Early Use Survey

MPR Reference No.: 6237

Accelerated Benefits
Demonstration
Early Use Survey
(6-Month Followup)
Draft
April 3, 2007

Julita Milliner-Waddell
Lisa Schwartz
Deborah Peikes
David Wittenburg
Charles Michalopoulos
David Butler

CONTENTS

Section

Page

A.

INTRODUCTION ......................................................................................................... 1

B.

USE OF MEDICAL SERVICES ................................................................................. 27

C.

UNMET NEEDS ........................................................................................................ 38

D.

HEALTH INSURANCE COVERAGE......................................................................... 48

E.

SATISFACTION WITH AB SERVICES ..................................................................... 52

F.

CLOSING AND CONTACT INFORMATION ............................................................. 77

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SECTION A: INTRODUCTION

(All)
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.} I’m calling
to followup and see how {you are/(NAME) is} doing since {you were/he/she was} selected to participate in
the Accelerated Benefits (AB) Demonstration in {FILL MONTH}. You should have received a letter telling
you that someone from Mathematica Policy Research would be calling. The questions I have will take about
30 minutes to complete. {You/He/She} will receive a check for $25 for completing the interview. I’d like to
start now, but if {you get/(NAME) gets} 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. Is that okay?
YES, CONTINUE...........................................
(NAME) WILL CALL MPR..............................
CALL BACK LATER ......................................
DID NOT RECEIVE LETTER/
DOES NOT RECALL LETTER ...................
NEEDS/REQUESTS PROXY ........................
POSSIBLE PARTICIPATION PROBLEM ......
REFUSED .....................................................

01 (A56)
02 (A67)
03 (A55)
04
05
06
r

(A19)
(A13)
(A13)
(A69)

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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 how {you have/he/she has} been doing since we last
spoke in {FILL MONTH}. This is in reference to the Accelerated Benefits Demonstration in which {you
were/(NAME) was} selected to participate in {FILL MONTH}. 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
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 ......................................................

01
02 (A55)
03 (A8a)
04 (HUDI)

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REFUSED .....................................................

r (A65a)

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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 how {he/she has} been doing since we last spoke in {FILL MONTH}. This
is in reference to the Accelerated Benefits Demonstration in which {he/she was} selected to participate in
{FILL MONTH}. 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 .....................................................

01
02
03
04
r

(A55)
(A8a)
(HUDI)
(A8b)

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 how {he/she has} been doing since we
last spoke in {FILL MONTH}. This is in reference to the Accelerated Benefits Demonstration in which
(NAME) was selected to participate in {FILL MONTH}. 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. 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 (A8b)
POSSIBLE INTERPRETER REFUSED......... r (A8b)

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(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 (A8b)
(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 .....................................................

01
02
03
04
05

(A7c)
(A7c)
(A7c)
(A7c)
(A7c)

06
07
08
09
10
d
r

(A7c)
(A7c)

DON’T KNOW ...............................................
REFUSED .....................................................

d
r

(A7c)
(A7c)
(A7c)
(A7c)

(A7b=08)
A7b_other. How are you related to (NAME)?

(A7b=ANSWER OR d OR r)
A7c.
PROGRAMMER:
IF A7 = 01 (CONTINUE) ................................ 01 (A10a)
IF A7=02: CALLBACK TO INTERPRETER .. 02 (A55)

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(A5=03) (A6b=03)
A8a.
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 ...............................................
REFUSED .....................................................

d (A65a)
r (A65a)

SEEKING INTERPRETER
(A6b=r) (A6c=00 OR r) (A7=r)
A8b.
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)
(A8b=01)
A8c.
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
(A8c=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 ...........................

01
02
03
04 (A55)
05 (HUDI)
r (A65a)

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(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 how
(NAME) has been doing since we last spoke in {FILL MONTH}. This is in reference to the Accelerated
Benefits Demonstration which (NAME) was selected to participate in {FILL MONTH}. I work for
Mathematica Policy Research, a nationally recognized research company based in Princeton, New Jersey.
We are not selling anything or asking for contributions.
If (NAME) is available and you are ready to interpret, we can being 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
03
04
r

(A55)
(FAQs, THEN A10a)
(HUDI)
(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) (A7d=01) (A10=01 OR 03)
A10a. PROGRAMMER: IF A3=02, START HERE: (Hello, my name is __________________ calling on behalf of
the Social Security Administration.} I’m calling to followup and see how {you are/(NAME) is} doing since
{you were/he/she was} selected to participate in the Accelerated Benefits (AB) Demonstration in {FILL
MONTH}. You should have received a letter telling you that someone from Mathematica Policy Research
would be calling. The questions I have will take about 30 minutes to complete. {You/He/She} will receive a
check for $25 for completing the interview. I’d like to start now, but if {you get/(NAME) gets} 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. Is
that okay?
PROGRAMMER: IF A3=01, A7c=01, OR A10=01 OR 03, START HERE: The interview will take about 30
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 PROXY ........................
POSSIBLE PARTICIPATION PROBLEM ......
REFUSED .....................................................

01 (A56)
02 (A67)
03 (A55)
04
05
06
r

(A19)
(A13)
(A13)
(A69)

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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 PROXY .................

01
02
03
04 (A13a)

(A11=01, 02, OR 03)
A12.
Hello, my name is ________________________. Thank you for calling in to complete the survey. The
purpose of the survey is to followup and see how (you are/(NAME) is) doing since (you were/he/she was)
selected to participate in the Accelerated Benefits (AB) Demonstration in {FILL MONTH}. You should have
received a letter telling you that someone from Mathematica Policy Research would be calling. The
questions I have will take about 30 minutes to complete. (You/He/She) will receive a check for $25 for
completing the interview. I’d like to start now, but if (you get/(NAME) gets) 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. Is that okay?
YES, CONTINUE...........................................
WANTS TO SCHEDULE INTERVIEW ..........
NEEDS/REQUESTS PROXY ........................
POSSIBLE PARTICIPATION PROBLEM ......
REFUSED .....................................................

01 (A56)
02 (A55)
03
04
r (A69)

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DIFFICULTY PARTICIPATING (SPEAKING WITH NAME/INFORMANT/UNKNOWN PROXY 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 PROXY ................. 03
(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}?
PROGRAMMER: INSERT A FLAG AFTER NOTING BARRIER, IF KNOWN FROM BASELINE.
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: I’m calling to followup and see how {you are/(NAME) is} doing since {you
were/he/she was} selected to participate in the Accelerated Benefits (AB) Demonstration in {FILL MONTH}.
You should have received a letter telling you that someone from Mathematica Policy Research would be
calling. We’d like to work with you {and (NAME)} to help {you/him/her} participate so that we can find out
how {you have /he/she has} been doing. {You/He/She} will receive a check for $25 for completing the
interview. 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 07 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)
IF IN FIELD SAMPLE: I could send an interviewer
to {your/(NAME’s)} home, ........................... 04 (A37)
{PROGRAMMER: DISPLAY 06
ONLY IF A13=03}
IF SPEAKING WITH INFORMANT: You could act
as a proxy for (NAME), or ........................... 05 (A42)
You could give us the name of someone else who
could assist {you/(NAME)}? ........................ 06 (A40)
Or, do you have another way? (SPECIFY) ... 07
DON’T KNOW ...............................................
REFUSED .....................................................

d (A40)
r (A69)

DON’T KNOW ...............................................
REFUSED .....................................................

d (A40)
r (A69)

(A14=07)
A15.
What way is that?

(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

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(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) 01 (A55) FLAG AMP
CALL BACK—FEW MINUTES (TTY) ............ 02 (A55) STORE TTY
INFO
CALL BACK—FEW MINUTES (RELAY) ....... 03 (A55) STORE
RELAY INFO
NO, CALL BACK LATER (AMPLIFIER)......... 04 (A55) FLAG AMP
NO, CALL BACK LATER (TTY) ..................... 05 (A55) STORE TTY
INFO
NO, CALL BACK LATER (RELAY) ................ 06 (A55) STORE
RELAY INFO
NO, CALL BACK (GENERAL) ....................... 07 (A55)
HUNG UP ...................................................... 08 (HUDI)
DON’T KNOW ............................................... d (A55)
REFUSED ..................................................... r (A65a)
INTERVIEWER: IF A18=01, EXIT CASE AND TRANSFER
CALL
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 how {you have/(NAME)has} been doing since {you were/he/she was}
selected to participate in the Accelerated Benefits Demonstration in {FILL MONTH}. I work for Mathematica
Policy Research. We are conducting a survey for the Social Security Administration about the Accelerated
Benefits Demonstration. 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
received 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.

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GO TO A56

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(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
(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

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(A22a=ANSWER)
A23a. INTERVIEWER: IS STATE IN THE U.S. OR DC?
YES ............................................................... 01 (A56)
NO ................................................................. 00
(A23a=00)
A23b. 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.
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.....................
NAME NOW 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 (A24d)
(A24a=ANSWER)
A24b. INTERVIEWER: IS DATE DURING FIELD PERIOD – BY MONTH, YEAR?
YES ............................................................... 01 (A24c)
NO ................................................................. 00 (A24d)
A24c.

Thank you. We will call back when (NAME) returns.
GO TO A55 AND SCHEDULE CALL BACK

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(A24a=00) (A24b=00)
A24d. I’m sorry, but (we are not able to interview persons who live outside the U.S./we will not be interviewing for
AB at that time). [IF A24a=00, SAY: When did (NAME) move away?] Thank you for your time. Have a nice
day.
| | |/| 2 | 0 | | |
MONTH
YEAR
DON’T KNOW ................................................
REFUSED ......................................................

d
r

EXIT CASE
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. We could . . .
CODE ONE
{PROGRAMMER: DISPLAY 01 ONLY
IF RETURN EXPECTED BY JANUARY 2008}
call after {he/she} returns home and is feeling
better, ......................................................... 01
If (NAME) is well enough, we can call {him/her}
at the institution or hospital, ........................ 02
We could send an interviewer to visit (NAME)
at the institution or hospital, or. ................... 03
We could speak to someone who is
knowledgeable about (NAME’S) health ...... 04
(NAME) TOO ILL/SEEK PROXY ................... 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(A55)

(A40)
(A40)
(A40)
(A65a)

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(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

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)

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(A30=01)
A31a. When do you expect (NAME) to return to live in the U.S.?
| | |/| 2 | 0 |
MONTH
YEAR

|

|

NEVER .......................................................... 00 (A31d)
(A31a=ANSWER)
A31b. INTERVIEWER: IS DATE DURING FIELD PERIOD?
YES ............................................................... 01 (A31c)
NO ................................................................. 00 (A31d)
A31c.

Thank you. We will call back when (NAME) returns.
GO TO A55 AND SCHEDULE CALL
BACK

(A31a=00) (A31b=00)
A31d. 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.

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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)
(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: |

|

|

|-|

|

|

|-|

|

DON’T KNOW ...............................................
REFUSED .....................................................

|

|

| (A70)

d (A65a)
r (A65a)

PROGRAMMER: STORE NAME AND PHONE INFORMATION IN LOCATOR = LEADS;
DO NOT OVERWRITE
FOR PILOT STUDY ONLY: POSSIBLE IN-PERSON INTERVIEW
NO A36 THIS VERSION.
POSSIBLE IN-PERSON INTERVIEW—MAIN STUDY
(A14=04)
A37.
Our field representative will be working in your area in the near future and will contact you to arrange an
interview with you in person.
A38.

Let me confirm your 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;

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DO NOT OVERWRITE

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(A38=01 OR 00)
A39.
If your 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

(A39=02)
A39a. Please tell me what your 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)

(A39a=INFO)
A39b. On what date will we be able to reach you at this new {ADDRESS AND PHONE NUMBER}?
| | |/| | |/|
MONTH DAY

|

| |
YEAR

|

DON’T KNOW ...............................................
REFUSED .....................................................

(A70)

d (A65a)
r (A65a)

SEEKING PROXY
(A14=06 OR d) (A15a=d) (A26=04, 05, OR d) (A27=d)
A40.
(IF A14=06 OR d, SAY: Who else/OTHERWISE SAY: Is there someone (else) who) can 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 PROXY........
PROXY COMES TO PHONE ........................
PROXY NOT AVAILABLE NOW....................
PROXY LIVES ELSEWHERE .......................
NO PROXY AVAILABLE ...............................
DON’T KNOW ...............................................
REFUSED .....................................................

01
02
03
04
05
d
r

(A49)
(A45)
(A65a)
(A65a)
(A65a)

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PROXY COMES TO PHONE (INFORMANT WILL PROXY)
(A40=01 OR 02)
A41.
{IF A40 =02, USE Hello, my name is __________________, calling on behalf of the Social Security
Administration.} Are you the person who is most knowledgeable about (NAME’s) health and daily activities?
YES ............................................................... 01
WANTS MORE INFORMATION .................... 02
NO ................................................................. 00 (A44)
DON’T KNOW ............................................... d (A44)
REFUSED ..................................................... r (A65a)
PROGRAMMER: MAKE FAQs AVAILABLE FROM THIS SCREEN.
(A41=01, 02) (A14=05)
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 PROXY 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 .....................................................

01
02
03
04
05

(A47)
(A47)
(A47)
(A47)
(A47)

06
07
08
09
10
d
r

(A47)
(A47)

DON’T KNOW ...............................................
REFUSED .....................................................

d
r

(A47)
(A47)
(A47)
(A47)

(A43=08)
A43_other. How are you related to (NAME)?

GO TO A47

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RESPONDENT NOT LIKELY PROXY
(A41=00 OR d)
A44.
(The Social Security Administration recently sent (NAME) a letter saying that we would be calling to see how
{he/she} has been doing since {he/she} was selected to participate in the Accelerated Benefits
Demonstration (AB) in [FILL MONTH]. 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. We are not selling anything or asking for contributions.) The
questions I have will take about 30 minutes to complete. (NAME) will receive a check for $25 for completing
the interview. Is there someone else who knows about {his/her} health and daily activities?
YES ............................................................... 01
REQUESTS LETTER .................................... 02 (A68)
NO OTHER PROXY AVAILABLE .................. 00 (A65a)
REFUSED ..................................................... r (A65a)
ANOTHER PROXY 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 PROXY 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
(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)

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GO TO A70

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SPEAKING WITH PROXY
(A43=ANSWER, d OR r)
A47.
The interview will take about 30 minutes. If you get tired or need a break at any time, please tell me and we
will call back later to finish the interview. Let’s start now.
CONTINUE.................................................... 01
CALL BACK LATER ...................................... 02 (A49)
PROXY 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
PROXY 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 how (NAME) is doing
since {he/she was} selected to participate in the Accelerated Benefits (AB) Demonstration in {FILL MONTH}.
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.
We are not selling anything or asking for contributions.) We were told that you are the most knowledgeable
person to respond to the survey on behalf of (NAME).
The interview will take about 30 minutes. (NAME) will receive a check for $25 for completing the interview.
Would you be able to help us?
CONTINUE....................................................
CALL BACK LATER ......................................
SEEK ANOTHER PROXY .............................
WANTS LETTER SENT ................................
DON’T KNOW ...............................................
REFUSED .....................................................

01
02
03
04
d
r

(A51)
(A53)
(A52)
(A53)
(A69)

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(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 PROXY INFORMATION IN LOCATING DATABASE, GO TO A68

SEEK ANOTHER PROXY - CONTACT INFORMATION
(A50=03 OR d)
A53.
Can you give me the name and phone number for someone else who might be knowledgeable about
(NAME’s) 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: |

|

|

|-|

|

|

|-|

|

DON’T KNOW ...............................................
REFUSED .....................................................

|

|

|

(A69)

d (A65a)
r (A65a)

PROGRAMMER: STORE PROXY INFORMATION IN LOCATING DATABASE

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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.

RESPONDENT VERIFICATION
(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
PROXY .......................................................... 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 PROXY 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)

DON’T KNOW ...............................................
REFUSED .....................................................

(A62)

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.......................................................

00
01
02
03

(A61=01)
A63.
PROGRAMMER CHECK: IS (NAME’s) IDENTITY VERIFIED AND IS BIRTHDATE VERIFIED?
YES (VERIFIED)............................................ 01 (A71)
NO (FAILED VERIFICATION) ....................... 00

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(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 xxx-xxx-xxxx.
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.......................

01
02
03
04
05
06
07

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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 xxx-xxx-xxxx. We are available
days, evenings, and weekends. Please ask for Abigail Brooks 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
PROXY 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 ............
OPPOSED TO RANDOM ASSIGNMENT .....
NONE GIVEN ................................................
OTHER (SPECIFY) .......................................

01
02
03
04
05
06
07
08

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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
PROXY .......................................................... 03

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SECTION B: USE OF MEDICAL SERVICES

(All)
B1.

I’d like to start by asking about {your/(NAME’s)} health and usual sources of medical care during the past
6 months. In general, would you say {your/(NAME’s)} health now is . . .
excellent, .......................................................
very good,......................................................
good,..............................................................
fair, or ............................................................
poor? .............................................................
DON’T KNOW ...............................................
REFUSED .....................................................

(All)
B2.
(NBS)

01
02
03
04
05
d
r

Compared to (MONTH, YEAR SIX MONTHS AGO), how would you rate {your/(NAME’s)} health in general
now? Is it . . .
much better now, .............................................. 01
somewhat better now,....................................... 02
about the same, ................................................ 03
somewhat worse now, or .................................. 04
much worse now?............................................. 05
DON’T KNOW .................................................. d
REFUSED ........................................................ r

(All)
B3.

During the past 6 months, that is between MONTH and MONTH YEAR, did {you/(NAME)} have a doctor
whom {you/he/she} saw or a place {you/he/she} went to regularly to receive medical care?
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

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(All)
B4a.

Which of the following types of doctors did {you/(NAME)} see or go to for medical care during the past
6 months? Did you see . . .
. . . an internist, general practitioner, or family doctor?
CODE ONE
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

B4b.

. . . a specialist?
PROBE:

Specialists include doctors such as surgeons, allergists, (if female: obstetricians, gynecologists,)
orthopedists, cardiologists, and dermatologists. Specialists mainly treat one type of problem.
CODE ONE
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

B4c.

. . . a psychologist, psychiatrist, or social worker?
CODE ONE
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

B4d.

. . . some other kind of doctor?
CODE ONE
YES ............................................................... 01
NO ................................................................. 00 (B5)
DON’T KNOW ............................................... d (B5)
REFUSED ..................................................... r (B5)

(B4d=01)
B4_Other. What other type of doctor did {you/(NAME)} go to for medical care during the past 6 months?
_________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

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(All)
B5.
(2006
NHIS)

In the past 6 months, did {you/(NAME)} change the doctor or place {you usually go/he/she usually goes} to
for medical care?
PROBE: Between MONTH and MONTH 2008.
YES ............................................................... 01
NO ................................................................. 00 (B7)
DON’T KNOW ............................................... d (B7)
REFUSED ..................................................... r (B7)

(B5=01)
B6.

Why did {you/(NAME)} change the doctor or place {you usually go/he/she usually goes} to for medical care
in the past 6 months?
PROBE: Were there any other reasons?
CODE ALL THAT APPLY
DOCTOR OR HOSPITAL DID NOT ACCEPT
AB/POMCO INSURANCE .......................... 01
NAME OR DOCTOR MOVED; NO LONGER
ACCESSIBLE ............................................. 02
TRANSPORTATION PROBLEM ................... 03
FOUND A SPECIALIST FOR CONDITION ... 04
WANTED TO USE AB DOCTORS ................ 05
DID NOT LIKE PREVIOUS DOCTOR ........... 06
DOCTOR/STAFF WAS INSENSITIVE .......... 07
DOCTOR DID NOT WANT TO TREAT PEOPLE
WITH {MY/NAME’S} CONDITION .............. 08
PHYSICAL ACCESS PROBLEM (E.G.,
WHEELCHAIR RAMP, ACCESSIBLE
MEDICAL EQUIPMENT) ............................ 09
HEALTH GOT WORSE ................................. 10
OTHER (SPECIFY) ....................................... 11
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

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(B4a-B4d = MULTIPLE CODES OF 01)
B7.
Of all the (different types of) doctors or places {you/(NAME)} saw or went to for medical care during the past
6 months, which did {you/he/she} see most often? Was it . . .
CODE ONE
an internist, general practitioner, or
family doctor, .............................................. 01 (B8)
a specialist, .................................................... 02 (B8)
a psychiatrist, psychologist, or
social worker, or.......................................... 03 (B8)
some other kind of place or doctor?............... 04
DON’T KNOW ............................................... d (B8)
REFUSED ..................................................... r (B8)
(B7=04)
B7_Other. What other type of doctor or place did {you/(NAME)} see or go to most often for medical care during the
past 6 months?
_________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................
(All)
B8.

d
r

How often did {you/(NAME)} see ({this/a} doctor/visit this place) in the past 6 months?
PROBE: Between MONTH and MONTH 2008.
|

|

| NUMBER OF VISITS PAST 6 MONTHS

(B9a)

ZERO............................................................. 00 (B9a)
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(B8=d OR r)
B8a.
In the past 6 months, would you say {you/(NAME)} saw {(this/a) doctor/visited (this/a)} clinic . . .
PROBE: Between MONTH and MONTH 2008.
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

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(All)
B9.

Now I’m going to ask you to rate the quality of care that {you/(NAME)} received from the [FILL TYPE OF
DOCTOR @ B7/B7_OTHER] {you/he/she} saw most often in the past 6 months. Could you please tell me
the name of the doctor who you saw or the place that you went to most often for medical care in the past
6 months?
_________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

B9a.

d
r

Thinking about the last time {you/(NAME)} saw/went to [FILL RESPONSE @ B9], how would you rate the
thoroughness of the examination? Would you say excellent, very good, good, fair or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
B9b.

How would you rate the care (you/he/she) received in terms of respect and attention to privacy?
PROBE: Would you say the care {you/he/she} received was excellent, very good, good, fair, or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
B9c.

. . . personal interest?
PROBE: Would you say the care {you/he/she} received was excellent, very good, good, fair, or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r

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(All)
B9d.

. . . availability in emergency?
PROBE: Would you say the care {you/he/she} received was excellent, very good, good, fair, or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
B9e.

. . . office hours for appointments?
PROBE: Would you say the care {you/he/she} received was excellent, very good, good, fair, or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
B9f.

. . . answering questions over the telephone?
PROBE: Would you say the care {you/he/she} received was excellent, very good, good, fair, or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r

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(All)
B9g.

. . . wait time to see the doctor?
PROBE: Would you say the care {you/he/she} received was excellent, very good, good, fair, or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
B10.

Overall, how would you rate the medical care {you/(NAME)} received in the past 6 months from all of the
doctors and other medical providers {you/he/she} saw in terms of overall quality of care and services?
Would you 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 .....................................................

(All)
B10a.

01
02
03
04
05
n
d
r

In the last 6 months, {have you/has (NAME)} seen a medical care provider that was out-of-network for the
AB health plan?
PROBE:

The amount of money that {you need/he she needs} to pay for services is higher when {you
go/he/she goes} out of network.
YES ............................................................... 01
NO ................................................................. 00 (B11)
DON’T KNOW ............................................... d (B11)
REFUSED ..................................................... r (B11)

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(B10a = 01)
B10b. Why did {you/(NAME)} go out-of-network for medical care?
PROBE1 :

The amount of money that {you need/he she needs} to pay for services is higher when {you
go/he/she goes} out of network.

PROBE 2:

Where there any other reasons?

IF NEEDED: This information will help SSA better address the insurance needs of people in {your/his/her}
situation.
RECORD VERBATIM RESPONSE, THEN CODE ALL THAT APPLY
_______________________________________________________________________
CODE ALL THAT APPLY
DOCTOR I WANTED TO SEE DID NOT
ACCEPT AB/AB CARD .............................. 01
AB CO-PAY TOO HIGH ................................ 02
AB PAYS TOO SLOWLY............................... 03
DON’T LIKE ANY DOCTORS IN AB
NETWORK ................................................. 04
AB DOCTORS ARE NOT ACCESSIBLE
TO {ME/(NAME)} ........................................ 05
OTHER .......................................................... 06
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(All)
B11.

Now, I have some questions about other sources of medical care. {Have you/Has (NAME)} visited an
emergency room for medical care in the past 6 months?
PROBE: Between MONTH and MONTH 2008.
YES ............................................................... 01
NO ................................................................. 00 (B13)
DON’T KNOW ............................................... d (B13)
REFUSED ..................................................... r (B13)

(B11=01)
B11a. How many times {did you/(NAME)} visit an emergency room for medical care in the past 6 months?
PROBE: Between MONTH and MONTH 2008.
|

|

| NUMBER OF EMERGENCY ROOM VISITS (B12)

DON’T KNOW ...............................................
REFUSED .....................................................

d
r

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(B11a=d OR r)
B11b. In the past 6 months, would you say {you/(NAME)} visited an emergency room . . .
PROBE: Between MONTH and MONTH 2008.
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
B12a.

When {you/(NAME)} visited the emergency room during the last 6 months, did . . .
. . . {your/his/her} symptoms come on after {your/his/her} doctor’s regular office hours?
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

B12b.

. . . {you/he/she} go to the emergency room because this is where {you/he/she} always {go/goes} for
medical care?
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r
IF AB –BASIC, GO TO B13

(AB PLUS ONLY)
B12c. . . . {you/he/she} speak with {your/his/her} AB care manager before going to the emergency room?
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(AB PLUS ONLY)
B12d.
. . .{you/he/she} speak with {your/his/her} AB care manager after {you/he/she} went to the emergency
room?
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

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(All)
B13.

In the last 6 months how many times {were you/was (NAME)} a patient in a hospital overnight? Would
{you/he/she} say . . .
Never, ............................................................
1 to 2 times, ...................................................
3 to 5 times, ...................................................
6 to 10 times, or .............................................
More than 10 times? ......................................
DON’T KNOW ...............................................
REFUSED .....................................................

00 (B14)
01
02
03
04
d
r

(B13 NE 01)
B13a. All together, how many nights did {you/(NAME)} spend in the hospital since [FILL 6 MONTHS AGO]?
|

|

| NUMBER OF HOSPITAL NIGHT STAYS

DON’T KNOW ...............................................
REFUSED .....................................................
(All)
B14.

How many times in the last 6 months [BETWEEN MONTH AND MONTH 2008] {were you/was (NAME)} a
patient overnight in a nursing home, convalescent home, or other long-term health care facility? Please
include skilled nursing facilities and rehabilitation facilities. Would {you/he/she} say . . .
Never, ............................................................
1 to 2 times, ...................................................
3 to 5 times, ...................................................
6 to 10 times, or .............................................
More than 10 times? ......................................
DON’T KNOW ...............................................
REFUSED .....................................................

(All)
B15.
(NHIS II)

d
r

00
01
02
03
04
d
r

During the past 6 months, did you get any medical treatments such as injections, therapy, blood or urine
testing, or catheter care at home?
YES ............................................................... 01
NO ................................................................. 00 (C1)
DON’T KNOW ............................................... d (C1)
REFUSED ..................................................... r (C1)

(B15=01)
B16.
Did {you/(NAME)} receive these medical treatments and care from a nurse or other health care
professional?
YES ............................................................... 01
NO ................................................................. 00 (B19)
DON’T KNOW ............................................... d (B19)
REFUSED ..................................................... r (B19)

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(B16=01)
B17.
During how many of the past 6 months did {you/(NAME)} receive care at home from a nurse or other health
care professional? Was it one month, two months or all three months?
ONE............................................................... 01
TWO .............................................................. 02
THREE/ALL ................................................... 03
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(B16=01)
B18.
What was the total number of home visits {you/(NAME)} received from a nurse or other health care
professional [between MONTH and MONTH 2008]?
|

|

| (0-99) TOTAL HOME VISITS

DON’T KNOW ...............................................
REFUSED .....................................................

d
r

(B15=01)
B19.
Do family members or friends help {you/(NAME)} with these medical treatments at home?
YES ............................................................... 01
NO ................................................................. 00 (C1)
DON’T KNOW ............................................... d (C1)
REFUSED ..................................................... r (C1)
(B19=01)
B20.
Have these friends or family members been trained by a health care professional to administer these
treatments?
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(B19=01)
B21.
Do you receive any home medical treatments from friends or relatives that you feel should be administered
by a health professional?
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

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SECTION C: UNMET NEEDS

(All)
C1.

These next questions are about medical needs that may or may not have been addressed during the last
6 months. 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?
PROBE: Between MONTH and MONTH 2008.
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
C2.

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} thought {you/he/she} needed?
PROBE: Between MONTH and MONTH 2008.
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

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(C1 OR C2 = 01)
C3.
In the past 6 months, why did {you/(NAME)} not see a doctor or postpone 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 ............ 07
TRANSPORTATION PROBLEM .......................................... 08
WAITING FOR UPCOMING APPOINTMENT ...................... 09
COULD NOT FIND SPECIALISTS KNOWLEDGEABLE
ABOUT CONDITION ........................................................ 10
PHYSICAL ACCESS PROBLEM (E.G., WHEELCHAIR RAMP,
ACCESSIBLE MEDICAL EQUIPMENT)............................ 11
DOCTORS DON’T WANT TO TREAT PEOPLE WITH
{MY/(NAME’S) DISABILITY............................................... 12
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
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 (SPECIFY) ..............................................................
DON’T KNOW ......................................................................
REFUSED ............................................................................

13
14
15
16
17

18
19

20
21
22
23

24
25
26
d
r

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(All)
C4.

In the past 6 months, {were you/was (NAME)} referred to another doctor, specialist, therapist, psychologist,
or other medical professional, or sent for tests or x-rays by a doctor or clinic {you/he/she} visited?
PROBE: Between MONTH and MONTH 2008.
YES ............................................................... 01
NO ................................................................. 00 (C7)
DON’T KNOW ............................................... d (C7)
REFUSED ..................................................... r (C7)

(C4=01)
C5.
Did {you/(NAME)} or will {you/he/she} go for all, some, or none of the visits or tests for which {you
were/(he/she) was} referred?
ALL ................................................................ 01 (C7)
SOME ............................................................ 02
NONE ............................................................ 03
DON’T KNOW ............................................... d (C7)
REFUSED ..................................................... r (C7)

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(C5=02 OR 03)
C6.
Why did or will {you/(NAME)} not go for all of {your/his/her} recommended visits or tests?
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
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 (SPECIFY) ..............................................................
DON’T KNOW ......................................................................

07
08
09
10
11
12
13
14
15
16
17

18
19

20
21
22
23

24
25
26
d

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REFUSED ............................................................................

r

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(All)
C7.

In the past 6 months, did a doctor order or recommend any medical procedures, including surgery for
{you/(NAME)}?
PROBE: Between MONTH and MONTH 2008.
YES ............................................................... 01
NO ................................................................. 00 (C9)
DON’T KNOW ............................................... d (C9)
REFUSED ..................................................... r (C9)

(C7=01)
C7a.
Did {you/(NAME)} have the procedure or surgery when the doctor ordered it, did {you/he/she} put off getting
the procedure or surgery, or did {you/he/she} not have it at all?
YES—GOT PROCEDURE OR SURGERY ... 01 (C9)
NO—PUT OFF HAVING PROCEDURE
OR SURGERY............................................ 02
NO—DIDN’T HAVE IT AT ALL ...................... 03
DON’T KNOW ............................................... d (C9)
REFUSED ..................................................... r (C9)

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(C7a=02 OR 03)
C8.
Why did {you/(NAME)} not get or postpone getting the recommended procedure or surgery?
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
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 (SPECIFY) ..............................................................
DON’T KNOW ......................................................................
REFUSED ............................................................................

07
08
09
10
11
12
13
14
15
16
17

18
19

20
21
22
23

24
25
26
d
r

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(All)
C9.

In the past 6 months, was there any time when {you/(NAME)} put off or postponed getting mental health
care or counseling {you/he/she} thought {you/he/she} needed?
YES ............................................................... 01
NO ................................................................. 00 (C10)
DON’T KNOW ............................................... d (C10)
REFUSED ..................................................... r (C10)

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(C9=01)
C9a.
In the past 6 months, why did {you/(NAME)} not get or postpone getting mental health care or counseling?
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 FOR MENTAL
HEALTH CARE/COUNSELING BY INSURANCE
COMPANY ........................................................................ 05
AWAITING APPROVAL OR REFERRAL FROM
INSURANCE COMPANY FOR MENTAL HEALTH
CARE/COUNSELING ........................................................ 06
ACCESS
COULD NOT GET CONVENIENT APPOINTMENT ...........
TRANSPORTATION PROBLEM ..........................................
WAITING FOR UPCOMING APPOINTMENT ......................
COULD NOT FIND KNOWLEDGEABLE MENTAL
HEALTH SPECIALIST.......................................................
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.....................................................

07
08
09
10
11
12
13
14
15
16
17

18
19

AVOIDANCE/ALTERNATIVES
THOUGHT PROBLEM WOULD GO AWAY, OR
PROBLEM WENT AWAY ..................................................
USED HOME REMEDY........................................................
HEALTH GOT WORSE ........................................................
HEALTH OF OTHER FAMILY MEMBER INTERFERED......

20
21
22
23

OTHER REASONS
OTHER (SPECIFY) ..............................................................

24

DON’T KNOW ......................................................................
REFUSED ............................................................................

d
r

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(All)
C10.

In the past 6 months was there any time when {you/(NAME)} needed home health care but did not get it?
YES ............................................................... 01
NO ................................................................. 00 (C11)
DON’T KNOW ............................................... d (C11)
REFUSED ..................................................... r (C11)

(C10=01)
C10a. Why did {you/(NAME)} not get home health care when you needed it in the past 6 months?
PROBE: Were there any other reasons?
CODE ALL THAT APPLY

(All)
C11.

COULD NOT AFFORD IT/TOO EXPENSIVE
NO INSURANCE ...........................................
INSURANCE DID NOT COVER ....................
HOME HEALTH AGENCY DID NOT
ACCEPT INSURANCE ...............................
WAITING FOR UPCOMING
APPOINTMENT..........................................
FAMILY MEMBER PROVIDED HELP ...........
OTHER REASON (SPECIFY) .......................

01
02
03

05
06
07

DON’T KNOW ...............................................
REFUSED .....................................................

d
r

04

The next questions are about prescriptions. {Do you/Does (NAME)} regularly take prescription medications?
YES ............................................................... 01
NO ................................................................. 00 (C17)
DON’T KNOW ............................................... d (C17)
REFUSED ..................................................... r (C17)

(C11=01)
C11a. How many different prescription medications {do you/does (NAME)} regularly take?
|

|

| PRESCRIBED MEDICATIONS

DON’T KNOW ...............................................
REFUSED .....................................................

(C13)
d
r

(C11a=d OR r)
C12.
Would you say that {you/(NAME)} regularly take one to two prescriptions, three to four, five to six, or more
than six prescription medicines?
1 TO 2............................................................
3 TO 4............................................................
5 TO 6............................................................
MORE THAN 6 ..............................................
DON’T KNOW ...............................................

01
02
03
04
d

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REFUSED .....................................................

r

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(C11=01)
C13.
What is {your/(NAME’s)} average monthly out-of-pocket costs for all prescription medications {you/he/she}
takes?
PROBE: Your best estimate is fine.
$|

|

|,|

|

|

| .................................

(C15)

DON’T KNOW ...............................................
REFUSED .....................................................

d
r

Less than $100 per month, ............................
$100 - $150 per month, .................................
$150 - $200 per month, .................................
$200 - $250 per month, .................................
$250 - $300 per month, or .............................
More than $300 per month? ..........................
DON’T KNOW ...............................................
REFUSED .....................................................

01
02
03
04
05
06
d
r

(C13=d OR r)
C14.
Would {you/(NAME)} say it is . . .

(All)
C15.
(NHIS)

In the last 6 months, were there any prescription medicines that {you/(NAME)} did not get when first
prescribed, or that {you/he/she} did not refill immediately when {you/he/she} ran out, or that {you/he/she} got
less than the prescribed amount?
YES ............................................................... 01
NO ................................................................. 00 (C17)
DON’T KNOW ............................................... d (C17)
REFUSED ..................................................... r (C17)

(C15=01)
C16.
In the last 6 months, why did {you/(NAME)} not get prescription medicines when they were first prescribed,
not refill them immediately when {you/he/she} ran out, or got less than prescribed?
PROBE: Were they any other reasons?
CODE ALL THAT APPLY
COST............................................................. 01
SIDE EFFECTS ............................................. 02
STIGMA/EMBARRASSED ............................ 03
FORGOT TO TAKE ....................................... 04
TRANSPORTATION PROBLEMS/
COULD NOT PICK UP ............................... 05
OTHER (SPECIFY) ....................................... 06
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

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SECTION D: HEALTH INSURANCE COVERAGE
(Control)
D1.
Now I have some questions about health insurance. The last time we spoke to {you/(NAME)}, {you/he/she}
did not have any health insurance. These next questions are about health insurance coverage that
{you/he/she} might have gotten since the last time we spoke.
(AB Basic and AB Plus Only)
D1.
Now, I have some questions about health insurance. The last time we spoke to {you/(NAME)}, {you/he/she}
did not have any health insurance. Because {you are/he/she is} participating in the AB study, {you now
have/he/she now has} the AB health benefit. These next questions are about health insurance coverage
{you/he/she} might have in addition to the AB health benefit.
{Are you/Is (NAME)} currently covered by Medicaid?
PROBE: Medicaid is a program that pays for the health care of persons in need. In {your/(NAME’s)} state,
you may also hear it called {STATEMED FROM (NAME’s) CURRENT STATE}. Your Medicaid
looks like {DESCRIBE STATE CARD}.
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(All)
D2.

{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

(All)
D2.

{Are you/Is (NAME)} currently covered by a plan from the Indian Health Service?
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

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(All)
D4.

(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)
D5.

(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 (D7)
NO ................................................................. 00
DON’T KNOW ............................................... d (D7)
REFUSED ..................................................... r (D7)

(D5=00)
D6.
In the past 6 months (BETWEEN MONTH AND MONTH 2008), (were you/was NAME) eligible to participate
in a COBRA plan?
YES ............................................................... 01
NO ................................................................. 00 (D7)
DON’T KNOW ............................................... d (D7)
REFUSED ..................................................... r (D7)
(D6=01)
D6a.
Why (aren’t you/isn’t NAME) covered by a COBRA plan?
PROBE: Are there any other reasons?
CODE ALL THAT APPLY
TOO EXPENSIVE.......................................... 01
HAVE AB HEALTH BENEFIT ........................ 02
MY PRE-EXISTING CONDITIONS
ARE NOT COVERED ................................. 03
MY DOCTORS/HOSPITALS
ARE NOT IN THE PLAN............................. 04
MISSED ENROLLMENT DEADLINE............. 05
OTHER (SPECIFY) ....................................... 06
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

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(All)
D7.

{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? Please do not include COBRA, dental, optical, or prescription coverage here.
YES ............................................................... 01
NO ................................................................. 00 (D10)
DON’T KNOW ............................................... d (D10)
REFUSED ..................................................... r (D10)

(D7=01)
D8.
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 (D11)
SPOUSE/PARTNER’S EMPLOYER.............. 02 (D11)
NO, NOT PROVIDED BY CURRENT OR
FORMER EMPLOYER ............................... 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(D8=01)
D9.
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?
CODE ONE ONLY
PAID BY (NAME)...........................................
PAID BY FAMILY MEMBER(S) .....................
PAID BY BOTH (NAME) AND FAMILY
MEMBER....................................................
OTHER ..........................................................
DON’T KNOW ...............................................
REFUSED .....................................................

01 (D11)
02 (D11)
03 (D11)
04
d (D11)
r (D11)

(D9=04)
D9_Other. Who or what is the other source that pays for {your/(NAME’s) private insurance?
_________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

GO TO D11
(D7=01, d OR r)
D10.
In the past 6 months {were you/ was (NAME)} eligible for private insurance?
YES ............................................................... 01
NO ................................................................. 00 (D11)
DON’T KNOW ............................................... d (D11)
REFUSED ..................................................... r (D11)

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(D10=01)
D10a. Why {aren’t you/isn’t (NAME)} covered by private insurance?
PROBE: Are there any other reasons?

CODE ALL THAT APPLY
TOO EXPENSIVE.......................................... 01
HAVE AB HEALTH BENEFIT ........................ 02
MY PRE-EXISTING CONDITIONS
ARE NOT COVERED ................................. 03
MY DOCTORS/HOSPITALS
ARE NOT IN THE PLAN............................. 04
MISSED ENROLLMENT DEADLINE............. 05
OTHER (SPECIFY) ....................................... 06
___________________________________
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(All)
D11.
(CAHPS
Modified)

Thinking about the quality of care {you have/(NAME) has} received during the past 6 months, {your/his/her}
current health, and the AB services {you have/he/she has} received since [FILL 6 MONTHS AGO] please tell
me if {you/he/she} strongly agree{s), agree{s}, disagree{s} or strongly disagree{s} with the following
statements.
You see {yourself/(NAME)} working for pay in the next year. {Do you/Does (NAME)} strongly agree, agree,
disagree, or strongly disagree?
STRONGLY AGREE .....................................
AGREE ..........................................................
DISAGREE ....................................................
STRONGLY AGREE .....................................
DON’T KNOW ...............................................
REFUSED .....................................................

01
02
03
04
d
r

(E1)
(E1)
(E1)
(E1)

(D11=01 OR 02)
D12.
You see {yourself/(NAME)} working and earning enough to stop receiving disability benefits in the next year.
{Do you/Does (NAME)} strongly agree, agree, disagree, or strongly disagree?
STRONGLY AGREE .....................................
AGREE ..........................................................
DISAGREE ....................................................
STRONGLY AGREE .....................................
DON’T KNOW ...............................................
REFUSED .....................................................

01
02
03
04
d
r

CONTROL—GO TO F1

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SECTION: AB BASIC + AB PLUS ONLY

SECTION E: SATISFACTION WITH AB SERVICES

(All)
E1.

Next, I’d like to ask some questions about AB benefits. Please tell me if the following statements regarding
AB benefits are true or false.
The AB benefit includes coverage for . .

(All)
E1a.

. . .prescription drugs.
PROBE: {Do you/Does (NAME)} believe this is true or false?
TRUE............................................................. 01
FALSE ........................................................... 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
E1b.

. . .mental health services.
PROBE: {Do you/Does (NAME)} believe this is true or false?
TRUE............................................................. 01
FALSE ........................................................... 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
E1c.

. . .assistive services.
PROBE: {Do you/Does (NAME)} believe this is true or false?
TRUE............................................................. 01
FALSE ........................................................... 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
E1d.

. . .primary care services.
PROBE: {Do you/Does (NAME)} believe this is true or false?
TRUE............................................................. 01
FALSE ........................................................... 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

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(All)
E1e.

. . .specialty care services.
PROBE: {Do you/Does (NAME)} believe this is true or false?
TRUE............................................................. 01
FALSE ........................................................... 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
E1f.

. . .dental care.
PROBE: {Do you/Does (NAME)} believe this is true or false?
TRUE............................................................. 01
FALSE ........................................................... 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
E1g.

. . .vision care.
PROBE: {Do you/Does (NAME)} believe this is true or false?
TRUE............................................................. 01
FALSE ........................................................... 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
E1h.

. . .transportation services.
PROBE: {Do you/Does (NAME)} believe this is true or false?
TRUE............................................................. 01
FALSE ........................................................... 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(E1a=01)
E2.
{Have you/Has (NAME)} used the prescription drug benefit available through AB?
YES ............................................................... 01
NO ................................................................. 00 (E2c)
DON’T KNOW ............................................... d (E3)
REFUSED ..................................................... r (E3)

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(E2=01)
E2a.
How satisfied {are you/is (NAME)} with the AB prescription drug benefit? {Are you/Is (NAME)} very satisfied,
satisfied, dissatisfied, or very dissatisfied?

VERY SATISFIED .........................................
SATISFIED ....................................................
DISSATISFIED ..............................................
VERY DISSATISFIED ...................................
DON’T KNOW ...............................................
REFUSED .....................................................

01
02
03
04
d
r

(E3)
(E3)

(E3)
(E3)

(E2a=03 OR 04)
E2b.
Please tell me why {you are/(NAME) is} dissatisfied with the AB prescription drug benefit.
RECORD VERBATIM
_________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

GO TO E3
(E2=00)
E2c.
Why {haven’t you/has (NAME) used the prescription drug benefit available through AB?
RECORD VERBATIM, THEN CODE BELOW
_________________________________________________________
CODE ALL THAT APPLY
DO NOT TAKE ANY Rx DRUGS................... 01
ALREADY HAD DRUG COVERAGE............. 02
OTHER .......................................................... 03
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(E1b=01)
E3.
{Have you/Has (NAME)} used the mental health benefit available through AB?
YES ............................................................... 01
NO ................................................................. 00 (E3c)
DON’T KNOW ............................................... d (E4)
REFUSED ..................................................... r (E4)

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(E3=01)
E3a.
How satisfied {are you/is (NAME)} with the AB mental health benefit {Are you/Is (NAME)} very satisfied,
satisfied, dissatisfied, or very dissatisfied?

VERY SATISFIED .........................................
SATISFIED ....................................................
DISSATISFIED ..............................................
VERY DISSATISFIED ...................................
DON’T KNOW ...............................................
REFUSED .....................................................

01
02
03
04
d
r

(E4)
(E4)

(E4)
(E4)

(E3a=03 OR 04)
E3b.
Please tell me why {you are/(NAME) is} dissatisfied with the AB mental health benefit.
RECORD VERBATIM
_________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

GO TO E4

(E3=00)
E3c.
Why {haven’t you/has (NAME) used the mental health benefit available through AB?
RECORD VERBATIM, THEN CODE BELOW
_________________________________________________________
CODE ALL THAT APPLY
DID NOT NEED SERVICE ............................ 01
ALREADY HAD COVERAGE FOR THIS ...... 02
OTHER .......................................................... 03
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(E1c=01)
E4.
{Have you/Has (NAME)} used the assistive services benefit available through AB?
YES ............................................................... 01
NO ................................................................. 00 (E4c)
DON’T KNOW ............................................... d (E5)
REFUSED ..................................................... r (E5)

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(E4=01)
E4a.
How satisfied {are you/is (NAME)} with the AB assistive services benefit?
satisfied, satisfied, dissatisfied, or very dissatisfied?

VERY SATISFIED .........................................
SATISFIED ....................................................
DISSATISFIED ..............................................
VERY DISSATISFIED ...................................
DON’T KNOW ...............................................
REFUSED .....................................................

{Are you/Is (NAME)} very

01
02
03
04
d
r

(E5)
(E5)

(E5)
(E5)

(E4a=03 OR 04)
E4b.
Please tell me why {you are/(NAME) is} dissatisfied with the AB assistive services benefit.
RECORD VERBATIM
_________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

GO TO E5
(E4=00)
E4c.
Why {haven’t you/has (NAME) used the assistive services benefit available through AB?
RECORD VERBATIM, THEN CODE BELOW
_________________________________________________________
CODE ALL THAT APPLY
DID NOT NEED SERVICE ............................ 01
ALREADY HAD COVERAGE FOR THIS ...... 02
OTHER .......................................................... 03
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(E1d=01)
E5.
{Have you/Has (NAME)} used the primary care service benefit available through AB?
YES ............................................................... 01
NO ................................................................. 00 (E5c)
DON’T KNOW ............................................... d (E6)
REFUSED ..................................................... r (E6)

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(E5=01)
E5a.
How satisfied {are you/is (NAME)} with the AB primary care service benefit? {Are you/Is (NAME)} very
satisfied, satisfied, dissatisfied, or very dissatisfied?

VERY SATISFIED .........................................
SATISFIED ....................................................
DISSATISFIED ..............................................
VERY DISSATISFIED ...................................
DON’T KNOW ...............................................
REFUSED .....................................................

01
02
03
04
d
r

(E6)
(E6)

(E6)
(E6)

(E5a=03 OR 04)
E6b.
Please tell me why {you are/(NAME) is} dissatisfied with the AB primary care service benefit.
RECORD VERBATIM
_________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

GO TO E6
(E5=00)
E5c.
Why {haven’t you/has (NAME) used the primary care service benefit available through AB?
RECORD VERBATIM, THEN CODE BELOW
_________________________________________________________
CODE ALL THAT APPLY
DID NOT NEED SERVICE ............................ 01
ALREADY HAD COVERAGE FOR THIS ...... 02
OTHER .......................................................... 03
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(E1e=01)
E6.
{Have you/Has (NAME)} used the specialty care services benefit available through AB?
YES ............................................................... 01
NO ................................................................. 00 (E6c)
DON’T KNOW ............................................... d (E7)
REFUSED ..................................................... r (E7)

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(E6=01)
E6a.
How satisfied {are you/is (NAME)} with the AB specialty care benefit? {Are you/Is (NAME)} very satisfied,
satisfied, dissatisfied, or very dissatisfied?

VERY SATISFIED .........................................
SATISFIED ....................................................
DISSATISFIED ..............................................
VERY DISSATISFIED ...................................
DON’T KNOW ...............................................
REFUSED .....................................................

01
02
03
04
d
r

(E7)
(E7)

(E7)
(E7)

(E6a=03 OR 04)
E6b.
Please tell me why {you are/(NAME) is} dissatisfied with the AB specialty care benefit.
RECORD VERBATIM
_________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

GO TO E7
(E6=00)
E6c.
Why {haven’t you/has (NAME) used the specialty care benefit available through AB?
RECORD VERBATIM, THEN CODE BELOW
_________________________________________________________
CODE ALL THAT APPLY
DID NOT NEED SERVICE ............................ 01
ALREADY HAD COVERAGE FOR THIS ...... 02
OTHER .......................................................... 03
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(E1f=01)
E7.
{Have you/Has (NAME)} used the dental care benefit available through AB?
YES ............................................................... 01
NO ................................................................. 00 (E7c)
DON’T KNOW ............................................... d (E8)
REFUSED ..................................................... r (E8)

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(E7=01)
E7a.
How satisfied {are you/is (NAME)} with the AB dental care benefit? {Are you/Is (NAME)} very satisfied,
satisfied, dissatisfied, or very dissatisfied?

VERY SATISFIED .........................................
SATISFIED ....................................................
DISSATISFIED ..............................................
VERY DISSATISFIED ...................................
DON’T KNOW ...............................................
REFUSED .....................................................

01
02
03
04
d
r

(E8)
(E8)

(E8)
(E8)

(E7a=03 OR 04)
E7b.
Please tell me why {you are/(NAME) is} dissatisfied with the AB dental care benefit.
RECORD VERBATIM
_________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

GO TO E8
(E7=00)
E7c.
Why {haven’t you/has (NAME) used the dental care benefit available through AB?
RECORD VERBATIM, THEN CODE BELOW
_________________________________________________________
CODE ALL THAT APPLY
DID NOT NEED SERVICE ............................ 01
ALREADY HAD COVERAGE FOR THIS ...... 02
OTHER .......................................................... 03
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(E1g=01)
E8.
{Have you/Has (NAME)} used the vision care benefit available through AB?
YES ............................................................... 01
NO ................................................................. 00 (E8c)
DON’T KNOW ............................................... d (E9)
REFUSED ..................................................... r (E9)

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(E8=01)
E8a.
How satisfied {are you/is (NAME)} with the AB vision care benefit? {Are you/Is (NAME)} very satisfied,
satisfied, dissatisfied, or very dissatisfied?

VERY SATISFIED .........................................
SATISFIED ....................................................
DISSATISFIED ..............................................
VERY DISSATISFIED ...................................
DON’T KNOW ...............................................
REFUSED .....................................................

01
02
03
04
d
r

(E9)
(E9)

(E9)
(E9)

(E8a=03 OR 04)
E8b.
Please tell me why {you are/(NAME) is} dissatisfied with the AB vision care benefit.
RECORD VERBATIM
_________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

GO TO E9
(E8=00)
E8c.
Why {haven’t you/has (NAME) used the vision care benefit available through AB?
RECORD VERBATIM, THEN CODE BELOW
_________________________________________________________
CODE ALL THAT APPLY
DID NOT NEED SERVICE ............................ 01
ALREADY HAD COVERAGE FOR THIS ...... 02
OTHER .......................................................... 03
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(E1h=01)
E9.
The AB health plan includes help with transportation to doctors’ offices, clinics, or other medical facilities.
This help can be a shuttle bus, tokens or vouchers for a bus or taxi, or payments for mileage. In the past
6 months did {you/(NAME)} call the AB health plan to get help with transportation?
YES ............................................................... 01
NO ................................................................. 00 (E9e)
DON’T KNOW ............................................... d (E10)
REFUSED ..................................................... r (E10)

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(E9=01)
E9a.
In the past 6 months, when {you/(NAME)} called to get help with transportation from {your/his/her} health
plan, how often did {you/he/she} get it? Would {you/he/she} say . . .
never..............................................................
sometimes .....................................................
usually, or ......................................................
always?..........................................................
DON’T KNOW ...............................................
REFUSED .....................................................

00
01
02
03
d
r

(E9=01)
E9b.
In the past 6 months, how often did the help with transportation meet {your/(NAME’s)} needs? Would
(CAHPS)
{you/he/she} say . . .
never..............................................................
sometimes .....................................................
usually, or ......................................................
always?..........................................................
DON’T KNOW ...............................................

00
01
02
03
d

(E9=01)
E9c.
How satisfied {are you/is (NAME)} with the AB transportation benefit? {Are you/Is (NAME)} very satisfied,
satisfied, dissatisfied, or very dissatisfied?
VERY SATISFIED .........................................
SATISFIED ....................................................
DISSATISFIED ..............................................
VERY DISSATISFIED ...................................
DON’T KNOW ...............................................
REFUSED .....................................................

01
02
03
04
d
r

(E10)
(E10)

(E10)
(E10)

(E9c=03 OR 04)
E9d.
Please tell me why {you are/(NAME) is} dissatisfied with the transportation benefit.
RECORD VERBATIM
_________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

GO TO E10

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(E9=00)
E9e.
Why {haven’t you/has (NAME) used the transportation benefit available through AB?
RECORD VERBATIM, THEN CODE BELOW
_________________________________________________________
CODE ALL THAT APPLY
DID NOT NEED SERVICE ............................ 01
ALREADY HAD COVERAGE FOR THIS ...... 02
OTHER .......................................................... 03
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(All)
E10.

Did someone at POMCO explain the benefits available through AB to {you/(NAME)}?

(CAHPS)

YES ............................................................... 01
NO ................................................................. 00 (E11)
DON’T KNOW ............................................... d (E11)
REFUSED ..................................................... r (E11)
(E10=01)
E10a. How satisfied {were you/was (NAME)} with the explanation of plan benefits provided by POMCO? {Were
you/Was (NAME)} very satisfied, satisfied, dissatisfied, or very dissatisfied with the explanation?
VERY SATISFIED .........................................
SATISFIED ....................................................
DISSATISFIED ..............................................
VERY DISSATISFIED ...................................
DON’T KNOW ...............................................
REFUSED .....................................................

01
02
03
04
d
r

(E11)
(E11)

(E11)
(E11)

(E10a=03 or 04)
E10b. Why {were you/was (NAME)} dissatisfied with the POMCO explanation of AB benefits?
RECORD VERBATIM
_________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................
(All)
E11.

d
r

Did {you/(NAME)} receive written materials explaining the AB plan from POMCO?
YES ............................................................... 01
NO ................................................................. 00 (E12)
DON’T KNOW ............................................... d (E12)
REFUSED ..................................................... r (E12)

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(E11=01)
E11a. How satisfied {were you/was (NAME)} with the written materials {you/he/she} received explaining the AB
health benefit? {Were you/Was (NAME)} very satisfied, satisfied, dissatisfied, or very dissatisfied with the
explanation?
VERY SATISFIED .........................................
SATISFIED ....................................................
DISSATISFIED ..............................................
VERY DISSATISFIED ...................................
DON’T KNOW ...............................................
REFUSED .....................................................

01
02
03
04
d
r

(E12)
(E12)

(E12)
(E12)

(E11a=03 or 04)
E11b. Why {were you/was (NAME)} dissatisfied with the written materials {you/he/she} received about the AB
health benefit?
RECORD VERBATIM
_________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

PROGRAMMER: IF AB PLUS MEMBER, GO TO E12, ELSE GO TO E26.

AB PLUS ONLY
(All)
E12.

These next questions are about the services {you/(NAME)} receive from Care Guide as part of your
participation in AB. As part of AB, {you were/he/she was} assigned to a care manager. Our records indicate
that {your/his/her} care manager’s name is [FILL NAME]. Is this correct?
YES ............................................................... 01 (E13)
NO ................................................................. 00
DON’T KNOW ............................................... d (E12b)
REFUSED ..................................................... r (E12b)

(E12=00)
E12a. What is the name of your AB care manager?
RECORD VERBATIM RESPONSE

_______________________________________________________________________ (E13)
NO CARE MANAGER ...................................
DON’T KNOW ...............................................
REFUSED .....................................................

n
d
r

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(E12=d OR r OR E12a = n, d OR r)
E12b. The care manager is the nurse or other medically trained person who would have contacted {you/(NAME)}
about the treatment and care plan for {your/his/her} condition. The care manager would call {you/(NAME)}
on a regular basis to discuss {your/his/her} treatment plan. He or she is affiliated with Care Guide. {Have
you/Has (NAME)} been in touch with such a person?
YES ............................................................... 01
NO ................................................................. 00 (E18)
DON’T KNOW ............................................... d (E18)
REFUSED ..................................................... r (E18)
(E12 OR E12b = 01)
E13.
{Do you/Does (NAME)} have regularly scheduled appointments to talk with {CARE MANAGER/{his/her} care
manager} by telephone?
YES ............................................................... 01
NO ................................................................. 00 (E14a)
DON’T KNOW ............................................... d (E14a)
REFUSED ..................................................... r (E14a)
(E13=01)
E14.
How often {are you/is (NAME)} scheduled to talk with {CARE MANAGER/{his/her} care manager}?
PROBE: Your best estimate is fine.
|

|

| TIMES PER

CODE ONE
WEEK ............................................................ 01
MONTH ......................................................... 02
OTHER (SPECIFY) ....................................... 03
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

GO TO E14b

(E13=00, d, OR r)
E14a. How often {do you/does (NAME)} usually talk with {CARE MANAGER/{his/her} care manager}?
PROBE: Your best estimate is fine.
|

|

| TIMES PER

CODE ONE
WEEK ............................................................ 01
MONTH ......................................................... 02
OTHER (SPECIFY) ....................................... 03
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

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(E12 OR E12b = 01)
E14b. {Do you/Does (NAME)} know how to reach {CARE MANAGER/{his/her} care manager}?
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r
PROGRAMMER: IF E13=01, GO TO E15, ELSE GO TO E16.

(E13=01)
E15.
During the past 6 months {were you/was (NAME)} able to keep all scheduled appointments with {CARE
MANAGER/{his/her} care manager}?
YES ............................................................... 01 (E16)
NO ................................................................. 00
DON’T KNOW ............................................... d (E16)
REFUSED ..................................................... r (E16)

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(E15=00)
E15a. Why {were you/was (NAME)} not able to keep all scheduled appointments with {CARE MANAGER/{his/her}
care manager}?
CODE ALL THAT APPLY
ACCESS
COULD NOT GET CONVENIENT APPOINTMENT ............
TELEPHONE WAS DISCONNECTED .................................
WAITING FOR UPCOMING APPOINTMENT ......................
OTHER TECHNICAL PROBLEM (NO TTY, RELAY
AVAILABLE) ......................................................................
QUALITY
DID NOT LIKE CARE MANAGER’S ADVICE.......................
RECOMMENDED CLINIC/OFFICE IN UNSAFE
NEIGHBORHOOD.............................................................
CARE MANAGER DID NOT KEEP APPOINTMENT............
INSENSITIVE/DISRESPECTFUL DOCTORS/MEDICAL
STAFF (NEGATIVE ATTITUDES, MISPERCEPTION
ABOUT DISABILITY).........................................................
POOR COORDINATION OF CARE WITH OTHER
MEDICAL PROVIDERS.....................................................
AVOIDANCE/ALTERNATIVES
USED A DIFFERENT TREATMENT PLAN ..........................
HEALTH GOT WORSE/TOO SICK ......................................
HEALTH OF OTHER FAMILY MEMBER INTERFERED......
OTHER (SPECIFY) ..............................................................
_______________________________________________
DON’T KNOW ......................................................................
REFUSED ............................................................................
(All)
E16.

01
02
03
04
05
06
07

08
09
10
11
12
13
d
r

Did {CARE MANAGER/your/(NAME’s) care manager} work out a treatment or care plan for {your/his/her}
condition with {you/him/her}?
YES ............................................................... 01
NO ................................................................. 00 (E17a)
DON’T KNOW ............................................... d (E17a)
REFUSED ..................................................... r (E17a)

(E16=01)
E16a. {Have you/Has (NAME)} been able to follow the recommended treatment and care plans suggested by
{CARE MANAGER/{his/her} care manager}?
YES ............................................................... 01 (E16c)
NO ................................................................. 00
DON’T KNOW ............................................... d (E16c)
REFUSED ..................................................... r (E16c)

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(E16a=00)
E16b. Why {haven’t you/hasn’t (NAME)} been able to follow the recommended treatment and care plan suggested
by {CARE MANAGER/{his/her} care manager}?
CODE ALL THAT APPLY
NO CARE PLAN RECOMMENDED .....................................
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)................
RECOMMENDED DOCTORS DON’T WANT TO TREAT
PEOPLE WITH {MY/(NAME’S) DISABILITY .....................
QUALITY
DID NOT LIKE CARE MANAGER’S ADVICE.......................
PROBLEMS AT PLACE—LONG WAIT, NO BATHROOM,
NOT ACCESSIBLE............................................................
RECOMMENDED CLINIC/OFFICE IN UNSAFE
NEIGHBORHOOD.............................................................
INSENSITIVE/DISRESPECTFUL DOCTORS/MEDICAL
STAFF (NEGATIVE ATTITUDES, MISPERCEPTION
ABOUT DISABILITY).........................................................
POOR COORDINATION OF CARE WITH OTHER
MEDICAL PROVIDERS.....................................................
AVOIDANCE/ALTERNATIVES
THOUGHT PROBLEM WOULD GO AWAY, OR PROBLEM
WENT AWAY.....................................................................
USED A DIFFERENT TREATMENT PLAN ..........................
HEALTH GOT WORSE/TOO SICK ......................................
HEALTH OF OTHER FAMILY MEMBER INTERFERED......
OTHER (SPECIFY) ..............................................................
_______________________________________________
DON’T KNOW ......................................................................
REFUSED ............................................................................
(All)
E16c.

00
01
02
03
04
05
06
07
08
09

10
11

12
13
14
15
16
d
r

To what extent {do you/does (NAME)} feel that {your/his/her} goals, needs, and overall input are represented
in the treatment plan that was developed for {you/him/her}? Would you say . . .
Completely,....................................................
Quite a bit, .....................................................
Somewhat, or ................................................
Not at all? ......................................................
DON’T KNOW ...............................................
REFUSED .....................................................

01 (E17a)
02
03
04
d (E17a)
r (E17a)

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(E16b = 02, 03 OR 04)
E16d. From {your/her/his} perspective, how can {your/his/her} treatment plan be improved?
RECORD VERBATIM RESPONSE

_______________________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................
(All)
E17a.

Overall, how would {you/(NAME)} rate the quality
MANAGER/{your/his/her} care manager} in terms of . . .

of

{your/his/her}

d
r

interaction

with

{CARE

. . . respect and attention to privacy?
PROBE: Would {you/(NAME)} say it was excellent, very good, good, fair, or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(All)
E17b.

. . . personal interest?
PROBE: Would {you/(NAME)} say it was excellent, very good, good, fair, or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
E17c.

. . . availability in emergency?
PROBE: Would {you/(NAME)} say it was excellent, very good, good, fair, or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d

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REFUSED .....................................................

r

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(All)
E17d.

. . . answering questions over the telephone?
PROBE: Would {you/(NAME)} say it was excellent, very good, good, fair, or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
E17e.

. . . coordinating care across providers and services?
PROBE: Would {you/(NAME)} say it was excellent, very good, good, fair, or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r
PROGRAMMER: IF ANY E17a THROUGH E17e=04 OR 05,
GO TO E17_OTHER, ELSE GO TO E18.

(ANY OF E17a TO E17e = 04 OR 05)
E17_Other
What could be done to improve the quality of interaction with {CARE MANAGER/{your/his/her} care
manager}?
RECORD VERBATIM RESPONSE

_______________________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

(MIS INDICATES STARTED PGAP INTERVENTION)
E18.
Now I’d like to talk about the part of the AB program that provides a counselor to help {you/(NAME)} set
goals that will help {you/him/her} become more active, and prepare to return to work. Our records show that
the counselor assigned to work with {you/him/her} in this area is {FILL PGAP COUNSELOR NAME]. Is this
correct?
YES ............................................................... 01 (E19)
NO ................................................................. 00
DON’T KNOW ............................................... d (E18b)
REFUSED ..................................................... r (E18b)

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(E18=00)
E18a. What is the name of the counselor who helps you with goal setting?
RECORD VERBATIM RESPONSE

_________________________________________________________________
(E19)
NO PGAP COUNSELOR............................... n
DON’T KNOW ............................................... d
REFUSED ..................................................... r
(E18 = d OR r) (E18a = n, d OR r)
E18b. This person would be a counselor who would contact {you/(NAME)} regularly to help {you/him/her} set goals
and plan regular activities that would help {you/him/her} become more active, and get ready to return to
work. He or she is affiliated with Care Guide. {Have you/Has (NAME)} been in touch with such a person?
YES ............................................................... 01
NO ................................................................. 00 (E27)
DON’T KNOW ............................................... d (E27)
REFUSED ..................................................... r (E27)
(All)
E19.

{Do you/Does (NAME)} have regularly scheduled appointments to talk with {PGAP COUNSELOR
NAME/{your/his/her} counselor} by telephone?
YES ............................................................... 01
NO ................................................................. 00 (E20a)
DON’T KNOW ............................................... d (E20a)
REFUSED ..................................................... r (E20a)

(E19=01)
E20.
How often {are you/is (NAME)} scheduled to talk with {PGAP COUNSELOR NAME/{your/his/her}
counselor}?
PROBE: Your best estimate is fine.
|

|

| TIMES PER

CODE ONE
WEEK ............................................................ 01
MONTH ......................................................... 02
OTHER (SPECIFY) ....................................... 03
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

GO TO E20b

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(E19=00, d OR r)
E20a. How often {do you/does (NAME)} usually talk with {PGAP COUNSELOR NAME/{your/his/her} counselor}?
PROBE: Your best estimate is fine.
|

|

| TIMES PER

CODE ONE
WEEK ............................................................ 01
MONTH ......................................................... 02
OTHER (SPECIFY) ....................................... 03
DON’T KNOW ...............................................
REFUSED .....................................................
(All)
E20b.

d
r

{Do you/Does (NAME)} know how to reach {PGAP COUNSELOR NAME/{your/his/her} counselor}?
YES ............................................................... 01
NO ................................................................. 00
DON’T KNOW ............................................... d
REFUSED ..................................................... r
PROGRAMMER: IF E19=01, GO TO E21, ELSE GO TO E22.

(E19=01)
E21.
During the past 6 months {were you/was (NAME)} able to keep all scheduled appointments with {PGAP
COUNSELOR NAME/{your/his/her} counselor}?
YES ............................................................... 01 (E22)
NO ................................................................. 00
DON’T KNOW ............................................... d (E22)
REFUSED ..................................................... r (E22)

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(E21=00)
E21a. Why {were you/was (NAME)} not able to keep all scheduled appointments with {PGAP COUNSELOR
NAME/{your/his/her} counselor}?
CODE ALL THAT APPLY
ACCESS
COULD NOT GET CONVENIENT APPOINTMENT ............
TELEPHONE DISCONNECTED ..........................................
WAITING FOR UPCOMING APPOINTMENT ......................
OTHER TECHNICAL PROBLEM (NO TTY/RELAY
AVAILABLE) ......................................................................
QUALITY
DID NOT LIKE EMPLOYMENT COUNSELOR’S ADVICE ...
CLINIC/OFFICE IN UNSAFE NEIGHBORHOOD .................
INSENSITIVE/DISRESPECTFUL COUNSELOR/STAFF
(NEGATIVE ATTITUDES, MISPERCEPTION ABOUT
DISABILITY) ......................................................................
PGAP COUNSELOR DID NOT KEEP APPOINTMENT .......
AVOIDANCE/ALTERNATIVES
USED OTHER ACTIVITIES/(MY/(NAME’S) OWN
STRATEGIES TO PREPARE ............................................
HEALTH GOT WORSE ........................................................
HEALTH OF OTHER FAMILY MEMBER INTERFERED......
OTHER (SPECIFY) ..............................................................
_______________________________________________
DON’T KNOW ......................................................................
REFUSED ............................................................................
(All)
E22.

01
02
03
04
05
06

07
08

09
10
11
12
d
r

Did {PGAP COUNSELOR NAME/{your/his/her} counselor} help you set goals and plan activities that would
help {you/him/her} prepare to return to work?
YES ............................................................... 01
NO ................................................................. 00 (E25a)
DON’T KNOW ............................................... d (E25a)
REFUSED ..................................................... r (E25a)

(E22=01)
E23.
{Have you/Has (NAME)} been able to follow the recommended activities and achieve the goals that
{you/he/she} set with {PGAP COUNSELOR NAME/{your/his/her} counselor}?
YES ............................................................... 01 (E24)
NO ................................................................. 00
DON’T KNOW ............................................... d (E24)
REFUSED ..................................................... r (E24)

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(E23=00)
E23a. Why {haven’t you/hasn’t (NAME)} been able to follow the recommended activities and achieve the goals that
{you/he/she} set with {PGAP COUNSELOR NAME/{your/his/her} counselor}?
CODE ALL THAT APPLY
NO ACTIVITIES RECOMMENDED ................................. 00
DID NOT LIKE PGAP COUNSELOR’S ADVICE ............. 01
ACTIVITIES TOO HARD ................................................. 02
GOALS ARE UNREASONABLE/NOT ATTAINABLE ...... 03
USED OTHER ACTIVITIES/MY OWN STRATEGIES
TO PREPARE............................................................... 04
TRANSPORTATION PROBLEM ..................................... 05
HEALTH GOT WORSE ................................................... 06
HEALTH OF OTHER FAMILY MEMBER INTERFERED. 07
OTHER (SPECIFY) ......................................................... 08
____________________________________________
DON’T KNOW ................................................................. d
REFUSED ....................................................................... r
(E22=01)
E24.
To what extent {do you/does (NAME)} feel that {your/his/her} goals, needs, and overall input are represented
in the plan developed for {you/him/her}? Would you say . . .
Completely,....................................................
Quite a bit, .....................................................
Somewhat, or ................................................
Not at all? ......................................................
DON’T KNOW ...............................................
REFUSED .....................................................

01 (E25a)
02
03
04
d (E25a)
r (E25a)

(E24 = 02, 03, OR 04)
E24a. From {your/(NAME’s} perspective, how could {your/his/her} plan be improved?
RECORD VERBATIM RESPONSE
___________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

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(All)
E25a.

Overall, how would {you/(NAME)} rate the quality of {your/his/her} interaction with {PGAP COUNSELOR
NAME/{your/his/her} counselor} in terms of . . .
. . . respect and attention to privacy?
PROBE: Would {you/(NAME)} say it was excellent, very good, good, fair, or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
E25b.

. . . personal interest?
PROBE: Would {you/(NAME)} say it was excellent, very good, good, fair, or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(All)
E25c.

. . . availability in emergency?
PROBE: Would {you/(NAME)} say it was excellent, very good, good, fair, or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r

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(All)
E25d.

. . . answering questions over the telephone?
PROBE: Would {you/(NAME)} say it was excellent, very good, good, fair, or poor?
CODE ONE
EXCELLENT.................................................. 01
VERY GOOD................................................. 02
GOOD............................................................ 03
FAIR .............................................................. 04
POOR ............................................................ 05
DON’T KNOW ............................................... d
REFUSED ..................................................... r
PROGRAMMER: IF ANY OF E25a THROUGH E25d=04 OR 05,
GO TO E25_OTHER, ELSE GO TO E27.

(ANY OF E25a TO E25d = 04 OR 05)
E25_Other What could be done to improve
NAME/{your/his/her} counselor}?

the

quality

of

interaction

with

{PGAP

COUNSELOR

RECORD VERBATIM RESPONSE

_______________________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

GO TO E27

(MIS SHOWS NO AB)
E26.
The program records show that {you have not/(NAME) has not} participated in any of the services provided
by AB. Please tell me why {you have/he/she has} not used the health plan services, (IF AB PLUS SAY: or
any of the services offered by a care manager or counselor through AB.)
RECORD VERBATIM RESPONSE

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

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(All)
E27.

What would {you/(NAME)} do or add to AB benefits and services to make it more helpful to {you/him/her}?
RECORD VERBATIM RESPONSE

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

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SECTION F: CLOSING AND CONTACT INFORMATION

(All)
F1.

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 $25 check for completing this survey. Is {your/(NAME’s)} current address and phone
number… READ FROM PRELOADS?
SAME AS PROVIDED ................................... 00 (F3)
INCORRECT INFORMATION ABOVE,
NEED TO ENTER NEW INFORMATION ... 01
DON’T KNOW ............................................... d
REFUSED ..................................................... r

(F1=01, d, OR r)
F2.
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)
F3.

{Do you have/Does (NAME) have} an email address?
YES ............................................................... 01
NO ................................................................. 00 (F5)
DON’T KNOW ............................................... d (F5)
REFUSED ..................................................... r (F5)

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(F3=01)
F4.
What is {your/(NAME’s)} email address?

DON’T KNOW ...............................................
REFUSED .....................................................
(All)
F5.

d
r

INTERVIEWER: ARE YOU SPEAKING WITH (NAME), AN INTERPRETER, OR A PROXY?
NAME ............................................................ 01 (F10)
INTERPRETER ............................................. 02
PROXY .......................................................... 03

(F5=2)
F6.

What is your full name?
INTERVIEWER: PRESS 1 TO CONTINUE
NAME:

DISPLAY PROXY’S/INTERPRETER’S FULL NAME FROM SCREENER OR PRELOADED
INFORMATION WITH FIRST NAME BOLD}
FIRST NAME:
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

(F5=02)
F7.
What is the correct spelling of your name and your current mailing address and phone number?
PROGRAMMER: DISPLAY PROXY’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

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(F5=02)
F8.
Do you have an email address?
YES ............................................................... 01
NO ................................................................. 00 (F10)
DON’T KNOW ............................................... d (F10)
REFUSED ..................................................... r (F10)
(F8=01)
F9.
What is your email address?

DON’T KNOW ...............................................
REFUSED .....................................................
(All)
F10.

d
r

To whom should we make the $25.00 check for completing the interview payable?
SAMPLE MEMBER .......................................
INTERPRETER .............................................
PROXY ..........................................................
SOMEONE ELSE ..........................................
DON’T KNOW ...............................................
REFUSED .....................................................

01
02
03
04
d
r

(F12)
(F12)
(F12)
(F12)
(F12)

(F10=04)
F11.
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

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F11a.

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 .....................................................

F12.

01
02
03
04
05
06
07
08
09
10
d
r

We will mail (NAME) the check for $25.00 to {him/her} at {FILL ADDRESS} within the next two weeks. We
would like to contact {you/(NAME)} again in about ______ months to see how {you are/he/she is} 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 (THNX2)
DON’T KNOW ............................................... d (THNX2)
REFUSED ..................................................... r (THNX2)

(F12=01)
F13.
What is that person’s name, address, and telephone number?
NAME
ADDRESS LINE 1
ADDRESS LINE 2
CITY/TOWN
STATE
ZIP CODE

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(F12=01)
F13a. TELEPHONE
TELEPHONE NUMBER: Please give me the telephone number, area code first.

DON’T KNOW ...............................................
REFUSED .....................................................

d
r

(F12=01)
F13b. Do you have a cell phone, pager number or email address for CP1?
YES ............................................................... 01
NO ................................................................. 00 (F14)
DON’T KNOW ............................................... d (F14)
REFUSED ..................................................... r (F14)
(F13b=01)
F13c. What is CP1’s cell phone number? Please give me the number, area code first.

What is CP1’s pager number? Please give me the number, area code first.

What is CP1’s email address?

DON’T KNOW ...............................................
REFUSED .....................................................

d
r

(F12=01)
F14.
How is CP1 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

(F15)
(F15)
(F15)
(F15)
(F15)
(F15)
(F15)
(F15)
(F15)
(F15)
(F15)

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(F14=08)
F14_Other. How is CP1 related to {you/(NAME)}?

DON’T KNOW ...............................................
REFUSED .....................................................

d
r

CONTACT PERSON 2
F15.

Can you give me the name, address, and phone number of a second person who would always know how to
reach {you/(NAME)}?
YES ............................................................... 01
NO ................................................................. 00 (THNX2)
DON’T KNOW ............................................... d (THNX2)
REFUSED ..................................................... r (THNX2)
NAME
ADDRESS LINE 1
ADDRESS LINE 2
CITY/TOWN
STATE
ZIP CODE
FIRST NAME:
DON’T KNOW ...............................................
REFUSED .....................................................

d
r

(F15=01)
F15a. TELEPHONE
TELEPHONE NUMBER: Please give me the telephone number, area code first?

DON’T KNOW ...............................................
REFUSED .....................................................

d
r

(F15=01)
F15b. Do you have a cell phone, pager number or email address for CP2?
YES ............................................................... 01
NO ................................................................. 00 (F16)
DON’T KNOW ............................................... d (F16)
REFUSED ..................................................... r (F16)

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(F15b=01)
F15c. What is CP2’s cell phone number? Please give me the number, area code first.

What is CP2’s pager number? Please give me the number, area code first.

What is CP2’s email address?

DON’T KNOW ...............................................
REFUSED .....................................................

d
r

(F15=01)
F16.
How is CP2 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

(THNX2)
(THNX2)
(THNX2)
(THNX2)
(THNX2)
(THNX2)
(THNX2)
(THNX2)
(THNX2)
(THNX2)
(THNX2)

(F16=08)
F16_Other. How is CP2 related to {you/(NAME)}?

DON’T KNOW ...............................................
REFUSED .....................................................

d
r

PROGRAMMER: IF E1b AND E9b =01, d, OR r, GO TO THNX1, ELSE GO TO THNX2.
(E1b AND E7B = 00, d, OR r)
THNX1. Thank you very much for your time. I will refer {your/(NAME’S) case to the AB Demonstration office so that
someone can contact {you/him/her} and arrange to have {you/him/her} meet with a care manager and/or an
employment counselor. Best wishes to {you/(NAME)}.
THNX2. That was my last question. Thanks very much for your time. Best wishes to {you/(NAME)}.

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