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pdfMPR Reference No.: 6237
Accelerated Benefits
Demonstration
Baseline Survey
Draft
May 2007
Julita Milliner-Waddell
Lisa Schwartz
Deborah Peikes
David Wittenburg
Charles Michalopoulos
David Butler
Prepared by:
Mathematica Policy Research, Inc. and MDRC
CONTENTS
Section
Page
A.
CASE MANAGEMENT AND RESPONDENT SELECTION ........................................ 1
B.
HEALTH INSURANCE COVERAGE AND CONSENT.............................................. 30
C.
HEALTH AND FUNCTIONAL STATUS..................................................................... 41
D.
USE OF MEDICAL SERVICES ................................................................................. 50
E.
EMPLOYMENT HISTORY AND SUPPORTS ........................................................... 63
F.
HOUSEHOLD COMPOSITION AND INCOME ......................................................... 77
G.
BACKGROUND......................................................................................................... 80
H.
CONTACT INFORMATION AND STUDY GROUP ASSIGNMENT DISCLOSURE .. 81
I.
INTERVIEWER OBSERVATIONS ............................................................................ 90
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SECTION A: CASE MANAGEMENT AND RESPONDENT SELECTION
A1.
Hello, my name is _________. I’m calling on behalf of the Social Security Administration. May I
please speak with (NAME)?
SPEAKING ........................................................................
(NAME) COMES TO PHONE ...........................................
CALL BACK LATER ..........................................................
WANTS MORE INFORMATION .......................................
HUNG UP DURING INTRODUCTION..............................
SPANISH INTERVIEWER NEEDED ................................
LANGUAGE BARRIER (NOT SPANISH) .........................
POSSIBLE PARTICIPATION PROBLEM .........................
UNAVAILABLE DURING FIELD PERIOD ........................
HOSPITALIZED ................................................................
INSTITUTIONALIZED .......................................................
INCARCERATED ..............................................................
(NAME) MOVED ...............................................................
(NAME) DECEASED.........................................................
SWITCH TO AMPLIFIER/CONTINUE ..............................
NO SUCH PERSON AT THIS NUMBER ..........................
OTHER: SUPERVISOR REVIEW NEEDED....................
LIVING OUTSIDE USA .....................................................
REFUSED .........................................................................
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
r
(A55)
(A3)
(HUDI)
(A4)
(A5)
(A13)
(A24)
(A25)
(A25)
(A27)
(A28)
(A65)
(A18)
(A69b)
(A69)
(A24a)
(A69)
SPEAKING TO NAME OR INTERPRETER / NAME OR INTERPRETER COMES TO PHONE / TO
NAME AFTER REMAIL
(A1=01 OR 02)
A2.
{Hello, my name is ________________, calling on behalf of the Social Security Administration.}
Recently, the Social Security Administration sent you a letter saying that someone from
Mathematica Policy Research would be calling to see if you would be eligible to participate in a
special demonstration project for recently disabled persons. Mathematica Policy Research is a
nationally recognized research company based in Princeton, New Jersey. We are conducting a
survey for the Social Security Administration about this special project which is called the
Accelerated Benefits Demonstration or AB. We are not selling anything or asking for
contributions. The interview will take about 40 minutes to complete.
There are no right or wrong answers. 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 now.
CONTINUE........................................................................
(NAME) WILL CALL MPR .................................................
CALL BACK LATER ..........................................................
DID NOT RECEIVE LETTER/
DOES NOT RECALL LETTER.......................................
NEEDS/REQUESTS ASSISTANT ....................................
POSSIBLE PARTICIPATION PROBLEM .........................
REFUSED .........................................................................
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01 (A56)
02 (A67)
03 (A55)
04
05
06
r
(A19)
(A13)
(A13)
(A69)
(REV—5/7/07)
WANTS MORE INFORMATION
(A1=04)
A3.
The Social Security Administration recently sent {you/(NAME)} a letter saying that someone from
Mathematica Policy Research would be calling to see if {you/she/he} would be eligible to
participate in a special demonstration project for recently disabled persons. Mathematica Policy
Research is a nationally recognized research company based in Princeton, New Jersey. We are
conducting a survey for the Social Security Administration about this special project which is
called the Accelerated Benefits Demonstration or AB. We are not selling anything or asking for
contributions.
PROGRAMMER: ALLOW INTERVIEWER TO ACCESS FAQs FROM THIS SCREEN.
SPEAKING ........................................................................
(NAME) COMES TO PHONE ...........................................
CALL BACK LATER ..........................................................
HUNG UP DURING INTRODUCTION..............................
SPANISH INTERVIEWER NEEDED ................................
LANGUAGE BARRIER (NOT SPANISH) .........................
POSSIBLE PARTICIPATION PROBLEM .........................
UNAVAILABLE DURING FIELD PERIOD ........................
HOSPITALIZED ................................................................
INSTITUTIONALIZED .......................................................
INCARCERATED ..............................................................
(NAME) MOVED ...............................................................
(NAME) DECEASED.........................................................
SWITCH TO AMPLIFIER/CONTINUE ..............................
NO SUCH PERSON AT THIS NUMBER ..........................
OTHER: SUPERVISOR REVIEW NEEDED....................
LIVING OUTSIDE USA .....................................................
REFUSED .........................................................................
01
02
03
05
06
07
08
09
10
11
12
13
14
15
16
17
18
r
(A10a)
(A10a)
(A55)
(HUDI)
(A5)
(A13)
(A24)
(A25)
(A25)
(A27)
(A28)
(A65)
(A18)
(A69b)
(A69)
(A24a)
(A69)
SPANISH INTERVIEWER NEEDED
(A1=06) (A3=06)
A4.
Please hold on and I will transfer you to a Spanish speaking interviewer. OR, IF NO SPANISH
INTERVIEWER AVAILABLE, SAY: I will have a Spanish speaking interviewer call you back.
When would be a good time to call?
SPANISH INTERVIEWER AVAILABLE
[EXIT CASE AND TRANSFER CALL] ........................... 01
SPANISH INTERVIEWER NOT AVAILABLE
[GO TO CALL BACK SCREEN AND SET
CALL BACK]................................................................... 02 (A55)
PROGRAMMER: FLAG AS SPANISH CASE
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LANGUAGE BARRIER—NOT SPANISH
(A1=07) (A3=07)
A5.
Can someone there speak English?
ENGLISH SPEAKER COMES TO PHONE ......................
CALL BACK LATER ..........................................................
NO ONE SPEAKS ENGLISH............................................
HUNG UP..........................................................................
REFUSED .........................................................................
01
02
03
04
r
(A55)
(A8)
(HUDI)
(A65a)
POSSIBLE INTERPRETER COMES TO PHONE
(A5=01)
A6.
Hello, my name is _____________, calling on behalf of the Social Security Administration. The
Social Security Administration recently sent (NAME) a letter saying that someone from
Mathematica Policy Research would be calling to see if (he/she) would be eligible to participate in
a special demonstration project for recently disabled persons. Mathematica Policy Research is a
nationally recognized research company based in Princeton, New Jersey. We are conducting a
survey for the Social Security Administration about this special project which is called the
Accelerated Benefits Demonstration or AB. We are not selling anything or asking for
contributions. We are looking for someone who is 18 years or older to help (NAME) by
interpreting the interview for us. Are you 18 years of age or older?
YES ................................................................................... 01
NO ..................................................................................... 00 (A6b)
HUNG UP.......................................................................... 02 (HUDI)
REFUSED ......................................................................... r (A6b)
(A6=01)
A6a.
Would you be able to help (NAME) by interpreting the interview?
YES ................................................................................... 01 (A7)
NO ..................................................................................... 00
INTERPRETER REFUSED............................................... r
(A6=00 OR r) (A6a=00 OR r)
A6b.
Is there someone else 18 years or older who could come to the phone and help with the
interview?
YES, PERSON COMES TO PHONE................................
CALL BACK LATER ..........................................................
NO ONE SPEAKS ENGLISH............................................
HUNG UP..........................................................................
REFUSED .........................................................................
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01
02
03
04
r
(A55)
(A8)
(HUDI)
(A8a)
(REV—5/7/07)
POSSIBLE INTERPRETER 18+ COMES TO PHONE
(A6b=01)
A6c.
Hello, my name is _____________, calling on behalf of the Social Security Administration. Social
Security recently sent (NAME) a letter saying that we would be calling to see if {she/he} would be
eligible to participate in a special demonstration project for recently disabled persons. I work for
Mathematica Policy Research, a nationally recognized research company based in Princeton,
New Jersey. We are conducting a survey for the Social Security Administration about this special
project which is called the Accelerated Benefits Demonstration or AB. We are looking for an
interpreter who is 18 years or older to help (NAME) with the interview. There are no right or
wrong answers. Would you be able to help (NAME) by interpreting the interview?
PROBE: We are not selling anything or asking for contributions.
YES ................................................................................... 01
NO ..................................................................................... 00 (A8a)
POSSIBLE INTERPRETER REFUSED............................ r (A8a)
(A6a=01) (A6c=01)
A7.
If (NAME) is available and you are ready to interpret, we can begin now. If you or (NAME) 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.
CONTINUE........................................................................ 01
CALL BACK LATER .......................................................... 02
POSSIBLE INTERPRETER REFUSED............................ r (A8a)
(A7=01 OR 02)
A7a.
(Before we begin), please tell me your name (so we can ask for you when we call back later).
PROBE: IF PERSON IS RELUCTANT TO GIVE NAME, SAY: The first name is all we need.
FIRST, MIDDLE, LAST
DON’T KNOW ...................................................................
REFUSED .........................................................................
d
r
(A7a=ANSWER, d OR r)
A7b.
What is {your/their} relationship to (NAME)?
(NAME’s) SPOUSE/PARTNER.........................................
(NAME’S} MOTHER..........................................................
(NAME’s) FATHER............................................................
(NAME’s) CHILD ...............................................................
GRANDPARENT OF (NAME)...........................................
BROTHER/SISTER (NATURAL/STEP) OF (NAME) ........
AUNT/UNCLE OF (NAME) ...............................................
OTHER RELATIVE (SPECIFY) ........................................
NOT RELATED .................................................................
STAFF AT RESIDENCE ...................................................
DON’T KNOW ...................................................................
REFUSED .........................................................................
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01
02
03
04
05
06
07
08
09
10
d
r
(A7c)
(A7c)
(A7c)
(A7c)
(A7c)
(A7c)
(A7c)
(A7c)
(A7c)
(A7c)
(A7c)
(REV—5/7/07)
(A7b=08)
A7b_other. How are you related to (NAME)?
DON’T KNOW ...................................................................
REFUSED .........................................................................
d
r
(A7b=ANSWER OR d OR r)
A7c.
PROGRAMMER:
IF A7 = 01 (CONTINUE) ................................................... 01 (A10a)
IF A7=02: CALLBACK TO INTERPRETER ..................... 02 (A55)
(A5=03) (A6b=03)
A8.
I will try to find an interpreter to do the interview. Can you tell me what language (NAME)
speaks?
YES (RECORD LANGUAGE) ........................................... 01 (A55)
____________________________________________
NO (INTERVIEWER: RECORD YOUR BEST
GUESS HERE) (SPECIFY)............................................ 02 (A65a)
____________________________________________
DON’T KNOW ................................................................... d (A65a)
REFUSED ......................................................................... r (A65a)
SEEKING INTERPRETER
(A6b=r) (A6c=00 OR r) (A7=r)
A8a.
Is there someone else, 18 years or older who might be able to interpret the questions for
(NAME)? This could be someone who lives with (NAME) such as a family member or friend, or
someone like a social worker or case worker.
YES ................................................................................... 01
NO ..................................................................................... 00 (A65a)
DON’T KNOW ................................................................... d (A65a)
POSSIBLE INTERPRETER REFUSED............................ r (A65a)
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(A8a=01)
A8b.
What is that person’s name and phone number so we can call and ask for them by name?
NAME: PREFIX, FIRST, MIDDLE, LAST, SUFFIX
PROBE IF NEEDED: We only need the first name.
Please give me the telephone number, area code first.
PHONE NUMBER: ( __ __ __ ) __ __ __ - __ __ __ __
GO TO CALL BACK SCREEN (A55) AND SET CALL BACK
DON’T KNOW ...................................................................
POSSIBLE INTERPRETER REFUSED............................
d (A65a)
r (A65a)
CALL BACK TO NAMED INTERPRETER
(A8b=ANSWER AFTER CALL BACK)
A9.
Hello, my name is ___________________, calling on behalf of the Social Security Administration.
May I please speak to {INTERPRETER’S NAME}?
SPEAKING ........................................................................
INTERPRETER COMES TO PHONE...............................
GATEKEEPER ASKS WHY CALLING .............................
CALL BACK LATER ..........................................................
HUNG UP DURING INTRODUCTION .............................
INTERPRETER REFUSED...............................................
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01
02
03
04 (A55)
05 (HUDI)
r (A65a)
(REV—5/7/07)
(A9=01 OR 02 OR 03)
A10.
{IF A9=02 DISPLAY: Hello, my name is ________________, calling on behalf of the Social
Security Administration.} I’m calling {you/INTERPRETER} because {your/his/her} name was
given as someone who might be able to help (NAME) participate in a survey we’re doing for
Social Security by interpreting for {him/her}. Let me tell you about the survey… BRIEF PAUSE.
Recently, the Social Security Administration sent (NAME) a letter saying that someone from
Mathematica Policy Research would be calling to see if {you/(NAME)} would be eligible to
participate in a special demonstration project for recently disabled persons. I work for
Mathematica Policy Research, a nationally recognized research company based in Princeton,
New Jersey. We are conducting a survey for the Social Security Administration about this special
project which is called the Accelerated Benefits Demonstration or AB. We are not selling
anything or asking for contributions.)
If (NAME) is available and you are ready to interpret, we can begin now. If you or (NAME) 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.
YES, CONTINUE ..............................................................
CALL BACK LATER ..........................................................
WANTS MORE INFORMATION .......................................
HUNG UP DURING INTRODUCTION..............................
INTERPRETER REFUSED...............................................
01
02 (A55)
03 (FAQs, THEN A10a)
04 (HUDI)
r (A65a)
PROGRAMMER: MAKE FAQs AVAILABLE FROM THIS SCREEN.
SPEAKING TO NAME OR INTERPRETER/NAME OR INTERPRETER COMES TO PHONE/AMPLIFIER
TURNED ON/SPEAKING TO NAME AFTER REMAIL
(A3=01 OR 02) (A10=01 OR 03)
A10a. PROGRAMMER: IF A3=02, START HERE: (Hello, my name is __________________ calling on
behalf of the Social Security Administration.} Recently, Social Security sent {you/(NAME)} a letter
saying that someone from Mathematica Policy Research would be calling to see if {you/(NAME)}
would be eligible to participate in a special demonstration project for recently disabled persons. I
work for Mathematica Policy Research, a nationally recognized research company based in
Princeton, New Jersey. We are conducting a survey for the Social Security Administration about
this special project which is called the Accelerated Benefits Demonstration or AB. We are not
selling anything or asking for contributions.)
PROGRAMMER: IF A3=01, A7c=01, OR A10=01 OR 03, START HERE: The interview will take
about 40 minutes to complete. There are no right or wrong answers. 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 now.
CONTINUE........................................................................
(NAME) WILL CALL MPR .................................................
CALL BACK LATER ..........................................................
DID NOT RECEIVE LETTER/
DOES NOT RECALL LETTER.......................................
NEEDS/REQUESTS ASSISTANT ....................................
POSSIBLE PARTICIPATION PROBLEM .........................
REFUSED .........................................................................
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01 (A56)
02 (A67)
03 (A55)
04
05
06
r
(A19)
(A13)
(A13)
(A69)
(REV—5/7/07)
NAME OR UNKNOWN INFORMANT CALLS IN
A11.
INTERVIEWER: WHO CALLED IN? CODE BASED ON SUPERVISOR INSTRUCTION.
(NAME)..............................................................................
(NAME) USING TTY .........................................................
(NAME) USING RELAY ....................................................
INFORMANT/POSSIBLE ASSISTANT .............................
01
02
03
04 (A13a)
(A11=01, 02, OR 03)
A12.
Hello, my name is ________________________. Thanks for calling in. I’ll be your interviewer
today. The Accelerated Benefits Demonstration Survey is about your health, insurance coverage,
and employment prior to becoming disabled. The information you and other participants give us
will be used to determine your eligibility for the project and will improve Social Security’s
programs for disabled persons.
The interview {will take about 40 minutes/2 - 3 hours because we are using TTY/Relay.} There
are no right or wrong answers. If you get tired and 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 now.
CONTINUE........................................................................
WANTS TO SCHEDULE INTERVIEW..............................
NEEDS/REQUESTS ASSISTANT ....................................
POSSIBLE PARTICIPATION PROBLEM .........................
REFUSED .........................................................................
01 (A56)
02 (A55)
03
04
r (A69)
DIFFICULTY PARTICIPATING (SPEAKING WITH NAME/INFORMANT/UNKNOWN ASSISTANT WHO
CALLS IN)
(A1=08) (A2=05 OR 06) (A3=08) (A10a=05 OR 06) (A12=03 OR 04)
A13.
INTERVIEWER: WHO ARE YOU SPEAKING WITH?
SAMPLE MEMBER/(NAME) ............................................. 01
INTERPRETER ................................................................. 02
INFORMANT/POSSIBLE ASSISTANT ............................. 03
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(A11=04) (A13=01, 02, OR 03)
A13a. INTERVIEWER: IF BARRIER KNOWN, CONFIRM BY SAYING: (Just to confirm),
{You have a/NAME has a}
OR
{You are/(NAME) is} FILL APPROPRIATE CATEGORY.
{PROGRAMMER IF A11=04, USE: Thank you very much for calling and offering to help
(because of (NAME’s) {FILL KNOWN BARRIER}). IF NEEDED: What problem does (NAME)
have that might prevent {him/her} from participating for {himself/herself}?
PROBE: What kind of difficulty or barrier {do you/does (NAME)} have?
INTERVIEWER: IF MORE THEN ONE PROBLEM, PROBE: What would you say is the main
reason {you/(NAME)} cannot participate in this interview.
CODE ONE
HEARING DIFFICULTY .................................................... 01
SPEECH DIFFICULTY...................................................... 02
COGNITIVE BARRIER...................................................... 03
PHYSICAL BARRIER........................................................ 04
HOSPITALIZED ................................................................ 06 (A25)
INSTITUTIONALIZED ....................................................... 07 (A25)
INCARCERATED .............................................................. 08 (A27)
DECEASED....................................................................... 09 (A65)
LIVING OUTSIDE USA ..................................................... 10 (A24a)
DON’T KNOW ................................................................... d (A14)
REFUSED ......................................................................... r (A69)
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(A13a=01, 02, 03, 04, OR d)
A14.
(IF A1=08 OR A3=08 SAY: Recently, the Social Security Administration sent {you/(NAME)} a
letter saying that someone from Mathematica Policy Research would be calling to see if
{you/he/she} would be eligible to participate in a special demonstration project for recently
disabled persons. Mathematica Policy Research is a nationally recognized research company
based in Princeton, New Jersey. We are conducting a survey for the Social Security
Administration about this special project which is called the Accelerated Benefits Demonstration
Project or AB.) It is important that {you/(NAME)} participate(s) in the survey so that we can
determine if {you/he/she} is eligible for AB. We’d like to work with you (and (NAME)) to help
{you/him/her} participate and see if {you are/he is/she is} eligible. To help {you/(NAME)}
participate, we can make a few adjustments. Please tell me which one will work best or be the
easiest for you. [READ CHOICES 01 TO 06 BELOW] . .
CODE ONE
I can break the interview into a few short calls, ................ 01 (A17)
{PROGRAMMER: DISPLAY 02 ONLY IF A13a=01 OR 02}
I can have someone call you from an amplifier
phone in a few minutes, ................................................. 02 (A18)
{PROGRAMMER: DISPLAY 03 ONLY IF A13a=01}
I can have someone call you in a few minutes
using Relay or TTY,........................................................ 03 (A18)
{PROGRAMMER: DISPLAY 04 ONLY IF A13=03}
IF SPEAKING WITH INFORMANT:
You could help NAME answer questions for
(himself/herself), or......................................................... 04 (A42)
You could give us the name of someone else who
could help {you/(NAME)}answer questions.................... 05 (A40)
Or, do you have another way? (SPECIFY) ...................... 06
DON’T KNOW ...................................................................
REFUSED .........................................................................
d (A40)
r (A69)
(A14=07)
A15.
What way is that?
DON’T KNOW ...................................................................
REFUSED .........................................................................
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d (A40)
r (A69)
(REV—5/7/07)
(A15=ANSWER)
A16.
Thank you. I will ask my supervisor if that would work. Someone will call {you/(NAME)} back and
let you know.
GO TO CALL BACK SCREEN AT A55
(A14=01)
A17.
If {you are/(NAME) is} ready now, we can begin.
YES, READY..................................................................... 01 (A56)
NO, CALL BACK LATER .................................................. 00 (A49)
(A1=15) (A3=15) (A14=02 OR 03)
A18.
We will switch to our {amplifier phone/TTY operator/Relay operator} and contact you in a few
minutes.
PROBE: PROBE FOR TTY OR RELAY IF UNCLEAR.
INTERVIEWER: IF "SWITCH IN A FEW MINUTES," CALL SUPERVISOR FOR HELP.
CALL BACK—FEW MINUTES (AMPLIFIER) ...................
CALL BACK—FEW MINUTES (TTY) ...............................
CALL BACK—FEW MINUTES (RELAY) ..........................
NO, CALL BACK LATER (AMPLIFIER) ............................
NO, CALL BACK LATER (TTY) ........................................
NO, CALL BACK LATER (RELAY) ...................................
NO, CALL BACK (GENERAL) ..........................................
HUNG UP..........................................................................
DON’T KNOW ...................................................................
REFUSED .........................................................................
01
02
03
04
05
06
07
08
d
r
(A55) FLAG AMP
(A55) STORE TTY INFO
(A55) STORE RELAY INFO
(A55) FLAG AMP
(A55) STORE TTY INFO
(A55) STORE RELAY INFO
(A55)
(HUDI)
(A55)
(A65a)
INTERVIEWER: IF A18=01, EXIT CASE AND
TRANSFER CALL
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NAME REQUESTS LETTER
(A2=04) (A10a=04)
A19.
The letter was from the Social Security Administration and said that someone from Mathematica
Policy Research would be calling to see if you would be eligible to participate in a special
demonstration project for recently disabled persons. I work for Mathematica Policy Research.
We are conducting a survey for the Social Security Administration about this special project which
is called the Accelerated Benefits Demonstration or AB. The AB Survey is about your health,
insurance coverage, and employment prior to becoming disabled. The information you and other
participants give us will be used to improve programs for disabled persons. We are not selling
anything or asking for contributions. If you like, I can read the letter to you now and we can start
the interview. I will also mail you another copy. You should receive the letter in about a week.
Let’s get started. Should I read the letter?
DO NOT READ LETTER, CONTINUE..............................
READ LETTER, CONTINUE.............................................
CALL BACK LATER ..........................................................
NO, WANTS LETTER MAILED.........................................
REFUSED .........................................................................
01
02
03
00
r
(A56)
(A55)
(A20)
(A69)
(A19=02)
A19a. PROGRAMMER: LOAD ADVANCE LETTER HERE.
INTERVIEWER: READ ADVANCE LETTER TO RESPONDENT.
GO TO A56
(A19=00)
A20.
I want to make sure we have your correct name and address. The records show… (READ
PRELOADED NAME/ADDRESS). Is this correct?
PROGRAMMER: DISPLAY NAME FROM PRELOADS
NAME: PREFIX, FIRST, MIDDLE, LAST, SUFFIX
ADDRESS 1
ADDRESS 2
CITY, STATE, ZIP
YES ................................................................................... 01 (A68)
NO ..................................................................................... 00
HUNG UP.......................................................................... 02 (HUDI)
REFUSED ......................................................................... r (A69)
(A20=00)
A21.
Is the name wrong, the address wrong, or are both wrong?
NAME WRONG................................................................. 01
ADDRESS WRONG.......................................................... 02 (A22a)
BOTH WRONG ................................................................. 03
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(A21=01 OR 03)
A22.
What is your correct name? I need to confirm that you are the same (NAME) as in our records.
PROBE: Did you get married or change your name?
RECORD NEW NAME:
YES, SAME PERSON—CONFIRMED ............................. 01
NO/NOT CONFIRMED...................................................... 00 (A22b)
HUNG UP.......................................................................... 02 (HUDI)
REFUSED ......................................................................... r (A69)
IF A21=01, GO TO A68
IF A21=03, GO TO A22a
(A21=02 OR 03)
A22a. What is your correct address? ENTER BELOW
ADDRESS 1 ...................................................................... 01
ADDRESS 2 ...................................................................... 02
CITY, STATE, ZIP ............................................................. 03
GO TO A68
(A22=00)
A22b. Thank you. I’ll need to check with my supervisor and get back to you.
PROGRAMMER: FLAG FOR SUPERVISOR
REVIEW
(A22a=ANSWER)
A23.
INTERVIEWER: IS STATE IN THE U.S. OR DC?
YES ................................................................................... 01 (A56)
NO ..................................................................................... 00
(A23=00)
A23a. I might have recorded the address wrong. Is the correct address outside the United States?
YES ................................................................................... 01 (A24a)
NO ..................................................................................... 00 (FIX A20 THEN GO TO A56)
REFUSED ......................................................................... r (A69)
PROGRAMMER: STORE CHANGES IN UPDATE; DO NOT OVERWRITE
OLD INFO.
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INELIGIBLE (INTERIM/POSSIBLE FINAL)
(A1=09) (A3=09)
A24.
Please tell me why {you/(NAME)} will not be available to participate in the survey.
NOTE: PROGRAMMER, THESE CASES ARE INTERIM UNTIL AFTER SUPERVISOR
REVIEW. THEY WILL NOT CYCLE THROUGH THE SCREENER AGAIN UNLESS
SUPERVISOR/PROGRAMMER RESETS CASE STATUS.
INTERVIEWER: PRESS ENTER TO CONTINUE.
WILL BE HOSPITALIZED .................................................
INCARCERATED ..............................................................
WILL BE INSTITUTIONALIZED........................................
LIVING OUTSIDE THE USA.............................................
DECEASED.......................................................................
OTHER BARRIER (SPECIFY)..........................................
01
02
03
04
05
06
(A25)
(A27)
(A25)
(A65)
(A66)
(A1=18) (A3=18) (A13a=10) (A23b=01) (A24=04)
A24a. When do you expect (NAME) to return to live in the U.S.?
| | |/| 2 | 0 | |
MONTH
YEAR
|
NEVER .............................................................................. 00
(A24a=ANSWER)
A24b. INTERVIEWER: IS DATE DURING FIELD PERIOD – BY JANUARY 2008?
YES ................................................................................... 01 (A24c)
NO ..................................................................................... 00 (A24d)
A24c.
Thank you. We will call back when (NAME) returns.
GO TO A55 AND SCHEDULE CALL BACK
(A24a=00) (A24b=00)
A24d. I’m sorry, but (we are not able to enroll persons who live outside the U.S. in AB at this time/we will
not be interviewing for AB at that time). Thank you for your time. Have a nice day.
EXIT CASE
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NAME INSTITUTIONALIZED/HOSPITALIZED
(A1=10 OR 11) (A3=10 OR 11) (A13a=06 OR 07) (A24=01 OR 03)
A25.
I’m sorry to hear that. Until what date will (NAME) be staying there?
PROBE: Your best estimate is fine.
| | |/| 2 | 0 | | |
MONTH
YEAR
PERMANENTLY ............................................................... 01
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r
(A25=ANSWER)
A26.
I understand that (NAME) is not able to be at home just now. In order to help {him/her}
participate, we could make some adjustments. Please tell me what would work best.
{PROGRAMMER: DISPLAY 01 ONLY IF RETURN EXPECTED BY [MONTH, YEAR FIELD PERIOD
STARTS + 12 MONTHS]}
CODE ONE
We could call after {he/she} returns home and
is feeling better, .............................................................. 01 (A55)
If (NAME) is well enough, we can call {him/her}
at the institution or hospital, or ....................................... 02
Someone could help NAME answer questions
for (himself/herself)......................................................... 03 (A40)
(NAME) TOO ILL............................................................... 04 (A66)
DON’T KNOW ................................................................... d (A40)
REFUSED ......................................................................... r (A65a)
(A1=12) (A3=12) (A13a=08) (A24=02) (A26=02 OR 03)
A27.
Please tell me the name and phone number of the place where I can contact (NAME). If you
don’t have all the information, please tell me what you can.
NAME OF INSTITUTION/HOSPITAL
Please tell me the telephone number starting with the area code first.
PHONE NUMBER: { __ __ __ ) __ __ __ - __ __ __ __
DON’T KNOW ...................................................................
REFUSED .........................................................................
d (A40)
r (A65a)
PROGRAMMER: STORE NAME OF HOSPITAL OR INSTITUTION
AND PHONE NUMBER IN LOCATOR, AND GO TO A70
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NEW CONTACT INFORMATION FOR NAME
(A1=13) (A3=13)
A28.
Do you know how I can reach (NAME)?
YES ................................................................................... 01
NO ..................................................................................... 00 (A34)
REFUSED ......................................................................... r (A34)
(A28=01)
A29.
Please tell me {his/her} new address and phone number. Also, if (NAME’s) name has changed
please tell me the new name.
PROBE: If you don’t have all the information please tell me what you can.
NAME: PREFIX, FIRST, MIDDLE, LAST, SUFFIX
ADDRESS 1
ADDRESS 2
CITY, STATE, ZIP
Please tell me the telephone number starting with the area code first.
TELEPHONE:
|
|
|
|-|
|
|
|-|
|
|
DON’T KNOW ...................................................................
REFUSED .........................................................................
|
|
d (A32)
r (A32)
(A29=ADDRESS)
A30.
PROGRAMMER CHECK A29: IS STATE OUTSIDE THE UNITED STATES AND DC?
YES (OUTSIDE USA) ....................................................... 01
NO (INSIDE USA) ............................................................. 00
(FIX A29, THEN GO TO A32)
(A30=01)
A31.
When do you expect (NAME) to return to live in the U.S.?
| | |/| 2 | 0 |
MONTH
YEAR
|
|
NEVER .............................................................................. 00 (A31c)
(A31=ANSWER)
A31a. INTERVIEWER: IS DATE DURING FIELD PERIOD?
YES ................................................................................... 01 (A31b)
NO ..................................................................................... 00 (A31c)
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A31b. Thank you. We will call back when (NAME) returns.
GO TO A55 AND SCHEDULE CALL BACK
(A31=00) (A31a=00)
A31c.
I’m sorry, but (we are not able to enroll persons who live outside the U.S. in AB at this time/we will
not be interviewing for AB at that time). Thank you for your time. Have a nice day.
EXIT CASE
(A29=d or r) (A30=00)
A32.
PROGRAMMER CHECK: DOES A29 CONTAIN A VALID PHONE NUMBER?
YES ................................................................................... 01 (A70)
NO ..................................................................................... 00
(A32=00)
A33.
Is there a better telephone number where I can reach (NAME)?
YES, RECORD BELOW ................................................... 01 (A70)
NO ..................................................................................... 00 (A65a)
TELEPHONE:
|
|
|
|-|
|
|
|-|
|
|
DON’T KNOW ...................................................................
REFUSED .........................................................................
|
|
d (A65a)
r (A65a)
PROGRAMMER: IF A33=01 STORE (NAME) CONTACT DATA IN
LOCATOR, AND GO TO A70
PROGRAMMER: FLAG FOR LOCATING.
LEAD INFORMATION
(A28=00 OR r)
A34.
Is there someone else who might know how to reach (NAME)?
YES ................................................................................... 01
NO ..................................................................................... 00 (A65a)
DON’T KNOW ................................................................... d (A65a)
REFUSED ......................................................................... r (A65a)
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(A34=01)
A35.
What’s that person’s name and phone number?
PROBE: If you don’t have all the information, please tell me what you can.
PREFIX, FIRST, MIDDLE, LAST, SUFFIX
Please give me the telephone number, starting with the area code first.
TELEPHONE: |
|
|
|-|
|
|
|-|
|
|
|
| (A70)
DON’T KNOW ...................................................................
REFUSED .........................................................................
d (A65a)
r (A65a)
PROGRAMMER: STORE NAME AND PHONE INFORMATION IN
LOCATOR = LEADS; DO NOT OVERWRITE
A36.
Let me confirm {your/(NAME’s)} address. Is it still… READ BELOW
PROGRAMMER: DISPLAY NAME’S CONTACT INFORMATION FROM PRELOADED
INFORMATION
PREFIX, FIRST, MIDDLE, LAST, SUFFIX
ADDRESS 1
ADDRESS 2
CITY, STATE, ZIP
UPDATE PHONE NUMBER
YES ................................................................................... 01
NO ..................................................................................... 00 (UPDATE AND GO
TO A39)
REFUSED ......................................................................... r (A69)
PROGRAMMER: STORE UPDATE NAME AND PHONE INFORMATION IN
LOCATOR = LEADS; DO NOT OVERWRITE
(A36=01 OR 00)
A37.
If {your/(NAME’s)} current address or phone number will change within the next month or so,
please tell me the new address and phone number.
NO CHANGES EXPECTED.............................................. 01 (A70)
ADDRESS OR PHONE WILL CHANGE........................... 02
DON’T KNOW ................................................................... d (A69)
REFUSED ......................................................................... r (A69)
PROGRAMMER: STORE UPDATED INFORMATION IN UPDATE
ADDRESS BLOCK; DO NOT OVERWRITE
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(A37=02)
A38.
Please tell me what {your/(NAME’s)} new address and/or phone number will be.
PREFIX, FIRST, MIDDLE, LAST, SUFFIX
ADDRESS 1
ADDRESS 2
CITY, STATE, ZIP
UPDATE PHONE NUMBER
DON’T KNOW ...................................................................
REFUSED .........................................................................
d (A65a)
r (A65a)
(A38=INFO)
A39.
On what date will we be able to reach {you/(NAME)} at this new {ADDRESS AND PHONE NUMBER}?
| | |/| | |/|
MONTH DAY
|
| |
YEAR
|
DON’T KNOW ...................................................................
REFUSED .........................................................................
(A70)
d (A65a)
r (A65a)
SEEKING ASSISTANT
(A14=06 OR d) (A15a=d) (A26=04, 05, OR d) (A27=d)
A40.
(IF A14=05 OR d, SAY: Who else/OTHERWISE SAY: Is there someone (else) who) can help
{you/(NAME)} answer questions about {your/(NAME’s)} health and daily activities? This could be
someone who lives with {you/(NAME)} such as a family member or friend, or someone like a
social worker or case worker.
INFORMANT WILL SERVE AS ASSISTANT ...................
ASSISTANT COMES TO PHONE ....................................
ASSISTANT NOT AVAILABLE NOW ...............................
ASSISTANT LIVES ELSEWHERE ...................................
NO ASSISTANT AVAILABLE ...........................................
DON’T KNOW ...................................................................
REFUSED .........................................................................
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19
01
02
03
04
05
d
r
(A49)
(A45)
(A65a)
(A65a)
(A65a)
(REV—5/7/07)
ASSISTANT COMES TO PHONE (INFORMANT WILL ASSIST)
(A40=01 OR 02)
A41.
{IF A40 =02, USE Hello, my name is __________________, calling on behalf of the Social
Security Administration.} Are you someone who can help NAME answer questions about
(his/her) health and daily activities?
YES ...................................................................................
WANTS MORE INFORMATION .......................................
NO .....................................................................................
DON’T KNOW ...................................................................
REFUSED .........................................................................
01
02
00 (A44)
d (A44)
r (A65a)
PROGRAMMER: MAKE FAQs AVAILABLE FROM THIS SCREEN.
(A41=01, 02) (A14=04)
A42.
What is your name?
PROBE IF NEEDED: We only need your first name.
NAME: PREFIX, FIRST, MIDDLE, LAST, SUFFIX
DON’T KNOW ...................................................................
REFUSED .........................................................................
d
r
PROGRAMMER: STORE ASSISTANT NAME IN UPDATE ADDRESS BLOCK.
(A42=ANSWER, d OR r)
A43.
What is your relationship to (NAME)?
(NAME’S) SPOUSE/PARTNER ........................................
(NAME’S) MOTHER..........................................................
(NAME’S) FATHER ...........................................................
(NAME’S) CHILD...............................................................
GRANDPARENT OF (NAME)...........................................
BROTHER/SISTER (NATURAL/STEP)
OF (NAME).....................................................................
AUNT/UNCLE OF (NAME) ...............................................
OTHER RELATIVE (SPECIFY) ........................................
NOT RELATED .................................................................
STAFF AT RESIDENCE ...................................................
DON’T KNOW ...................................................................
REFUSED .........................................................................
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20
01
02
03
04
05
(A47)
(A47)
(A47)
(A47)
(A47)
06
07
08
09
10
d
r
(A47)
(A47)
(A47)
(A47)
(REV—5/7/07)
(A43=08, d or r))
A43_other. How are you related to (NAME)?
DON’T KNOW ...................................................................
REFUSED .........................................................................
d
r
GO TO A47
(A41=00 OR d)
A44.
(The Social Security Administration recently sent (NAME) a letter saying that we would be calling
to see if {she/he} would be eligible to participate in a special demonstration project for recently
disabled persons. I work for Mathematica Policy Research, a nationally recognized research
company based in Princeton, New Jersey. We are conducting a survey for the Social Security
Administration about this special project which is called the Accelerated Benefits Demonstration
or AB. We are not selling anything or asking for contributions.) Is there someone else who
knows about (NAME’s) health and daily activities?
YES ................................................................................... 01
REQUESTS LETTER........................................................ 02 (A68)
NO OTHER ASSISTANT AVAILABLE.............................. 00 (A65a)
REFUSED ......................................................................... r (A65a)
ANOTHER ASSISTANT LIVES ELSEWHERE
(A40=04) (A44=01)
A45.
What is this person’s name and phone number?
PROBE: If you don’t have all the information, please tell me what you have.
PREFIX, FIRST, MIDDLE, LAST, SUFFIX
DON’T KNOW ...................................................................
REFUSED .........................................................................
d
r (A65a)
Please give me the telephone number, starting with the area code first.
TELEPHONE: |
|
|
|-|
|
|
|-|
|
|
|
|
DON’T KNOW ...................................................................
REFUSED .........................................................................
d (A65a)
r (A65a)
PROGRAMMER: STORE ASSISTANT CONTACT INFORMATION IN LOCATING
DATABASE, GO TO A70
(A45=INFO)
A46.
PROGRAMMER: IS THERE A VALID PHONE NUMBER AT A45?
YES ................................................................................... 01 (A70)
NO ..................................................................................... 00
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(A46=00)
A46a. Is there a better telephone number where I can reach (NAME)?
YES, RECORD BELOW ................................................... 01
NO ..................................................................................... 00
TELEPHONE: |
|
|
|-|
|
|
|-|
|
|
|
|
DON’T KNOW ...................................................................
REFUSED .........................................................................
d (A65a)
r (A65a)
GO TO A70
SPEAKING WITH ASSISTANT
(A43=ANSWER, d OR r)
A47.
The interview will take about 40 minutes. We can start now. If you or (NAME) get(s) tired or
need(s) a break at any time, please tell me and we will call back later to finish the interview.
CONTINUE........................................................................ 01
CALL BACK LATER .......................................................... 02 (A49)
ASSISTANT WANTS LETTER ......................................... 03 (A52)
REFUSED ......................................................................... r (A69)
(A47=01)
A48.
Before we start please tell me your name.
(A17=00) (A40=03) (A47=02)
A49.
Please tell me (that person’s name/your name) so we can ask for (you/them) by name when we
call back.
PROBE: Your first name is fine.
PREFIX, FIRST, MIDDLE, LAST, SUFFIX
DON’T KNOW ...................................................................
REFUSED .........................................................................
d
r
IF A47=01, GO TO A50
IF A47=02, GO TO A55
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ASSISTANT COMES TO PHONE
(A47=01)
A50.
{USE Hello, my name is ________________, calling on behalf of the Social Security
Administration.} Recently, Social Security sent (NAME) a letter saying that we would be calling to
see if {he/she} would be eligible to participate in a special demonstration project for recently
disabled persons. I work for Mathematica Policy Research, a nationally recognized research
company based in Princeton, New Jersey. We are conducting a survey for the Social Security
Administration about this special demonstration project which is called the Accelerated Benefits
Demonstration or AB. We were told that you can help (NAME) answer questions about (his//her)
health and daily activities.
The interview will take about 40 minutes. In appreciation, we will mail [NAME] a check for $25.00
when we finish the interview. Would you be able to help us?
CONTINUE........................................................................
CALL BACK LATER ..........................................................
SEEK ANOTHER ASSISTANT .........................................
WANTS LETTER SENT ....................................................
DON’T KNOW ...................................................................
REFUSED .........................................................................
01
02
03
04
d
r
(A51)
(A53)
(A52)
(A53)
(A69)
(A50=01 OR 02)
A51.
{IF (A49=01) Before we start,} Please tell me your name {IF (A49=02) so we can call back and
ask for you.}
PREFIX, FIRST, MIDDLE, LAST, SUFFIX
REFUSED .........................................................................
r
IF A50=01, GO TO A56
IF A50=02, GO TO A55
(A50=04)
A52.
Please tell me your name and address so we can mail the letter to you.
PREFIX, FIRST, MIDDLE, LAST, SUFFIX
ADDRESS 1
ADDRESS 2
CITY, STATE, ZIP CODE
PROGRAMMER: STORE ASSISTANT INFORMATION IN LOCATING
DATABASE, GO TO A68
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SEEK ANOTHER ASSISTANT - CONTACT INFORMATION
(A50=03 OR d)
A53.
Can you give me the name and phone number for someone else who might be able to help
(NAME) answer questions about (his/her) health and daily activities?
YES ................................................................................... 01
NO ..................................................................................... 00 (A65a)
DON’T KNOW ................................................................... d (A65a)
REFUSED ......................................................................... r (A65a)
(A53=01)
A54.
What is that person’s (name and) telephone number?
PROBE FOR A52=01 ONLY: If you don’t have all the information, please tell me what you have.
PREFIX, FIRST, MIDDLE, LAST, SUFFIX
DON’T KNOW ...................................................................
REFUSED .........................................................................
d
r
Please give me the telephone number, starting with the area code first.
TELEPHONE: |
|
|
|-|
|
|
|-|
|
|
|
| |(A69)
DON’T KNOW ...................................................................
REFUSED .........................................................................
d (A65a)
r (A65a)
PROGRAMMER: STORE ASSISTANT INFORMATION IN LOCATING DATABASE
CALL BACK LATER TO SAME NUMBER (INTERIM)
(A1=03) (A2=03) (A3=03) (A4=02) (A5=02) (A6b=02) (A7d=02) (A8a=01) (A8c=INFO) (A9=04) (A10=02) (A10a=03)
(A12=02) (A16=ANSWER) (A18=02, 03, 04, 05, 06, 07, OR d) (A19=03) (A26=01) (A50=02)
A55.
I’d be happy to call {you/(NAME)} back at a more convenient time. Please tell me when I should
call again.
IF A4=02, SAY:
I will have a Spanish interviewer call {you/(NAME)} back. When will be a good
time to call?
IF A8a=01, SAY:
I will have a {FILL LANGUAGE} interviewer call {you/(NAME)} back. When
will be a good time to call?
PROGRAMMER: SEND TO CALL BACK SCREEN AND INTERVIEWER WILL SET CALL
BACK STATUS THERE.
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(A2=01) (A10a=01) (A12=01) (A17=01) (A19=01) (A19a=ANSWER) (A23a=01) (A23b=00) (A44b=01) (A50=01) (A51=ANSWER)
A56.
INTERVIEWER: WHO ARE YOU SPEAKING WITH?
(NAME).............................................................................. 01
INTERPRETER ................................................................. 02
ASSISTANT ...................................................................... 03
(A56=ANSWER)
A57.
Before we start, I need to confirm that I’ve reached the right person. Is {your/(NAME’s)} full name
{FILL FROM PRELOADS}?
PROGRAMMER: IF A56=01, PRELOAD (NAME’S) INFO. IF A56=02,
PRELOAD INTERPRETER’S INFO. IF A56=03, PRELOAD ASSISTANT INFO.
YES ................................................................................... 01 (A59)
NAME CHANGED ............................................................. 02
NO ..................................................................................... 00 (A64)
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r
(A57=02,00, d, OR r)
A58.
For the record, what is {your/(NAME’s)} (new) name?
NAME
IDENTITY CONFIRMED ................................................... 01
IDENTITY NOT CONFIRMED .......................................... 02 (A64)
DON’T KNOW ................................................................... d (A64)
REFUSED ......................................................................... r (A64)
PROGRAMMER: STORE NAME CHANGE IN NAME UPDATE BLOCK
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(A57=01)
A59.
And in what state {are you/is (NAME)} now living?
CAPI INTERVIEWER: DO NO READ QUESTION: RECORD STATE BELOW AND CONTINUE.
STATE |
|
| TWO LETTER CODE
DON’T KNOW ...................................................................
REFUSED .........................................................................
d
r
PROGRAMMER: STORE STATE CHANGE FOR USE IN
FUTURE QUESTIONS AT STATE UPDATE BLOCK
A60.
What is {your/(NAME’s)} date of birth?
| | |
MONTH
(1 – 12)
|
| |
DAY
(1 - 31)
|
|
| | |
YEAR
(1939 – 1988)
(A62)
DON’T KNOW ...................................................................
REFUSED .........................................................................
d
r
(A60=d OR r)
A60a. How old {are you/is (NAME)}?
PROBE: Your best guess is fine.
RECORD AGE: ................................................................. |
DON’T KNOW ...................................................................
|
| YEARS (18 – 67)
d
(A60=ANSWER OR d)
A61.
PROGRAMMER: IS A60 AGE=+2 OR – 2 YEARS OF NAME’S AGE?
YES ................................................................................... 01 (A63)
NO ..................................................................................... 00
(A60=ANSWER)
A62.
PROGRAMMER CHECK BIRTHDATE: IS MONTH, DAY, YEAR OF BIRTH AT A60=MONTH,
DAY, AND YEAR OF BIRTH ON RECORD?
NO MATCH .......................................................................
1 MATCHES......................................................................
2 MATCH...........................................................................
3 MATCH...........................................................................
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00
01
02
03
(REV—5/7/07)
(A61=01)
A63.
PROGRAMMER CHECK: IS (NAME’s) IDENTITY VERIFIED AND IS BIRTHDATE VERIFIED?
YES (VERIFIED) ............................................................... 01 (A71)
NO (FAILED VERIFICATION)........................................... 00
(A57=00, d OR r) (A58=02, d OR r) (A63=00)
A64.
Thanks for your patience. There seems to be a problem with my information. I need to check
with my supervisor about what to do next. Someone from MPR will get back to you. Good-bye.
Thank you.
(A1=14) (A3=14) (A13a=09) (A24=05)
A65.
I am sorry to hear (NAME) has passed away. I was calling about a study we are conducting for
the Social Security Administration. You might have seen a letter we recently sent (NAME)
explaining the study. When did (NAME) pass away?
| | |
MONTH
(1 – 12)
|
| |
DAY
(1 - 31)
|
|
| | |
YEAR
(2005 – 2006)
DON’T KNOW ...................................................................
REFUSED .........................................................................
d
r
Thank you. Please accept my condolences. Good-bye.
(A5=r) (A6b=r) (A6d=r) (A8a=02, d, OR r) (A8b=00, d OR r) (A8c=d OR r) (A9=r) (A10=r) (A18=r) (A26=r) (A27=r) (A33=00, d, OR r)
(A34=00, d, OR r) (A35=d OR r) (A39a=d OR r) (A39b=d OR r) (A40=05, d OR r) (A41=r) (A45=r) (A46=r) (A46a=d OR r)
(A49=r) (A53=00, d, OR r) (A54=d OR r)
A65a. Please write down my toll free number and give it to someone who might know about (NAME’s)
health and daily activities so they can get more information about the study. The toll free number
is 866-275-8659.
GO TO A69
BARRIERS TO PARTICIPATION – (INTERIM NON-RESPONSE/POSSIBLE FINAL NON-RESPONSE)
(A1=18) (A3=18) (A24=06) (A30a=ANSWER) (A31=01)
A66.
Thank you very much for explaining. Those are all the questions I have. Thanks for your time.
Good-bye.
INTERVIEWER: PRESS ENTER TO CONTINUE
HOSPITALIZED ................................................................
INSTITUTIONALIZED .......................................................
COGNITIVE BARRIER......................................................
HEARING/SPEECH BARRIER .........................................
PHYSICAL BARRIER........................................................
UNAVAILABLE DURING FP.............................................
FINAL LANGUAGE BARRIER ..........................................
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01
02
03
04
05
06
07
(REV—5/7/07)
RESPONDENT WILL CALL MPR (INTERIM)
(A2=02) (A10a=02) (A17=05 OR 06)
A67.
Thanks for offering to call in. Please write down our toll-free number. It is 866-275-8659. We are
available days, evenings, and weekends. Please ask for Amy Bates when you call. If you call
after hours, please leave a message and we will get back to you the next day.
INTERVIEWER: PRESS ENTER TO CONTINUE
(NAME) WILL CALL .......................................................... 01
(NAME) WILL CALL/TTY .................................................. 02
(NAME) WILL CALL/RELAY ............................................. 03
REQUEST FOR LETTER (INTERIM)
(A20=01) (A22=ANSWER) (A22a=ANSWER)
A68.
You should receive the letter in about a week. Thank you for your time. Good-bye.
INTERVIEWER: PRESS 1 TO CONTINUE
(NAME) REQUESTS LETTER.......................................... 01
ASSISTANT REQUESTS LETTER................................... 02
REFUSAL THANKS (INTERIM/FINAL)
(A1=17 OR r) (A2=r) (A3=17 OR r) (A10a=r) (A12=r) (A13a=r) (A14=r) (A15=r) (A19=r) (A20=r) (A22=r) (A23b=r) (A38=r)
(A39=d OR r) (A47=r) (A50=r) (A54=INFO) (A65a=ANSWER)
A69.
Thank you for your time. Have a nice day. Good-bye.
PROGRAMMER: FLAG FOR SUPERVISOR REVIEW.
(A69=ANSWERED)
A69a. INTERVIEWER: CODE REFUSAL REASON TO BEST OF KNOWLEDGE.
AFRAID TO LOSE BENEFITS..........................................
NO TIME ...........................................................................
NO INTEREST ..................................................................
TOO SICK .........................................................................
DON’T TRUST GOVERNMENT/SSA ...............................
NONE GIVEN....................................................................
OTHER (SPECIFY) ...........................................................
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01
02
03
04
05
06
07
(REV—5/7/07)
WRONG NUMBER/NO SUCH PERSON
(A1=16) (A3=16) (A49=08)
A69b. I’m sorry. Did I reach {NUMBER DIALED}?
YES ................................................................................... 01 (A69c)
NO ..................................................................................... 00 (A69c)
(A69b=01 OR 00)
A69c.
Sorry to have bothered you. Thank you.
THANKS FOR INFORMATION PROVIDED
(A27=INFO) (A30b=INFO) (A32=01) (A33=01) (A35=INFO) (A39=01) (A39b=INFO) (A46=INFO) (A46a=01)
A70.
Thank you for your time. Have a nice day. Good-bye.
CONTINUE WITH INTERVIEW
(A63=01)
A71.
RESPONDENT CHECK SCREEN
INTERVIEWER: WE SHOW THE RESPONDENT IS ________________________.
INTERVIEWER: IS THIS INFORMATION CORRECT?
YES ................................................................................... 01 (B1)
NO ..................................................................................... 00
(A71=00)
A72.
INTERVIEWER: WHO IS THE RESPONDENT?
SAMPLE MEMBER/(NAME) ............................................. 01
INTERPRETER ................................................................. 02
ASSISTANT ...................................................................... 03
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SECTION B: HEALTH INSURANCE COVERAGE AND CONSENT
(All)
B1.
First, I’d like to ask about different types of health insurance coverage {you/(NAME)} might have.
{Are you/Is (NAME)} currently covered by Medicaid? Medicaid is a program that pays for the
health care of persons in need. In your state, you may also hear it called {STATEMED FROM
(NAME’s) CURRENT STATE}.
YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r
(All)
B2.
{Are you/Is (NAME)} currently covered by Medicare? Medicare is the health insurance plan for
people 65 years old and older or for people with certain disabilities. The Medicare card is red,
white and blue and says “Medicare Health Insurance” in the white section across the top.
YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r
(All)
B3.
{Are you/Is (NAME)} currently covered by a Medi-Gap plan? A Medi-Gap plan pays for costs not
covered by Medicare.
YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r
(All)
B4.
{Are you/Is (NAME)} currently covered by military health care, through Armed Forces retirement
benefits, the VA, TRICARE, CHAMPUS, or CHAMP-VA?
PROBE:
TRICARE is a managed health care program for active duty and retired members of
the uniformed services, their families and survivors. CHAMPUS is a health care
program for dependents of active or retired military personnel. CHAMP-VA is health
insurance for dependents or survivors of disabled veterans.
YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r
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(REV—5/7/07)
(All)
B5.
{Are you/Is (NAME)} currently covered by a plan from the Indian Health Service?
YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r
(All)
B6.
(Are you/Is (NAME)} currently covered by Workers Compensation?
PROBE: Workers Compensation provides wage replacement benefits, medical treatment,
vocational rehabilitation, and other benefits to workers or their dependents who are
injured at work or acquire an occupational disease.
YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r
(All)
B7.
(Are you/Is (NAME)} currently covered by a COBRA plan?
PROBE: COBRA (The Consolidated Omnibus Budget Reconciliation Act) gives workers and
their families who lose health benefits the right to continue health benefits provided by
their former employer’s group plan for a limited period of time.
YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r
(All)
B8.
{Are you/Is (NAME)} currently covered by a state government program other than Medicaid?
YES ................................................................................... 01
NO ..................................................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r
(All)
B9.
Not counting COBRA, dental, optical, or prescription plans, {are you/is (NAME)} currently covered
by private health insurance, for example, private insurance that {you get/(he/she) gets} through a
former employer, a family member, or that {you purchase/(he/she) purchases} on {your/his/her}
own?
YES ................................................................................... 01
NO ..................................................................................... 00 (B12)
DON’T KNOW ................................................................... d (B12)
REFUSED ......................................................................... r (B12)
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(REV—5/7/07)
(B9=01)
B10.
Is {your/(NAME’s)} private health insurance provided through {your/his/her} current or former
employer or through {your/his/her} spouse or partner’s current or former employer?
(NAME’s) EMPLOYER ...................................................... 01 (B13)
SPOUSE/PARTNER’S EMPLOYER................................. 02 (B13)
NO, NOT PROVIDED BY CURRENT OR
FORMER EMPLOYER................................................... 00
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r
(B9=01)
B11.
Is {your/(NAME’s)} private health insurance paid for by {you/(NAME)}, a family member, by both
{you/(NAME)} and a family member, or by someone else?
PAID BY (NAME) ..............................................................
PAID BY FAMILY MEMBER(S) ........................................
PAID BY BOTH {NAME) AND FAMILY MEMBER............
OTHER..............................................................................
DON’T KNOW ...................................................................
REFUSED .........................................................................
01
02
03
04
d
r
(B13)
(B13)
(B13)
(B13)
(B13)
(B11=04)
B11_Other. Who or what is the other source?
_________________________________________________________________
DON’T KNOW ...................................................................
REFUSED .........................................................................
d
r
GO TO B13
(B1, B2, B3, B4, B5, B6, B7, B8, AND B9 =00, d, or r)
B12.
Let me confirm. {Do you/Does (NAME)} have any health insurance coverage to help pay for
services from hospitals or doctors? This kind of health insurance covers doctor visits, trips to the
emergency room, and hospital stays.
YES ................................................................................... 01
NO ..................................................................................... 00 (B15) ELIGIBLE
DON’T KNOW ................................................................... d
REFUSED ......................................................................... r
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(B12=01, d OR r)
B12a. What kind of health insurance coverage {do you/does (NAME)} have?
PROBE: Anything else?
READ LIST IF NECESSARY
CODE ALL THAT APPLY
MEDICAID......................................................................... 01
MEDICARE ....................................................................... 02
MEDI-GAP......................................................................... 03
VA/TRICARE/CHAMPUS/CHAMP-VA.............................. 04
INDIAN HEALTH SERVICE .............................................. 05
WORKER’S COMPENSATION......................................... 06
COBRA.............................................................................. 07
STATE GOVERNMENT PROGRAM ................................ 08
PRIVATE HEALTH INSURANCE (SPECIFY) .................. 09
OTHER HEALTH INSURANCE (SPECIFY) ..................... 10
DON’T KNOW ...................................................................
REFUSED .........................................................................
d
r
(B1, B2, B3, B4, B5, B6, B7, B8, B9 OR B12=01) OR (B12a=ANSWER)
B13.
Does someone from {your/(NAME’s)} health plan such as a nurse or caseworker call or visit
{you/(NAME)} on a regular basis to check on {your/his/her} condition?
YES ................................................................................... 01
NO ..................................................................................... 00 (B16)
DON’T KNOW ................................................................... d (B16)
REFUSED ......................................................................... r (B16)
(B13=01)
B14.
How often does someone from {your/(NAME’s)} health plan call or visit {you/him/her}? Would
you say . . .
once per week, ..................................................................
twice per month, ................................................................
once per month, ................................................................
once every 3 months, or....................................................
some other schedule? .......................................................
DON’T KNOW ...................................................................
REFUSED .........................................................................
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01
02
03
04
05
d
r
(B16)
(B16)
(B16)
(B16)
(B16)
(B16)
(REV—5/7/07)
(B14=05)
B14_Other. What is the other schedule?
PROBE: Your best estimate is fine.
|
|
| TIMES PER
CODE ONE
WEEK ............................................................................... 01
MONTH ............................................................................ 02
QUARTER........................................................................ 03
YEAR................................................................................ 04
OTHER (SPECIFY) .......................................................... 05
DON’T KNOW ..................................................................
REFUSED ........................................................................
d
r
GO TO B16
(B12=00)
B15.
In what month and year did {you/(NAME)} last have health insurance coverage?
| | | |
MONTH
|
| |
YEAR
|
NEVER HAD INSURANCE .............................................. 00 (B16)
DON’T KNOW .................................................................. d
REFUSED ........................................................................ r
(B15=ANSWER, d OR r)
B15a. When {you/(NAME)} had insurance {in FILL MONTH/YEAR/the last time} what kind of insurance
did {you/(NAME)} have?
PROBE: Anything else?
READ LIST IF NECESSARY
CODE ALL THAT APPLY
MEDICAID....................................................................... 01
MEDICARE ..................................................................... 02
MEDI-GAP....................................................................... 03
VA/TRICARE/CHAMPUS/CHAMP-VA............................ 04
INDIAN HEALTH SERVICE ............................................ 05
WORKER’S COMPENSATION....................................... 06
COBRA............................................................................ 07
STATE GOVERNMENT PROGRAM .............................. 08
PRIVATE HEALTH INSURANCE (SPECIFY) ................ 09
OTHER HEALTH INSURANCE (SPECIFY) ................... 10
DON’T KNOW .................................................................
REFUSED .......................................................................
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d
r
(REV—5/7/07)
(All)
B16.
Sometimes people have (IF INSURED “additional”) health plans that cover specific health needs
like prescription drugs or dental plans. These next questions are about these kinds of limited
coverage plans.
{Do you/Does (NAME)} have Medicare Part D coverage for prescription drugs?
IF NEEDED:
Medicare Part D is prescription drug insurance coverage that is provided by
private companies and available to everyone with Medicare.
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
B16a. IF ANY OF B1 TO B9=01, OR B12=01, OR B16=01 SAY:
Not counting the health plan(s) that you already told me about, {do you/does (NAME)} have a
separate insurance plan that helps pay for prescription medications?
IF B12=00, SAY:
(Although {you don’t/(NAME) does not} currently have coverage that helps pay for services from
hospitals or doctors) {do you/does (NAME)} have insurance that helps pay for prescription
medications?
PROBE: Do not include Medi-Gap or Medicare Part D plans here.
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
B17.
IF ANY OF B1 TO B9=01, OR B12=01:
Not counting the health plan(s) that you already told me about, {do you/does (NAME)} have
coverage for dental care?
IF B12=00, SAY:
(Although {you don’t/(NAME) does not} currently have coverage that helps pay for services from
hospitals or doctors) {do you/does (NAME)} have coverage for dental care?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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(All)
B18.
IF ANY OF B1 TO B9=01, OR B12=01 SAY:
Not counting the health plan(s) that you already told me about, {do you/does (NAME)} have
optical coverage for eyeglasses or contact lenses?
IF B12=00, SAY:
(Although {you don’t/(NAME) does not} currently have coverage that helps pay for services from
hospitals or doctors) {do you/does (NAME)} have optical coverage for eyeglasses or contact
lenses?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
ELIG_ck. PROGRAMMER: DO ANY OF QUESTIONS B1, B2, B3, B4, B5, B6, B7, B8, B9=01, OR
DOES B12=01, d or r?
YES ................................................................................. 01 (END1)
NO ................................................................................... 00 (B19)
CONSENT
B19.
Thank you for taking the time to answer my questions. Based on your answers, you can take
part in the Accelerated Benefits research study or AB for short. I would like to tell you a little
more about this. Please stop me at any time if you have a question.
The purpose of the study is to learn if receiving a generous health care benefit and other services
improves the health and ability of people with disabilities to return to work, if they choose to do
so. The Social Security Administration is paying for the study.
If you agree to participate in the AB study, you will be placed into one of three groups. One
group will be given health benefits. A second group will be given the same health benefits and
will also be offered services to help them meet their health needs and make it easier for them to
return to work, if they choose to do so. The third group will not get any extra benefits. Picking
which group you are in will be done randomly, like flipping a coin. You will have the same chance
of being assigned to any of the three groups as everyone else in the study.
Do you have any questions about what I’ve read so far?
YES ................................................................................. 01 (B19a)
NO ................................................................................... 00 (B20)
(B19=01)
B19a. INTERVIEWER: ASK IF NECESSARY: What is your question?
INTERVIEWER: ENTER VERBATIM QUESTION
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(All)
B20.
Being in the study will not affect your Social Security benefits in any way. If you agree to be in
this study, we will conduct a 30 minute interview with you now for which you will receive $25. We
will also contact you in about [PROGRAMMER: DO NOT DISPLAY AFTER COMPLETES =
600: six months and then again in about] a year and a half to find out about your health and
the care you are receiving. You will receive $25 for each of the interviews you complete. You
can refuse to answer any question. This will not affect your ability to take part in AB.
If you are selected to receive the AB health benefits, they could be very valuable to you. You will
be able to use up to $100,000 in health care services. The AB health benefits will cover
treatments that could help improve your health so that you can enjoy more independence and an
increased level of activity.
If you are assigned to one of the groups that receives the AB health benefits, we will send you a
description of the study and the benefits in writing. You will be asked to sign a form stating that
you understand this information. Once you return the signed form, we will give your information
to the organizations that will be managing the health benefits and services. Someone from
POMCO, the organization managing your health benefits, will be available to answer any
questions you might have about the benefits package. You will be able to use these health
benefits until you become eligible for Medicare.
Do you have any questions at this time?
YES ................................................................................. 01 (B20a)
NO ................................................................................... 00 (B21)
(B20=01)
B20a. INTERVIEWER: ASK IF NECESSARY: What is your question?
INTERVIEWER: ENTER VERBATIM QUESTION
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(All)
B21.
In addition to your answers during our interviews, if you agree to be in the study, we will get
information from administrative records about your benefits and your earnings from work. We will
also get information about your use of health care and other services from the organizations
providing AB services. The study team will get this information for up to five years but will use
this information only for research purposes. Any information we collect will be kept confidential.
Only the study staff will be able to see this information. Your name will never appear in any
public document.
Taking part in the study is up to you, and it does not require you to do anything. If you agree to be
in the study, you do not have to use the health benefits or any other services that are offered.
Being in the study will not change any of the rules that determine whether you receive Disability
Insurance cash benefits.
You may leave the study at any time, but if you leave the study, you will no longer receive the AB
health care benefits. We will use any information we collect while you are in the study.
If you have any questions about the program or your rights as a participant, you may contact
program staff at 1-866-275-8659.
Do you have any questions now?
YES ................................................................................. 01 (B21a)
NO ................................................................................... 00 (B22)
(B21=01)
B21a. INTERVIEWER: ASK IF NECESSARY: What is your question?
INTERVIEWER: ENTER VERBATIM QUESTION
(All)
B22.
Do you understand everything I have read to you?
YES ................................................................................. 01 (B23)
NO ................................................................................... 00 (B22a)
(B22=01)
B22a. INTERVIEWER: ASK IF NECESSARY: What questions can I answer for you?
INTERVIEWER: ENTER VERBATIM QUESTION
(All)
B23.
Do you agree to be in the study?
YES ................................................................................. 01 (C1)
NO ................................................................................... 00
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(REV—5/7/07)
(B23=00)
B24.
Please remember that by agreeing to be in the study today you are only agreeing to be randomly
assigned to one of the three study groups. If you are assigned to one of the groups that receives
health benefits, you do not have to use those benefits. Being in the study will not affect your
Social Security benefits in any way, and your information will be kept confidential. Your
participation in this study is very important because it will allow SSA to learn how to better serve
individuals with a disability. Will you reconsider your decision?
YES, I WILL PARTICIPATE ............................................ 01 (C1)
NO, I WILL NOT PARTICIPATE ..................................... 00
(B24=00)
B25.
I’d like to mail you some information about the study so that you can take some more time to
review it and reconsider whether you would like to participate. I will check back with you in about
a week to see if you have any questions. The materials I send will also include a toll free number
you can call to get answers to any questions you may have before I call you again. Please let me
confirm your mailing address. RECORD ADDRESS INFORMATION. Thank you very much for
your time.
GO TO THNX
(B1, B2, B3, B4, B5, B6, B7, B8, B9, OR B12=01, d, OR r)
>END1< Thank you very much for your time. Those are all the questions I have. (IF B12 NE d OR r,
SAY: At this time, the AB program is only for persons who do not currently have health
insurance. Best wishes to you (and (NAME)).
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(REV—5/7/07)
STATE MEDICAID PROGRAM NAMES
STATE
PROGRAM NAME
STATE
PROGRAM NAME
Alabama
Alabama Medicaid
Nebraska
Nebraska Medical Assistance Program
Alaska
Alaska Medicaid
Nevada
HIWA (Health Insurance for Work
Enhancement)
Arizona
Arizona Health Care Cost Containment System
(AHCCCS)
New Hampshire
Medicaid
Arkansas
Arkansas Medical Assistance/ /Connect Care
New Jersey
New Jersey FamilyCare
California
Medi-Cal
New Mexico
SALUD/Molina/Lovelace/Presbyterian
Colorado
Medicaid
New York
New York Medicaid CHOICE/Family Health
Plus
Connecticut
CT Medicaid
North Carolina
Carolina ACCESS
Delaware
Diamond State Health Plan
North Dakota
Medicaid
District of
Columbia
Medical Assistance (MA)
Ohio
Aged, Blind, or Disabled (ABD)
Program/Covered Families and Children
(CFC) Program
Florida
MediPass
Oklahoma
SoonerCare
Georgia
Georgia Better Health Care
Oregon
Oregon Health Plan
Hawaii
Hawaii Medicaid:FFS (fee for Service) and MedQUEST
Pennsylvania
HealthChoices/Lancaster Community Health
Plan'
Idaho
Idaho Medicaid Access Card
Rhode Island
RIte Care
Illinois
Family Care/Medical Assistance/MediPlan
South Carolina
Partners for Health
Indiana
Hoosier Healthwise
South Dakota
Medicaid/Medical Assistance
Iowa
Medical Assistance
Tennessee
TennCare
Kansas
MediKan, HealthWave
Texas
Texas Health Steps (THSteps)
Kentucky
KYHealthChoices/Kentucky Patient Access and
Care System(KenPAC)
Utah
Utah Medical Assistance Program (UMAP)
Louisiana
CommunityCARE Program/LaMedicaid
Vermont
Vermont Health Access Plan (VHAP)
Maine
MaineCare
Maryland
HealthChoice Program
Massachusetts
MassHealth
Virginia
Medicaid/Medallion/Medallion II
Michigan
PROGRAMMER: HIDE SENTENCE “In your
state” FOR MICHIGAN RESPONDENTS
Washington
Healthy Options/medical coupons
Community Choice Michigan, Great Lakes Health
Plan, Health Plan of Michigan, HealthPlus
Partners, M-CAID, McLaren Health Plan, Midwest
Health Plan, Molina Health Care, OmniCare
Health Plan, PHP-MM Family Care, Priority Health
Government Programs, Total Health Care, UP
Health Plan
Minnesota
Medical Assistance (MA)
West Virginia
West Virginia Physician Assured Access
System (PAAS)/Mountain Health Trust-(MHT)
Mississippi
Mississippi Medicaid
Wisconsin
BadgerCare/Medical Assistance
Missouri
Missouri Medicaid
Wyoming
Medicaid
Montana
Montana Medicaid/PASSPORT to Health
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SECTION C: HEALTH AND FUNCTIONAL STATUS
(All)
C1.
Let’s continue with the interview. The next questions are about {your/(NAME’s)} health.
In general, would you say {your/(NAME’s)} health is…
excellent, .........................................................................
very good,........................................................................
good, ...............................................................................
fair, or ..............................................................................
poor? ...............................................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
01
02
03
04
05
d
r
(All)
C2ft.
How tall {are you/is (NAME)}?
INTERVIEWER: ENTER FEET ON THIS SCREEN AND INCHES ON THE NEXT.
| | FEET
(3-8)
DON’T KNOW .................................................................
REFUSED .......................................................................
d (C3)
r (C3)
(C2ft>3)
C2in.
PROBE: ROUND TO NEAREST WHOLE NUMBER (E.G., ENTER 6 FOR 5 ½ INCHES).
INTERVIEWER: ENTER INCHES ON THIS SCREEN.
|
| | INCHES
(0-12)
DON’T KNOW .................................................................
REFUSED .......................................................................
d
r
(All)
C3.
How much {do you/does (NAME)} weigh?
|
| | | (50-999)
POUNDS
DON’T KNOW .................................................................
REFUSED .......................................................................
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d
r
(REV—5/7/07)
(All)
C4.
What physical, mental, or sensory disability is the main reason {you/(NAME)} applied for disability
benefits?
PROBE 1: What do doctors call {your/(NAME’s)} health condition?
PROBE 2: What causes this condition?
INTERVIEWER: RECORD VERBATIM RESPONSE.
(C5)
NEVER APPLIED FOR DISABILITY BENEFITS............ 01
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
[FLAG AND GO TO C4a]
(C4=01,d or r)
C4a.
{Do you/Does(NAME)} have a health problem or disability which prevents {you/(NAME)} from
working or which limits the kind or amount of work {you/he/she} can do?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
[FLAG AND GO TO C7]
[FLAG AND GO TO C7]
[FLAG AND GO TO C7]
(C4a=01)
C4b.
What is the health problem or disability which prevents {you/(NAME)} from working or which limits
the kind or amount of work {you/he/she} can do?
INTERVIEWER: RECORD VERBATIM RESPONSE.
(All)
C5.
{Do you/Does (NAME)} have any other physical, mental or sensory conditions that make
{you/him/her} eligible for disability benefits?
YES ................................................................................. 01
NO ................................................................................... 00 (C7)
DON’T KNOW ................................................................. d (C7)
REFUSED ....................................................................... r (C7)
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(REV—5/7/07)
(C5=01)
C6.
What are those conditions?
PROBE 1: What do doctors call {your/(NAME’s)} health condition?
PROBE 2: What causes this condition?
INTERVIEWER: RECORD VERBATIM RESPONSE.
CONDITION 1
CONDITION 2
CONDITION 3
(All)
C7.
{Do you/Does (NAME)} use a wheelchair, scooter, walker, crutches or cane to move around?
YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(IF NOT CONDUCTING INTERVIEW OVER TTY OR TTD)
C8.
Some people use things to help hear or speak, such as a hearing aid, American sign language or
ASL, TTY or TTD, or speech recognition software. {Do you/Does (NAME)} use anything like
this?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
C8a.
Some people use things to help them read such as large print or Braille, or a screen reader. {Do
you/Does (NAME)} use anything like this?
YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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(REV—5/7/07)
(C8 OR C8a =01)
C9.
What {do you/does (NAME)} use?
CODE ALL THAT APPLY
LARGE PRINT OR BRAILLE .......................................... 01
SCREEN READER ......................................................... 02
ADAPTED COMPUTER KEYBOARD ............................ 03
HEARING AID OR HEARING DEVICE .......................... 04
AMERICAN SIGN LANGUAGE (ASL) ............................ 05
TTD/TTY.......................................................................... 06
SPEECH RECOGNITION SOFTWARE ......................... 07
OTHER (SPECIFY)......................................................... 08
___________________________________________
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
C10.
These next questions are about activities {you/(NAME)} might do during a typical day and
whether {you need/he/she needs} help from others with these activities.
{Do you/Does (NAME)} need help or supervision from others with bathing or showering?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
C10a. {Do you/Does (NAME)} need help or supervision from others with dressing?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
C10b. {Do you/Does (NAME)} need help or supervision from others with preparing meals?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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(REV—5/7/07)
(All)
C10c. {Do you/Does (NAME)} need help or supervision from others with eating?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
C10d. {Do you/Does (NAME)} need help or supervision from others with using the toilet?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
C10e. {Do you/Does (NAME)} need help or supervision from others with using the telephone?
YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(C7 NE 02)
C10f.
{Do you/Does (NAME)} need help or supervision from others with using public transportation?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(C7 NE 02)
C10g. {Do you/Does (NAME)} need help or supervision from others with riding as a passenger in a car?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
C10h. {Do you/Does (NAME)} need help or supervision from others to get in and out of bed or a chair?
YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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(REV—5/7/07)
(C7 NE 02)
C10i.
{Do you/Does (NAME)} need help or supervision from others to get around inside the home?
YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
C10j.
{Do you/Does (NAME)} need reminders, help or supervision from others to take {your/his/her}
medication?
YES ................................................................................. 01
NO ................................................................................... 00
DO NOT TAKE MEDICATION ........................................ 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(C7 NE 01 OR 02)
C10k. {Do you/Does (NAME)} have difficulty walking?
YES ................................................................................. 01
NO ................................................................................... 00
NOT APPLICABLE/UNABLE TO DO.............................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
C10l.
{Do you/Does (NAME)} have difficulty lifting or carrying a 10 pound package?
YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(C7 NE 01 OR 02)
C10m. {Do you/Does (NAME)} have difficulty climbing a flight of stairs?
YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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(REV—5/7/07)
(C7 NE 01 OR 02)
C10n. {Do you/Does (NAME)} have difficulty standing for long periods of time?
YES ................................................................................. 01
NO ................................................................................... 00
UNABLE TO DO ............................................................. 02
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
C11.
Now, please think about the past 4 weeks. During the past 4 weeks, how much difficulty did
{you/(NAME)} have doing {your/his/her} daily work and chores because of {your/his/her} physical
health? Would you say . . .
None, ..............................................................................
A little, .............................................................................
Some, .............................................................................
A lot, or ............................................................................
Could {you/he/she} not do daily work? ...........................
DON’T KNOW .................................................................
REFUSED .......................................................................
01
02
03
04
05
d
r
(All)
C11a. How much bodily pain {have you/has NAME} had in the past 4 weeks? Would you say . . .
None, ..............................................................................
A little, .............................................................................
Some, or .........................................................................
A lot? ..............................................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
01
02
03
04
d
r
(All)
C11b. During the past 4 weeks, how much energy did {you/(NAME)} have? Would you say . . .
None, ..............................................................................
A little, .............................................................................
Some, or .........................................................................
A lot? ..............................................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
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01
02
03
04
d
r
(REV—5/7/07)
(All)
C11c. During the past 4 weeks, how much did {your/(NAME’s)} physical health or emotional problems
limit {your/his/her} usual social activities with family or friends? Would you say . . .
None, ..............................................................................
A little, .............................................................................
Some, .............................................................................
A lot, or ............................................................................
Could {you/he/she} not do social activities?....................
DON’T KNOW .................................................................
REFUSED .......................................................................
01
02
03
04
05
d
r
(All)
C12.
During the past 4 weeks, how often have {you/(NAME)} been bothered by emotional problems,
such as feeling unhappy, anxious, depressed, or irritable? Would you say . . .
All of the time,..................................................................
Most of the time,..............................................................
Some of the time, ............................................................
A little of the time, or .......................................................
None of the time?............................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
01
02
03
04
00
d
r
(All)
C13. During the past 4 weeks, how much of the time have {you/(NAME)} felt downhearted and blue?
Would you say . . .
All of the time,..................................................................
Most of the time,..............................................................
Some of the time, ............................................................
A little of the time, or .......................................................
None of the time?............................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
01
02
03
04
00
d
r
(All)
C14. During the past 4 weeks, how much did personal or emotional problems keep {you/(NAME)} from
doing {your/his/her} usual work, school or other daily activities? Would you say . . .
Not at all, ........................................................................
A little, .............................................................................
Some, .............................................................................
A lot, or ............................................................................
Could {you/he/she} not do daily activities? ....................
DON’T KNOW .................................................................
REFUSED .......................................................................
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01
02
03
04
05
d
r
(REV—5/7/07)
(C12 AND C13 NE 00, d OR r)
C15. During the past 4 weeks, how often have physical health problems been the main cause of these
feelings? Would you say . . .
All of the time,..................................................................
Most of the time,..............................................................
Some of the time, ............................................................
A little of the time, or .......................................................
None of the time?............................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
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01
02
03
04
00
d
r
(REV—5/7/07)
SECTION D: USE OF MEDICAL SERVICES
(All)
D1.
INTERVIEWER CHECKPOINT: DOES THE RESPONDENT SEEM FATIGUED, CONFUSED,
OR IN NEED OF ENCOURAGEMENT?
SEEMS FATIGUED/CONFUSED ...................................
NEEDS ENCOURAGEMENT .........................................
NOT SURE......................................................................
NO ...................................................................................
01
02
03
00
(D1a)
(D1c)
(D1a)
(D2)
(D1=01 OR 00)
D1a. {Are you/Is (NAME)} feeling tired, or can we continue?
TIRED.............................................................................. 01
CONTINUE...................................................................... 02 (D1d)
(D1a=01)
D1b. Would {you/(NAME)} like to take a break? I can either hold on or call {you/(NAME)} back and
continue the interview at another time?
YES, BREAK, HOLD ON ................................................ 01 (D1d)
YES, BREAK AND CALL BACK ..................................... 02 (D1d)
NO, CONTINUE NOW .................................................... 03 (D1d)
(D1=02)
D1c. You’re doing fine. (Your answers are very helpful to this study./There are no right or wrong
answers to these questions.)
(D1=01, 02 OR 03)
D1d. INTERVIEWER ACTION: WHAT DID YOU DO?
NOT FATIGUED; NO ENCOURAGEMENT
PROVIDED...................................................................
FATIGUED; HELD ON ....................................................
FATIGUED; SCHEDULED CALL BACK.........................
FATIGUED, BUT WANTED TO CONTINUE ..................
PROVIDED ENCOURAGEMENT AND CONTINUED...
01
02
03
04
05
(GO TO CALL BACK SCREEN)
(All)
D2.
These next questions are about {your/(NAME’s)} usual sources of medical care.
{Do you/Does (NAME)} have a doctor whom {you see/he/she sees} or a place {you go/he/she
goes} to regularly to receive medical care?
YES ................................................................................. 01
NO ................................................................................... 00 (D3)
DON’T KNOW ................................................................. d (D3)
REFUSED ....................................................................... r (D3)
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(REV—5/7/07)
(D2=01)
D2a.
Which one of the following kinds of doctors or places {do you/does (NAME)} see or go to most
often? Do you see . . .
PROBE: Specialists include doctors such as surgeons, allergists, (IF FEMALE: obstetricians,
gynecologists), orthopedists, cardiologists, and dermatologists. Specialists mainly
treat just one type of problem.
IF RESPONDS WITH MORE THAN ONE: Please tell me which one of these {you/(NAME)}
go(es) to most frequently?
CODE ONE
a general practitioner, an internist, or family doctor,....... 01 (D3)
a specialist,...................................................................... 02 (D3)
a psychiatrist or psychologist, or ..................................... 03 (D3)
{do you/does (NAME)} go to a clinic, or .......................... 04 (D3)
some other kind of place or doctor?................................ 05
DON’T KNOW ................................................................. d (D3)
REFUSED ....................................................................... r (D3)
(D2a=05)
D2_Other. What is this other place or type of doctor {you go/(NAME) goes} to most often?
_________________________________________________________________
DON’T KNOW .................................................................
REFUSED .......................................................................
d
r
(All)
D3.
How many times {have you/has NAME} seen ({this/a} doctor/visited this place) in the past six
months, that is since {FILL DATE}?
PROBE: Your best estimate is fine.
|
|
| NUMBER OF VISITS PAST 6 MONTHS
DON’T KNOW .................................................................
REFUSED .......................................................................
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(D3b)
d
r
(REV—5/7/07)
(D3=d OR r)
D3a.
In the past 6 months, would you say {you/(NAME)} saw {this/a} {doctor/visited {this/a} clinic} . . .
CODE ONE
zero times,....................................................................... 00
1 to 2 times,..................................................................... 01
3 to 4 times,..................................................................... 02
5 to 6 times, or................................................................. 03
more than 6 times? ......................................................... 04
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
D3b.
How would {you/(NAME)} rate the medical care {you/he/she} received in the past 6 months in
terms of overall quality of care and services? Would {you/(NAME)} say it was excellent, very
good, good, fair, or poor?
EXCELLENT ...................................................................
VERY GOOD...................................................................
GOOD .............................................................................
FAIR ................................................................................
POOR..............................................................................
DID NOT RECEIVE MEDICAL CARE ............................
DON’T KNOW .................................................................
REFUSED .......................................................................
01
02
03
04
05
n
d
r
(All)
D3c.
In the past 6 months, was there any time when {you/(NAME)} didn’t see a doctor or get the
medical care {you/he/she} needed?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
D3d.
In the past 6 months, was there any time when {you/(NAME)} put off or postponed seeing a
doctor or getting medical care {you/he/she} needed?
YES ................................................................................. 01
NO ................................................................................... 00 (D4)
DON’T KNOW ................................................................. d (D4)
REFUSED ....................................................................... r (D4)
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(REV—5/7/07)
(D3c OR D3d=01)
D3e.
In the past 6 months, why is it that {you/(NAME)} did not see a doctor at all or postponed seeing
a doctor?
PROBE: Were there any other reasons?
CODE ALL THAT APPLY
COST/INSURANCE
COULD NOT AFFORD IT/TOO EXPENSIVE........................................................... 01
NO INSURANCE....................................................................................................... 02
INSURANCE DID NOT COVER ............................................................................... 03
DOCTOR OR HOSPITAL DID NOT ACCEPT INSURANCE ................................... 04
DENIED APPROVAL OR REFERRAL TO SEE SPECIALIST BY
INSURANCE COMPANY....................................................................................... 05
AWAITING APPROVAL OR REFERRAL FROM INSURANCE
COMPANY TO SEE SPECIALIST ......................................................................... 06
ACCESS
COULD NOT GET CONVENIENT APPOINTMENT ...............................................
TRANSPORTATION PROBLEM ..............................................................................
WAITING FOR UPCOMING APPOINTMENT ..........................................................
COULD NOT FIND SPECIALISTS KNOWLEDGEABLE ABOUT CONDITION.......
PHYSICAL ACCESS PROBLEM (E.G., WHEELCHAIR RAMP,
ACCESSIBLE MEDICAL EQUIPMENT)................................................................
DOCTORS DON’T WANT TO TREAT PEOPLE WITH
{MY/(NAME’S) DISABILITY ...................................................................................
QUALITY
DID NOT LIKE DOCTOR OR DOCTOR’S ADVICE .................................................
WENT TO ANOTHER DOCTOR INSTEAD..............................................................
PROBLEMS AT PLACE—LONG WAIT, NO BATHROOM, NOT ACCESSIBLE ..
CLINIC/OFFICE IN UNSAFE NEIGHBORHOOD.....................................................
DOCTORS DON’T SPEND ENOUGH TIME ............................................................
INSENSITIVE/DISRESPECTFUL DOCTORS/MEDICAL STAFF
(NEGATIVE ATTITUDES, MISPERCEPTION ABOUT DISABILITY)....................
POOR COORDINATION OF CARE WITH OTHER MEDICAL PROVIDERS ..........
AVOIDANCE/ALTERNATIVES
WAS AFRAID ............................................................................................................
THOUGHT PROBLEM WOULD GO AWAY, OR PROBLEM WENT AWAY............
USED HOME REMEDY ............................................................................................
HEALTH GOT WORSE.............................................................................................
HEALTH OF OTHER FAMILY MEMBER INTERFERED .........................................
OTHER REASONS
DENIED APPROVAL FOR DURABLE MEDICAL EQUIPMENT (DME)
OR REPAIR OF DME ............................................................................................
AWAITING APPROVAL FOR DURABLE MEDICAL EQUIPMENT (DME)
OR REPAIR OF DME ............................................................................................
OTHER......................................................................................................................
DON’T KNOW ...........................................................................................................
REFUSED .................................................................................................................
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07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
d
r
(REV—5/7/07)
(All)
D4.
In the past 6 months, {were you/was (NAME)} referred to another doctor, specialist, therapist,
psychologist, or medical professional?
YES ................................................................................. 01
NO ................................................................................... 00 (D6a)
DON’T KNOW ................................................................. d (D6a)
REFUSED ....................................................................... r (D6a)
(D4=01)
D4a.
Did {you/(NAME)} go for all of the visits for which {you were/he/she was} referred?
YES ................................................................................. 01 (D5)
NO ................................................................................... 00
DON’T KNOW ................................................................. d (D5)
REFUSED ....................................................................... r (D5)
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(REV—5/7/07)
(D4a=00)
D4b.
Why is it that {you/(NAME)} did not go for all of {your/his/her} recommended visits?
PROBE: Were there any other reasons?
CODE ALL THAT APPLY
COST/INSURANCE
COULD NOT AFFORD IT/TOO EXPENSIVE........................................................... 01
NO INSURANCE....................................................................................................... 02
INSURANCE DID NOT COVER ............................................................................... 03
DOCTOR OR HOSPITAL DID NOT ACCEPT INSURANCE ................................... 04
DENIED APPROVAL OR REFERRAL TO SEE SPECIALIST BY
INSURANCE COMPANY....................................................................................... 05
AWAITING APPROVAL OR REFERRAL FROM INSURANCE
COMPANY TO SEE SPECIALIST ......................................................................... 06
ACCESS
COULD NOT GET CONVENIENT APPOINTMENT ...............................................
TRANSPORTATION PROBLEM ..............................................................................
WAITING FOR UPCOMING APPOINTMENT ..........................................................
COULD NOT FIND SPECIALISTS KNOWLEDGEABLE ABOUT CONDITION ......
PHYSICAL ACCESS PROBLEM (E.G., WHEELCHAIR RAMP,
ACCESSIBLE MEDICAL EQUIPMENT)................................................................
DOCTORS DON’T WANT TO TREAT PEOPLE WITH
{MY/(NAME’S) DISABILITY ...................................................................................
QUALITY
DID NOT LIKE DOCTOR OR DOCTOR’S ADVICE .................................................
WENT TO ANOTHER DOCTOR INSTEAD..............................................................
PROBLEMS AT PLACE—LONG WAIT, NO BATHROOM, NOT ACCESSIBLE .....
CLINIC/OFFICE IN UNSAFE NEIGHBORHOOD.....................................................
DOCTORS DON’T SPEND ENOUGH TIME ............................................................
INSENSITIVE/DISRESPECTFUL DOCTORS/MEDICAL STAFF
(NEGATIVE ATTITUDES, MISPERCEPTION ABOUT DISABILITY)....................
POOR COORDINATION OF CARE WITH OTHER MEDICAL PROVIDERS ..........
AVOIDANCE/ALTERNATIVES
WAS AFRAID ............................................................................................................
THOUGHT PROBLEM WOULD GO AWAY, OR PROBLEM WENT AWAY............
USED HOME REMEDY ............................................................................................
HEALTH GOT WORSE.............................................................................................
HEALTH OF OTHER FAMILY MEMBER INTERFERED .........................................
OTHER REASONS
DENIED APPROVAL FOR DURABLE MEDICAL EQUIPMENT (DME)
OR REPAIR OF DME ...........................................................................................
AWAITING APPROVAL FOR DURABLE MEDICAL EQUIPMENT (DME)
OR REPAIR OF DME ............................................................................................
OTHER......................................................................................................................
IT IS SCHEDULED FOR A FUTURE DATE .............................................................
DON’T KNOW ...........................................................................................................
REFUSED .................................................................................................................
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07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
d
r
(REV—5/7/07)
(All)
D5.
In the past 6 months, did a doctor or clinic send {you/(NAME)} for tests or x-rays?
YES ................................................................................. 01
NO ................................................................................... 00 (D6)
DON’T KNOW ................................................................. d (D6)
REFUSED ....................................................................... r (D6)
(D5=01)
D5a.
Did {you/(NAME)} go for all of the tests or x-rays for which {you were/he/she was} sent?
YES ................................................................................. 01 (D6)
NO ................................................................................... 00
DON’T KNOW ................................................................. d (D6)
REFUSED ....................................................................... r (D6)
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(REV—5/7/07)
(D5a=00)
D5b.
Why is it that {you/(NAME)} did not go for all of {your/his/her} recommended tests or x-rays?
PROBE: Were there any other reasons?
CODE ALL THAT APPLY
COST/INSURANCE
COULD NOT AFFORD IT/TOO EXPENSIVE............................................................ 01
NO INSURANCE........................................................................................................ 02
INSURANCE DID NOT COVER ................................................................................ 03
DOCTOR OR HOSPITAL DID NOT ACCEPT INSURANCE .................................... 04
DENIED APPROVAL OR REFERRAL TO SEE SPECIALIST BY
INSURANCE COMPANY........................................................................................ 05
AWAITING APPROVAL OR REFERRAL FROM INSURANCE
COMPANY TO SEE SPECIALIST .......................................................................... 06
ACCESS
COULD NOT GET CONVENIENT APPOINTMENT ................................................
TRANSPORTATION PROBLEM ...............................................................................
WAITING FOR UPCOMING APPOINTMENT ...........................................................
COULD NOT FIND SPECIALISTS KNOWLEDGEABLE ABOUT CONDITION .......
PHYSICAL ACCESS PROBLEM (E.G., WHEELCHAIR RAMP,
ACCESSIBLE MEDICAL EQUIPMENT).................................................................
DOCTORS DON’T WANT TO TREAT PEOPLE WITH
{MY/(NAME’S) DISABILITY ....................................................................................
QUALITY
DID NOT LIKE DOCTOR OR DOCTOR’S ADVICE ..................................................
WENT TO ANOTHER DOCTOR INSTEAD...............................................................
PROBLEMS AT PLACE—LONG WAIT, NO BATHROOM, NOT ACCESSIBLE ......
CLINIC/OFFICE IN UNSAFE NEIGHBORHOOD......................................................
DOCTORS DON’T SPEND ENOUGH TIME .............................................................
INSENSITIVE/DISRESPECTFUL DOCTORS/MEDICAL STAFF
(NEGATIVE ATTITUDES, MISPERCEPTION ABOUT DISABILITY).....................
POOR COORDINATION OF CARE WITH OTHER MEDICAL PROVIDERS ...........
AVOIDANCE/ALTERNATIVES
WAS AFRAID .............................................................................................................
THOUGHT PROBLEM WOULD GO AWAY, OR PROBLEM WENT AWAY.............
USED HOME REMEDY .............................................................................................
HEALTH GOT WORSE..............................................................................................
HEALTH OF OTHER FAMILY MEMBER INTERFERED ..........................................
OTHER REASONS
DENIED APPROVAL FOR DURABLE MEDICAL EQUIPMENT (DME)
OR REPAIR OF DME ............................................................................................
AWAITING APPROVAL FOR DURABLE MEDICAL EQUIPMENT (DME)
OR REPAIR OF DME .............................................................................................
OTHER.......................................................................................................................
IT IS SCHEDULED FOR A FUTURE DATE ..............................................................
DON’T KNOW ............................................................................................................
REFUSED ..................................................................................................................
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(All)
D6.
In the past 6 months, did a doctor order or recommend any medical procedures or surgery for
{you/(NAME)}?
YES ................................................................................. 01
NO ................................................................................... 00 (D7)
DON’T KNOW ................................................................. d (D7)
REFUSED ....................................................................... r (D7)
(D6=01)
D6a.
Did {you/(NAME)} have all of the procedures or surgeries {your/his/her} doctor recommended?
YES ................................................................................. 01 (D7)
NO ................................................................................... 00
DON’T KNOW ................................................................. d (D7)
REFUSED ....................................................................... r (D7)
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(REV—5/7/07)
(D6a=00)
D6b.
Why is it that {you/(NAME)} did not have the recommended procedures or surgeries?
CODE ALL THAT APPLY
COST/INSURANCE
COULD NOT AFFORD IT/TOO EXPENSIVE........................................................... 01
NO INSURANCE....................................................................................................... 02
INSURANCE DID NOT COVER ............................................................................... 03
DOCTOR OR HOSPITAL DID NOT ACCEPT INSURANCE ................................... 04
DENIED APPROVAL OR REFERRAL TO SEE SPECIALIST BY
INSURANCE COMPANY....................................................................................... 05
AWAITING APPROVAL OR REFERRAL FROM INSURANCE
COMPANY TO SEE SPECIALIST ......................................................................... 06
ACCESS
COULD NOT GET CONVENIENT APPOINTMENT ...............................................
TRANSPORTATION PROBLEM ..............................................................................
WAITING FOR UPCOMING APPOINTMENT ..........................................................
COULD NOT FIND SPECIALISTS KNOWLEDGEABLE ABOUT CONDITION ......
PHYSICAL ACCESS PROBLEM (E.G., WHEELCHAIR RAMP,
ACCESSIBLE MEDICAL EQUIPMENT)................................................................
DOCTORS DON’T WANT TO TREAT PEOPLE WITH
{MY/(NAME’S) DISABILITY ...................................................................................
QUALITY
DID NOT LIKE DOCTOR OR DOCTOR’S ADVICE .................................................
WENT TO ANOTHER DOCTOR INSTEAD..............................................................
PROBLEMS AT PLACE—LONG WAIT, NO BATHROOM, NOT ACCESSIBLE .....
CLINIC/OFFICE IN UNSAFE NEIGHBORHOOD.....................................................
DOCTORS DON’T SPEND ENOUGH TIME ............................................................
INSENSITIVE/DISRESPECTFUL DOCTORS/MEDICAL STAFF
(NEGATIVE ATTITUDES, MISPERCEPTION ABOUT DISABILITY)....................
POOR COORDINATION OF CARE WITH OTHER MEDICAL PROVIDERS ..........
AVOIDANCE/ALTERNATIVES
WAS AFRAID ............................................................................................................
THOUGHT PROBLEM WOULD GO AWAY, OR PROBLEM WENT AWAY............
USED HOME REMEDY ............................................................................................
HEALTH GOT WORSE.............................................................................................
HEALTH OF OTHER FAMILY MEMBER INTERFERED .........................................
OTHER REASONS
DENIED APPROVAL FOR DURABLE MEDICAL EQUIPMENT (DME)
OR REPAIR OF DME ...........................................................................................
AWAITING APPROVAL FOR DURABLE MEDICAL EQUIPMENT (DME)
OR REPAIR OF DME ............................................................................................
IT IS SCHEDULED FOR A FUTURE DATE .............................................................
OTHER......................................................................................................................
DON’T KNOW ...........................................................................................................
REFUSED .................................................................................................................
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(All)
D7.
How many times in the last 6 months {were you/was (NAME)} admitted for an overnight or longer
stay in a hospital? Would you say . . .
PROBE: Your best estimate is fine.
Never...............................................................................
1 to 2 times......................................................................
3 to 5 times......................................................................
6 to 10 times, or...............................................................
More than 10 times? .......................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
00 (D8)
01
02
03
04
d
r
(D7=01,02,03,04.d,or r)
D7a.
All together, how many nights did {you/(NAME)} spend in the hospital last year?
|
|
| NUMBER OF HOSPITAL NIGHT STAYS
DON’T KNOW .................................................................
REFUSED .......................................................................
d
r
(All)
D8.
How many times in the last 6 months {were you/was (NAME)} a patient in a nursing home,
convalescent home, or other long-term health care facility? Please include skilled nursing
facilities and rehabilitation facilities. Would you say . . .
Never...............................................................................
1 to 2 times......................................................................
3 to 5 times......................................................................
6 to 10 times, or...............................................................
More than 10 times? .......................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
00
01
02
03
04
d
r
(All)
D9.
{INTERVIEWER: IF D7 OR D8 NE 00, SAY: Aside from hospital stays and outpatient surgery}
how many times in the last 6 months did {you/(NAME)} see or talk to a medical doctor about
{your/her/his} health? Please include visits to clinics or psychiatrists but do include visits to other
mental health professionals such as therapists or counselors. Would you say . . .
Never...............................................................................
1 to 2 times......................................................................
3 to 5 times......................................................................
6 to 10 times, or...............................................................
More than 10 times? .......................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
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01
02
03
04
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(All)
D10.
How many times did {you/(NAME)} visit an emergency room in the past 6 months? Would you
say . . .
Never...............................................................................
1 to 2 times......................................................................
3 to 5 times......................................................................
6 to 10 times, or...............................................................
More than 10 times? .......................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
00
01
02
03
04
d
r
(All)
D11.
The next few questions are about filling prescriptions. In the past 6 months, were there any
prescription medicines that {you were/(NAME) was} supposed to use, but did not get when first
prescribed because of the cost?
PROBE:
That is, {you/he/she} did not fill the prescription at all when {you/he/she} got it.
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
D12.
In the past 6 months, were there any prescription medicines that {you were/(NAME) was}
supposed to use, but did not get the entire prescription filled because of the cost?
PROBE:
That is, {you/he/she} filled the prescription but got less than the prescribed amount,
for example, if the prescription was written for 30 pills {you/he/she} got a lesser
amount.
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
D13.
In the past 6 months, were there any prescription medicines that {you were/(NAME) was}
supposed to use, but did not refill when {you/he/she} ran out because of the cost?
PROBE:
That is, {you/he/she} went some time without being able to take the needed
medication because it was finished.
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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(All)
D14.
In the past 6 months, were there any prescription medicines that {you/(NAME)} used less often
than prescribed in order to stretch them out because of the cost?
PROBE:
That is, {you/he/she} used less of the medication or skipped days of taking the
medication.
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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(REV—5/7/07)
SECTION E: EMPLOYMENT HISTORY AND SUPPORTS
(All)
E1.
Now I’d like to talk a little about {your/(NAME’s)} employment history. {Are you/Is (NAME)}
currently working at a job for pay? Include both part-time and full-time jobs, as well as any selfemployment, but only include jobs for pay or profit.
YES ................................................................................. 01
NO ................................................................................... 00 (E7)
DON’T KNOW ................................................................. d (E7)
REFUSED ....................................................................... r (E7)
(E1=01)
E2.
How many jobs {do you/does (NAME)} currently have?
|
| NUMBER OF JOBS (1-5)
DON’T KNOW .................................................................
REFUSED .......................................................................
d
r
(E1=01)
E3.
(IF E2 > 1, SAY: For these questions, please answer about {your/his/her} main job; that is, the
job on which {you work/he/she works} the most hours for pay.)
What kind of work {do you/does (NAME)} do on {this job/your/his/her main job}?
PROBE: That is, what is {your/(NAME’s)} occupation?
INTERVIEWER: ENTER VERBATIM RESPONSE
_________________________________________________________________________________
DON’T KNOW .................................................................
REFUSED .......................................................................
d
r
(E1=01)
E4.
What kind of business is {this/the one where {you work/(NAME) works} the most hours for pay}?
INTERVIEWER: ENTER VERBATIM RESPONSE
PROBE 1:
For what type of organization or industry {do you/does (NAME)} work? For
example, accounting firm, daycare center, educational facility, food services.
PROBE 2:
What does the company {you/he/she} {work/works} for make, sell, or do?
_________________________________________________________________________________
DON’T KNOW .................................................................
REFUSED .......................................................................
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d
r
(REV—5/7/07)
(E1=01)
E4mth. In what month and year did {you/(NAME)} start working at {this job/your/his/her main job}?
PROBE: Your best estimate is fine.
INTERVIEWER: ENTER MONTH HERE AND YEAR ON NEXT SCREEN
| | | (1-12)
MONTH
DON’T KNOW .................................................................
REFUSED .......................................................................
d (E4a)
r (E4a)
(E1=01)
E4yr.
INTERVIEWER: ENTER YEAR
|
|
|
|
| YEAR
(E5)
DON’T KNOW .................................................................
REFUSED .......................................................................
d
r
(E4yr=d OR r)
E4a.
Would you say {you/(NAME)} began working at {this job/your/his/her main job} . . .
PROBE: Your best estimate is fine.
within the past year, ........................................................
between a year and a year and a half,............................
between a year and a half and two years ago, or ...........
more than 2 years ago? ..................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
01
02
03
04
d
r
(E1=01)
E5.
How many hours per week {do you/does (NAME)} usually work at {this job/(your/his/her) main
job}?
PROBE: Include overtime if {you/he/she} usually work(s) overtime.
|
|
| HOURS PER WEEK (1-60)
DON’T KNOW .................................................................
REFUSED .......................................................................
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(E6)
d
r
(REV—5/7/07)
(E5=d OR r)
E5a.
Would you say {you work/NAME works} . . .
CODE ONE
Less than 10 hours per week, ......................................... 01
between 10 and 15 hours per week,............................... 02
between 16 and 20 hours per week,............................... 03
between 21 and 25 hours per week,............................... 04
between 26 and 30 hours per week,............................... 05
between 31 and 35 hours per week, or........................... 06
more than 35 hours per week? ....................................... 07
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(E1=01)
E6.
{Are you/Is (NAME)} self-employed at {this job/your/his/her main job}?
PROBE: Self-employed means that {you/(NAME)} work(s) for {(yourself/himself/herself/or own
your/his/her)} own business.
YES ................................................................................. 01 (E7a)
NO ................................................................................... 00 (E7a)
DON’T KNOW ................................................................. d (E7a)
REFUSED ....................................................................... r (E7a)
(E1 NE 01)
E7.
Now please think about the last time {you/(NAME)} worked for pay. How many jobs did
{you/(NAME)} have when {you/he/she} last worked? Include both part-time and full-time jobs, as
well as any self-employment, but only include jobs {you/(NAME)} held for pay or profit.
|
| NUMBER OF JOBS (1-5)
NEVER WORKED........................................................... 00 (FLAG AND CONTINUE TO E17)
DON’T KNOW ................................................................. d (E8)
REFUSED ....................................................................... r (E8)
(All)
E7a.
PROGRAMMER: CHECK E1. IS E1=01 (YES, CURRENTLY EMPLOYED)?
YES ................................................................................. 01 (E7b)
NO ................................................................................... 00 (E8)
(E7a=01)
E7b.
{Do you/Does (NAME)} currently work for the same employer that (you/he/she) had before
(you/he/she) started getting Social Security Disability Benefits?
YES ................................................................................. 01 (E13)
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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(E7 NE 00 AND E7b NE 01)
E8.
What kind of work did {you/(NAME)} do when [IF E7a=01 FILL “on that job?”, IF E7a=00. FILL
“when (you/he/she) last worked for pay or profit?”]
PROBE: That is, what was {your/(NAME’s)} occupation?
INTERVIEWER: ENTER VERBATIM RESPONSE
_______________________________________________________________
DON’T KNOW .................................................................
REFUSED .......................................................................
d
r
(E7 NE 00 AND E7b NE 01)
E9.
What kind of business did {you/he/she} work for?
INTERVIEWER: ENTER VERBATIM RESPONSE
PROBE 1:
For what type of organization or industry did {you/(NAME)} work? For example,
accounting firm, daycare center, educational facility, food services.
PROBE 2:
What does the company {you/(NAME)} worked for make, sell, or do?
PROBE 3:
Please think of the main job {you/(NAME)} had before applying for SSDI.
_________________________________________________________________________________
DON’T KNOW .................................................................
REFUSED .......................................................................
d
r
(E7 NE 00 AND E7b NE 01)
E9mth. In what month and year did {you/(NAME)} start working at {that job/your/his/her main job}?
PROBE: Your best estimate is fine.
INTERVIEWER: ENTER MONTH HERE AND YEAR ON NEXT SCREEN
| | | (1-12)
MONTH
DON’T KNOW .................................................................
REFUSED .......................................................................
d
r
(E7 NE 00 AND E7b NE 01)
E9yr.
INTERVIEWER: ENTER YEAR
|
|
|
|
| YEAR
(E10)
DON’T KNOW .................................................................
REFUSED .......................................................................
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d
r
(REV—5/7/07)
(E9yr=d OR r)
E9a.
Would you say {you/(NAME)} began working at that job . . .
PROBE: Your best estimate is fine.
within the past year, ........................................................
between a year and a year and a half,............................
between a year and a half and two years ago, or ...........
more than 2 years ago? ..................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
01
02
03
04
d
r
(E7 NE 00 AND E7b NE 01)
E10.
How many hours per week did {you/(NAME)} usually work at {your/his/her} {main} job?
PROBE: Include overtime if {you/he/she} usually worked overtime.
| | | HOURS PER WEEK (1-60)
(E12)
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(E10=d OR r)
E11.
Would you say {you/NAME) worked . . .
CODE ONE
less than 10 hours per week, .......................................... 01
between 10 to 15 hours per week,.................................. 02
between 16 to 20 hours per week,.................................. 03
between 21 to 25 hours per week,.................................. 04
between 26 to 30 hours per week,.................................. 05
between 31 to 35 hours per week, or.............................. 06
more than 35 hours per week? ....................................... 07
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(E7 NE 00 AND E7b NE 01)
E12.
{Were you/Was (NAME)} self-employed at that job?
PROBE:
Self-employed means that {you/(NAME)} worked for {yourself/himself/herself} or
owned {your/his/her} own business.
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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(REV—5/7/07)
(E7 NE 00)
E13.
There are a number of special work programs available to people with disabilities. [IF E1=01
FILL “Is {your/(NAME’s)} current” IF E7 > 1 FILL “Was {your/(NAME’s)} last” job] part of a
sheltered workshop program, transitional employment program, the Business Enterprise Program
for the blind, or a supported employment program?
PROBE:
A sheltered workshop is a program that provides employment with subsidized
wages (or special wages that would not be available in a regular job) for people
with disabilities.
PROBE:
A transitional employment program allows workers with disabilities to work at
reduced levels while they ease back into the workplace.
PROBE:
The Business Enterprise Program for the blind offers legally blind persons the
opportunity to own their own businesses.
PROBE:
Supported employment programs provide job coaches or other on-the-job supports
to help individuals with disabilities get and keep jobs.
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(E7 NE 00)
E14.
For these next questions please think about the {main} job {you/(NAME)} had [IF E7 > 1 FILL
“when {you/he/she} last worked for pay or profit.” IF E7b NE 01, FILL “before {you/he/she}
started getting Social Security Disability Benefits.”]
What would be the easiest way for you to report {your/(NAME’s)} total earnings before taxes or
other deductions for that job—would that be hourly, weekly, bi-weekly, twice monthly, monthly,
annually, or some other way?
PROBE:
{Your/(NAME’s)} main job is the one at which {you/he/she} worked the most hours.
HOURLY .........................................................................
WEEKLY .........................................................................
BI-WEEKLY.....................................................................
TWICE MONTHLY ..........................................................
MONTHLY.......................................................................
ANNUALLY .....................................................................
OTHER............................................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
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01
02
03
04
05
06
07
d
r
(E15)
(E15)
(E15)
(E15)
(E15)
(E15)
(E16)
(E16)
(REV—5/7/07)
(E14=07)
E14_Other. What is this other basis?
_______________________________________________________________
DON’T KNOW .................................................................
REFUSED .......................................................................
d
r
(E14=NE d OR r) (E14_Other=ANSWER, d, r)
E15.
What was {your/(NAME’s)} usual (hourly/weekly/bi weekly/twice monthly/monthly/annual) pay,
including tips and commissions on this job before taxes or other deductions were taken?
PROBE: Your best estimate is fine.
INTERVIEWER: PLEASE ENTER CENTS AFTER DECIMAL POINT, INCLUDING 00.
$|
|
|
|,|
|
|
|.|
|
|
DON’T KNOW .................................................................
REFUSED .......................................................................
(E17)
d
r
(E14=d OR r) (E15=d OR r)
E16.
I’ll read you some ranges. Please try to estimate {your/(NAME’s)} annual pay. Would you say
{you/(NAME)} earned ...
PROBE: Does this include tips and commissions?
Less than $10,000,..........................................................
$10,000 or more, but less than $20,000, ........................
$20,000 or more but less than $30,000, .........................
$30,000 or more but less than $40,000, .........................
$40,000 or more but less than $50,000, .........................
$50,000 or more but less than $75,000, .........................
$75,000 or more but less than $100,000, or ...................
more than $100,000? ......................................................
01
02
03
04
05
06
07
08
DON’T KNOW .................................................................
REFUSED .......................................................................
d
r
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(REV—5/7/07)
(All)
E17.
Now, please tell me how true the following statements are for {you/(NAME)}.
You see {yourself/(NAME)} working for pay in the next two years. Would you say this is definitely
true, somewhat true, or not at all true for {you/(NAME)}?
DEFINITELY TRUE......................................................... 01
SOMEWHAT TRUE ........................................................ 02
NOT AT ALL TRUE......................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
E17a. You see {yourself/(NAME)} working and earning enough to stop receiving disability benefits in the
next two years.
PROBE AS NEEDED: Would you say this is definitely true, somewhat true, or not at all true for
{you/(NAME)}?
DEFINITELY TRUE......................................................... 01
SOMEWHAT TRUE ........................................................ 02
NOT AT ALL TRUE......................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(E1 NE 01; PROGRAMMER: IF E1=01, GO TO E21)
E18.
Now, I am going to read you some reasons why people are sometimes unable to work. Please
tell me how true these reasons are for {you/(NAME)}.
{You/(NAME)} would need special equipment or medical devices that {you do/he does/she does}
not currently have in order to work.
PROBE AS NEEDED: Would {you/(NAME)} say this is definitely true, somewhat true, or not at
all true for {you/him/her}?
DEFINITELY TRUE......................................................... 01
SOMEWHAT TRUE ........................................................ 02
NOT AT ALL TRUE......................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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(E1 NE 01)
E18a. {You do/(NAME) does} not have the personal assistance {you/he/she} need(s) to get ready for
work each day.
PROBE: This includes things like dressing and bathing.
PROBE AS NEEDED: Would {you/(NAME)} say this is definitely true, somewhat true, or not at all
true for {you/him/her}?
DEFINITELY TRUE......................................................... 01
SOMEWHAT TRUE ........................................................ 02
NOT AT ALL TRUE......................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(E1 NE 01)
E18b. {You/(NAME)} cannot get the help that {you/he/she} need(s) caring for children or others.
PROBE AS NEEDED: Would {you/(NAME)} say this is definitely true, somewhat true, or not at
all true for {you/him/her}?
DEFINITELY TRUE......................................................... 01
SOMEWHAT TRUE ........................................................ 02
NOT AT ALL TRUE......................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(E1 NE 01)
E18c.
{You do/(NAME) does} not have reliable transportation to and from a job.
PROBE AS NEEDED: Would {you/(NAME)} say this is definitely true, somewhat true, or not at
all true for {you/him/her}?
DEFINITELY TRUE......................................................... 01
SOMEWHAT TRUE ........................................................ 02
NOT AT ALL TRUE......................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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(REV—5/7/07)
(E1 NE 01)
E18d. Most jobs don’t offer a flexible enough schedule.
PROBE AS NEEDED: Would {you/(NAME)} say this is definitely true, somewhat true, or not at all
true for {you/him/her}?
DEFINITELY TRUE......................................................... 01
SOMEWHAT TRUE ........................................................ 02
NOT AT ALL TRUE......................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(E1 NE 01)
E18e. Most jobs {you/(NAME)} would be offered don’t pay enough.
PROBE AS NEEDED: Would {you/(NAME)} say this is definitely true, somewhat true, or not at all
true for {you/him/her}?
DEFINITELY TRUE......................................................... 01
SOMEWHAT TRUE ........................................................ 02
NOT AT ALL TRUE......................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(E1 NE 01)
E18f.
Most jobs don’t offer health insurance benefits.
PROBE AS NEEDED: Would {you/(NAME)} say this is definitely true, somewhat true, or not at all
true for {you/him/her}?
DEFINITELY TRUE......................................................... 01
SOMEWHAT TRUE ........................................................ 02
NOT AT ALL TRUE......................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(E1 NE 01)
E18g. {You/(NAME)} would lose benefits (you need/he needs/she needs} like Social Security, private
disability insurance, workers’ compensation, or Medicaid, if {you/he/she} accepted a job.
PROBE AS NEEDED: Would {you/(NAME)} say this is definitely true, somewhat true, or not at
all true for {you/him/her}?
DEFINITELY TRUE......................................................... 01
SOMEWHAT TRUE ........................................................ 02
NOT AT ALL TRUE......................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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(E1 NE 01)
E18h. {You are/(NAME) is} too sick to work.
PROBE AS NEEDED: Would {you/(NAME)} say this is definitely true, somewhat true, or not at
all true for {you/him/her}?
DEFINITELY TRUE......................................................... 01
SOMEWHAT TRUE ........................................................ 02
NOT AT ALL TRUE......................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(E1 NE 01)
E18i.
{You have/(NAME) has} too much pain to work.
PROBE AS NEEDED: Would {you/(NAME)} say this is definitely true, somewhat true, or not at
all true for {you/him/her}?
DEFINITELY TRUE......................................................... 01
SOMEWHAT TRUE ........................................................ 02
NOT AT ALL TRUE......................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(E1 NE 01)
E18j.
{You have/(NAME) has} a hard time getting along with people at work.
PROBE AS NEEDED: Would {you/(NAME)} say this is definitely true, somewhat true, or not at
all true for {you/him/her}?
DEFINITELY TRUE......................................................... 01
SOMEWHAT TRUE ........................................................ 02
NOT AT ALL TRUE......................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(E1 NE 01)
E18k.
{You have/(NAME) has} trouble dealing with stress at work.
PROBE AS NEEDED: Would {you/(NAME)} say this is definitely true, somewhat true, or not at
all true for {you/him/her}?
DEFINITELY TRUE......................................................... 01
SOMEWHAT TRUE ........................................................ 02
NOT AT ALL TRUE......................................................... 03
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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(E18g=01 or 02)
E19.
You said that {you believe/(NAME) believes} that if {you/he/she} accepted a job {you/he/she}
would lose benefits {you/he/she} needed such as Social Security, disability insurance, workers’
compensation, or Medicaid.
What benefits {were you/was (NAME)} worried about losing?
READ IF NECESSARY.
PRIVATE DISABILITY INSURANCE ..............................
WORKERS’ COMPENSATION.......................................
VETERANS’ BENEFITS .................................................
MEDICARE .....................................................................
MEDICAID.......................................................................
SSA DISABILITY BENEFITS ..........................................
PUBLIC ASSISTANCE OR WELFARE ..........................
FOOD STAMPS ..............................................................
PERSONAL ASSISTANCE SERVICES (PAS)...............
UNEMPLOYMENT BENEFITS .......................................
OTHER STATE DISABILITY BENEFITS........................
OTHER GOVERNMENT BENEFITS ..............................
OTHER............................................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
01
02
03
04
05
06
07
08
09
10
11
12
13
d
r
(E19=13)
E19_other.
What other benefits?
_______________________________________________________________
DON’T KNOW .................................................................
REFUSED .......................................................................
d
r
(E18g=01 or 02)
E20.
There are many ways people find out about how working will affect their benefits. For example,
some people call the Social Security office, some search the internet, and others contact
disability service organizations. Did {you/(NAME)} contact anyone or do any of these things in
order to find out how {your/his/her} benefits would be affected if {you/he/she} went to work?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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(All)
E21.
Now I would like to ask you a few general questions about the rules for receiving Social Security
Disability Benefits. You can tell me what your best guess is in response to these questions.
Don’t worry about it if you don’t know the exact answer.
ADD IF NECESSARY: The Social Security Administration would like to know how well people
understand SSDI rules and regulations.
In general, once a person starts receiving Social Security Disability cash benefits, how many
months does he or she need to wait before becoming eligible for Medicare?
|
|
| NUMBER OF MONTHS (0-98)
IT VARIES ....................................................................... 99
NONE, CAN RECEIVE IMMEDIATELY.......................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
E22.
As of today, how many months will {you/(NAME)} have to wait until {you become/he
becomes/she becomes} eligible for Medicare?
|
|
| NUMBER OF MONTHS (0-98)
DON’T KNOW .................................................................
REFUSED .......................................................................
d
r
(All)
E23.
Can a person who is getting Social Security Disability Benefits continue to receive Medicare while
working?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
E24.
Can a person continue to receive Social Security cash benefits while working?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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E25.
If {you take/(NAME) takes} a job or {become/becomes} self-employed and {you are/(he/she) is}
still disabled, {you/he/she} will be eligible for a trial work period. For how many months can
{you/he/she} continue to receive cash benefits during a trial work period?
|
|
| NUMBER OF MONTHS (0-98)
IT VARIES ....................................................................... 99
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
E26.
If {you continue/(NAME) continues} to work beyond the trial work period, {you/he/she} can
continue to receive Social Security Disability benefits for another 36 months provided
{your/his/her} earnings are not “substantial.” How much money can {you/he/she} earn each
month and continue to receive benefits?
$|
|,|
|
|
|.00 AMOUNT PER MONTH (0-5,000)
DON’T KNOW .................................................................
REFUSED .......................................................................
d
r
(All)
E27.
Can a person who is receiving Social Security Disability benefits get help with education, training
or rehabilitation so that he or she can start a new line of work?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
E28.
Do you remember whether you received an information booklet called “What you need to know
when you get Social Security disability benefits” when you received your award notice?
YES ................................................................................. 01
NO ................................................................................... 00 (E29)
DON’T KNOW ................................................................. d (E29)
REFUSED ....................................................................... r (E29)
(E28=01)
E28a. Have you had a chance to read the information booklet?
YES ................................................................................. 01
SOME OF IT/SKIMMED IT.............................................. 02
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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SECTION F: HOUSEHOLD COMPOSITION AND INCOME
(All)
F1.
My next questions are about {your/(NAME’s)} household. By household I mean people who live
with {you/(NAME)} and share living expenses, for whom {you/(NAME)} provide financial support,
or who provide {you/(NAME)} with financial support.
How many adults 18 years of age or older live in {your/(NAME’s)} household, including
{yourself/(NAME)}?
PROBE:
This includes all adults who usually live there, even if they are temporarily away on
business, vacation, in a hospital, away at school or on military duty.
|
|
| ADULTS (1-10)
LIVES IN A GROUP HOME ........................................... 99 (F8)
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
F2.
How many children under 18 years of age live in {your/(NAME’s)} household?
PROBE:
This includes all children who usually live there, even if they are temporarily away on
vacation, in a hospital, or away at school.
ZERO/NONE ................................................................... 00 (F5)
|
|
| CHILDREN (1-10)
DON’T KNOW .................................................................
REFUSED .......................................................................
d (F4a)
r (F4a)
(F2 ≥ 01)
F3.
For how many children under age 18 {are you/ is (NAME)} a primary provider or caregiver?
ZERO...............................................................................
ONE.................................................................................
TWO ................................................................................
THREE ............................................................................
FOUR ..............................................................................
FIVE OR MORE ..............................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
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F4a.
How old is the (youngest) child {you care/(NAME) cares} for?
PROGRAMMER: FILL YOUNGEST IF F3>01
|
|
| ENTER AGE IN YEARS (1-17)
LESS THAN ONE YEAR................................................. 01
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
PROGRAMMER: IF F3 < 02, GO TO F5. IF F3 > 02, GO TO F4b.
(F3 ≥ 01)
F4b.
How old is the oldest child {you care/(NAME) cares} for?
|
|
| ENTER AGE IN YEARS (1-17)
(All)
F5.
PROGRAMMER: DOES SAMPLE MEMBER LIVE ALONE; THAT IS, F1=01 AND F2=00?
YES ................................................................................. 01 (F7)
NO ................................................................................... 00
(PROGRAMMER: IF F1=01 AND E1=01, GO TO F7)
F6.
Now please think back to last year. How many of the {FILL SUM OF F1 PLUS F2} people in
{your/(NAME’s)} household worked at a job for pay last year?
|
|
| (1-10)
ZERO/NONE ................................................................... 00 (F8)
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(All)
F7.
[IF F6>1, SAY: Counting everyone in {your/(NAME’S)} household who worked for pay last year],
what was {your/(NAME’S)} total household income in 2006? Please include benefits, earnings,
and all other sources of income.
Was it:
Less than $10,000,..........................................................
$10,000 or more, but less than $20,000, ........................
$20,000 or more but less than $30,000, .........................
$30,000 or more but less than $40,000, .........................
$40,000 or more but less than $50,000, .........................
$50,000 or more but less than $75,000, .........................
$75,000 or more but less than $100,000, or ...................
more than $100,000? ......................................................
DON’T KNOW .................................................................
REFUSED .......................................................................
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F8.
{Do you/Does (NAME)}…
Own {your/his/her} home,................................................
Rent {your/his/her} home, ...............................................
Live with family or friends and pay part of the
rent or mortgage,..........................................................
Live with family or friends and not pay, ...........................
Live in a group shelter, ....................................................
Live in an assisted living facility, or .................................
Live in some other housing arrangement?......................
DON’T KNOW .................................................................
REFUSED .......................................................................
01 (G1)
02 (F9)
03
04
05
06
07
d
r
(F9)
(F9)
(F9)
(F9)
(F9)
(F9)
(F8=06)
F8_Other. What is {your/(NAME’s)} living arrangement?
DON’T KNOW .................................................................
REFUSED .......................................................................
d
r
(F8 NE 01)
F9.
{Do you/Does (NAME)} live in public housing, for example, housing owned by the Housing
Authority or the Housing Commission?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(F8 NE 01 OR 05)
F10.
Does {your/(NAME’s)} household receive Section 8 rental assistance?
PROBE:
This voucher program lets {you/(NAME)} choose where {you live/he she lives} and, if
the landlord agrees, the Housing Authority or the Housing Commission or other city
rental assistance program will pay part of {your/his/her} rent.
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(F8 NE 01)
F11.
Does {your/(NAME’s)} household pay a reduced rent because it meets low-income eligibility
requirements?
YES ................................................................................. 01
NO ................................................................................... 00
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
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SECTION G: BACKGROUND
(All)
G1.
We’re almost finished. I just have a few final questions about {you/(NAME)}.
What is the highest year or grade {you/(NAME)} finished in school?
INTERVIEWER:
IF ATTENDED SCHOOL BUT COMPLETED LESS THAN HIGH SCHOOL,
CODE AS 1. IF NEVER ATTENDED SCHOOL, CODE AS 10.
INTERVIEWER:
IF RESPONDENT SAYS THEY WERE HOME SCHOOLED, PROBE FOR
HIGHEST YEAR, GRADE, DEGREE, OR CERTIFICATE COMPLETED.
INTERVIEWER:
IF RESPONDENT SAYS HIGH SCHOOL, PROBE: Did {you/(NAME)}
receive a diploma, GED, or certificate of completion?
CODE ONE
DID NOT COMPLETE HIGH SCHOOL OR GED ......................
HIGH SCHOOL: DIPLOMA.......................................................
HIGH SCHOOL: GED ...............................................................
CERTIFICATE OF COMPLETION.............................................
SOME COLLEGE/SOME POSTSECONDARY
VOCATIONAL COURSES ......................................................
2-YEAR OR 3-YEAR COLLEGE DEGREE (ASSOCIATE’S
DEGREE) OR VOCATIONAL SCHOOL DIPLOMA................
4-YEAR COLLEGE DEGREE (BACHELOR’S DEGREE) .........
SOME GRADUATE WORK/NO GRADUATE DEGREE............
GRADUATE OR PROFESSIONAL DEGREE
(e.g., MA, MBA, Ph.D., JD, MD)..............................................
NEVER ATTENDED SCHOOL ..................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
05
06
07
08
09
10
d
r
(All)
G2.
{Are you/Is (NAME)} now married, living with a partner, separated, divorced, widowed, or {have
you/has (he/she)} never been married?
CODE ONE
MARRIED...................................................................................
LIVING WITH PARTNER ...........................................................
SEPARATED..............................................................................
DIVORCED ................................................................................
WIDOWED .................................................................................
NEVER MARRIED .....................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
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03
04
05
06
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r
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SECTION H: CONTACT INFORMATION AND STUDY GROUP ASSIGNMENT
(All)
H1.
PROGRAMMER:
IF WE HAVE NAME, ADDRESS, AND PHONE NUMBER FROM EITHER
THE SCREENER OR FROM THE OTHER PRELOADED INFORMATION
DISPLAY THAT NAME, ADDRESS, AND PHONE NUMBER.
That concludes this interview. Please verify {your/(NAME’s)} current contact information so that I
can send {you/him/her} the consent materials. Is {your/(NAME’s)} current address and phone
number… READ FROM PRELOADS?
SAME AS PROVIDED ............................................................... 00 (H3)
INCORRECT INFORMATION ABOVE,
NEED TO ENTER NEW INFORMATION ............................... 01
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(H1=01, d, OR r)
H2.
UPDATE INFORMATION BELOW
What is the correct spelling of {your/(NAME’s)} name and {your/(NAME’s)} current mailing
address and phone number?
PROBE: Is there an apartment number?
NAME (VERIFY SPELLING) ______________________________
ADDRESS LINE 1
ADDRESS LINE 2
CITY/TOWN
STATE
ZIP CODE
TELEPHONE
(All)
H2a.
{Do you/Does (NAME)} have a cell phone number?
YES ......................................................................................... 01
NO
......................................................................................... 00 (H3)
DON’T KNOW ............................................................................ d (H3)
REFUSED .................................................................................. r (H3)
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H2b.
What is {your/(NAME’s)} cell phone number?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(All)
H3.
{Do you have/Does (NAME) have} an email address?
YES ......................................................................................... 01
NO
......................................................................................... 00 (H5)
DON’T KNOW ............................................................................ d (H5)
REFUSED .................................................................................. r (H5)
(H3=01)
H4.
What is {your/(NAME’s)} email address?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(All)
H5.
INTERVIEWER: ARE YOU SPEAKING WITH (NAME) OR AN INTERPRETER?
NAME ......................................................................................... 01 (H10)
INTERPRETER .......................................................................... 02
(H5=2)
H6.
What is your full name?
INTERVIEWER: PRESS 1 TO CONTINUE
NAME:
DISPLAY INTERPRETER’S FULL NAME FROM SCREENER OR PRELOADED
INFORMATION WITH FIRST NAME BOLD}
FIRST NAME:
DON’T KNOW ............................................................................
REFUSED ..................................................................................
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(H5=02)
H7.
What is the correct spelling of your name and your current mailing address and phone number?
PROGRAMMER: DISPLAY INTERPRETER’S FULL ADDRESS IF AVAILABLE
PROBE: Is there an apartment number?
NAME (VERIFY SPELLING)______________________________________________
ADDRESS LINE 1______________________________________________________
ADDRESS LINE 2______________________________________________________
CITY/TOWN __________________________________________________________
STATE ______________________________________________________________
ZIP CODE ____________________________________________________________
TELEPHONE _________________________________________________________
(H5=02)
H7a.
Do you have a cell phone number?
YES ......................................................................................... 01
NO
......................................................................................... 00 (H8)
DON’T KNOW ............................................................................ d (H8)
REFUSED .................................................................................. r (H8)
(H7a=01)
H7b.
What is your cell phone number?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(H5=02)
H8.
Do you have an email address?
YES ......................................................................................... 01
NO
......................................................................................... 00 (H10)
DON’T KNOW ............................................................................ d (H10)
REFUSED .................................................................................. r (H10)
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(H8=01)
H9.
What is your email address?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(All)
H10.
To whom should we make the $25.00 check for completing the interview payable?
SAMPLE MEMBER .................................................................... 01 (H12)
INTERPRETER .......................................................................... 02 (H12)
SOMEONE ELSE....................................................................... 03
DON’T KNOW ............................................................................ d (H12)
REFUSED .................................................................................. r (H12)
(H10=04)
H11.
What is the name and address of the person we should send the check to?
NAME
ADDRESS LINE 1
ADDRESS LINE 2
CITY/TOWN
STATE
ZIP CODE
TELEPHONE
H11a. What is {FILL NAME FROM H11} relationship to {you/(NAME)}?
(NAME’s) SPOUSE/PARTNER..................................................
(NAME’s) MOTHER ...................................................................
(NAME’s) FATHER.....................................................................
(NAME’s) CHILD ........................................................................
GRANDPARENT OF (NAME)....................................................
BROTHER/SISTER OF (NAME)................................................
AUNT/UNCLE OF (NAME) ........................................................
OTHER RELATIVE OF (NAME) ................................................
NOT RELATED ..........................................................................
STAFF AT RESIDENCE ............................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
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H12.
We will mail the check for $25.00 to {you/(NAME)} at {FILL ADDRESS} within the next two
weeks. We would like to contact you again in about {FILL: If this is complete #1-600: six months;
If this is complete #601+: a year and a half} to see how you are doing and update our
information. In case we have trouble reaching {you/him/her}, what is the name, address, and
phone number of a close relative or friend who is not living with {you/(NAME)} and is likely to
know {your/his/her} location in the future? For example, a mother, father, brother, sister, aunt,
uncle, or close friend.
{Do you/Does (NAME)} have a contact person?
CONTACT PERSON 1
YES ......................................................................................... 01
NO
......................................................................................... 00 (H17)
DON’T KNOW ............................................................................ d (H17)
REFUSED .................................................................................. r (H17)
(H12=01)
H13.
What is that person’s name and address?
NAME
ADDRESS LINE 1
ADDRESS LINE 2
CITY/TOWN
STATE
ZIP CODE
(H12=01)
H13a. Please give me the telephone number, area code first.
DON’T KNOW ...........................................................................
REFUSED .................................................................................
d
r
(H12=01)
H13b. Do you have a cell phone, pager number or email address for [NAME AT H13]?
YES ........................................................................................... 01
NO ............................................................................................. 00 (H14)
DON’T KNOW ........................................................................... d (H14)
REFUSED ................................................................................. r (H14)
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H13c. What is [NAME AT H13]’s cell phone number? Please give me the number, area code first.
What is {his/her} pager number? Please give me the number, area code first.
What is {his/her} email address?
DON’T KNOW ...........................................................................
REFUSED .................................................................................
d
r
(H12=01)
H14.
How is [NAME AT H13] related to {you/(NAME)}, if at all?
(NAME’s) SPOUSE/PARTNER.................................................
(NAME’s) MOTHER ..................................................................
(NAME’s) FATHER....................................................................
(NAME’s) CHILD .......................................................................
GRANDPARENT OF (NAME)...................................................
BROTHER/SISTER OF (NAME)...............................................
AUNT/UNCLE OF (NAME) .......................................................
OTHER RELATIVE OF (NAME) ...............................................
NOT RELATED .........................................................................
STAFF AT RESIDENCE ...........................................................
DON’T KNOW ...........................................................................
REFUSED .................................................................................
01
02
03
04
05
06
07
08
09
10
d
r
(H15)
(H15)
(H15)
(H15)
(H15)
(H15)
(H15)
(H15)
(H15)
(H15)
(H15)
(H14=08)
H14_Other. How is {he/she} related to {you/(NAME)}?
DON’T KNOW ...........................................................................
REFUSED .................................................................................
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CONTACT PERSON 2
H15.
Can you give me the name and address of another person who would always know how to reach
{you/(NAME)}?
YES ........................................................................................... 01
NO ............................................................................................. 00 (H17)
DON’T KNOW ........................................................................... d (H17)
REFUSED ................................................................................. r (H17)
NAME
ADDRESS LINE 1
ADDRESS LINE 2
CITY/TOWN
STATE
ZIP CODE
FIRST NAME:
DON’T KNOW ...........................................................................
REFUSED .................................................................................
d
r
(H15=01)
H15a. Please give me the telephone number, area code first.
DON’T KNOW ..........................................................................
REFUSED ................................................................................
d
r
(H15=01)
H15b. Do you have a cell phone, pager number or email address for [NAME AT H15]?
YES ........................................................................................... 01
NO ............................................................................................. 00 (H16)
DON’T KNOW ........................................................................... d (H16)
REFUSED ................................................................................. r (H16)
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H15c. What is {his/her} cell phone number? Please give me the number, area code first.
What is {his/her} pager number? Please give me the number, area code first.
What is {his/her} email address?
DON’T KNOW ...........................................................................
REFUSED .................................................................................
d
r
(H15=01)
H16.
How is {he/she} related to {you/(NAME)}, if at all?
(NAME’s) SPOUSE/PARTNER.................................................
(NAME’s) MOTHER ..................................................................
(NAME’s) FATHER....................................................................
(NAME’s) CHILD .......................................................................
GRANDPARENT OF (NAME)...................................................
BROTHER/SISTER OF (NAME)...............................................
AUNT/UNCLE OF (NAME) .......................................................
OTHER RELATIVE OF (NAME) ...............................................
NOT RELATED .........................................................................
STAFF AT RESIDENCE ...........................................................
DON’T KNOW ...........................................................................
REFUSED .................................................................................
01
02
03
04
05
06
07
08
09
10
d
r
(H17)
(H17)
(H17)
(H17)
(H17)
(H17)
(H17)
(H17)
(H17)
(H17)
(H17)
(H16=08)
H16_Other. How is {he/she} related to {you/(NAME)}?
DON’T KNOW ...........................................................................
REFUSED .................................................................................
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H17.
ASSIGNMENT
ASSIGNED TO AB-BASIC:
That was the last question I had. As I mentioned at the beginning of the interview, our computer
randomly assigns participants to one of three groups. At this point I have very good news: {you
have/(NAME) has} been randomly assigned to the group that is eligible to receive health benefits.
We will be mailing {you/(NAME)} further information about the benefits, along with a toll free
number that you can call if {you have/he/she has} any questions. Please {review/ask (NAME) to
review} the information when {you/he/she} receive(s) it, and return a signed a copy to us within
two weeks. {You/(NAME)} will not be able to use {your/his/her} benefits until we receive the
signed form, so it is important that {you/he/she} mail this back as soon as possible. Once again,
congratulations, and we will be in touch with {you/(NAME)} in about [PROGRAMMER: IF #
COMPLETE =1-600, FILL “6 months” IF # COMPLETE > 601, FILL “a year and a half”] to see
how {you are/he/she is} doing.
ASSIGNED TO AB-PLUS:
That was the last question I had. As I mentioned at the beginning of the interview, our computer
randomly assigns participants to one of three groups. At this point I have very good news: {you
have/(NAME) has} been randomly assigned to the group that is eligible to receive health benefits,
and additional services that may make it easier for {you/him/her} to gain more independence.
We will be mailing {you/(NAME)} further information about the benefits, along with a toll free
number that you can call if {you have/he/she has} any questions. Please {review/ask (NAME) to
review} the information when {you/he/she} receive(s) it, and return a signed a copy to us within
two weeks. We will not be able to activate {your/his/her} benefits until we receive the signed
form, so it is important that {you/he/she} mail this back as soon as possible. Once again,
congratulations, and we will be in touch with {you/(NAME)} in about _[PROGRAMMER: IF #
COMPLETE =1-600, FILL “6 months” IF # COMPLETE > 601, FILL “a year and a half”] to see
how {you are/he/she is} doing.
ASSIGNED TO CONTROL GROUP:
That was the last question I had. As I mentioned at the beginning of the interview, our computer
will randomly assign participants to one of three groups. The answers you provided today will not
affect which group {you are/(NAME) is} in. We will send {you/NAME} a letter that notifies
{you/him/her} of {your/his/her} assignment when we mail the $25 we promised to send to thank
you for completing this interview.
(All)
THNX. (That was my last question.) Thank you very much for your time. Best wishes to you {and
(NAME)}.
H19.
INTERVIEWER: CHECK APPROPRIATE BOX BELOW.
PROGRAMMER: MAKE FAQs AVAILABLE FROM THIS SCREEN.
SAMPLE MEMBER ACCEPTS ASSIGNMENT........................ 01
SAMPLE MEMBER REFUSES AFTER
ASSIGNMENT........................................................................ 02
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FLAG FOR SUPERVISOR
REVIEW/SPECIAL
HANDLING.
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I. INTERVIEWER OBSERVATIONS
(All)
I1.
In general, do you feel the respondent was intellectually capable of responding?
YES ...........................................................................................
NO .............................................................................................
DON’T KNOW ...........................................................................
01
00
d
(All)
I2.
Do you feel the respondent understood the consent statement?
YES ...........................................................................................
NO .............................................................................................
DON’T KNOW ...........................................................................
01
00
d
(All)
I3.
In general, do you feel the respondent understood the questions?
YES ...........................................................................................
NO .............................................................................................
DON’T KNOW ...........................................................................
01
00
d
(All)
I2.
In general, do you feel the respondent’s answers were reasonably accurate?
YES ...........................................................................................
NO .............................................................................................
DON’T KNOW ...........................................................................
01
00
d
(All)
I5.
In general, how tiring did the interview seem to be for the respondent?
VERY TIRING ...........................................................................
A LITTLE TIRING ......................................................................
NOT TIRING..............................................................................
DON’T KNOW ...........................................................................
01
02
03
d
(All)
I6.
In general, did the respondent have difficulty hearing you during the interview?
YES ...........................................................................................
NO .............................................................................................
DON’T KNOW ...........................................................................
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01
00
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(I8)
(I8)
(REV—5/7/07)
(All)
I7.
In general, do you feel the respondent’s hearing difficulty affected the interview?
YES ...........................................................................................
NO .............................................................................................
DON’T KNOW ...........................................................................
01
00
d
(All)
I8.
Record any special circumstances encountered while interviewing respondent.
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MPR DOCUMENTATION:
H:\PROJECT\6237\common\Tasks- Active (survey files, task 2)\Survey Files\1-Baseline Quex\CURRENT\AB-Baseline (db) q24.doc
(REV—5/7/07) 5/9/2007 2:05 PM
Dot revised for Lisa Schwartz
ABD – 6237-320
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| File Type | application/pdf |
| File Title | Microsoft Word - AB-Baseline _db_ q24.doc |
| Author | LSchwartz |
| File Modified | 2007-05-09 |
| File Created | 2007-05-09 |