Various Pretesting Activities (see attached list)

Generic Clearence for Questionnaire Pretesting Research

omb0915cpsasecenc1.wpd

Various Pretesting Activities (see attached list)

OMB: 0607-0725

Document [pdf]
Download: pdf | pdf

SURVEY OF HEALTH INSURANCE AND PROGRAM PARTICIPATION

Draft #5

March 19, 2009



SECTION A: ROSTER and DEMOGRAPHICS


1. What are the names of all persons living or staying [here/at your home]? (Let’s start with you.)

PROBE: Is there a middle name (or suffix, like junior or senior)?

PROBE: Anyone else?

ENTER FIRST, LAST, THEN MIDDLE NAME AND SUFFIX, IF APPLICABLE.

First Name Last Name Middle Name Suffix


2. READ IF NECESSARY

For Person 2: How is NAME related to you?

For Persons 3+: And how about NAME? (How is NAME related to you?)

He/She is your...

(1) Husband/Wife

(2) Unmarried partner

(3) Child (biological/step/adopted)

(4) Grandchild

(5) Mother/Father

(6) Brother/Sister

(7) Other relative (Uncle, Cousin, In-law, etc.)

(8) Foster child

(9) Housemate/roommate

(10) Roomer/boarder

(11) Other nonrelative


3. READ IF NECESSARY:

For Persons 2+: Is NAME male or female?

For Persons 3+: And how about NAME? (Is NAME male or female)?


4. For Person 1: What is your age and date of birth?

For Persons 2+: And how about NAME? (What is NAME’S age and date of birth?)

5. For Person 1: Are you of Hispanic, Latino, or Spanish origin?

For Persons 2+: How about NAME? (Is NAME of Hispanic, Latino, or Spanish origin?)


6. For Person 1: I am going to read you a list of five race categories. Please choose one or more races that (NAME/you) (considers yourself/consider NAME/considers himself/considers herself) to be: White; Black or African American; American Indian or Alaska Native; Asian; OR Native Hawaiian or Other Pacific Islander.

Do not probe unless response is Hispanic or a Hispanic origin.

Enter all that apply.

(1) White

(2) Black or African American

(3) American Indian or Alaska Native

(4) Asian

(5) Native Hawaiian or Other Pacific Islander

(6) Other - DO NOT READ


7. ASK ONLY FOR PEOPLE AGE 15+

For Person 1: What is the highest degree or level of school you have COMPLETED?

For Persons 2+: How about NAME? (What is the highest degree or level of school NAME has COMPLETED?)

(1) No schooling

(2) Nursery school to 6th grade

(3) 7th or 8th grade

(4) 9th - 11th grade

(5) 12th grade, NO DIPLOMA

(6) High school graduate

(7) Some college, but no degree

(8) Associate's degree (AA, AS)

(9) Bachelor's degree (BA, BS)

(10) Some graduate school, but no degree

(11) Master's degree (MA, MS, MEng, MEd, MSW, MBA)

(12) Professional or Doctorate degree (MD, DDS, DVM, LLB, JD, PhD, EdD)


8. ASK ONLY FOR PEOPLE AGE 15+

Person 1: Did you ever serve on active duty in the U.S. Armed Forces?

Persons 2+: How about NAME? (Did NAME ever serve on active duty in the Armed Forces?)


9. ASK ONLY FOR PEOPLE AGE 15+

READ IF NECESSARY:

Person 1: Are you now married, widowed, divorced, separated, or never married?

Persons 2+: How about NAME? (Is NAME now married, widowed, divorced, separated, or never married?)

(1) Married

(2) Widowed

(3) Divorced

(4) Separated

(5) Never married


10. Is [your/the combined] total annual income [of all members of this household] above or below [$XX – amount is meant to approximate a poverty threshold, and should be calculated based on household size and number of children under 18]?

(1) Above

(2) Below


Specifications for dollar amount:

If there is no one under 18 living in the household then fill these amounts, based on the number of household members:

1 person: 20000

2 people: 25000

3 people: 30000

4 people: 40000

5 people: 45000

6 people: 50000

7 people: 60000

8 people: 65000

9 people: 75000

10+: 75000 + (# people - 9)*5000


If there is at least one child age 0-17 living in the household then fill these amounts, based on the number of household members :

1 person: 30000

2 people: 40000

3 people: 45000

4 people: 55000

5 people: 65000

6 people: 75000

7 people: 85000

8 people: 95000

9 people: 115000

10+: 115000 + (# people - 9)*10000









SECTION B: DISABILITY


DISINTRO

We want to learn about people who have physical, mental, or emotional conditions that cause serious difficulty with their daily activities. =>


HUHDSEAR

Person 1: Are you deaf or do you have serious difficulty hearing?

Persons 2+: How about [NAME]? (Is [NAME] deaf or does NAME have serious difficulty hearing?)

Yes =>

No =>

DK/REF =>


HUHDSEYE

Person 1: Are you blind or do you have serious difficulty seeing even when wearing glasses?

Persons 2+: How about [NAME]? (Is [NAME] blind or does [NAME] have serious difficulty seeing even when wearing glasses?)

Yes =>

No =>

DK/REF =>


HUHDSREM

Person 1: Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

Persons 2+: How about [NAME]? (Because of a physical, mental, or emotional condition, does [NAME] have serious difficulty concentrating, remembering, or making decisions?)

Yes =>

No =>

DK/REF =>


HUHDSPHY

Person 1: Do you have serious difficulty walking or climbing stairs?

Persons 2+: How about [NAME]? (Does [NAME] have serious difficulty walking or climbing stairs?)

Yes =>

No =>

DK/REF =>


HUHDSDRS

Person 1: Do you have difficulty dressing or bathing?

Persons 2+: How about [NAME]? (Does [NAME] have difficulty dressing or bathing?)

Yes =>

No =>

DK/REF =>


HUHDSOUT

Person 1: Because of a physical, mental, or emotional condition do you have difficulty doing errands alone such as visiting a doctor's office or shopping?

Persons 2+: How about [NAME]? (Because of a physical, mental, or emotional condition does NAME have difficulty doing errands alone such as visiting a doctor's office or shopping?)

Yes =>

No =>

DK/REF =>


Note: repeat series for all household members age 15+





























SECTION C: LABOR FORCE


WORKYN

Did you work at a job or business at any time during 2008?

Yes => WKSWORK

No => WTEMP

DK/Ref => WTEMP


WTEMP

Did you do any temporary, part-time, or seasonal work even for a few days during 2008?

Yes => WKSWORK

No => RSNNOTW

DK/Ref => RSNNOTW


WKSWORK

During 2008 in how many weeks did you work even for a few hours? Include paid vacation and sick leave as work.

1-52 weeks

DK/REF

=> HRSWK


HRSWK

In the [fill number of weeks from WKSWORK] weeks that you worked, how may hours did you usually work per week?

[number of hours]

DK/REF

=> CK-RSNNOTW


CK-RSNNOTW

  • if weeks worked (from WKSWORK) is less than 40 => RSNNOTW

  • else => WORKEARN


RSNNOTW

What was the main reason you did not work in 2008?

Ill or disabled

Retired

Taking care of home or family

Going to school

Could not find work

Other

=> CK-WORKEARN


CK-WORKEARN

  • if WTEMP = No/DK/REF => Section D (page 8)

  • else => WORKEARN


WORKEARN

How much did you earn from this work before taxes and other deductions during 2008?

PROBE: Your best estimate is fine.

Amount: $

DK/REF

=> EARNPD


EARNPD

READ IF NECESSARY: Is this a weekly, every other week, twice a month, monthly, or yearly amount?

Weekly

Every other week (bi-weekly)

Twice a month

Monthly

Yearly

=> TIPS


TIPS

Does this amount include all tips, bonuses, overtime pay, or commissions you may have received from this work in 2008?

Yes => Section D, page 8

No => TIPSEARN

DK/Ref => Section D, page 8


TIPSEARN

How much did you earn in tips, bonuses, overtime pay, or commissions from that work in 2008?

Amount: $

DK/REF


NOTE: repeat WORKYN thru TIPSEARN for all household members age 15+

















SECTION D: PROGRAMS, PENSION AND INTEREST INCOME

A. PROGRAMS


1.Unemployment Compensation


UNEMP

At any time during 2008 did you receive any State or Federal unemployment compensation?

Yes => UNEMPAMT

No => SOCIAL SECURITY

DK/Ref => SOCIAL SECURITY


UNEMPAMT

How many payments did you receive from State or Federal unemployment compensation during 2008?

[number] =>

DK/Ref =>

=> SOCIAL SECURITY

NOTE: repeat UNEMP and UNEMPAMT for all household members age 15+


2. Social Security


SSYN

During 2008 did (you/anyone in this household) receive any Social Security payments from the U.S. Government?

Yes => SSWHO

No => SSI

DK/Ref => SSI


SSWHO

Read only if necessary

Who received Social Security payments either for themselves or as combined payments with other family members?

PROBE: Anyone else?

[line numbers] => SSEASY

DK/Ref => SSI


SSEASY

What is the easiest way for you to tell us (name's/your) Social Security payment; monthly, quarterly, or yearly?

Monthly => SSMTHS

Quarterly => SSMTHS

Yearly => SSAMT

DK/Ref => CK-SSR


SSMTHS

For how many (months/quarters) did (name/you) receive Social Security in 2008?

[number] =>

DK/Ref =>

=> CK-SSR


SSAMT

How much did (you/name) receive in Social Security payments in 2008?

[number] =>

DK/Ref =>

=> CK-SSR


CK-SSR

  • If NAME is 65+ => SSI

  • else => SSR


SSR

What were the reasons (name/you) (was/were) getting Social Security in 2008?

Enter all that apply, separate using the space bar or a comma.

Probe: Any Other Reason?

Retired

Disabled

Widowed

Spouse

Surviving child

Dependent child

On behalf of surviving, dependent, or disabled children

Other

=> SSI

NOTE: repeat SSEASY thru SSR for each name selected in SSWHO


3. SSI


SSIYN

During 2008 did (you/anyone in this household) receive any SSI payments, that is, Supplemental Security Income?

Note: SSI are assistance payments to low-income aged, blind and disabled persons,

and come from state or local welfare offices, the Federal government, or both.

Yes => SSIWHO

No => TANF

DK/Ref => TANF


SSIWHO

Read only if necessary

Who received SSI?

PROBE: Anyone else?

[line numbers] =>

DK/Ref =>

=> TANF


4. TANF


Q59A88

At any time during 2008, even for one month, did (you/anyone in this household) receive any CASH assistance from a state or county welfare program such as (State Program Name)?

PROBE: Include cash payments from: welfare or welfare-to-work programs, Temporary Assistance for Needy Families program (TANF), Aid to Families with Dependent Children (AFDC), General Assistance/Emergency Assistance program, Diversion Payments, Refugee Cash and Medical Assistance program, General Assistance from Bureau of Indian Affairs, or

Tribal Administered General Assistance.

PROBE: Do not include food stamps, SSI, energy assistance, WIC, School meals, or

transportation, childcare, rental, or education assistance.

Yes => TANFWHO

No => FOOD STAMPS

DK/Ref => FOOD STAMPS


TANFWHO

Read only if necessary

Who received this CASH assistance?

PROBE: Anyone Else?

[line numbers] =>

DK/Ref =>

=> TANFEASY


TANFEASY

What is the easiest way for you to tell us (name's/your) CASH assistance payments;

weekly, every other week, twice a month, monthly, or yearly?

Weekly => TANFPAY

Every other week (bi-weekly) => TANFPAY

Twice a month => TANFPAY

Monthly => TANFPAY

Yearly => TANFAMT

DK/Ref => FOOD STAMPS


TANFPAY

How many (weekly/every other week/ twice a month/ monthly) cash assistance payments did (name/you) receive in 2008?

[number] =>

DK/Ref =>

=> FOOD STAMPS


TANFAMT

During 2008, how much CASH assistance did (name/you) receive?

[number] =>

DK/Ref =>

=> FOOD STAMPS

NOTE: repeat TANFEASY thru TANFAMT for each name selected in TANFWHO


5. Food Stamps


FSYN

Did (you/ anyone in this household) get food stamps or a food stamp benefit card at

any time during 2008?

Yes => FSWHO

No => CK-WIC

DK/Ref => CK-WIC


FSWHO

Which of the people now living here were covered by food stamps during 2008?

PROBE: Anyone else?

[line numbers] =>

DK/Ref =>

=> FSAMT


FSAMT

How many months were food stamps received in 2008?

[number] =>

DK/Ref =>

=> CK-WIC

NOTE: repeat FSAMT for each name selected in FSWHO


CK-WIC

  • if there is at least one female age xx-xx in the household => WIC

  • else => RETIREMENT


6. WIC


WICYS

At any time during 2008, (was/were) (you/ anyone in this household) on WIC, the

Women, Infants, and Children Nutrition Program?

Yes => WICWHO

No => RETIREMENT

DK/Ref => RETIREMENT


WICWHO

Read only if necessary

Who received WIC for themselves or on behalf of a child?

PROBE: Anyone else?

[line numbers] =>

DK/Ref =>

=> RETIREMENT


B. RETIREMENT AND PENSIONS


PNSNYN

During 2008 did (you/ anyone in this household) receive any pension or retirement

income from a previous employer or union, or any other type of retirement income

(other than Social Security)?

Yes => PNSNWHO

No => INTEREST

DK/Ref => INTEREST


PNSNWHO

Read only if necessary

Who received pension or retirement income?

PROBE: Anyone else?

[line numbers] =>

DK/Ref =>

=> PNSNEASY


PNSNEASY

What is the easiest way for you to tell us (name's/your) pension or retirement income; weekly, every other week, twice a month, monthly, or yearly?

Weekly => PNSNPAY

Every other week (bi-weekly) => PNSNPAY

Twice a month => PNSNPAY

Monthly => PNSNPAY

Yearly => PNSNAMT

DK/Ref => INTEREST


PNSNPAY

How many (weekly/every other week/ twice a month/ monthly) payments did (name/you) receive in pension or retirement income in 2008?

[number] =>

DK/Ref =>

=> INTEREST


PNSNAMT

How much did (name/you) receive in pension or retirement income in 2008?

[dollar amount] =>

DK/Ref =>

NOTE: repeat PNSNEASY thru PNSNAMT for each name selected in PNSNWHO


C. INTEREST INCOME


INT1YN

At anytime during 2008 did (you/ anyone in this household): Have money in any kind of money market fund, interest earning checking account, or savings account?

Yes =>

No =>

DK/Ref =>

=> INT2YN


INT2YN

At anytime during 2008 did (you/ anyone in this household): Have any savings bonds?

Yes =>

No =>

DK/Ref =>

=> INT3YN


INT3YN

At anytime during 2008 did (you/ anyone in this household): Have any treasury notes, IRAs, certificates of deposit, or any other investments which pay interest?

Yes =>

No =>

DK/Ref =>

=> CK-INTWHO


CK-INTWHO

  • if INT1YN, INT2YN or INT3YN = yes => INTWHO

  • else => CK-EXP


INTWHO

Read only if necessary

Which members of this household ages 15 and over had (interest earning accounts or

money market funds/savings bonds/treasury notes, IRAs, CDs, or any other

investments which pay interest)?

Probe: Anyone Else?

[line numbers] => CK-INTAMT

DK/Ref => CK-EXP


CK-INTAMT

  • if respondent’s name was selected in INTWHO => INTAMT

  • else => CK-EXP


INTAMT

How much did (name/you) receive in interest from these sources during 2008, including even small amounts reinvested or credited to accounts?

Only include interest received from U.S. Savings Bonds cashed during 2008.

[dollar amount] =>

DK/Ref =>

NOTE: repeat INTAMT for each name selected in INTWHO


CK-EXP

  • if case ID = X => Health Insurance Control (SHI1)

  • else if case ID = Y => Health Insurance ACS

  • else if case ID = Z => Health Insurance Test (1)


SECTION E: HEALTH INSURANCE CONTROL


SHI1

These next questions are about health insurance coverage during the calendar year 2008. The questions apply to ALL persons of ALL ages.

=> SHI2


SHI2

At any time in 2008, (was/were) (you/ anyone in this household) covered by a health

insurance plan provided through (their/your) current or former employer or union?

PROBE: Military health insurance will be covered later in another question.

Yes => SHI3

No => SHI7

DK/REF => SHI7


SHI3

Who in this household were policyholders?

Enter all that apply, separate using the space bar or a comma.

PROBE: Anyone Else?

[line numbers] =>

DK/Ref =>

=> SHI4


SHI4

In addition to (name/you) who else in this household was covered by (name’s/your) plan?

Enter all that apply, separate using the space bar or a comma.

Probe: Anyone else?

[line numbers] =>

DK/Ref =>

=> SHI5


SHI5

Did (name’s/your) plan cover anyone living outside this household?

Yes => Who? [?] PROBE: Anyone else?

No =>

DK/REF =>

=> SHI6


SHI6

Did (name’s/your) former or current employer or union pay for all, part, or none of

the health insurance premium?

NOTE: Report here employer's contribution to employee's health insurance premiums,

not the employee's medical bills.

All

Part

None

=> SHI7

NOTE: Repeat SHI4 thru SHI6 for each policyholder selected in SHI3


SHI7

At any time during 2008, (was/were) (you/ anyone in this household) covered by a

health insurance plan that (you/they) PURCHASED DIRECTLY FROM AN

INSURANCE COMPANY, that is, not related to current or past employment?

Yes => SHI8

No => SHI11

DK/REF => SHI11


SHI8

Who in this household were policyholders?

Enter all that apply, separate using the space bar or a comma.

PROBE: Anyone Else?

[line numbers] =>

DK/Ref =>

=> SHI9


SHI9

In addition to (name/you) who else in this household was covered by (name’s/your) plan?

Enter all that apply, separate using the space bar or a comma.

Probe: Anyone else?

[line numbers] =>

DK/Ref =>

=> SHI10


SHI10

Did (name’s/your) plan cover anyone living outside this household?

Yes =>

No =>

DK/REF =>

=> SHI11

NOTE: Repeat SHI9 thru SHI10 for each policyholder selected in SHI8





SHI11

At any time in 2008, (was/were) (you/ anyone in this household) covered by the health insurance plan of someone who does not live in this household?

Yes => SHI12

No => SHI13

DK/REF => SHI13


SHI12

Who was that?

Enter all that apply, separate using the space bar or a comma.

PROBE: Anyone Else?

[line numbers] =>

DK/Ref =>

=> SHI13


SHI13

At any time in 2008, (was/were) (you/ anyone in this household) covered by Medicare?

Read if necessary: Medicare is the health insurance for persons 65 years old and over OR persons with disabilities.

Yes => SHI14

No => SHI15

DK/REF => SHI15


SHI14

Who was that?

Enter all that apply, separate using the space bar or a comma.

PROBE: Anyone Else?

[line numbers] =>

DK/Ref =>

=> SHI15


SHI15

At any time in 2008, (was/were) (you/ anyone in this household) covered by Medicaid / (fill state name)?

Read if necessary: Medicaid / (fill state name) is the Government Assistance Program that pays for health care.

Yes => SHI16

No => SHI21

DK/REF => CK-SHI21


SHI16

Who was that?

Enter all that apply, separate using the space bar or a comma.

PROBE: Anyone Else?

[line numbers] =>

DK/Ref =>

=> SHI17


SHI17

How many months during 2008, (was/were) (name/you) covered by Medicaid/(fill State name)?

Enter number of months (1-12)

=> CK-SHI21

NOTE: Repeat SHI7 for each person selected in SHI16


CK-SHI21

  • If anyone in the household is under 19 years old => SHI21

  • else => SHI18


SHI21

In (state), the (fill state CHIP program name) helps families get health insurance for

CHILDREN. (Just to be sure,) Were any of the children in this household covered

by that program?

Read if necessary: (fill state CHIP program name) is the name of your state's CHIP

program. It is the same as the Children's Health Insurance Program, which helps pay for

children's health care.

Yes => SHI22

No => SHI18

DK/REF => SHI18


SHI22

Who was that?

Enter all that apply, separate using the space bar or a comma.

PROBE: Anyone Else?

[line numbers] =>

DK/Ref =>

=> SHI18


SHI18

At any time in, 2008 (was/were) (you/ anyone in this household) covered by TRICARE, CHAMPUS, CHAMPVA, VA, military health care, or Indian Health Service?

NOTE: CHAMPVA is the Civilian Health And Medical Program of the Department of Veteran's Affairs.

Yes => SHI19

No => SHICI

DK/REF => SHICI


SHI19

Who was that?

Enter all that apply, separate using the space bar or a comma.

PROBE: Anyone Else?

[line numbers] =>

DK/Ref =>

=> SHI20


SHI20

What plan (was/were) (name/you) covered by?

Enter all that apply, separate using the space bar or a comma.

Probe: Any Other Plan?

TRICARE

CHAMPVA

VA

Indian Health Service

Other (specify)

=> SCHC1

NOTE: Repeat SHI20 for each person selected in SHI19


SHIC1

Other than the plans I have already talked about, during 2008, was anyone in this household covered by a health insurance plan [such as the (state-specific name plan) or any other type of plan/of any other type]?

Yes => SHIC2

No => CK-SHIC4

DK/REF => CK-SHIC4


SHIC2

Who has insurance?

Enter all that apply, separate using the space bar or a comma.

PROBE: Anyone Else?

[line numbers] =>

DK/Ref =>

=> SHIC3


SHIC3

What type of health insurance (was/were) (name/you) covered by in 2008?

Up to six entries allowed

Probe: Any Other Type Of Plan?

Medicare

Medicaid

TRICARE or CHAMPUS

CHAMPVA (CHAMPVA IS THE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERAN\'S AFFAIRS)

VA

Military Health Care

Children's Health Insurance Program (CHIP)

Indian Health Service

Other government health care

Employer/union provided (policyholder)

Employer/union provided (as dependent)

Privately purchased (policyholder)

Privately purchased (as dependent)

Plan of someone outside the household

Other (specify)

=> CK-SHIC4

NOTE: Repeat SHIC3 for each person selected in SHIC2


CK-SHIC4

  • if anyone in the household is uninsured => SHIC4

  • else => SHI24


SHIC4

I have recorded that (you/read list of names) (were/was) not covered by a health plan at any time during 2008. Is that correct?

Yes => SHI24

No => SHIC4A

DK/REF => SHIC4A


SHIC4A

Who should be marked as covered?

Enter all that apply, separate using the space bar or a comma.

PROBE: Anyone Else?

[line numbers] =>

DK/Ref =>

=> SHIC6


SHIC6

What type of health insurance (was/were) (name/you) covered by in 2008?

Up to six entries allowed

Probe: Any other type of plan?

Medicare

Medicaid

TRICARE or CHAMPUS

CHAMPVA (CHAMPVA IS THE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERAN\'S AFFAIRS)

VA

Military Health Care

Children's Health Insurance Program (CHIP)

Indian Health Service

Other government health care

Employer/union provided (policyholder)

Employer/union provided (as dependent)

Privately purchased (policyholder)

Privately purchased (as dependent)

Plan of someone outside the household

Other (specify)

=> SHI24

NOTE: Repeat SHIC6 for each person selected in SHIC4A


=> WRAP-UP (SHI24)








SECTION E: HEALTH INSURANCE ACS


HICEMPLOYER

I am now going to ask you some questions about your health insurance and health coverage. [Are you/Is NAME] currently covered by health insurance through a current or former employer or union of yours or another family member?

Yes

No

DK/Ref


HICDIRECT

[Are you/Is NAME] currently covered by health insurance purchased directly from an insurance company by you or another family member?

Yes

No

DK/Ref


HICMEDICARE

[Are you/Is NAME] currently covered by Medicare, for people age 65 or older or people with certain disabilities?

Yes

No

DK/Ref


HICMEDICAID

[Are you/Is NAME] currently covered by Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability?

Yes

No

DK/Ref


HICMILITARY

[Are you/Is NAME] currently covered by TRICARE or other military health care?

Yes

No

DK/Ref


HICVA

[Are you/Is NAME] currently covered through the Veterans’ Administration or have you ever used or enrolled [for? shouldn’t this be ‘in’?] Veterans’ Administration health care?

Yes

No

DK/Ref


HICINDIAN

[Are you/Is NAME] currently covered through the Indian Health Service?

Yes

No

DK/Ref


HICOTHER

[Are you/Is NAME] currently covered by any other health insurance or health coverage plan?

Yes

No

DK/Ref


NOTE: repeat HICEMPLOYER thru HICOTHER for all household members


=> WRAP-UP (SHI24)

SECTION E: HEALTH INSURANCE TEST



1. PERSON 1: These next questions are about health insurance coverage. [IF MULTI-PERSON HOUSEHOLD: First I’d like to ask you about yourself.]

PERSONS 2+: Next I’d like to ask you about NAME.

=> CK2


CK2:

  • if NAME is 65+ => 2

  • else go to 3


2. [Are you/Is NAME] covered by Medicare?

Yes => 16

No => 3

DK/REF => 3

Author Note: Create grid with household members (rows), months of coverage (columns) and plan types (within grid).


3. [Do you/Does NAME] have any type of health plan or health coverage?

Yes => 8

No => 4

DK/REF => 4


4. [Are you/Is NAME] covered by Medicaid, Medical Assistance, S-CHIP, or any other kind of government assistance program that helps pay for health care?

Yes => 16

No => CK5

DK/REF => CK5


CK5:

  • If Medicare already asked go to Q6

  • else go to Q5


5. [Are you/Is NAME] covered by Medicare?

Yes => 16

No => 6

DK/REF => 6


6. [Are you/Is NAME] covered by [fill state-specific program names for Medicaid, SCHIP and other government programs in respondent’s state].

Yes => 16

No => 7

DK/REF => 7


7. OK, I have recorded that [you are/NAME is] not covered by any kind of health plan or health coverage. Is that correct?

Yes (not covered) => 28

No (covered) => 8

DK/REF => 28


AUTHOR NOTE ON FILLS:

  • if the plan is currently held, fill Q8 thru Q15, Q23, Q24, QN2 and QN3 with “is” and fill N1 with “provides.”

  • else if the plan was held at some point in 2008 but is not currently held, or if Q26=yes, fill Q8 thru Q15, Q23, Q24, QN2 and QN3 with “was” and fill N1 with “provided.”


8. (ASK OR VERIFY)

In order to better understand the health care needs of Americans, we’d like to learn more about how [you/NAME] [get/got] that coverage. [Is/Was] it provided through a job, the government, or some other way?

PROBE: “Employer/union” coverage includes coverage from someone’s own employer or union as well as coverage from a spouse’s or parent’s employer or union.

PROBE: Include coverage through former employers and unions, and COBRA plans.

PROBE: If this coverage is provided through employment with the government or the military, consider that coverage through an employer.

PROBE: If this is a military plan (not related to employment) consider it government coverage.

Job (current or former) => 11

Government => 9

Other => 14

DK/REF => 13


9. (ASK OR VERIFY)

[Note the ‘or was’ is to avoid confusion for respondents with currently-held retiree plans].

[Is (or was)/Was] that coverage related to a JOB with the government?

PROBE: Include coverage through former employers and unions, and COBRA plans.

Yes => 11

No => 10

DK/REF => 10



10. (ASK OR VERIFY)

What type of government plan [is/was] it – Medicare, Medicaid, Medical Assistance or S-CHIP, military or Veterans’ Administration coverage, or something else?

READ IF NECESSARY: Some of the government programs in [STATE] are: [fill state-specific program names for Medicaid, SCHIP and other government programs in respondent’s state].

READ IF NECESSARY: Medicare is for people 65 years old and older or people with certain disabilities; Medicaid is for low-income families, disabled and elderly people who require nursing home care; and S-CHIP is for low-income families and children.

Medicare => CK16

Medicaid, Medical Assistance or S-CHIP => circle program name(s) above that were selected by respondent then => CK16

Military or Veterans’ Administration care => 12

Other => 13

DK/REF => 13


11. (ASK OR VERIFY, IF NECESSARY)

[Is/Was] that plan related to military service in any way?

Yes => Q12

No => Q15

DK/REF => Q15


12. (ASK OR VERIFY)

Which plan [are you/is NAME/were you/was NAME] covered by? [Is/Was] it TRICARE, CHAMPVA, Veterans’ Administration care, military health care, or something else?

TRICARE

TRICARE for Life

CHAMPVA

Veterans’ Administration

Military health care

Other (specify)

DK/REF

=> CK15


13. [Is/Was] it a government assistance-type plan?

Yes => CK16

No => N3

DK/REF => N3


14. (ASK OR VERIFY)

How [is/was] that coverage provided? [Is/Was] it through...

a parent or spouse => QN1

direct purchase from the insurance company => QN1

a union or business association => QN1

a school => CK16

or some other way? => QN3

DK/REF => QN3




N1. (ASK OR VERIFY)

Who [provides/provided] the coverage?

[display household roster] => CKN2

someone outside the household => CK16

DK/REF => N3


CKN2

  • if Q14=direct => CK16

  • else => N2


N2. And [is/was] that coverage provided through their job, direct purchase from the insurance company, or some other way?

job (current or former)[store name selected in N1 in Q15 as policyholder] => CK16

direct purchase from the insurance company )[store name selected in N1 in Q15 as policyholder] => CK16

some other way => N3

DK/REF => N3


N3. What type of plan is/was this?

=> CK16


CK15

  • if this is a job-based military plan => Q15

  • else => CK16


15. And who [is/was] the policyholder? [include “Someone outside household”]

Name of policyholder ____________________________________________________

PROBE: What is the name of the person who has the policy?

=> CK16

Author note:

  • if NAME is different from the policyholder named selected in Q15, flag the policyholder as having coverage [now/in 2008] for purposes of routing in CK29b

  • include an open-text field (25 characters) to capture a respondent-defined name or label for the plan (such as employer name or insurance carrier) in case there was extensive turnover (e.g.: multiple jobs and/or multiple plans from the same employer within the year) and/or complexity (e.g.: different members transitioned on and off the plans).


CK16:

  • if this is a currently-held plan => Q16

  • else if this is a plan not currently held but held at some point in 2008, or if Q26=yes

=> Q22




16. Did that coverage start before or after January 1, 2008?

PROBE: Your best estimate is fine.

[If this is a job-based plan fill: PROBE: When we say “that coverage” we mean any coverage through [policyholder’s] employer. So if [policyholder] switched plans offered by the employer, or even switched employers, we still consider this all the same coverage.]

[If this is a directly-purchased plan fill: PROBE: When we say “that coverage” we mean any coverage directly purchased by you or another policyholder. So if you/NAME switched plans but they were all directly-purchased, we still consider this all the same coverage.]

Before January 1, 2008 => CK20

On or after January 1, 2008 => Q18

DK/REF => Q17


17. Did [you/NAME] have the coverage at any time during 2008?

Yes => Q22

No => CK23

DK/REF => CK23


18. In what month did that coverage start?

Month [1-12] => pop-up: (READ IF NECESSARY) And what year was that?

2008 => CK20

2009 => CK23

DK/REF => Q19


19. Do you know if it was before or after January 1, 2009?

[If this is a job-based plan fill: PROBE: When we say “that coverage” we mean any coverage through [policyholder’s] employer. So if [policyholder] switched plans offered by the employer, or even switched employers, we still consider this all the same coverage.]

[If this is a directly-purchased plan fill: PROBE: When we say “that coverage” we mean any coverage directly purchased by you or another policyholder. So if you/NAME switched plans but they were all directly-purchased, we still consider this all the same coverage.]

Before January 1, 2009 => Q22

On or after January 1, 2009 => CK23

DK/REF => Q22


CK20:

  • If this is a Medicare plan => Q23

  • else => Q20


20. And has it been continuous since then?

[If this is a job-based plan fill: PROBE: When we say “that coverage” we mean any coverage through [policyholder’s] employer. So if [policyholder] switched plans offered by the employer, or even switched employers, we still consider this all the same coverage.]

[If this is a directly-purchased plan fill: PROBE: When we say “that coverage” we mean any coverage directly purchased by you or another policyholder. So if you/NAME switched plans but they were all directly-purchased, we still consider this all the same coverage.]

Yes => CK23

No => 21

DK/REF => 21




21. In what month did this most recent spell of coverage start?

Month [1-12] =>

Month [1-4] in 2009

DK/REF

=> CK23


22. What months in 2008 were you covered by that plan?

Month [1-12] => CK23

None => Q27

DK/REF => CK23


CK23:

  • if single-person household => CK26

  • else if 2-person household and NAME is a dependent (Q15, the policyholder, is the name of the other household member)

  • and if the plan began sometime in 2009 => Q27

  • if the plan began prior to January 1, 2009 => CK25

  • else => Q23


23. [If 2-person household fill] And [is/was] NAME also covered by [policyholder’s/ Medicaid/Medicare/Veterans’ Administration care/that] plan?

[Else fill]: [Is/Was] anyone else within this household also covered by [policyholder’s/ Medicaid/Medicare/Veterans’ Administration care/that] plan?

Yes => CK24

No => CK26

DK/REF => CK26

Author note: ensure fill correctly displays plan name


CK24

  • If 2-person household

  • and the plan began sometime in 2009 flag all names selected in Q23 as having coverage now for purposes of routing in CK29b and then => Q27

  • and the plan began prior to January 1, 2009 => CK25

  • else => Q24


24. Who? (Who else [is/was] covered by that plan)? => CK25


CK25

  • If the initial enrollee was covered the entire 12 months of 2008 => Q25

  • else if the plan began sometime in 2009 => flag all names selected in Q24 as having coverage now for purposes of routing in CK29b and then => Q27

  • else => QN4


25. And [was NAME/were NAMES] also covered all 12 months of 2008?

Yes => CK26

No => QN4

DK/REF => QN4



N4. [For first person selected in Q24 and for the policyholder in 2-person household where the first person reporting was the dependent (see CK23, 2nd bullet)]: What months during 2008 [was NAME] covered?

[For all others selected in Q24]: How about NAME? (What months during 2008 was NAME covered?) [repeat for each additional name selected in Q24]

Same months as initial enrollee [display months]

[Months 1-12]

DK/REF

=> CK26


CK26:

  • If this is a job-based plan and NAME was covered less than 12 months of 2008 by this plan => Q26

  • else => Q27


26. And before that plan, [were you/was NAME] covered by any other job-sponsored health plan at any time in 2008?

Yes => Q15

No, DK, REF => Q27


27. Other than [plan(s)], [are you/is NAME] also covered by any other type of health plan or health coverage? Do not include plans that cover only one type of care, such as dental or vision plans.

Yes => Q8

No, DK, REF => Q28


28. How about during 2008? (Other than [plan(s)] [were you/was NAME] covered by any (other) type of health plan or health coverage at any time during 2008?

PROBE: Do not include plans that cover only one type of care, such as dental or vision plans.

Yes => Q8

No, DK, REF => CK29a


CK29a:

  • If there are more household members on the roster who have not been asked about yet => CK29b

  • else => => WRAP-UP (SHI24)

CK29b:

  • If the next person on the roster was reported as having coverage (now or during 2008) during the course of any previous person’s interview => Q29 for that person

  • else => Q1 for that person


29. Now I’d like to ask you about [PERSON 2+]. Other than the [plan(s)] you reported earlier, does [PERSON 2+] have any other type of health plan or health coverage?

PROBE: Do not include plans that cover only one type of care, such as dental or vision plans.

Yes => Q8

No => Q30

DK/REF => Q30



30. How about during 2008? Other than the [plan(s)] you reported earlier, did [PERSON 2+] have any other type of health plan or health coverage at any time during 2008?

PROBE: Do not include plans that cover only one type of care, such as dental or vision plans.

Yes => Q8

No => go back to CK29a

DK/REF => go back to CK29a



=> WRAP-UP (SHI24)






SECTION F: WRAP-UP


SHI24

An important factor in evaluating a person's or family's health insurance situation is their current health status and/or the current health status of other family members.

=> SHI25


SHI25

Would you say (name's/your) health in general is excellent, very good, good, fair, or poor?

Excellent

Very good

Good

Fair

Poor

NOTE: Repeat SHI25 for each household member then => CK-END



CK-END

  • if this case ID was linked to an address and an advance letter was sent => VZIP

  • else => LINK


LINK

The Census Bureau would like to conduct additional research without taking up your time with more questions. We would like your permission to obtain the information that you have given to other government agencies on topics such as Social Security and Medicare benefits. Do you have any objections?

Yes =>

No =>

DK/REF =>

=> ZIP

LINK HELP SCREEN

WHY DOES THE CENSUS BUREAU WANT CONSENT TO GET ADDITIONAL INFORMATION?

Providing your consent allows the Census Bureau to get some additional data from other government agencies. This helps make sure the data are complete. The same confidentiality laws that protect your survey answers also protect any additional information we collect (Title 13, US Code, Section 9). Providing your consent is voluntary.


ZIP

What is your zip code?

[5 digit boxes]

DK/REF

H_ZIP (Help screen for ZIP)

WHY DO YOU WANT MY ZIP CODE?

Because this survey is a random sample of telephone numbers, we need zip codes and addresses to establish your geographic location. Your location within the U.S. is an important part of analyzing this survey. It helps us understand differences across urban, rural and suburban areas. You will NOT be placed on any type of mailing list.

=> ADDRESS


ADDRESS

And your address?

STREET NUMBER AND NAME

ADDITIONAL NUMBER/NAME

CITY

STATE

H_ADDRESS (Help screen for ADDRESS)

WHY DO YOU WANT MY ADDRESS?

Because this survey is a random sample of telephone numbers, we need zip codes and addresses to establish your geographic location. Your location within the U.S. is an important part of analyzing this survey. It helps us understand differences across urban, rural and suburban areas. You will NOT be placed on any type of mailing list.

=> END


VZIP

I just need to verify this. Is your zip code [fill zip code]?

Yes

No => What is your zip code? [5 digit boxes]

DK/REF

H_ZIP (Help screen for ZIP)

WHY DO YOU WANT MY ZIP CODE?

Because this survey is a random sample of telephone numbers, we need zip codes and addresses to establish your geographic location. Your location within the U.S. is an important part of analyzing this survey. It helps us understand differences across urban, rural and suburban areas. You will NOT be placed on any type of mailing list.

=> VADDRESS


VADDRESS

And is your address [fill address]?

Yes

No => What is your address? [street number, name, city, state]

DK/REF

H_ADDRESS (Help screen for ADDRESS)

WHY DO YOU WANT MY ADDRESS?

Because this survey is a random sample of telephone numbers, we need zip codes and addresses to establish your geographic location. Your location within the U.S. is an important part of analyzing this survey. It helps us understand differences across urban, rural and suburban areas. You will NOT be placed on any type of mailing list.


THANK YOU!!

File Typeapplication/octet-stream
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy