of spouse or parent

3. Became ineligible because of

age/left school

4. Employer does not offer coverage/

or not eligible for coverage

5. Cost is too high

6. Insurance company refused

coverage

7. Medicaid/Medical plan stopped

after pregnancy

8. Lost Medicaid/Medical plan

because of new job or increase

in income

9. Lost Medicaid (Other reason for losing Medicaid)

10. Other (specify)

CARD F19

0. Zero

1. Less than $500

2. $500 - $1,999

3. $2,000 - $2,999

4. $3,000 - $4,999

5. $5,000 or more

CARD F20

1. Yes, born in one of the 50 United States, or the District of Columbia

2. Yes, born in Puerto Rico, Guam, American Virgin Islands, or other U.S. territory

3. Yes, born abroad to American parent(s)

4. Yes, U.S. citizen by naturalization

4. No, not a citizen of the United States

CARD F21

0. Never attended/kindergarten only

1. 1st grade

2. 2nd grade

3. 3rd grade

4. 4th grade

5. 5th grade

6. 6th grade

7. 7th grade

8. 8th grade

9. 9th grade

10. 10th grade

11. 11th grade

12. 12th grade, no diploma

13. GED or equivalent

14. HIGH SCHOOL GRADUATE

15. Some college, no degree

16. Associate’s degree: occupational,

technical, or vocational program

17. Associate’s degree: academic program

18. Bachelor=s degree (Example: BA, AB, BS, BBA)

19. Master=s degree (Example: MA, MS, MEng, MEd, MBA)

20. Professional School degree (Example: MD, DDS, DVM, JD)

21. Doctoral degree (Example: Phd, EdD)

CARD F22

1. Working for pay at a job or business

2. With a job or business but not at work

3. Looking for work

4. Working, but not for pay, at a family-owned job or business

5. Not working at a job or business and not looking for work

CARD F23 – Each State Has Individual Card

CARD F23-AL

ALABAMA

Note: Where there is more than one program,

an asterisk* denotes which most resembles TANF.

Family Assistance (FA) Program*

JOBS

CARD F23-AK

ALASKA

Alaska Temporary Assistance Program (ATAP)

CARD F23-AZ

ARIZONA

Employing and Moving People Off Welfare

and Encouraging Responsibility (EMPOWER)

CARD F23-AR

ARKANSAS

Transitional Employment Assistance (TEA)

CARD F23-CA

CALIFORNIA

California Work Opportunity and Responsibility to Kids (CALWORKS)

CARD F23-CO

COLORADO

Colorado Works

CARD F23-CT

CONNECTICUT

Note: Where there is more than one program,

an asterisk* denotes which most resembles TANF.

Temporary Family Assistance (TFA)*

Jobs First

CARD F23-DE

DELAWARE

A Better Chance (ABC)

CARD F23-DC

DISTRICT OF COLUMBIA

Temporary Assistance for Needy Families (TANF)

CARD F23-FL

FLORIDA

Work and Gain Economic Self Sufficiency (WAGES)

CARD F23-GA

GEORGIA

Temporary Assistance for Needy Families (TANF)

CARD F23-HI

HAWAII

Temporary Assistance for Needy Families (TANF)

Pursuit of New Opportunities (PONO)

CARD F23-ID

IDAHO

Temporary Assistance for Families in Idaho (TAFI)

CARD F23-IL

ILLINOIS

Temporary Assistance for Needy Families (TANF)

CARD F23-IN

INDIANA

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Temporary Assistance for Needy Families (TANF)*

Indiana Manpower Placement and Comprehensive Training (IMPACT)

CARD F23-IA

IOWA

Note: Where there is more than one program,

an asterisk* denotes which most resembles TANF.

Family Investment Program (FIP)*

PROMISE JOBS

CARD F23-KS

KANSAS

Note: Where there is more than one program,

an asterisk* denotes which most resembles TANF.

Temporary Assistance for Families (TAF)*

KansasWorks

CARD F23-KY

KENTUCKY

Kentucky Transitional Assistance Program (K-TAP)

CARD F23-LA

LOUISIANA

Note: Where there is more than one program,

an asterisk* denotes which most resembles TANF.

Family Independence Temporary Assistance Program (FITAP)*

Family Independence Work Program (FIND Work)

CARD F23-ME

MAINE

Note: Where there is more than one program,

an asterisk* denotes which most resembles TANF.

Temporary Assistance for Needy Families (TANF)*

Additional Support for People in Retraining and Employment (ASPIRE)

CARD F23-MD

MARYLAND

Family Investment Program (FIP)

CARD F23-MA

MASSACHUSETTS

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Transitional Aid to Families with Dependent Children (TAFDC)*

Employment Services Program (ESP)

CARD F23-MI

MICHIGAN

Family Independence Program (FIP)

CARD F23-MN

MINNESOTA

Minnesota Family Investment Program (MFIP)

CARD F23-MS

MISSISSIPPI

Temporary Assistance for Needy Families (TANF)

CARD F23-MO

MISSOURI

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Temporary Assistance*

Beyond Welfare

CARD F23-MT

MONTANA

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Families Achieving Independence in Montana (FAIM)*

JOBS

CARD F23-NE

NEBRASKA

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Aid to Dependent Children (ADC)*

Employment First

CARD F23-NV

NEVADA

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Temporary Assistance for Needy Families (TANF)*

New Employees of Nevada (NEON)

CARD F23-NH

NEW HAMPSHIRE

Family Assistance Program (FAP)

New Hampshire Employment Program (NHEP)

CARD F23-NJ

NEW JERSEY

Work First New Jersey (WFNJ)

CARD F23-NM

NEW MEXICO

NMWorks

CARD F23-NY

NEW YORK

Family Assistance (FA) Program

CARD F23-NC

NORTH CAROLINA

Work First

CARD F23-ND

NORTH DAKOTA

Training, Employment, Education Management (TEEM)

CARD F23-OH

OHIO

Ohio Works First (OWF)

CARD F23-OK

OKLAHOMA

Temporary Assistance for Needy Families (TANF)

CARD F23-OR

OREGON

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Temporary Assistance for Needy Families (TANF)*

Job Opportunities and Basic Skills Program (JOBS)

CARD F23-PA

PENNSYLVANIA

Pennsylvania TANF

CARD F23-RI

RHODE ISLAND

Family Independence Program (FIP)

CARD F23-SC

SOUTH CAROLINA

Family Independence

CARD F23-SD

SOUTH DAKOTA

Temporary Assistance for Needy Families (TANF)

CARD F23-TN

TENNESSEE

Families First

CARD F23-TX

TEXAS

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Texas Works (Department of Human Services)*

Choices

CARD F23-UT

UTAH

Family Employment Program (FEP)

CARD F23-VT

VERMONT

Aid to Needy Families with Children (ANFC)

Reach UP

CARD F23-VA

VIRGINIA

Virginia Initiative for Employment not Welfare (VIEW)

CARD F23-WA

WASHINGTON

WorkFirst

CARD F23-WV

WEST VIRGINIA

West Virginia Works

CARD F23-WI

WISCONSIN

Wisconsin Works (W-2)

CARD F23-WY

WYOMING

Personal Opportunities with Employment Responsibility (POWER)

CARD C1

1. Parent (Biological, adoptive or step)

2. Grandparent

3. Aunt/Uncle

4. Brother/Sister

5. Other relative

6. Legal Guardian

7. Foster parent

8. Other non-relative

CARD C2

You may choose more than one.

1. Down syndrome

2. Cerebral palsy

3. Muscular dystrophy

4. Cystic fibrosis

5. Sickle cell anemia

6. Autism

7. Diabetes

8. Arthritis

9. Congenital heart disease

10. Other heart condition

CARD C3

0. Not true

1. Sometimes true

2. Often true

CARD C4

0. Never

1. 6 months or less

2. More than 6 months, but not more than 1 year ago

3. More than 1 year, but not more than 2 years ago

4. More than 2 years, but not more than 5 years ago

5. More than 5 years ago

CARD C5

0. None

1. 1

2. 2 - 3

3. 4 - 5

4. 6 - 7

5. 8 - 9

6. 10 - 12

7. 13 - 15

8. 16 or more

CARD C6

1. 1

2. 2 - 3

3. 4 - 5

4. 6 - 7

5. 8 - 9

6. 10 - 12

7. 13 - 15

8. 16 or more

CARD C7

1. Not true

2. Somewhat true

3. Certainly true

CARD C8

Overall, do you think that this child has difficulties in any of the following areas: emotions, concentration, behavior, or being able to get along with other people?

1. No

2. Yes, minor difficulties

3. Yes, definite difficulties

4. Yes, severe difficulties

CARD C9

1. In the past 6 months

2. 7 to 12 months ago

3. More than 12 months ago

CARD C10

You may choose more than one.

1. A pediatric or general medical care practice

2. A mental health private practice

3. A mental health clinic or center

4. The child’s school

5. Other

CARD CAL1

1. Acupuncture

2. Ayurveda

3. Biofeedback

4. Chelation Therapy

5. Chiropractic or Osteopathic Manipulation

6. Energy Healing Therapy

(such as Reiki,Therapeutic Touch, Polarity

Therapy, or Magnet Therapy)

7. Hypnosis

8. Massage

(such as Deep Tissue, Swedish, Bowen, Rolfing,

or Reflexology)

9. Naturopathy

CARD CAL2

You may choose more than one.

1. Curandera

2. Espiritistas

3. Hierbero or Yerbera

4. Shaman

5. Botanica

6. Native American Healer / Medicine Man

7. Sobador

CAL3

You may choose more than one.

Combination Herb pill Androstenedione Black cohosh Carnitine Chasteberry Chondroitin Coenzyme Q-10 Comfrey Conjugated Linolenic Acid (CLA) Cranberry (pills, gelcaps) Creatine DHEA Echinacea Ephedra Evening primrose Feverfew Fiber or Psyllium (pills or powder) Fish oil or omega 3 OR DHA fatty acid supplements Flaxseed Oil or Pills Garlic supplements (pills, gelcaps) Ginger pills or gelcaps Ginkgo biloba

You may choo Ginseng Glucosamine Goldenseal Guarana Grape Seed Extract Green tea pills (not brewed tea) EGCG (pills) Hawthorn Horny Goat Weed Kava kava Lecithin Lutein Lycopene Melatonin MSM (Methylsulfonylmethane) Milk thistle Prebiotics or Probiotics SAM-e Saw palmetto Senna Soy supplements or soy isoflavones St. John’s wort Valerian

CAL4

You may choose more than one.

Multivitamin and/or mineral combination

Calcium

Chromium

Coral Calcium

Folic Acid/folate

Iron

Magnesium

Niacin

Potassium

Selenium

Vitamin A

Vitamin B complex

Vitamin B6

Vitamin B12

Vitamin C

Vitamin D

Vitamin E

Vitamin K

Zinc

Vitamin Packet

CARD A1

1. Working for pay at a job or business

2. With a job or business but not at work

3. Looking for work

4. Working, but not for pay, at a family-owned job or business

5. Not working at a job or business and not looking for work

CARD A2

1. An employee of a PRIVATE company,

business, or individual for wages,

salary, or commission

2. A FEDERAL government employee

3. A STATE government employee

4. A LOCAL government employee

5. Self-employed in OWN business,

professional practice or farm

6. Working WITHOUT PAY in

family-owned business or farm

CARD A3

1. 1-9 employees

2. 10-24 employees

3. 25-49 employees

4. 50-99 employees

5. 100-249 employees

6. 250-499 employees

7. 500-999 employees

8. 1000 employees or more

CARD A4

You may choose more than one.

Place drawing of joints here.

CARD A5

You may choose more than one.

1. Pocket talker or other personal listening device

2. Amplified telephone

3. Amplified or vibrating alarm clock

4. Notification or signaling system (light

signaler for doorbell, baby cry monitor,

etc.)

5. Television/Theater headset or closed-

captioned TV

6. TTY (teletypewriter) TDD (telecommunications device for the deaf)

or telephone relay service

7. Video relay service

8. Sign language interpreter

9. Other

CARD A6

You may choose more than one.

1. Amplification/Hearing aids

2. Masking with wearable device (with or

without hearing aids)

3. Masking with non-wearable device

(sound generators to help with sleep)

4. Cognitive therapy with counseling

5. Stress reduction or relaxation methods

6. Biofeedback

7. Tinnitus retraining therapy (TRT)

8. Psychiatric treatment

9. Surgery to cut the hearing nerve

10. Drugs or medications

11. Nutritional supplements

12. Music therapy

13. Temporal mandibular joint treatment

14. Alternative methods (hypnosis,

acupuncture, etc.)

15. Other

CARD A7

You may choose more than one.

1. Motorcycles/Auto

racing/Snowmobile/Motor boat

2. Operating farm machinery

3. Wood cutting, woodworking, or other

workshop power tools

4. Lawn mower, electric trimmer, leaf/snow blower

5. Firearms

6. Household appliances: Blender/mixer, food processor, vacuum cleaner, hair dryer, etc.

7. MP3 Player/iPod

8. Playing in a music group

9. Other music-related activities: Rock concerts, stereos, disco/clubs or bars

10. Other noisy, non-work-related activities

CARD A8

1. ALL of the time

2. MOST of the time

3. SOME of the time

4. A LITTLE of the time

5. NONE of the time

CARD A9

0. Not at all difficult

1. Only a little difficult

2. Somewhat difficult

3. Very difficult

4. Can't do at all

6. Do not do this activity

CARD A10

You may choose more than one.

1. Vision/problem seeing

2. Hearing problem

3. Arthritis/rheumatism

4. Back or neck problem

5. Fracture, bone/joint injury

6. Other injury

7. Heart problem

8. Stroke problem

9. Hypertension/high blood pressure

10. Diabetes

11. Lung/breathing problem (e.g., asthma and

emphysema)

12. Cancer

13. Birth defect

14. Mental retardation

15. Other developmental problem

(e.g., cerebral palsy)

16. Senility

17. Depression/anxiety/emotional problem

18. Weight problem

Other impairment/problem

CARD A11

0. Never

1. 6 months or less

2. More than 6 months, but not more than 1 year ago.

3. More than 1 year, but not more than 2 years ago

4. More than 2 years, but not more than 5 years ago

5. More than 5 years ago

CARD A12

0. None

1. 1

2. 2-3

3. 4-5

4. 6-7

5. 8-9

6. 10-12

7. 13-15

8. 16 or more

CARD A13

1. 1

2. 2-3

3. 4-5

4. 6-7

5. 8-9

6. 10-12

7. 13-15

8. 16 or more

CARD A14

1. It's unlikely you've been exposed to HIV

2. You were afraid to find out if you were HIV positive (that you had HIV)

3. You didn't want to think about HIV or about being HIV positive

4. You were worried your name would be reported to the government if you tested positive

5. You didn't know where to get tested

6. You don't like needles

7. You were afraid of losing job, insurance, housing, friends, family, if people knew you were

positive for AIDS infection

8. Some other reason (specify)

9. No particular reason

CARD A15

1. Someone suggested you should be tested

2. You might have been exposed through sex or drug use

3. You might have been exposed through your work or at work

4. You just wanted to find out if you were infected or not

5. For part of a routine medical check-up, or for

hospitalization or surgical procedure

6. You were sick or had a medical problem

7. You were pregnant or delivered a baby

8. For health or life insurance coverage

9. For military induction, separation, or

military service

10. For immigration

11. For marriage license or to get married

12. You were concerned you could give HIV

to someone

13. You wanted medical care or new

treatments if you tested positive

14. Some other reason (specify)

15. No particular reason

CARD A16

1. Private doctor/HMO

2. AIDS clinic/counseling/testing site

3. Hospital, emergency room,

outpatient clinic

4. Other type of clinic

5. Public health department

6. At home

7. Drug treatment facility

8. Military induction or military

service site

9. Immigration site

10. In a correctional facility (jail or

prison)

11. Other location (specify)

CARD A17

a. You have hemophilia and have

received clotting factor

concentrations

b. You are a man who has had sex with

other men, even just one time

c. You have taken street drugs by

needle, even just one time

d. You have traded sex for money or

drugs, even just one time

e. You have tested positive for HIV,

(the virus that causes AIDS)

f. You have had sex (even just one

time) with someone who would

answer "yes" to any of these

statements

CARD A18

You may choose more than one.

1. Breathing the air around a person

who is sick with TB

2. Sharing eating/drinking utensils

3. Through semen or vaginal

secretions shared during sexual

intercourse

4. From smoking

5. From mosquito or other insect bites

6. Other

ALT1

1. Acupuncture

2. Ayurveda

3. Biofeedback

4. Chelation Therapy

5. Chiropractic or Osteopathic Manipulation

6. Energy Healing Therapy

(such as Reiki,Therapeutic Touch, Polarity

Therapy, or Magnet Therapy)

7. Hypnosis

8. Massage

(such as Deep Tissue, Swedish, Bowen, Rolfing,

or Reflexology)

9. Naturopathy

ALT2

You may choose more than one.

1. Prescription medications

2. Over-the-counter medications

3. Surgery

4. Physical therapy

5. Mental health counseling

ALT3

You may choose more than one.

1. Medical Doctor (including specialists)

2. Nurse Practitioner/Physician Assistant

3. Psychiatrist

4. Dentist (including specialists)

5. Doctor of Osteopathy (D.O.)

6. Psychologist/Social Worker

7. Pharmacist

ALT4

You may choose more than one.

1. Never thought about it

2. No reason

3. Didn’t need it in the last 12 months

4. It didn’t work for me before

5. It costs too much

6. I had side effects last time

7. A health care provider told me not to use it

8. Medical science has not shown that it works

9. Some other reason

ALT5

You may choose more than one.

1. Never heard of it/don’t know much about it

2. Never thought about it

3. No reason

4. Don’t need it

5. Don’t believe in it/It doesn’t work

6. It costs too much

7. It is not safe to use

8. A health care provider told me not to use it

9. Medical science has not shown that it works

10. Some other reason

ALT6

You may choose more than one.

1. Curandera

2. Espiritistas

3. Hierbero or Yerbera

4. Shaman

5. Botanica

6. Native American Healer / Medicine Man

7. Sobador

ALT7

You may choose more than one.

Combination Herb pill Androstenedione Black cohosh Carnitine Chasteberry Chondroitin Coenzyme Q-10 Comfrey Conjugated Linolenic Acid (CLA) Cranberry (pills, gelcaps) Creatine DHEA Echinacea Ephedra Evening primrose Feverfew Fiber or Psyllium (pills or powder) Fish oil or omega 3 OR DHA fatty acid supplements Flaxseed Oil or Pills Garlic supplements (pills, gelcaps) Ginger pills or gelcaps Ginkgo biloba

Ginseng Glucosamine Goldenseal Guarana Grape Seed Extract Green tea pills (not brewed tea) EGCG (pills) Hawthorn Horny Goat Weed Kava kava Lecithin Lutein Lycopene Melatonin MSM (Methylsulfonylmethane) Milk thistle Prebiotics or Probiotics SAM-e Saw palmetto Senna Soy supplements or soy isoflavones St. John’s wort Valerian

ALT8

You may choose more than one.

1. Never thought about it

2. No reason

3. Didn’t need it in the past 30 days

4. It didn’t work for me before

5. It costs too much

6. I had side effects last time

7. A health care provider told me not to use it

8. Medical science has not shown that it works

9. Some other reason

ALT9

You may choose more than one.

Multivitamin and/or mineral combination

Calcium

Chromium

Coral Calcium

Folic Acid/folate

Iron

Magnesium

Niacin

Potassium

Selenium

Vitamin A

Vitamin B complex

Vitamin B6

Vitamin B12

Vitamin C

Vitamin D

Vitamin E

Vitamin K

Zinc

Vitamin Packet