CONTACT INFORMATION AND DEMOGRAPHICS (dm)
DM-1. Are you still at {INSERT CURRENT ADDRESS ON FILE}?
(NEW)
YES 1 (DM-3)
NO 2
DM-2. What is your current address?
(NEW)
STREET ADDRESS
CITY
STATE
ZIP CODE
DM-3. Is there another telephone number where we can reach you?
(NEW)
YES 1
NO 2 (DM-5)
DM-4. What is that number?
(NEW)
|__|__|__| - |__|__|__| - |__|__|__|__|
TELEPHONE NUMBER
DM-5. Are you planning to move in the next 3 months?
(NEW)
YES 1
NO 2 (DM-10)
DM-6. What will your new address be?
(NEW)
STREET ADDRESS
CITY
STATE
ZIP CODE
DM-7. When will you move to this new address?
(EIR)
|__|__| / |__|__| / |__|__|__|__|
MONTH DAY YEAR
DM-8. Will you keep the same telephone number?
(NEW)
YES 1 (DM-10)
NO 2
DM-9. What will your new telephone number be?
(NEW)
|__|__|__| - |__|__|__| - |__|__|__|__|
TELEPHONE NUMBER
Next, I will re-ask you some questions about yourself.
DM-10. What is your marital status?
(UCDI)
Never married, 1
Married, 2
Living as married, 3
Separated, 4
Divorced, or 5
Widowed? 6
DM-11. What is the highest grade in school that you completed?
(UCDI)
NO FORMAL SCHOOLING 1
SOME ELEMENTARY SCHOOLING 2
COMPLETED 8TH GRADE 3
SOME HIGH SCHOOL 4
COMPLETED HIGH SCHOOL OR GED 5
SOME COLLEGE OR TECHNICAL SCHOOL 6
COMPLETED ASSOCIATE’S DEGREE 7
COMPLETED BACHELOR’S DEGREE 8
SOME GRADUATE SCHOOL 9
COMPLETED MASTER’S DEGREE 10
COMPLETED DOCTORAL DEGREE 11
DM-12. Describe who you have been living with during the past 30 days.
(NEW)
[INTERVIEWER: CODE ALL THAT APPLY.]
LIVING ALONE 1
LIVING WITH SPOUSE ONLY 2
LIVING WITH CHILDREN ONLY 3
LIVING WITH SPOUSE AND CHILDREN 4
LIVING WITH PARENTS 5
LIVING WITH OTHER RELATIVES (OTHER THAN
SPOUSE, CHILDREN, OR PARENTS) 6
LIVING WITH FRIENDS 7
LIVING WITH OTHER NON-RELATED ADULTS
(NOT NECESSARILY FRIENDS) 8
OTHER (SPECIFY) 9
DM-13. Which of following best describes where you have been living during the past 30 days? Would you say…
(NEW)
At one address in an apartment or house, 1
At more than one address in apartments or houses, 2
In a homeless shelter or homeless with no
particular address, or 3 (DM-21)
Some other place? (SPECIFY) 4 (DM-21)
IF RESPONDENT LIVES ALONE, WITH FRIENDS, WITH OTHER NON-RELATED ADULTS, OR IN SOME OTHER PLACE (DM-12 = 1, 7, 8, OR 9), CONTINUE WITH DM-14.
IF RESPONDENT LIVES WITH SPOUSE ONLY (DM-12 = 2), GO TO DM-21.
ELSE, GO TO DM-18.
DM-14. In this place where you live, do you receive visits from a case manager or some other person from a city or state agency?
(NEW)
YES 1
NO 2
DM-15. Are there staff from a mental health agency or other city or state agency who are living at the residence?
(NEW)
YES 1
NO 2
DM-16. Are your meals prepared by residential staff employed by a mental health center or other city or state agency?
(NEW)
YES 1
NO 2
IF RESPONDENT RECEIVES VISITS FROM A CASE MANAGER, STAFF FROM A MENTAL HEALTH AGENCY LIVE AT THE RESIDENCE, OR MEALS ARE PREPARED BY STAFF (DM-14 = 1 OR DM-15 = 1 OR DM-16 = 1), CONTINUE WITH DM-17. OTHERWISE, GO TO BOX DM-1.
DM-17. Are there other people living in the apartment or house who receive help from the same agency as you?
(NEW)
YES 1
NO 2
BOX DM-1
IF RESPONDENT LIVES ALONE (DM-12 = 1), THEN GO TO DM-21.
DM-18. How many adults age 18 or over lived with you for most of the past 30 days?
(NEW)
|__|__| ADULTS
IF NO ADULTS LIVE WITH RESPONDENT (DM-18 = 0), THEN GO TO DM-20.
DM-19. Of these adults, how many are dependent on you for support?
(NEW)
|__|__| DEPENDENT ADULTS
DM-20. How many children under the age of 18 lived with you for most of the past 30 days?
(NEW)
|__|__| CHILDREN
DM-21. In the past three months, how many days have you been…
(OCAM)
Living in a shelter or on the street? |__|__|
In jail or a correctional facility? |__|__|
HEALTH STATUS (HS)
The next few questions ask about your health and how well you are able to do your usual activities. First I will ask about your health now. Please try to answer the question as accurately as you can.
HS-1. In general, would you say your health is…
(SF-12)
Excellent, 1
Very good, 2
Good, 3
Fair, or 4
Poor? 5
Now, I’m going to ask about activities that you might do during a typical day. As I read each item, please tell me if your health now limits you a lot, limits you a little, or does not limit you at all in these activities.
HS-2. Does your health now limit you in moderate activities such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? Does it limit you…
(SF-12)
A lot, 1
A little, or 2
Not at all? 3
HS-3. Does your health now limit you in climbing several flights of stairs? Does it limit you…
(SF-12)
A lot, 1
A little, or 2
Not at all? 3
The next two questions ask about your physical health and your daily activities.
HS-4. During the past 4 weeks, how much of the time have you accomplished less than you would have liked to as a result of your physical health? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
HS-5. During the past 4 weeks, how much of the time were you limited in the kind of work or other regular daily activities you do as a result of your physical health? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
Now I will ask about any emotional problems and your daily activities.
HS-6. During the past 4 weeks, how much of the time have you accomplished less than you would have liked to as a result of any emotional problems, such as feeling depressed or anxious? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
HS-7. During the past 4 weeks, how much of the time did you not do work or other activities as carefully as usual as a result of any emotional problems, such as feeling depressed or anxious? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
HS-8. During the past 4 weeks, how much did pain interfere with your normal work, including both work outside the home and housework? Did it interfere.
(SF-12)
Not at all, 1
A little bit, 2
Moderately, 3
Quite a bit, or 4
Extremely? 5
These next questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give me the one answer that comes closest to the way you have been feeling.
HS-9. During the past 4 weeks, how much of the time have you felt calm and peaceful? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
HS-10. During the past 4 weeks, how much of the time did you have a lot of energy? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
HS-11. During the past 4 weeks, how much of the time have you felt downhearted and depressed? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
HS-12. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities, like visiting with friends or relatives? Would you say…
(SF-12)
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time? 5
ALCOHOL AND SUBSTANCE USE (AS)
The next set of questions are about how frequently you drink alcoholic beverages or use drugs. Remember that your answers are strictly confidential.
ASK AS-2 AND AS-3 IMMEDIATELY AFTER A ‘YES’ RESPONSE FOR EACH SUB-ITEM IN
AS-1. (EXAMPLE: ASK AS-1A. IF ‘YES’ THEN ASK AS-2A, AS-3A, ETC. GO BACK TO AS-1B AND IF ‘YES’ THEN ASK AS-2B, AS-3B, ETC.)
AS-1. In the past 30 days, how many days have you used {INSERT SUBSTANCE}…
(ASI)
a. Any alcohol at all? |__|__|
b. Alcohol to the point where you felt the effects of it,
for example you felt like you got “a buzz,” were
“high,” or drunk? |__|__|
c. Marijuana? (This includes pot, reefer, hashish,
cannabis.) |__|__|
d. Heroin? (This includes smack, horse, tar.) |__|__|
e. Non-prescription methadone? (This includes
Dolophine and LAAM.) |__|__|
f. Other opiates or analgesics? (This includes morphine,
dreamer junk, Demerol, Darvon, Darvocet, Codeine,
school boy, Percodan, Dilaudid, Talwin, OxyContin.) |__|__|
g. Barbiturates? (This includes Seconal, reds, red
devis, Nembutal, Tuninal or rainbows, phenobarbital
yellow jackets, purple hearts.) |__|__|
h. Sedatives, benzodiazepines, tranquilizers, or
hypnotics? (This includes Valium, Librium, Xanax,
Halcion, Klonipin.) |__|__|
i. Cocaine, crack, or coca leaves? |__|__|
j. Methamphetamines, amphetamines, or stimulants?
(This includes Ecstasy, uppers, bennies, meth, speed,
speedball, dexies, pep pill, crank, crystal, monster
pep pill, black beauties, ice, batu.) |__|__|
Hallucinogens? (This includes LSD, acid, purple
haze, mescaline, mesc, cactus, PCP, angel dust,
mushrooms, peyote.) |__|__|
l. Inhalants? (This includes nitrous oxide, whippets, glue,
amyl nitrate, mush, lockerroom, poppers, snappers,
gasoline, paint, nail polish remover.) |__|__|
m. More than one substance per day, including
alcohol? |__|__|
ONLY ASK AS-2 AND AS-3 FOR MARIJUANA (AS-1C = 1); OTHER OPIATES OR ANALGESICS
(AS-1F = 1); BARBITURATES (AS-1G = 1); SEDATIVES, TRANQUILIZERS, OR HYPNOTICS
(AS-1H = 1); AND METHAMPHETAMINES, AMPHETAMINES, OR STIMULANTS (AS-1J = 1).
AS-2. Was this prescribed for you?
(ASI)
YES 1
NO 2 (NEXT ITEM IN AS-1 OR AS-4)
AS-3. How many days in the past 30 did you take at least one extra dose of {INSERT SUBSTANCE}?
(ASI)
|__|__| DAYS
AS-4. Out of all the drugs I just mentioned, which substance is the major problem for you?
(ASI)
NO MAJOR PROBLEM 0
ALCOHOL 1
MARIJUANA 2
HEROIN 3
METHADONE 4
OTHER OPIATES/ANALGESICS 5
BARBITUATES 6
SEDATIVES/BENZODIAZEPINES/HYPNOTICS/
TRANQUILIZERS 7
COCAINE/CRACK 8
METHAMPHETAMINES/AMPHETAMINES/
STIMULANTS 9
HALLUCINOGENS 10
INHALANTS 11
MAJOR PROBLEM WITH ALCOHOL AND ONE
OR MORE DRUGS (SPECIFY ) 12
MAJOR PROBLEM WITH MORE THAN ONE
DRUG (SPECIFY) 13
IF NO MAJOR ALCOHOL OR SUBSTANCE ABUSE PROBLEM (AS-4 = 0),
THEN GO TO AS-7.
AS-5. How long was your last period of voluntary abstinence from this major substance?
(ASI)
[INTERVIEWER: PROBE IF NECESSARY: “Have you ever stopped using this substance for over a month? When was the last time you stopped using this substance for over a month? Did you stay clean on your own, or were you in some sort of a controlled environment at the time? How long did that period of abstinence last?”
[INTERVIEWER: CODE ‘00’ IF RESPONDENT HAS NEVER BEEN ABSTINENT.]
|__|__| NUMBER
MONTHS 1
YEARS 2
IF RESPONDENT HAS NEVER BEEN ABSTINENT (AS-5 = 00), THEN GO TO AS-7.
AS-6. How many months ago did this abstinence end?
(ASI)
[INTERVIEWER: CODE ‘00’ IF RESPONDENT IS STILL ABSTINENT.]
|__|__| NUMBER
MONTHS 1
YEARS 2
AS-7. In the past 30 days have you injected drugs?
(ASI)
YES 1
NO 2
AS-8. How many times have you had alcohol DT’s in the past 30 days?
(ASI)
[INTERVIEWER: STATE IF NECESSARY: “DT’s occur 24 to 48 hours after a person’s last drink. They consist of tremors or shaking and delirium or severe disorientation. They are often accompanied by fever. There are sometimes, but not always, hallucinations. True DT’s are usually so severe that they require some type of medical care or outside intervention.”]
|__|__| NUMBER OF TIMES
AS-9. How many times have you overdosed on drugs in the past 30 days?
(ASI)
|__|__| NUMBER OF TIMES
AS-10. How many times have you been treated for alcohol abuse in the past 30 days?
(ASI)
|__|__| NUMBER OF TIMES
AS-11. How many of those treatments involved a detox with no follow-up?
(ASI)
|__|__| NUMBER OF DETOX TREATMENTS
AS-12. How many times have you been treated for drug abuse in the past 30 days?
(ASI)
|__|__| NUMBER OF TIMES
AS-13. How many of those treatments involved a detox with no follow-up?
(ASI)
|__|__| NUMBER OF DETOX TREATMENTS
AS-14. How much have you spent on alcohol in the past 30 days?
(ASI)
$|__|__|__|__| . |__|__|
AS-15. How much have you spent on drugs in the past 30 days?
(ASI)
$|__|__|__|__| . |__|__|
AS-16. How many days in the past 30 days have you been treated in an outpatient setting or attended self-help groups like AA or NA?
(ASI)
|__|__| NUMBER OF DAYS
AS-17. How many days in the past 30 days have you experienced alcohol problems?
(ASI)
|__|__| NUMBER OF DAYS
AS-18. How many days in the past 30 days have you experienced drug problems?
(ASI)
|__|__| NUMBER OF DAYS
AS-19. How troubled or bothered have you been in the past 30 days by alcohol problems? Would you say…
(ASI)
Not at all, 1
Slightly, 2
Moderately, 3
Considerably, or 4
Extremely? 5
AS-20. How troubled or bothered have you been in the past 30 days by drug problems? Would you say…
(ASI)
Not at all, 1
Slightly, 2
Moderately, 3
Considerably, or 4
Extremely? 5
AS-21. How important to you now is treatment for these alcohol problems? Would you say…
(ASI)
Not at all, 1
Slightly, 2
Moderately, 3
Considerably, or 4
Extremely? 5
AS-22. How important to you now is treatment for these drug problems? Would you say…
(ASI)
Not at all, 1
Slightly, 2
Moderately, 3
Considerably, or 4
Extremely? 5
AS-23. [INTERVIEWER: IS THE INFORMATION COLLECTED ON ALCOHOL AND DRUG USE SIGNIFICANTLY DISTORTED BY THE RESPONDENT’S MISREPRESENTATION?]
(ASI)
YES 1
NO 2
AS-24. [INTERVIEWER: IS THE INFORMATION COLLECTED ON ALCOHOL AND DRUG USE SIGNIFICANTLY DISTORTED BY THE RESPONDENT’S INABILITY TO UNDERSTAND THE QUESTIONS?]
(ASI)
YES 1
NO 2
HEALTH CARE SERVICE UTILIZATION (HC)
HC-1. {In the past 3 months/Since INSERT DATE FROM LAST INTERVIEW}, did you receive any care in an emergency room?
(HCC)
YES 1
NO 2 (HC-9)
HC-2. How many times {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} did you go to an emergency room?
(HCC)
|__|__| TIMES
I would like to get more information about your emergency room visits. Let’s begin with the most recent time you visited an emergency room and work backwards {over the past 3 months/since INSERT DATE FROM LAST INTERVIEW}.
ASK HC-3 TO HC-8 ABOUT EACH EMERGENCY ROOM VISIT IN PAST THREE MONTHS.
HC-3. When did you go?/When did you go before that?
(HCC)
|__|__| - |__|__|__|__|
MONTH YEAR
HC-4. Where did you go?
(HCC)
NAME OF EMERGENCY ROOM
HC-5. There may be more than one reason for this visit. Please tell us all the reasons for this visit. Was it for a…
(HCC)
YES NO
a. Physical problem? 1 2
b. Mental health problem? 1 2
c. Alcohol problem? 1 2
d. Drug problem? 1 2
e. Some other problem? (SPECIFY) 1 2
HC-6. Were you admitted to the hospital following this emergency room visit?
(HCC)
YES 1
NO 2 (NEXT VISIT OR HC-9)
HC-7. There may be more than one reason why you were admitted to the hospital following this emergency room visit. Please tell us all the reasons for this admission into the hospital. Was it for a…
(HCC-Mod)
YES NO
a. Physical problem? 1 2
b. Mental health problem? 1 2
c. Alcohol problem? 1 2
d. Drug problem? 1 2
e. Some other problem? (SPECIFY) 1 2
HC-8. How many nights did you stay in the hospital?
(HCC)
|__|__| NIGHTS
HC-9. {In the past 3 months/Since INSERT DATE FROM LAST INTERVIEW}, have you stayed overnight in a hospital {other than the ones you mentioned in the previous questions}?
(HCC)
YES 1
NO 2 (HC-15)
HC-10. How many times {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} were you admitted to a hospital other than the times you mentioned earlier?
(HCC)
|__|__| TIMES
ASK HC-11 TO HC-14 ABOUT EACH HOSPITAL VISIT IN PAST THREE MONTHS.
HC-11. When did you stay in the hospital?/When did you stay before that?
(HCC)
|__|__| - |__|__|__|__|
MONTH YEAR
HC-12. Where did you stay?
(HCC)
NAME OF HOSPITAL
HC-13. There may be more than one reason for this hospital stay. Please tell us all the reasons for your admission. Was it for a…
(HCC)
YES NO
a. Physical problem? 1 2
b. Mental health problem? 1 2
c. Alcohol problem? 1 2
d. Drug problem? 1 2
e. Some other problem? (SPECIFY) 1 2
HC-14. How many nights did you stay in the hospital?
(HCC)
|__|__| NIGHTS
HC-15. {Other than a hospital or emergency room, did/Did} you receive help for a psychiatric emergency or crisis from some other source {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW}? This includes help from a mobile treatment or outreach team, crisis center, psychiatric stabilization program, peer crisis support, or other program providing psychiatric crisis care.
(HCC-Mod)
YES 1
NO 2 (HC-21)
ASK HC-16 TO HC-20 ABOUT EACH PSYCHIATRIC EMERGENCY CENTER VISIT
IN PAST THREE MONTHS.
HC-16. Where did you go?/Where did you go before that?
(HCC)
NAME OF PSYCHIATRIC EMERGENCY CENTER
HC-17. How many times {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} did you receive services at this particular place?
(HCC)
|__|__| TIMES
HC-18. When you went to {INSERT NAME OF PSYCHIATRIC EMERGENCY CENTER} who did you see? Anyone else?
(NEW)
PROVIDER 1
PROVIDER 2
PROVIDER 3
ASK HC-19 AND HC-20 ABOUT EACH PROVIDER NAMED IN HC-18.
HC-19. How many times {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} did you see {INSERT NAME OF PROVIDER IN HC-18}?
(HCC)
|__|__| TIMES
HC-20. Did {INSERT NAME OF PROVIDER IN HC-18}…
(HCC)
YES NO
a. Write a prescription for you or consult with you on
medication? 1 2
b. Provide you with some kind of mental health
counseling? 1 2
c. Provide you with some kind of vocational
counseling? 1 2
d. Provide you with some kind of spiritual or religious
guidance? 1 2
e. Provide you with some kind of peer support? 1 2
HC-21. {Other than your hospital stays, emergency room visits, and visits for psychiatric crises that you have already mentioned, did/Did} you go to another clinic or mental health provider {during the past 3 months/since INSERT DATE FROM LAST INTERVIEW}?
(HCC)
YES 1
NO 2 (HC-28)
HC-22. How many times {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} did you go to another clinic or mental health provider?
(HCC)
|__|__| TIMES
ASK HC-23 TO HC-27 ABOUT EACH CLINIC OR
MENTAL HEALTH PROVIDER VISIT IN PAST THREE MONTHS.
HC-23. Where did you go?/Where did you go before that?
(HCC)
NAME OF CLINIC OR MENTAL HEALTH PROVIDER
HC-24. Please tell us all the reasons for your visit. Was it for a…
(HCC)
YES NO
a. Physical problem? 1 2
b. Mental health problem? 1 2
c. Alcohol problem? 1 2
d. Drug problem? 1 2
e. Some other problem? (SPECIFY) 1 2
HC-25. How many times {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} did you receive services at this particular place?
(HCC)
|__|__| TIMES
HC-26. When you went to {INSERT NAME OF CLINIC OR MENTAL HEALTH PROVIDER} who did you see? Anyone else?
(NEW)
PROVIDER 1
PROVIDER 2
PROVIDER 3
ASK HC-27 AND HC-28 ABOUT EACH PROVIDER NAMED IN HC-26.
HC-27. How many times {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} did you see {INSERT NAME OF PROVIDER IN HC-26}?
(HCC)
|__|__| TIMES
HC-28. Did {INSERT NAME OF PROVIDER IN HC-26}…
(HCC)
YES NO
a. Write a prescription for you or consult with you on
medication? 1 2
b. Provide you with some kind of mental health
counseling? 1 2
c. Provide you with some kind of vocational
counseling? 1 2
d. Provide you with some kind of spiritual or religious
guidance? 1 2
e. Provide you with some kind of peer support? 1 2
HC-29. Are you currently taking any prescription medications for an emotional or mental problem, or a problem with your nerves?
(PORT/NSHA-Mod)
YES 1
NO 2 (NEXT SECTION)
HC-30. What are the names of each of the prescription medicines that you are taking for an emotional or mental problem or a problem with your nerves? Any others?
(PORT/NSHA-Mod)
MEDICATION 1
MEDICATION 2
MEDICATION 3
MEDICATION 4
EMPLOYMENT OUTCOMES and current income (EO)
A. EMPLOYMENT OUTCOMES
Now I’d like to ask you some questions about your work experience {in the past 3 months/since the last time we talked}. That would be the time period from {INSERT MONTH AND YEAR FROM THREE MONTHS AGO/INSERT DATE FROM LAST INTERVIEW} today.
EO-1. Have you had a job {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW}?
(NEW)
YES 1 (EO-3)
NO 2
EO-2. Have you filled out a job application or spoken with a prospective employer {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW}?
(IPS)
YES 1
NO 2
GO TO EO-30.
EO-3. How many jobs have you had {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW}? Please count all jobs you have held for pay. Remember that all of your responses are strictly confidential.
(NEW)
|__|__|
NUMBER OF JOBS
EO-4. Are you currently working at a job or business for pay?
(NSHA)
YES 1
NO 2
Now, I am going to ask some questions about any and all jobs you’ve held for pay {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW} starting with your {current/ most recent} job. If you {have/had} more than one job, tell me about the main job first. Also, if you have held more than one position within the same company, you should tell me about those positions as separate jobs. Again, remember that I am interested in all of the jobs you’ve had {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW}, and I cannot share this information with SSA under any circumstances.
ASK EO-5 TO EO-16 FOR EACH JOB HELD IN PAST THREE MONTHS/SINCE LAST INTERVIEW.
EO-5. What {is/was} your job title?/ What job did you do before that?
(NSHA)
[INTERVIEWER: USE THE SOC CODES LISTED BELOW TO CODE RESPONDENT’S MAIN JOB.]
NAME OF JOB/JOB TITLE
EO-6. What {do/did} you do on the job?
(NSHA)
[INTERVIEWER: PROBE IF NECESSARY: “What {is/was} your job description? What {are/were} your job responsibilities?]
[INTERVIEWER: USE THE SOC CODES LISTED BELOW TO CODE RESPONDENT’S MAIN JOB.]
JOB DUTIES
EO-7. What month and year did you begin that job?
(EIR)
|__|__| / |__|__|__|__|
MONTH YEAR
EO-8. What month and year did that job end?
(EIR)
|__|__| / |__|__|__|__|
MONTH YEAR
CURRENT JOB 99
EO-9. Is it possible that you {are/were} paid a piece rate? That is, your pay {is/was} not based on an hourly rate but on the number of times that you {produce/produced}?
(NEW)
YES 1 (EO-11)
NO 2
EO-10. What {is/was} your hourly wage?
(NEW)
$|___|___|___|.|__|__| HOURLY WAGE
EO-11. Now I want to know who {writes/wrote} your paycheck or {pays/paid} your wages. Which of the following best describes who {writes/wrote} your paycheck or {pays/paid} your wages for this job? Would you say…
(NEW)
The employer, 1
A mental health or rehabilitation agency, or 2
Someone else? (SPECIFY) 3
EO-12. {Is/Was} any person who {supervises/supervised} your work an employee of a mental health or rehabilitation agency?
(NEW)
YES 1
NO 2
EO-13. {Is/Was} this job reserved only for people who get services from a mental health or rehabilitation agency?
(NEW)
YES 1 (EO-15)
NO 2
EO-14. So this job could have been taken by anybody who applied for it and was qualified, including someone who does not have a disability?
(NEW)
YES 1
NO 2
EO-15. {Does/Did} this job have a time limit to it? That is, {is/was} it only temporary?
(NEW)
YES 1
NO 2 (NEXT JOB OR EO-17)
EO-16. Describe what is meant by it being “time limited.” {Is/Was} this a seasonal job or a transitional job of some kind?
(NEW)
SEASONAL JOB 1
TRANSITIONAL JOB 2
OTHER JOB (SPECIFY) 3
EO-17. What was your main job {in the past 3 months/since INSERT DATE FROM LAST INTERVIEW}? Your main job is the job at which you worked the longest or worked the most hours.
(NEW)
[INTERVIEWER: SELECT THE MAIN JOB FROM LIST OF ALL JOBS IN PAST 3 MONTHS.]
NAME OF MAIN JOB/JOB TITLE
Now, I am going to ask you some additional questions about your main job, that is your job as (a/an) {INSERT JOB TITLE FROM EO-17}.
EO-18. Did anyone help you get this job?
(IPS-Mod)
YES 1
NO 2 (EO-20)
EO-19. Who helped you? Was it…
(IPS-Mod)
Someone from {INSERT NAME OF MHTS SITE}, 1
Someone from another vocational program
(SPECIFY), or 2
Someone else? (SPECIFY) 3
EO-20. How many hours per day {do/did} you usually work as (a/an) {INSERT JOB TITLE FROM EO-17}?
(NSHA-Mod)
|__|__|
HOURS
EO-21. How many days per week {do/did} you usually work as (a/an) {INSERT JOB TITLE FROM EO-17}?
(NSHA-Mod)
|__|
DAYS
EO-22. How many weeks per month {do/did} you usually work as (a/an) {INSERT JOB TITLE FROM EO-17}?
(NSHA)
|__|
WEEKS
EO-23. About how much {do/did} you earn at this job?
(NSHA)
$|___|___|___|___|___|___|___| |__|__| UNIT1
EO-24. Is that before taxes and other deductions {are/were} taken out or after taxes and other deductions {are/were} taken out?
(NEW)
BEFORE TAXES 1
AFTER TAXES 2
EO-25. {Are/Were} the following benefits available to you at your job as (a/an) {INSERT JOB TITLE FROM EO-17}?
(IPS)
YES NO
a. Medical insurance? 1 2
b. Vacation leave? 1 2
c. Sick leave? 1 2
d. Any other benefits? (SPECIFY) 1 2
EO-26. We would like to know how you {feel/felt} about your job as (a/an) {INSERT JOB TITLE FROM EO-17}. I am going to read you a series of statements about that job. Please tell me if you strongly agree, somewhat agree, somewhat disagree, or strong disagree.
(IJSS)
STRONGLY SOMEWHAT SOMEWHAT STRONGLY
AGREE AGREE DISAGREE DISAGREE
a. I feel good about this job. 1 2 3 4
b. This job is worthwhile. 1 2 3 4
c. The working conditions are good. 1 2 3 4
d. I have a fairly good chance for promotion in this job. 1 2 3 4
e. This is a dead-end job. 1 2 3 4
f. My co-workers help me to like this job more. 1 2 3 4
g. I am happy with the amount this job pays. 1 2 3 4
h. The vacation time and other benefits on this job are okay. 1 2 3 4
i. I need more money than this job pays. 1 2 3 4
j. This job does not provide the medical coverage I need. 1 2 3 4
k. My supervisor is fair. 1 2 3 4
l. My supervisor is hard to please. 1 2 3 4
m. My supervisor praises me when I do my job well. 1 2 3 4
n. My supervisor is difficult to get along with. 1 2 3 4
o. My supervisor recognizes my efforts. 1 2 3 4
p. My co-workers are easy to get along with. 1 2 3 4
q. My co-workers are lazy. 1 2 3 4
r. My co-workers are unpleasant. 1 2 3 4
s. My co-workers don’t like me. 1 2 3 4
t. I want to quit this job. 1 2 3 4
u. I often feel tense on the job. 1 2 3 4
v. I don’t know what’s expected of me on this job. 1 2 3 4
w. I feel physically worn out at the end of the day. 1 2 3 4
EO-27. Are you still working at this job?
(IPS)
YES 1 (EO-29)
NO 2
EO-28. What was the main reason this job ended?
(IPS)
QUIT 1
FIRED 2
LAID OFF 3
TIME LIMITED JOB SUCH AS SEASONAL OR
TEMPORARY JOB 4
REASSIGNED TO ANOTHER JOB 5
OTHER (SPECIFY) 6
EO-29. What could have made this a better job experience for you? Would you say…
(IPS-Mod)
YES NO
a. A more flexible schedule? 1 2
b. Additional supports from mental health or
vocational staff? 1 2
c. Changes in your work space or work setting? 1 2
d. More time off? 1 2
e. Anything else? (SPECIFY) 1 2
EO-30. Would you like to have a {different} paying job now in the community?
(IPS)
YES 1
NO 2
B. CURRENT INCOME SOURCES
EO-31. Please tell me how much money you received from the following sources during the past month. Remember, everything you tell me is strictly confidential.
(EIR-Mod)
a. Any earned income or money from all paid employment,
including tips or commissions. Please tell me the take
home amount $|__|__|,|__|__|__|.|__|__|
b. Social Security Disability Income $|__|__|,|__|__|__|.|__|__|
c. Social Security Retirement or Survivors Benefits $|__|__|,|__|__|__|.|__|__|
d. Supplemental Security Income (SSI) $|__|__|,|__|__|__|.|__|__|
f. VA or other armed services disability benefits $|__|__|,|__|__|__|.|__|__|
g. Other state or county social welfare benefits such as
general assistance or public aid $|__|__|,|__|__|__|.|__|__|
h. Food stamps or assistance from the Temporary
Assistance for Needy Families (TANF) program $|__|__|,|__|__|__|.|__|__|
i. Vocational program such as Vocational Rehabilitation,
the Job Training Partnership Act, or Easter Seal $|__|__|,|__|__|__|.|__|__|
j. Unemployment compensation $|__|__|,|__|__|__|.|__|__|
k. Retirement, pension (including military), investing, or
savings income that you receive regular payments
from $|__|__|,|__|__|__|.|__|__|
l. Alimony and child support $|__|__|,|__|__|__|.|__|__|
m. Money from family members including gifts, loans,
or bill payments $|__|__|,|__|__|__|.|__|__|
EO-32. Sometimes people’s income is increased through other sources that are not reported to the government. The kinds of things I’m referring to include money received by doing odd jobs such as babysitting or yard work, helping in a business, or doing work “under the table.” Did you receive any income this way last month that you have not already told me about? Remember, what you tell me is strictly confidential. I cannot share this information with anyone, no matter what the reason.
(EIR-Mod)
YES 1
NO 2 (BOX EO-1)
EO-33. How much did you receive that you have not already told me about?
(EIR-Mod)
$|__|__|,|__|__|__|.|__|__|
BOX EO-1
IF RESPONDENT LIVES WITH OTHER ADULTS IN A NON-SUPERVISED SETTING
{(DM-12 = 2, 3, 4, 5, OR 6) OR [(DM-12 = 7 OR 8) AND DM-11 = 15 AND DM-16 = 2 AND DM-17 = 2]},
THEN ASK EO-34. OTHERWISE, GO TO NEXT SECTION.
EO-34. About how much was your total household income last month? Household income means the total amount of money that everyone in your household, except yourself, received during the past month.
(EIR-Mod)
$|__|__|,|__|__|__|.|__|__|
QUALITY OF LIFE (QL)
This is called the Delighted-Terrible Scale. The scale goes from terrible, which has the lowest ranking of 1, to delighted, which has the highest ranking of 7. There are also points 2 through 6 with descriptions below them.
[INTERVIEWER: Read points on the scale.]
We’ll use this scale to help you tell me how you feel about different things in your life. All you have to do is point to the label on the scale that best describes how you feel. For example, if I ask “how do you feel about chocolate ice cream” and you are someone who loves chocolate ice cream, you might point to ‘delighted.’ On the other hand, if you hate chocolate ice cream, you might point to ‘terrible.’ If you feel equally satisfied and dissatisfied with chocolate ice cream, then you would point to the middle of the scale.
Let’s begin. The first question is a very general one.
QL-1. How do you feel about your life in general?
(QOLI-M)
TERRIBLE 1
UNHAPPY 2
MOSTLY DISSATISFIED 3
MIXED 4
MOSTLY SATISFIED 5
PLEASED 6
DELIGHTED 7
Now I want to ask about the vocational services you are getting.
QL-2. How do you feel about the vocational services you are receiving at {INSERT NAME OF MHTS SITE}?
(QOLI-M)
TERRIBLE 1
UNHAPPY 2
MOSTLY DISSATISFIED 3
MIXED 4
MOSTLY SATISFIED 5
PLEASED 6
DELIGHTED 7
1 UNIT
EVERY HOUR 10
EVERY DAY 11
EVERY WEEK 12
EVERY TWO WEEKS 13
TWICE A MONTH 14
EVERY MONTH 15
EVERY QUARTER 16
EVERY YEAR 17
OTHER (SPECIFY) 88
| File Type | application/msword |
| File Title | HE1 |
| Author | Beckey Downes |
| Last Modified By | 177717 |
| File Modified | 2009-03-18 |
| File Created | 2009-03-18 |