(CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
Survey Instrument
INTENDED AUDIENCE: Priority 1 through 8 veterans who have applied or are currently enrolled for VA health care services.
TIME BEGUN____________________________
INTRO. Hello, my name is <interviewer first and last name.> I’m calling on behalf of VA, the Department of Veteran Affairs. May I speak with <INSERT NAME>?
01 (SKIP TO INTRO) RESPONDENT AVAILABLE
02 (SKIP TO CALLBACK) RESPONDENT NOT AVAILABLE
03 (SKIP TO PROXY) RESPONDENT UNABLE TO DO INTERVIEW
PHYSICAL/MENTAL HEALTH REASON
04 DO NOT KNOW RESPONDENT/DO NOT RECOGNIZE NAME – MAKE A WRONG NUMBER
05 (SKIP TO BADNUM) RESPONDENT NOT AT NUMBER
06 TERMINATION SCREEN
BADNUM Do you have a telephone number where I might be able to reach <INSERT NAME>?
01 YES – MAKE NEW NUMBER DISPOSITION, COLLECT TELEPHONE NUMBER
02 NO – MAKE NO NUMBER AVAILABLE
03 NO – WILL NOT RELEASE TELEPHONE NUMBER
INTRODUCTION2A.: We are conducting a survey on behalf of VA about veterans’ use of health care services and needs. You may have recently received a letter from the Under Secretary for Health for the Department of Veteran Affairs, inviting you to participate in this survey. Your name was randomly selected from a list of veterans who enrolled to use VA health care services. This survey will take 10-20 minutes.
01 YES, CONTINUE //GO TO INTRO2AA//
02 REQUESTED CALLBACK
03 RESPONDENT HESITATES/NEED MORE INFORMATION //CONTINUE TO INTRO2B//
04 RESPONDENT DID NOT RECEIVE LETTER //RESPONDENT HESITATES/NEEDS MORE INFORMATION/CONTINUE TO INTRO2B//
05 RESPONDENT DID NOT RECEIVE LETTER //REFUSED
99 REFUSED
INTRO2B. IF NECESSARY MORE INFORMATION: This survey is about how many veterans use VA services and what types of services they do or do not use.
IF NECESSARY CONFIDENTIALITY: Your name and answers will be linked. However, VA will protect your identity and answers to the extent allowed under the law. Your answers will in no way affect your benefits. No information that you provide will be released to the general public in a way that can be traced back to you.
ONLY IF LEGITIMACY IS QUESTIONED READ: This survey has been reviewed and approved by the VHA Office of the Assistant Deputy Under Secretary for Health for Policy and Planning and the Office of Management and Budget. If you have any questions regarding the legitimacy of this survey, you may call the Department of Veterans Affairs in Washington, D.C. at 1-800-XXX-XXXX.
01 YES, CONTINUE
02 REQUESTED CALLBACK
03 REFUSED
INTRO2AA. Everything we talk about will be confidential, although this call may be monitored for quality assurance. Your participation is voluntary – you can choose not to answer any question or end the survey at anytime without an explanation. Your benefits will not change as a result of your answering any questions. If you choose not to participate, or answer a question, your benefits will also not be affected. However, your participation is important for this survey’s success – we need to talk to veterans like you. Would now be a good time?
01 YES, CONTINUE //GO TO SECTION A//
02 REQUESTED CALLBACK
03 REFUSED
PROXY We are conducting a survey about veterans’ use of health care services and needs. <INSERT NAME> may have recently received a letter from Dr. Kussman, the Under Secretary for Health for the Department of Veteran Affairs, inviting <INSERT NAME> to participate in this survey. <INSERT NAME> was randomly selected from a list of veterans who enrolled to use VA health care services. This is an important survey, would you be able to answer questions about <INSERT NAME>’s health care, insurance and health status?
IF NECESSARY MORE INFORMATION: This survey is about how many veterans use VA services and what types of services they do or do not use.
IF NECESSARY CONFIDENTIALITY: Your name and answers will be linked. However, VA will protect your identity and answers to the extent allowed under the law. Your answers will in no way affect your benefits. No information that you provide will be released to the general public in a way that can be traced back to you.
ONLY IF LEGITIMACY IS QUESTIONED READ: This survey has been reviewed and approved by the VHA Office of the Assistant Deputy Under Secretary for Health for Policy and Planning and the Office of Management and Budget. If you have any questions regarding the legitimacy of this survey, you may call the Department of Veterans Affairs in Washington, D.C. at 1-800-XXX-XXXX.
01 YES, CONTINUE //GO TO PROXY2//
02 NO
03 RESPONDENT WILL NOT CONTINUE WITHOUT LETTER //REFUSED///
98 DON’T KNOW
99 REFUSED
01 YES – CREATE VARIABLE “PROXY= 01 IF PROXY INTERVIEW AND 00 IF NOT PROXY”
02 NO – TERMINATE CREATE DISPOSITIN NO ELIGIBLE PROXY, RESPONDENT UNABLE
98 DON’T KNOW – TERMINATE CREATE DISPOSITION NO ELIGIBLE PROXY, RESPONDENT UNABLE
99 REFUSED – TERMINATE PROXY REFUSAL
PROXY_2. This survey will take 10-20 minutes. Everything we talk about will be confidential, although this call may be monitored for quality assurance. Your participation on behalf of <INSERT NAME> is voluntary – you can choose not to answer any question or end the survey at anytime without an explanation. <INSERT NAME> benefits will not change as a result of your answering any questions. If you choose not to participate, or answer a question, <INSERT NAME> benefits will also not be affected. However, your participation on behalf of <INSERT NAME> is important for this survey’s success – we need to talk to veterans like <INSERT NAME>. Would now be a good time?
IF NECESSARY MORE INFORMATION: This survey is about how many veterans use VA services and what types of services they do or do not use.
IF NECESSARY CONFIDENTIALITY: Your name and answers will be linked. However, VA will protect your identity and answers to the extent allowed under the law. Your answers will in no way affect your benefits. No information that you provide will be released to the general public in a way that can be traced back to you.
ONLY IF LEGITIMACY IS QUESTIONED READ: This survey has been reviewed and approved by the VHA Office of the Assistant Deputy Under Secretary for Health for Policy and Planning and the Office of Management and Budget. If you have any questions regarding the legitimacy of this survey, you may call the Department of Veterans Affairs in Washington, D.C. at 1-800-XXX-XXXX.
01 (SKIP TO RESIDE) YES
02 (SKIP TO CALLBACK) NO
RESIDE Does <INSERT NAME> still live at this telephone number or somewhere else?
01 (SKIP TO RELATION) STILL AT LOCATION
02 DIFFERENT LOCATION
98 DON’T KNOW
99 REFUSED
RESIDE_1 In what state does <INSERT NAME> live?
/PROVIDE LIST OF STATE NAMES/
98 DON’T KNOW
99 REFUSED
RELATION Before we begin, could you tell me how you would describe your relationship to <INSERT NAME>? I am going to read you a list. Are you <INSERT NAME>’s…
01 Spouse
02 Significant other
03 Parent
04 Sibling
05 Child
06 Some other relative
07 Friend
08 Caregiver
09 Guardian or Attorney
10 Social Worker or Case Worker
97 Some other relation
98 DON’T KNOW
99 REFUSED
CALLBACK When would be a convenient time to call back and speak with <INSERT NAME>?
/IF PROXY=01/ When would be a convenient time to call back <INSERT NAME>?
01 MAKE APPOINTMENT 104
02 CALL BACK ANYTIME 105
A: Health Insurance Module
PREA Many of the following questions may be simply answered as either yes or no. However, if you are unsure about it, just let me know and I will note that.
/IF PROXY=01 ALSO ASK/ Please remember when answering that we are talking about <INSERT NAME>
I would like to first ask about healthcare benefits …….
PREA: Are you enrolled in VA health care?
/IF PROXY=01/ Is <INSERT NAME> enrolled in VA Health care?
YES
NO
I DON’T REMEMBER ENROLLING
DON’T KNOW
REFUSED
A1. Are you covered by Medicare?
/IF PROXY=01ASK/ Is <INSERT NAME> covered by Medicare?
01 YES
02 //SKIP TO A7// NO
98 //SKIP TO A7// DON’T KNOW
99 //SKIP TO A7// REFUSED
A2. Did you choose to receive your Medicare coverage through a Medicare Advantage Plan and not through the Original Medicare Plan? Medicare Advantage Plans include Medicare HMOs (Health Maintenance Organizations), Medicare PPOs (Preferred Provider Organizations), Medicare Special Needs Plans, and Medicare Private Fee-for-Service Plans.
//IF PROXY=01ASK// Did <INSERT NAME> choose to receive Medicare coverage through a Medicare Advantage Plan and not through the Original Medicare Plan? Medicare Advantage Plans include Medicare HMOs (Health Maintenance Organizations), Medicare PPOs (Preferred Provider Organizations), Medicare Special Needs Plans, and Medicare Private Fee-for-Service Plans.
//SKIP TO A6// YES
NO
DON’T KNOW
REFUSED
A3. Does your Medicare coverage pay for care if you are hospitalized?
//IF PROXY=01ASK// Does <INSERT NAME>’s Medicare coverage pay for care if hospitalized?
[INTERVIEWER NOTE: This type of Medicare is also sometimes called "Part A"; if they have it, there is generally no premium because they or a spouse paid for it through payroll taxes while they were working.]
YES
NO
DON’T KNOW
99 REFUSED
A4. Does your Medicare coverage pay for doctor's office visits?
//IF PROXY=01ASK// Does <INSERT NAME>’s Medicare coverage pay for doctor’s office visits?
[INTERVIEWER NOTE: This type of Medicare is also sometimes called "Part B"; if they have it, they generally pay a monthly fee or premium which may be directly deducted from their Social Security check.]
YES
NO
DON’T KNOW
99 REFUSED
A5. Do you purchase any private health care coverage to supplement Medicare; that is to pay for services Medicare does not pay for?
//IF PROXY=01ASK// Does <INSERT NAME> purchase any private health care coverage to supplement Medicare; that is to pay for services Medicare does not pay for?
[IINTERVIEWER NOTE DO NOT READ: "Yes" - Types of private insurance a person can purchase to supplement Medicare include Medigap or Medicare Supplement. Does not include Medicare Advantage or Medicare + Choice.]
[INTERVIEWER NOTE DO NOT READ: "No" - A type of insurance that does not count is the Department of Defense's TRICARE for Life plan for Medicare eligible military retirees.]
01 YES
02 NO
DON’T KNOW
99 REFUSED
A6. Do you have Medicare prescription drug coverage, "Part D"?
//IF PROXY=01ASK// Does <INSERT NAME> have Medicare prescription drug coverage, "Part D?”
YES
NO
DON’T KNOW
99 REFUSED
A7. Are you currently covered by Medicaid for any of your health care?
//IF PROXY=01ASK// Is <INSERT NAME> currently covered by Medicaid for any of his or her health care?
[IF NECESSARY: Medicaid is a program that pays for Medical Assistance for certain individuals with low incomes and resources and is provided by your State governments' social services department.]
[Interviewer Note: "Medical Assistance" = "Medicaid" in some States.]
//RECALL LIST FROM 2005 FOR STATE MEDICAID PLAN NAME//
YES
NO
DON’T KNOW
REFUSED
A8. Are you currently covered by the Department of Defense's TRICARE or TRICARE for Life health care programs?
//IF PROXY=01ASK// Is <INSERT NAME> covered by the Department of Defense's TRICARE or TRICARE for Life health care programs?
YES
NO
DON’T KNOW
REFUSED
A9. Are you currently covered by any other individual or group health plan that either you, or an employer, or someone else, such as a family member obtains for you?
//IF PROXY=01ASK// Is <INSERT NAME> currently covered by any other individual or group health plan that either <INSERT NAME>, or an employer, or someone else, such as a family member obtains for <INSERT NAME>?
[INTERVIEWER NOTE DO NOT READ: "Yes" - Do count any private retiree health insurance plan.]
[INTERVIEWER NOTE DO NOT READ: "No" - Do not count private Medigap, Medicare Supplement, Medicare Advantage, or Medicare + Choice plans.]
YES
//SKIP TO A13// NO
//SKIP TO A13// DON’T KNOW
//SKIP TO A13// REFUSED
A10. Who provides this coverage? If more than one source applies, please indicate the primary source.
[INTERVIEWER: READ LIST CAN ONLY SELECT ONE]
Current employer, including COBRA coverage
Former employer
Individually purchased coverage
Federal, State, County, or local community health services program
Family member, such as a spouse, parent, etc.
Or from somewhere else? (SPECIFY)
DON’T KNOW
REFUSED
A10_O //IF A10=97 ASK// Who provides this coverage?
//TEXT RESPONSE//
DON’T KNOW
REFUSED
A10_OV [INTERVIEWER: CAN YOUR SPECIFY RESPONSE BE CODED USING THE LIST BELOW
IF YES, SELECT NOW.
01 Current employer, including COBRA coverage
02 Former employer
03 Individually purchased coverage
04 Federal, State, County, or local community health services program
05 Family member, such as a spouse, parent, etc.
96 NO, UNIQUE RESPONSE
A11. Does this coverage include prescription drug coverage?
YES
NO
DON’T KNOW
REFUSED
A12. Is this coverage provided through an HMO or other managed care organization?
[INTERVIEWER NOTE: An HMO or Health Maintenance Organization or other managed care coverage requires you to use certain doctors, hospitals, and other providers. If you use health care services or providers who are not in the plan, you pay more, or all of the cost for that health care.]
YES
NO
DON’T KNOW
REFUSED
A13. Do you currently have prescription drug coverage from VA?
//IF PROXY=01ASK// Does <INSERT NAME> currently have prescription drug coverage from VA?
YES
NO
DON’T KNOW
REFUSED
A14A. How many different over the counter medications did you use in the last 30 days?
//IF PROXY=01ASK// How many different over the counter medications did <INSERT NAME> use in the last 30 days?
[IF NECESSARY: Your best guess is fine.]
________ [0 – 50]
DON’T KNOW
REFUSED
///IF A14A IN 0, 98, 99 SKIP TO A15A, ALL ELSE CONTINUE///
A14B. Of these over the counter medications, how many did you obtain from VA?
//IF PROXY=01ASK// Of these over the counter medications, how many did <INSERT NAME> obtain from VA?
[INTERVIEWER NOTE: THESE MEDICATIONS COME FROM SOME VA FACILITY OR THROUGH THE MAIL FROM VA. DOES NOT REFER TO MEDICATIONS WHERE A RESPONDENT IS REIMBURSED FOR THE OUT OF POCKET COSTS.]
[IF NECESSARY: Your best guess is fine.]
________ [0 – 50]
DON’T KNOW
REFUSED
A15A. How many different prescription medications did you use in the last 30 days?
//IF PROXY=01ASK// How many different prescription medications did <INSERT NAME> use in the last 30 days?
[IF NECESSARY: Your best guess is fine.]
________ [0 – 50]
DON’T KNOW
REFUSED
///IF A15A IN 0, 98, 99 SKIP TO A16, ALL ELSE CONTINUE///
A15B. Of these prescription medications, how many did you obtain from VA?
//IF PROXY=01ASK// Of these prescription medications, how many did <INSERT NAME> obtain from VA?
[INTERVIEWER NOTE: THESE MEDICATIONS COME FROM SOME VA FACILITY OR THROUGH THE MAIL FROM VA. DOES NOT REFER TO MEDICATIONS WHERE A RESPONDENT IS REIMBURSED FOR THE OUT OF POCKET COSTS.]
[IF NECESSARY: Your best guess is fine.]
________ [0 – 50]
DON’T KNOW
REFUSED
PA16. On average, how much do you spend out-of-pocket for all your over the counter and prescription medications on a monthly basis, not including any health insurance premiums you may pay?
//IF PROXY=01ASK// On average, how much does <INSERT NAME> spend out-of-pocket for all <INSERT NAME>’s over the counter and prescription medications on a monthly basis, not including any health insurance premiums <INSERT NAME> may pay?
01 GAVE RESPONSE
98 DON’T KNOW
99 REFUSED
A16A. On average, how much do you spend out-of-pocket for all your over the counter and prescription medications on a monthly basis, not including any health insurance premiums you may pay?
//IF PROXY=01ASK// On average, how much does <INSERT NAME> spend out-of-pocket for all <INSERT NAME>’s over the counter and prescription medications on a monthly basis, not including any health insurance premiums <INSERT NAME> may pay?
[IF NECESSARY: Your best guess is fine.]
________ ENTER NUMBER [0 – 9999]
Section B: Reliance on VA
PREB1
Next , I will be asking you about use of medical health services in 20xx from both Non-VA sources, as well as from VA. First, my questions are about Non-VA provided Health Care Services.
/IF PROXY=01/ Next, I will be asking you about <INSERT NAME>’s use of medical or mental health services in from both Non-VA sources, as well as from VA. First, my questions are about Non-VA provided Health Care Services.
B1. In 20XX, did you use any medical or mental health care services that were not provided by or paid for by VA? Please include ANY service at all, such as a flu shot, a single prescription, a test of some sort, etc.
/IF PROXY=01/ In 20XX, did <INSERT NAME> use any medical or mental health care services that were not provided by or paid for by VA? Please include ANY service at all, such as a flu shot, a single prescription, a test of some sort, etc.
[INTERVIEWER NOTE: “NO NEED FOR SERVICES AT ALL” ONLY MARK IF SPONTANEOUSLY VOLUNTEERED BY RESPONDENT.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
00 (SKIP TO B25) NO NEED FOR SERVICES AT ALL
01 (SKIP TO B2) YES
02 NO
98 DON’T KNOW
99 REFUSED
//IF B1=2, 98, 99 AND [A1=01 OR A5=01 OR A7=01 OR A8=01 OR A9=01] THEN ASK, ELSE SKIP TO B14//
B1A. VALIDATION: Earlier I thought you said that you do have some type of Non-VA medical coverage. Just to make sure I have this right, I want to confirm that in 20XX, you never received any type of medical service, including flu shot, prescription, physical check-up or test or mental health services or assistance that was not provided or paid for by VA.
/IF PROXY =01/ Earlier I thought you said that <INSERT NAME> does have some type of Non-VA medical coverage. Just to make sure I have this right, I want to confirm that in 20XX, <INSERT NAME> never received any type of medical service, including flu shot, prescription, physical check-up or test or mental health services or assistance that was not provided or paid for by VA.
[INTERVIEWER NOTE: “NO NEED FOR SERVICES AT ALL” ONLY MARK IF SPONTANEOUSLY VOLUNTEERED BY RESPONDENT.]
00 (SKIP TO B25) NO NEED FOR SERVICES AT ALL
01 (SKIP TO B2) DID USE NON-VA SERVICE//LH previously were yes/no, but very difficult to train interviewers to do correctly so clarified
02 (SKIP TO B14) CONFIRMED THAT NO NON-VA CARE RECEIVED
98 (SKIP TO B14) DON’T KNOW/CAN’T REMEMBER
99 (SKIP TO B14) REFUSED
B2. In 20XX, did you stay overnight at any Non-VA Medical Hospital or a Non-VA Mental Health Facility?
/IF PROXY=01/ In 20XX, did <INSERT NAME> stay overnight at any Non-VA Medical Hospital or a Non-VA Mental Health Facility?
[INTERVIEWER NOTE: “Stay” is a single trip into and out, or admission into and discharge out of the hospital, NOT THE NUMDER OF DAYS THE PATIENT STAYED IN THE HOSPITAL.]
01 YES
02 (SKIP TO B11) NO
98 (SKIP TO B11) DON’T KNOW/DON’T REMEMDER
99 (SKIP TO B11) REFUSED
B3. Were any of these stays paid for or provided by VA?
/IF PROXY=01/ Were any of these stays paid for or provided by VA?
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PORTION.]
[INTERVIEWER NOTE: “Stay” is a single trip into and out or admission into and discharge out of the hospital.]
01 YES
02 (SKIP TO B5) NO
98 (SKIP TO B5) DON’T KNOW
99 (SKIP TO B5) REFUSED
B4. Were any of these stays not paid for or provided by VA?
/IF PROXY=01/ Were any of these stays not paid for or provided by VA?
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PORTION.]
[INTERVIEWER NOTE: “Stay” is a single trip into and OUT or admission into and discharge out of the hospital.]
01 YES
02 (SKIP TO B11) NO, ALL VA PROVIDED
98 (SKIP TO B11) DON’T KNOW/ DON’T REMEMDER
99 (SKIP TO B11) REFUSED
PREB5 //IF B4=01, ELSE GOTO B11// For the next group of questions, I would like you to only think about all of the stays you have just mentioned that were not paid for by VA.
/IF PROXY=01 AND IF B4=01, ELSE GOTO B11// For the next group of questions, I would like you to only think about all of <INSERT NAME>’s stays you have just mentioned that were not paid for by VA.
B5. In 20XX, how many overnight stays, if any, did you have at any Non-VA Medical Hospital. Please do not count stays for mental health or substance abuse treatment?
/IF PROXY=01/ In 20XX, how many overnight stays, if any, did <INSERT NAME> have at any Non-VA Medical Hospital. Please do not count stays for mental health or substance abuse treatment?
[INTERVIEWER NOTE: “Stay” is a single trip into and OUT or admission into and discharge out of the hospital.]
[IF NECESSARY: Your best guess is fine.]
enter number [range= 0 – 366]
998 don’t know
999 refused
/IF B5=0, 98, OR 99 GOTO B8, ELSE CONTINUE/
B6. /IF B5=1, ASK/ How many nights was that stay?
/IF B5>1 ASK/ How many nights was your first stay?
/if PROXY=01 AND B5=1, ASK/ How many nights was that stay?
/IF PROXY=01 AND B5>1 ASK/ How many nights was <INSERT NAME>’s first stay?
[INTERVIEWER NOTE: “Stay” is a single trip into and OUT or admission into and discharge out of the hospital.]
[IF NECESSARY: Your best guess is fine.]
enter number [range= 0 – 366]
998 don’t know
999 refused
/IF B5=1 GOTO B8/
B7. /IF B5>1 ASK/ In 20XX, how many nights in total did you stay in a Non-VA Hospital on your 2nd through /B5/ stays?
/IF PROXY=01 AND B5>1 ASK/ In 20XX, how many nights in total did <INSERT NAME> stay in a Non-VA Hospital on the 2nd through /B5/ stays?
[INTERVIEWER NOTE: “Stay” is a single trip into and OUT or admission into and discharge out of the hospital.]
[INTERVIEWER NOTE: this is the total number of nights for all stays. if necessary walk them through the math.]
[IF NECESSARY: Your best guess is fine.]
enter number [RANGE=0 –366]
998 don’t know
999 refused
B8. In 20XX, how many stays for mental health or substance abuse treatment, if any, did you have at any Non-VA Mental Health Facility, or other Non-VA medical facility? Please do not count any stays paid for by VA.
/IF PROXY=01/ In 20XX, how many stays for mental health or substance abuse treatment, if any, did <INSERT NAME> have at any Non-VA Mental Health Facility, or other Non-VA medical facility? Please do not count any stays paid for by VA.
[INTERVIEWER NOTE: “Stay” is a single trip into and out, or admission into and discharge out of the hospital.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
[IF NECESSARY: Your best guess is fine.]
ENTER NUMDER [RANGE=0- 366]
998 DON’T KNOW
999 REFUSED
/IF B8=0, 98, 99 GOTO B11, ELSE CONTINUE/
B9. /IF B8=1 ASK/ How many nights was that stay?
/IF B8>1 ASK/ How many nights was your first stay?
/IF PROXY=01AND B8=1 ASK/ How many nights was that stay?
/IF PROXY=01 AND B8>1 ASK/ How many nights was <INSERT NAME>’s first stay?
[INTERVIEWER NOTE: “Stay” is a single trip into and OUT or admission into and discharge out of the hospital.]
[IF NECESSARY: Your best guess is fine.]
ENTER NUMDER [RANGE=0- 366]
998 DON’T KNOW
999 REFUSED
/IF B8=1 GOTO B11, ELSE CONTINUE/
B10. In 20XX, how many nights in total did you stay in a Non-VA Facility for mental health or substance abuse treatment on your second through /B8 RESPONSE/ stays?
/IF PROXY=01/ In 20XX, how many nights in total did <INSERT NAME> stay in a Non-VA Facility for mental health or substance abuse treatment on the second through /B8 RESPONSE/ stays?
[INTERVIEWER NOTE: “Stay” is a single trip into and OUT or admission into and discharge out of the hospital.]
[INTERVIEWER NOTE: this is the total number of nights for all stays. if necessary walk them through the math.]
[IF NECESSARY: Your best guess is fine.]
ENTER NUMDER [RANGE=0 -366]
998 DON’T KNOW
999 REFUSED
///ASK IF SPLIT=1, ELSE SKIP TO B11B///
B11A. In 20xx, how many outpatient visits or trips, did you make to any Non-VA doctor’s office, hospital, or outpatient clinic? Please do not count dental, mental health, substance abuse visits or any visits paid for by VA?
/IF PROXY=01/ In 20xx, how many outpatient visits or trips, did <INSERT NAME> make to any Non-VA doctor’s office, hospital, or outpatient clinic? Please do not count dental, mental health, substance abuse visits or any visits paid for by VA?
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
[IF NECESSARY: Your best guess is fine.]
01 ENTER NUMBER [RANGE=0- 366]
998 DON’T KNOW
999 REFUSED
///ASK IF SPLIT=2, ELSE SKIP TO B22///
B11B. From October through December 20xx, how many outpatient visits or trips, did you make to any Non-VA doctor’s office, hospital, or outpatient clinic? Please do not count dental, mental health, substance abuse visits or any visits paid for by VA?
/IF PROXY=01/ From October through December 20xx, how many outpatient visits or trips, did <INSERT NAME> make to any Non-VA doctor’s office, hospital, or outpatient clinic? Please do not count dental, mental health, substance abuse visits or any visits paid for by VA?
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
01 ENTER NUMBER [RANGE=0- 366]
998 DON’T KNOW
999 REFUSED
B12. In 20XX, how many home health care visits, if any, were made to you by Non-VA providers or not paid for by VA?
/IF PROXY=01/ In 20XX, how many home health care visits, if any, were made to <INSERT NAME> by Non-VA providers or not paid for by VA?
[INTERVIEWER NOTE: THIS IS THE SUM OF ALL INDIVIDUAL PROVIDER’S VISITS.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
[IF NECESSARY: Your best guess is fine.]
ENTER NUMDER: [RANGE=0-366]
998 DON’T KNOW
999 REFUSED
B13. In 20XX, how many outpatient visits or trips for mental health or substance abuse treatment did you make to a Non-VA Mental Health or Substance Abuse Facility or Doctor’s office? Please do not count visits paid for by VA.
/IF PROXY=01/ In 20XX, how many outpatient visits or trips for mental health or substance abuse treatment did <INSERT NAME> make to a Non-VA Mental Health or Substance Abuse Facility or Doctor’s office? Please do not count visits paid for by VA.
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
[IF NECESSARY: Your best guess is fine.]
ENTER NUMDER: [RANGE=0-366]
998 DON’T KNOW
999 REFUSED
PREB14 Now, the next few Questions are in regards to any VA provided Healthcare.
B14. In 20XX, did you use any VA healthcare services, or did you have any of your health care paid for by VA?
/IF PROXY=01/ In 20XX, did <INSERT NAME> use any VA healthcare services, or did <INSERT NAME> have any health care paid for by VA?
IF NECESSARY: Please include ANY service at all such as a flu shot, a single prescription, a test, etc…
[INTERVIEWER NOTE: “NO NEED FOR SERVICES AT ALL” ONLY MARK IF SPONTANEOUSLY VOLUNTEERED DY RESPONDENT.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
00 (SKIP TO B25) NO NEED FOR SERVICES AT ALL
01 YES – VA PAID FOR SERVICE/RECEIVED SERVICES AT VA
02 NO- - VA DID NOT PAY FOR SERVICES/ DID NOT RECEIVE SERVICES
98 DON’T KNOW
99 REFUSED
B14_VAL VALIDATION: /IF B14=02 0R 98 OR 99 ASK, ELSE CONTINUE/ Just to make sure I have this correct, in 20XX you did not receive ANY health care services at all from VA. You did not get a flu shot, a single prescription, any tests, to any other health care service for which VA paid any portion of?
/IF PROXY=01 AND IF B14=02 0R 98 OR 99 ASK, ELSE CONTINUE/ Just to make sure I have this correct, in 20XX <INSERT NAME> did not receive ANY health care services at all from VA. <INSERT NAME> did not get a flu shot, a single prescription, any tests, to any other health care service for which VA paid any portion of?
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
01 (SKIP TO B25) (yes) DID NOT RECEIVE SERVICES FROM VA
02 (NO) RECEIVED SERVICES FROM VA
98 (SKIP TO B25) DON’T KNOW
99 (SKIP TO B25) REFUSED
B15. In 20XX, did you stay overnight at any VA Medical Hospital or a VA Mental Health Facility, or have any stays at Non-VA facilities that were paid for by VA?
/IF PROXY=01/ In 20XX, did <INSERT NAME> stay overnight at any VA Medical Hospital or a VA Mental Health Facility, or have any stays at Non-VA facilities that were paid for by VA?
[INTERVIEWER NOTE: “Stay” is a single trip into and out, or admission into and discharge out of the hospital, NOT THE NUMbER OF DAYS THE PATIENT STAYED IN THE HOSPITAL.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
01 YES
02 (SKIP TO B22) NO
98 (SKIP TO B22) DON’T KNOW
99 (SKIP TO B22) REFUSED
B16. In 20XX, how many total overnight stays, if any, did you have at a VA Medical Hospital, or a medical hospital paid for by VA? Please do not count stays for mental health and substance abuse treatment?
/IF PROXY=01/ In 20XX, how many total overnight stays, if any, did <INSERT NAME> have at a VA Medical Hospital, or a medical hospital paid for by VA? Please do not count stays for mental health and substance abuse treatment?
[INTERVIEWER NOTE: “Stay” is a single trip into and out, or admission into and discharge out of the hospital, NOT THE NUMbER OF DAYS THE PATIENT STAYED IN THE HOSPITAL.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
[IF NECESSARY: Your best guess is fine.]
ENTER NUMBER [RANGE=0-366]
998 DON’T KNOW
999 REFUSED
/IF B16=0, 98, 99 GOTO B19, ELSE CONTINUE/
B17. /IFB16=1 ASK/ How many nights was that stay?
/IF B16>1 ASK/ How many nights was that first stay?
/IF PROXY=01 AND B16=1 ASK/ How many nights was that stay?
/ IF PROXY=01 AND B16>1 ASK/ How many nights was <INSERT NAME>’s first stay?
[INTERVIEWER NOTE: “Stay” is a single trip into and out, or admission into and discharge out of the hospital, NOT THE NUMbER OF DAYS THE PATIENT STAYED IN THE HOSPITAL.]
[IF NECESSARY: Your best guess is fine.]
ENTER NUMBER [RANGE=0-366]
998 DON’T KNOW
999 REFUSED
/IF B16=1 GOTO B19, ELSE CONTINUE/
B18. In 20XX, how many nights in total did you stay in a VA Medical Hospital or other hospitals paid for by VA on your second through /B16 RESPONSE/ stays?
/IF PROXY=01/ In 20XX, how many nights in total did <INSERT NAME> stay in a VA Medical Hospital or other hospitals paid for by VA on the second through /B16 RESPONSE/ stays?
[INTERVIEWER NOTE: “Stay” is a single trip into and out, or admission into and discharge out of the hospital, NOT THE NUMbER OF DAYS THE PATIENT STAYED IN THE HOSPITAL.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
[INTERVIEWER NOTE: this is the total number of nights for all stays. if necessary walk them through the math.]
[IF NECESSARY: Your best guess is fine.]
ENTER NUMBER [RANGE=0 -366]
998 DON’T KNOW
999 REFUSED
B19. In 20XX, how many overnight stays, if any, did you have for mental health or substance abuse treatment at a VA Facility or at a facility paid for by VA?
/IF PROXY=01/ In 20XX, how many overnight stays, if any, did <INSERT NAME> have for mental health or substance abuse treatment at a VA Facility or at a facility paid for by VA?
[INTERVIEWER NOTE: “Stay” is a single trip into and out, or admission into and discharge out of the hospital, NOT THE NUMBER OF DAYS THE PATIENT STAYED IN THE HOSPITAL.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
[IF NECESSARY: Your best guess is fine.]
ENTER NUMBER [RANGE=0-366]
998 DON’T KNOW
999 REFUSED
/IF B19=0, 98, 99 GOTO B22, ELSE CONTINUE/
B20. / IF B19 =1 ASK/ How many nights was that stay?
/IF B19>1 ASK/ How many nights was your first stay?
/IF PROXY=01 AND B19 =1 ASK/ How many nights was that stay?
/IF PROXY=01 AND B19>1 ASK/ How many nights was <INSERT NAME>’s first stay?
[INTERVIEWER NOTE: “Stay” is a single trip into and out, or admission into and discharge out of the hospital, NOT THE NUMBER OF DAYS THE PATIENT STAYED IN THE HOSPITAL.]
[IF NECESSARY: Your best guess is fine.]
ENTER NUMBER [RANGE=0-366]
998 DON’T KNOW
999 REFUSED
/IF B19=1 GO TO B22, ELSE CONTINUE/
B21. In 20XX, how many nights in total did you stay in a VA Facility, or stays elsewhere that were paid for by VA for mental health or substance abuse care on your second through /D19 RESPONSE/ stays?
/IF PROXY=01/ In 20XX, how many nights in total did <INSERT NAME> stay in a VA Facility, or stays elsewhere that were paid for by VA for mental health or substance abuse care on the second through /B19 RESPONSE/ stays
[INTERVIEWER NOTE: “Stay” is a single trip into and OUT or admission into and discharge out of the hospital, NOT THE NUMBER OF DAYS THE PATIENT STAYED IN THE HOSPITAL.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
[INTERVIEWER NOTE: this is the total number of nights for all stays. if necessary walk them through the math.]
[IF NECESSARY: Your best guess is fine.]
ENTER NUMBER [RANGE=0 -366]
998 DON’T KNOW
999 REFUSED
PREB22 Now, the next few questions are in regards to any VA provided Healthcare.
///ASK IF SPLIT=1, ELSE SKIP TO B22B///
B22A. In 20xx, how many outpatient visits or trips did you make that were paid for by VA? That would include the number of times you went to a VA doctor, hospital or clinic for medical care or received medical care somewhere else that was paid for by VA. Do not count dental or mental health visits or trips to a pharmacy.
/IF PROXY=01/ In 20xx, how many outpatient visits or trips did <INSERT NAME> make that were paid for by VA? That would include the number of times <INSERT NAME> went to a VA doctor, hospital or clinic for medical care or received medical care somewhere else that was paid for by VA. Do not count dental or mental health visits or trips to a pharmacy.
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
01 ENTER NUMBER [RANGE=1-366]
998 DON’T KNOW
999 REFUSED
///ASK IF SPLIT=2, ELSE SKIP TO B25///
B22B. From October through December 20xx, how many outpatient visits or trips did you make that were paid for by VA? That would include the number of times you went to a VA doctor, hospital or clinic for medical care or received medical care somewhere else that was paid for by VA. Do not count dental or mental health visits or trips to a pharmacy.
/IF PROXY=01/ From October through December 20xx, how many outpatient visits or trips did <INSERT NAME> make that were paid for by VA? That would include the number of times <INSERT NAME> went to a VA doctor, hospital or clinic for medical care or received medical care somewhere else that was paid for by VA. Do not count dental or mental health visits or trips to a pharmacy.
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
01 ENTER NUMBER [RANGE=1-366]
998 DON’T KNOW
999 REFUSED
B23. In 20XX, how many home health care visits, if any, were made to you by VA providers or non-VA providers paid for by VA?
/IF PROXY=01/ In 20XX, how many home health care visits, if any, were made to <INSERT NAME> by VA providers or non-VA providers paid for by VA?
[INTERVIEWER NOTE: WE ARE LOOKING FOR THE SUM TOTAL OF ALL INDIVIDUAL PROVIDER VISITS.
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
[IF NECESSARY: Your best guess is fine.]
ENTER NUMBER [RANGE=0-366]
998 DON’T KNOW
999 REFUSED
B24. In 20XX, how many outpatient visits for mental health or substance abuse treatment, if any, did you make to VA or visits elsewhere that were paid for by VA?
/IF PROXY=01/ In 20XX, how many outpatient visits for mental health or substance abuse treatment, if any, did <INSERT NAME> make to VA or visits elsewhere that were paid for by VA?
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
[IF NECESSARY: Your best guess is fine.]
ENTER NUMBER [RANGE=0-366]
998 DON’T KNOW
999 REFUSED
B25. I am going to read you a list of possible ways you could use VA for your health care in the future. Please listen to them all, and then tell me the one that best describes the primary way you plan to use VA health care in the future. Do you plan to use VA as….
/IF PROXY=01/ I am going to read you a list of possible ways <INSERT NAME> could use VA for health care in the future. Please listen to them all, and then tell me the one that best describes the primary way <INSERT NAME> plans to use VA health care in the future. Does <INSERT NAME> plan to use VA as
[INTERVIEWER: PLEASE READ ENTIRE LIST. CHOOSE ONLY ONE. IF RESPONDENT WILL NOT PICK ONE, ENTER INTO “OTHER” BOTH RESPONSES]
01 Your primary source of healthcare;
/IF PROXY=01/ a primary source of healthcare
02 Backup to non-VA care for some minor services
/IF PROXY=01/ As backup to non-VA care for some minor services
03 A “safety net” to use only if needed
04 For prescriptions;
05 For specialized care
06 Some other way;
07 Or do you have No plans to use VA for healthcare
/IF PROXY=01/ Or does <INSERT NAME> have no plans to use VA for healthcare?
98 DON’T KNOW
99 REFUSED
B25_O /IF B25=06 ASK, ELSE CONTINUE/ Could you please tell me how you primarily plan to use VA for health care in the future?
/IF PROXY=01/ Could you please tell me how <INSERT NAME> primarily plans to use VA for health care in the future?
01 ENTER RESPONSE:
98 DON’T KNOW
99 REFUSED
B25_OV [INTERVIEWER: CAN YOUR SPECIFY RESPONSE BE CODED USING THE LIST BELOW
IF YES, SELECT NOW.
01 Your primary source of health care;
/IF PROXY=01/ a primary source of health care
02 Backup to non-VA care for some minor services
/IF PROXY=01/ As backup to non-VA care for some minor services
03 A “safety net” to use only if needed
04 For prescriptions;
05 For specialized care
96 NO, UNIQUE RESPONSE
Section C: Activities of Daily Living/Incidental Activities of Daily Living (ADL/IADL) ///ASK ALL RESPONDENTS///
PREC40 Now, I’d like to ask you some questions about your current health.
/IF PROXY=01/ Now, I’d like to ask you some questions about <INSERT NAME>’s current health.
C40. Compared to other people your age, would you say your health is:
/IF PROXY=01/ Compared to other people <INSERT NAME>’s age, would you say <ISNERT NAME>’s health is:
[INTERVIEWER PLEASE READ LIST]
01 Excellent
02 Very good
03 Good
04 Fair, or
05 Poor
98 DON’T KNOW
99 REFUSED
C41. Because of a physical, mental, or emotional condition, do you usually have difficulty concentrating, remembering, or making decisions?
/IF PROXY=01/. Because of a physical, mental, or emotional condition, does <INSERT NAME> usually have difficulty concentrating, remembering, or making decisions?
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
PREC42 I would now like to ask about your ability to do everyday activities without help. By help, I mean either the help of another person, including people who live with your, or the help of special equipment.
/IF PROXY=01/ I would now like to ask about <INSERT NAME>’s ability to do everyday activities without help. By help, I mean either the help of another person, including people who live with <INSERT NAME>, or the help of special equipment.
C42a Do you have any problem eating without the help of another person or special equipment?
/IF PROXY=01/Does <INSERT NAME> have any problem eating without the help of another person or special equipment?
01 YES
02 NO
03 CAN’T DO/ DON’T DO
98 DON’T KNOW
99 REFUSED
C42b. Do you have any problem getting in or out of bed without help?
/PROXY=01/ Does <INSERT NAME> have any problem getting in or out of bed without help?
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 YES
02 NO
03 CAN’T DO/ DON’T DO
98 DON’T KNOW
99 REFUSED
C42c Do you have any problem getting in or out of chairs without help?
/PROXY=01/ Does <INSERT NAME> have any problem getting in or out of chairs without help?
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 YES
02 NO
03 CAN’T DO/ DON’T DO
98 DON’T KNOW
99 REFUSED
C42d Do you have any problem walking around inside without help?
/PROXY=01/ Does <INSERT NAME> have any problem walking around inside without help?
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 YES
02 NO
03 CAN’T DO/ DON’T DO
98 DON’T KNOW
99 REFUSED
C42e Do you have any problem going outside without help of another person or special equipment?
/PROXY=01/ Does <INSERT NAME> have any problem going outside without help of another person or special equipment?
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 YES
02 NO
03 CAN’T DO/ DON’T DO
98 DON’T KNOW
99 REFUSED
C42f Do you have any problem dressing without help?
/PROXY=01/ Does <INSERT NAME> have any problem dressing without help?
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 YES
02 NO
03 CAN’T DO/ DON’T DO
98 DON’T KNOW
99 REFUSED
C42g Do you have any problem bathing without help?
/PROXY=01/ Does <INSERT NAME> have any problem bathing without help?
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 YES
02 NO
03 CAN’T DO/ DON’T DO
98 DON’T KNOW
99 REFUSED
C42h Do you have any problem getting to the bathroom or using the toilet?
/PROXY=01/ Does <INSERT NAME> have any problem getting to the bathroom or using the toilet?
01 YES
02 NO
03 CAN’T DO/ DON’T DO
98 DON’T KNOW
99 REFUSED
C42i Do you have any problem controlling bowel movements or urination or ever have any accidents?
/PROXY=01/ Does <INSERT NAME> have any problem controlling bowel movements or urination or ever have any accidents?
01 YES
02 NO
03 CAN’T DO/ DON’T DO
98 DON’T KNOW
99 REFUSED
//CREATE VARIABLE ADL. FOR EACH “YES” IN C42a-C42i ADD 1, ALL OTHER RESPONSES (02,03,98, 99) MAKE 0, SUM FOR A VARIABLE 0-9//
//IF ADL=0 GOTO PREC45, ELSE CONTINUE//
C43a/IF ADL=1 AND PROXY=00 ASK/ You said that you have a problem with one activity. Have you had this problem for three months or longer?
/IF ADL>1 AND PROXY=00 ASK/ You said that you have a problem with some activities. Have you had any of these problems for three months or longer?
/IF ADL=1 AND PROXY=01 ASK/ You said that <INSERT NAME> has a problem with one activity. Has <INSERT NAME> had this problem for three months or longer?
/IF ADL>1 AND PROXY=01 ASK/ You said that <INSERT NAME> has a problem with some activities. Has <INSERT NAME> had any of these problems for three months or longer?
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
//IF C43a=01 GO TO PRE C44, ELSE CONTINUE//
C43b/IF ADL=1 AND PROXY=00 ASK/ Do you EXPECT this problem will last for the next three months or longer?
/IF ADL>1 AND PROXY=00 ASK/ Do you EXPECT any of these problems will last for the next three months or longer?
/IF ADL=1 AND PROXY=01 ASK/ Do you EXPECT that <INSERT NAME>’s problem will last for the next three months or longer?
/IF ADL>1 AND PROXY=01 ASK/ Do you EXPECT that any of <INSERT NAME>’s problems will last for the next three months or longer?
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
//IF C43b=01 GO TO PREC44, ELSE CONTINUE//
C43c/IF ADL=1 AND PROXY=00 ASK/ Altogether, from beginning to end, will this problem have lasted three months or longer?
/IF ADL>1 AND PROXY=00 ASK/ Altogether, from beginning to end, will any of these problems have lasted three months or longer
/IF ADL=1 AND PROXY=01 ASK/ Altogether, from beginning to end, will <INSERT NAME>’s problem have lasted three months or longer?
/IF ADL>1 AND PROXY=01 ASK/ Altogether, from beginning to end, will any of <INSERT NAME>’s problems have lasted three months or longer?
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
PREC44/IF ADL=1 ASK/ We are interested in knowing about the severity of this problem.
/IF ADL>1 ASK/ We are interested in knowing about the severity of these problems.
//IF C42a=01 ASK, ELSE GOTO C44b//
C44a Earlier you said that you had a problem eating without help. Is it true that you are unable to eat without either stand-by assistance or hands-on assistance from another person?
/IF PROXY=01/ Earlier you said that <INSERT NAME> had a problem eating without help. Is it true that <INSERT NAME> is unable to eat without either stand-by assistance or hands-on assistance from another person?
[IF NECESSARY: “Stand-by assistance” means “within arm’s reach.”]
[IF NECESSARY: “Hands on assistance” means “physical assistance.”]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
//IF C42b=01 ASK, ELSE GOTO C44c//
C44b Earlier you said that you had a problem getting in or out of bed without help. Is it true that you are unable to get in or out of bed without either stand-by assistance or hands-on assistance from another person?
/IF PROXY=01/ Earlier you said that <INSERT NAME> had a problem getting in or out of bed without help. Is it true that <INSERT NAME> is unable to get in or out of bed without either stand-by assistance or hands-on assistance from another person?
[IF NECESSARY: “Stand-by assistance” means “within arms reach.”]
[IF NECESSARY: “Hands on assistance” means “physical assistance.”]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
//IF C42c=01 ASK, ELSE GOTO C44d//
C44c Earlier you said that you had a problem getting in or out of chairs without help. Is it true that you are unable to get in or out of chairs without either stand-by assistance or hands-on assistance from another person?
/IF PROXY=01/ Earlier you said that <INSERT NAME> had a problem getting in or out of chairs without help. Is it true that <INSERT NAME> is unable to get in or out of chairs without either stand-by assistance or hands-on assistance from another person?
[IF NECESSARY: “Stand-by assistance” means “within arm’s reach.”]
[IF NECESSARY: “Hands on assistance” means “physical assistance.”]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
//IF C42d=01 ASK, ELSE GOTO C44e//
C44d Earlier you said that you had a problem walking around inside without help. Is it true that you are unable to walk around inside without either stand-by assistance or hands-on assistance from another person?
/IF PROXY=01/ Earlier you said that <INSERT NAME> had a problem walking around inside without help. Is it true that <INSERT NAME> is unable to walk around inside without either stand-by assistance or hands-on assistance from another person?
[IF NECESSARY: “Stand-by assistance” means “within arm’s reach.”]
[IF NECESSARY: “Hands on assistance” means “physical assistance.”]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
//IF C42e=01 ASK, ELSE GOTO C44f//
C44e Earlier you said that you had a problem going outside without help. Is it true that you are unable to go outside without either stand-by assistance or hands-on assistance from another person?
/IF PROXY=01/ Earlier you said that <INSERT NAME> had a problem going outside without help. Is it true that <INSERT NAME> is unable to go outside without either stand-by assistance or hands-on assistance from another person?
[IF NECESSARY: “Stand-by assistance” means “within arm’s reach.”]
[IF NECESSARY: “Hands on assistance” means “physical assistance.”]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
//IF C42f=01 ASK, ELSE GOTO C44g//
C44f Earlier you said that you had a problem dressing without help. Is it true that you are unable to dress without either stand-by assistance or hands-on assistance from another person?
/IF PROXY=01/ Earlier you said that <INSERT NAME> had a problem dressing without help. Is it true that <INSERT NAME> is unable to dress without either stand-by assistance or hands-on assistance from another person?
[IF NECESSARY: “Stand-by assistance” means “within arm’s reach.”]
[IF NECESSARY: “Hands on assistance” means “physical assistance.”]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
//IF C42g=01 ASK, ELSE GOTO C44h//
C44g Earlier you said that you had a problem bathing without help. Is it true that you are unable to bathe without either stand-by assistance or hands-on assistance from another person?
/IF PROXY=01/ Earlier you said that <INSERT NAME> had a problem bathing without help. Is it true that <INSERT NAME> is unable to bathe without either stand-by assistance or hands-on assistance from another person?
[IF NECESSARY: “Stand-by assistance” means “within arm’s reach.”]
[IF NECESSARY: “Hands on assistance” means “physical assistance.”]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
//IF C42h=01 ASK, ELSE GOTO C44i//
C44h Earlier you said that you had a problem getting to the bathroom or using the toilet. Is it true that you are unable to get to the bathroom or use the toilet without either stand-by assistance or hands-on assistance from another person?
/IF PROXY=01/ Earlier you said that <INSERT NAME> had a problem getting to the bathroom or using the toilet. Is it true that <INSERT NAME> is unable to get to the bathroom or use the toilet without either stand-by assistance or hands-on assistance from another person?
[IF NECESSARY: “Stand-by assistance” means “within arm’s reach.”]
[IF NECESSARY: “Hands on assistance” means “physical assistance.”]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
//IF C42i=01 ASK, ELSE GOTO PREC45//
C44i Earlier you said that you had a problem controlling bowel movements or urination. Is it true that you are unable to control bowel movements or urinate, or to perform associated personal hygiene, without either stand-by assistance or hands-on assistance from another person?
/IF PROXY=01/ Earlier you said that <INSERT NAME> had a problem controlling bowel movements or urination. Is it true that <INSERT NAME> is unable to control bowel movements or urinate, or to perform associated personal hygiene, without either stand-by assistance or hands-on assistance from another person?
[IF NECESSARY: “Stand-by assistance” means “within arm’s reach.”]
[IF NECESSARY: “Hands on assistance” means “physical assistance.”]
[IF NECESSARY: “Associated personal hygiene” means “washing oneself, disposing of soiled items, changing clothing, and caring for a catheter or colostomy bag.”]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
PREC45 I would like to ask you about your ability to do some other every day activities without help. Please remember by help, I mean either help of another person, including people who live with you, or the help of special equipment.
/IF PROXY=01/ I would like to ask you about <INSERT NAME>’s ability to do some other every day activities without help. Please remember by help, I mean either help of another person, including people who live with <INSERT NAME> or the help of special equipment.
C45a Are you able to prepare meals without help?
/IF PROXY=01/ Is <INSERT NAME> able to prepare meals without help?
[INTERVIEWER NOTE: IF A PERSON DOES NOT DO, BUT IS ABLE TO DO, MARK AS “YES”.]
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 (SKIP TO C45b) YES
02 NO
98 (SKIP TO C45b) DON’T KNOW
99 (SKIP TO C45b) REFUSED
C45a_1 Does a disability or a health problem keep you from preparing meals without help?
/IF PROXY=01/ Does a disability or a health problem keep <INSERT NAME> from preparing meals without help?
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
C45b Are you able to do laundry without help?
/IF PROXY=01/ Is <INSERT NAME> able to do laundry without help?
[INTERVIEWER NOTE: IF A PERSON DOES NOT DO, BUT IS ABLE TO DO, MARK AS “YES”.]
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 (SKIP TO C45c) YES
02 NO
98 (SKIP TO C45c) DON’T KNOW
99 (SKIP TO C45c) REFUSED
C45b_1 Does a disability or a health problem keep you from doing laundry without help?
/IF PROXY=01/ Does a disability or a health problem keep <INSERT NAME> from doing laundry without help?
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
C45c Are you able to do light housework, such as washing dishes without help?
/IF PROXY=01/ Is <INSERT NAME> able to do light housework, such as washing dishes without help?
[INTERVIEWER NOTE: IF A PERSON DOES NOT DO, BUT IS ABLE TO DO, MARK AS “YES”.]
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 (SKIP TO C45d) YES
02 NO
98 (SKIP TO C45d) DON’T KNOW
99 (SKIP TO C45d) REFUSED
C45c_1 Does a disability or a health problem keep you from doing light housework without help?
/IF PROXY=01/ Does a disability or a health problem keep <INSERT NAME> from doing light housework without help?
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
C45d Are you able to shop for groceries without help?
/IF PROXY=01/ Is <INSERT NAME> able to shop for groceries without help?
[INTERVIEWER NOTE: IF A PERSON DOES NOT DO, BUT IS ABLE TO DO, MARK AS “YES”.]
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 (SKIP TO C45e) YES
02 NO
98 (SKIP TO C45e) DON’T KNOW
99 (SKIP TO C45e) REFUSED
C45d_1 Does a disability or a health problem keep you from shopping for groceries without help?
/IF PROXY=01/ Does a disability or a health problem keep <INSERT NAME> from shopping for groceries without help?
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
C45e Are you able to manage money such as keeping track of bills and handling cash without help?
/IF PROXY=01/ Is <INSERT NAME> able to manage money such as keeping track of bills and handling cash without help?
[INTERVIEWER NOTE: IF A PERSON DOES NOT DO, BUT IS ABLE TO DO, MARK AS “YES”.]
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 (SKIP TO C45f) YES
02 NO
98 (SKIP TO C45f) DON’T KNOW
99 (SKIP TO C45f) REFUSED
C45e_1 Does a disability or a health problem keep you from managing money without help?
/IF PROXY=01/ Does a disability or a health problem keep <INSERT NAME> from managing money without help?
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
C45f Are you able to take medicine without help?
/IF PROXY=01/ Is <INSERT NAME> able to take medicine without help?
[INTERVIEWER NOTE: IF A PERSON DOES NOT DO, BUT IS ABLE TO DO, MARK AS “YES”.]
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 (SKIP TO C45g) YES
02 NO
98 (SKIP TO C45g) DON’T KNOW
99 (SKIP TO C45g) REFUSED
C45f_1 Does a disability or a health problem keep you from taking medicine without help?
/IF PROXY=01/ Does a disability or a health problem keep <INSERT NAME> from taking medicine without help?
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
C45g Are you able to make telephone calls without help?
/IF PROXY=01/ Is <INSERT NAME> able to make telephone calls without help?
[INTERVIEWER NOTE: IF A PERSON DOES NOT DO, BUT IS ABLE TO DO, MARK AS “YES”.]
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 (SKIP TO C61) YES
02 NO
98 (SKIP TO C61) DON’T KNOW
99 (SKIP TO C61) REFUSED
C45g_1 Does a disability or a health problem keep you from making telephone calls without help?
/IF PROXY=01/ Does a disability or a health problem keep <INSERT NAME> from making telephone calls without help?
[INTERVIEWER IF NECESSARY: By without help, I mean you need neither the help of another person nor the help of special equipment.]
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
Section D: Key Drivers ///ASK ALL RESPONDENTS///
PRED5 I am now going to read you a list of statements and I would like you to tell me for each statement if you completely agree, agree, neither agree nor disagree, disagree, or completely disagree.
Quality //ROTATE//
D12b Veterans like me who use VA are satisfied with the health care they receive.
D12f VA health care providers explain treatment/diagnoses in a way that patients can understand.
D12g VA health care providers treat their patients with respect.
D12h VA health care providers listen to their patients' concerns.
01 Completely Agree
02 Agree
03 Neither agree nor disagree
04 Disagree
05 Completely Disagree
98 DON’T KNOW
99 REFUSED
//END ROTATE//
Cost //ROTATE//
D11a VA is the most cost-effective healthcare provider for veterans like me.
D11c VA offers veterans like me the best value for our health care dollar.
01 Completely Agree
02 Agree
03 Neither agree nor disagree
04 Disagree
05 Completely Disagree
98 DON’T KNOW
99 REFUSED
//END ROTATE//
Availability and Accessibility of Services //ROTATE//
D13b Veterans like me can get in and out of an appointment at VA in a reasonable time.
D13c When veterans like me go to VA for an appointment; they do not wait a long time to see the doctor.
D14b Veterans like me can see many different doctors, specialists, etc., in one visit to VA.
D15d VA patients can see the doctor/health care provider that they want.
01 Completely Agree
02 Agree
03 Neither agree nor disagree
04 Disagree
05 Completely Disagree
98 DON’T KNOW
99 REFUSED
//END ROTATE//
Convenience of Location //ROTATE//
D13d Transportation to and from the VA facility is manageable for veterans like me.
D13e There is a VA provider in my area that offers all of the health care services that veterans like me need.
D14a It is easy for veterans like me to get around in the VA health care facility.
D15f It is easy to get to my local VA facility.
01 Completely Agree
02 Agree
03 Neither agree nor disagree
04 Disagree
05 Completely Disagree
98 DON’T KNOW
99 REFUSED
//END ROTATE//
Other Factors: Friends Using VA Services //ROTATE//
D10c Veterans like me like going to VA because you can talk to other veterans.
D16a My best friends include veterans met through military service or veterans groups.
01 Completely Agree
02 Agree
03 Neither agree nor disagree
04 Disagree
05 Completely Disagree
98 DON’T KNOW
99 REFUSED
//END ROTATE//
Knowledge of VA Health Insurance //ROTATE//
D14c I feel I know what is available to me through my VA coverage.
D14d I understand how my VA health insurance coverage works.
01 Completely Agree
02 Agree
03 Neither agree nor disagree
04 Disagree
05 Completely Disagree
98 DON’T KNOW
99 REFUSED
Availability of NON-VA Health Care Alternatives //ROTATE//
D16d I have a doctor outside VA who I really like and trust.
D16e My family has a health insurance plan that covers me and the rest of the family.
01 Completely Agree
02 Agree
03 Neither agree nor disagree
04 Disagree
05 Completely Disagree
98 DON’T KNOW
99 REFUSED
//END ROTATE//
Other Issues //ROTATE//
D16c I would only use VA if I did not have access to any other source of health care.
D16f Veterans who can afford to use other sources of health care should leave the VA to those who really need it.
D15b It takes more than 30 days to get an appointment at VA.
D16b If the cost of health care to me increases, I will use VA more.
01 Completely Agree
02 Agree
03 Neither agree nor disagree
04 Disagree
05 Completely Disagree
98 DON’T KNOW
99 REFUSED
//END ROTATE//
Section E: Demographics
PREE1 Now, I’d like to ask you about your current health.
/IF PROXY=01/ Now, I’d like to ask you about <INSERT NAME>’s current health.
E1. Compared to other people your age, would you say your health is:
/IF PROXY=01/ Compared to other people <INSERT NAME>’s age, would you say <INSERT NAME>’s health is:
[INTERVIEWER PLEASE READ LIST]
01 Excellent
02 Very good
03 Good
04 Fair, or
05 Poor
98 DON’T KNOW
99 REFUSED
PREE2. The next few questions are about cigarette smoking.
E2. Have you smoked at least 100 cigarettes in your entire life?
/IF PROXY=01/ Has <INSERT NAME> smoked at least 100 cigarettes in <INSERT NAME>’s entire life?
01 YES
02 (SKIP TO PREE5) NO
98 DON’T KNOW
99 REFUSED
E3. Do you now smoke cigarettes every day, some days, or not at all?
/IF PROXY=01/ Does <INSERT NAME> now smoke cigarettes every day, some days, or not at all?
01 Every day
02 Some days
03 Not at all
98 DON’T KNOW
99 REFUSED
E4. During the past 12 months, have you stopped smoking for more than one day because you were trying to quit smoking?
/IF PROXY=01/ During the past 12 months, has <INSERT NAME> stopped smoking for more than one day because <INSERT NAME> was trying to quit smoking?
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
PREE5 We are almost finished. The last questions are for demographic purposes only.
E5. Which of the following best describes your current marital status?
/IF PROXY=01/ Which of the following best describes <INSERT NAME>’s current marital status?
[INTERVIEWER READ LIST.]
01 Married
02 Widowed
03 Divorced
04 Separated
05 Single – Never Married
98 DON’T KNOW
99 REFUSED
E6. /IF E5=01 OR 04 ASK/ Not including yourself, how many dependents, such as your spouse or dependent children do you currently have?
/IF E5 NE 01 OR 04 ASK/ Not including yourself, how many dependents, do you currently have?
/IF PROXY=01AND E5=01 OR 04 ASK/ Not including <INSERT NAME>, how many dependents, such as a spouse or dependent children does <INSERT NAME> currently have?
/IF PROXY=01 AND E5 NE 01 OR 04 ASK/ Not including <INSERT NAME>, how many dependents, does <INSERT NAME> currently have?
[INTERVIEWER NOTE: “DEPENDENT” IS ANYONE WHO RELIES ON THE RESPONDENT FOR AT LEAST HALF OF THAT PERSON’S FINANCIAL SUPPORT.]
01 ENTER NUMBER [RANGE=0-97]
98 DON’T KNOW
99 REFUSED
PERIOD OF SERVICE
PREE6A. In the following, we would like to obtain some information on your active duty military history. Most veterans have served only one continuous tour of duty, with no breaks in service. A one time discharge from the military after continuous service is one term of service. However, some veterans have experienced breaks in service and thus have served multiple terms of service. How many terms of active duty military service have you served? Please do not include Reserve or National Guard training or drill periods unless “activated” at the time.
/IF PROXY=01/ In the following, we would like to obtain some information on <INSERT NAME>’s active duty military history. Most veterans have served only one continuous tour of duty, with no breaks in service. A one time discharge from the military after continuous service is one term of service. However, some veterans have experienced breaks in service and thus have served multiple terms of service. How many terms of active duty military service has <INSERT NAME> served? Please do not include Reserve or National Guard training or drill periods unless “activated” at the time.
E6A. How many terms of active duty military service have you served? Please do not include Reserve or National Guard training or drill periods unless “activated” at the time.
/IF PROXY=01/ How many terms of active duty military service has <INSERT NAME> served? Please do not include Reserve or National Guard training or drill periods unless “activated” at the time.
[INTERVIEWER NOTE: WE ARE ONLY RECORDING THE FIRST SIX PERIODS.]
ENTER NUMBER [1-6]
98 (SKIP TO E8) DON’T KNOW
99 (SKIP TO E8) REFUSED
E6AT. /IFE6A >1/I would like to ask you the year you started and ended each of these terms of active duty military service. Starting with your first…
/IF E6A=1/ I would like to ask you the year you started and ended this term of active duty military service.
/IF PROXY=01/I would like to ask you the year <INSERT NAME> started and ended each of these terms of active duty military service. Starting with <INSERT NAME’s> first…
/IF PROXY=01 and E6=1/I would like to ask you the year <INSERT NAME> started and ended this term of active duty military service.
/START LOOP EQUAL TO E6A/
E6B_1. What year did your <first> term of active duty military service start?
/IF E6A=1/ What year did your term of active duty military service start?
/IF PROXY=01/ What year did <INSERT NAME>’s <first> term of active duty military service start?
/IF PROXY=01 and E6A=1/ What year did <INSERT NAME>’s term of active duty military service start?
01 ENTER YEAR [RANGE: >=1918]
9998 DON’T KNOW
9999 REFUSED
E6C_1. What year did your <first> term of active duty military service end?
/IF E6A=1/ What year did your term of active duty military service end?
/IF PROXY=01/ What year did <INSERT NAME>’s <first> term of active duty military service end?
/IF PROXY=01 and E6A=1/ What year did <INSERT NAME>’s term of active duty military service end?
01 ENTER YEAR [RANGE: >=1918]
9998 DON’T KNOW
9999 REFUSED
COMBAT STATUS
E7_1. During this term of military service were you ever in or exposed to combat?
/IF PROXY=01/ During this term of military service was <INSERT NAME> ever in or exposed to combat?
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
/END LOOP/
EMPLOYMENT STATUS
E8. How would you best characterize your employment status? I am going to read you a list. Please listen to all of the choices and then tell me which best describes you. Are you
01 Employed Fulltime
02 Self-employed fulltime
03 Employed part-time
04 Self employed part-time
05 Unemployed, looking for work, or laid off
06 Currently not employed – either retired, a homemaker, student, etc.
98 DON’T KNOW
99 REFUSED
ETHNICITY AND RACE
E9. Would you describe yourself as Hispanic, or Latino?
/IF PROXY=01/ Would you describe <INSERT NAME> as Hispanic, or Latino?
01 YES
02 NO
98 DON’T KNOW
99 REFUSED
E10. I am going to read you a list, please tell me which of the following describes your race? You can choose more than one. Are you …
/IF PROXY=01/ I am going to read you a list, please tell me which of the following describes <INSERT NAME>’s race? You can choose more than one….
[INTERVIEWER NOTE: PLEASE READ LIST.]
/MUL=5/
01 American Indian or Alaska Native
02 Asian
03 Black or African-American
04 Native Hawaiian or Other Pacific Islander
05 White
DON’T KNOW
REFUSED
HOUSEHOLD INCOME
PE11. Could you please tell me what your total annual household income was from all sources in 20XX.
/IF PROXY=01/ Could you please tell me what was <INSERT NAME>’s total annual household income was from all sources in 20XX.
[IF NECESSARY: I would like to remind you that everything we discuss is confidential, and that your answer to this question will not affect your benefits.]
[IF NECESSARY: Your best guess or estimate is fine.]
01 GAVE RESPONSE (ANNUALLY) ///GO TO E11Y///
02 GAVE RESPONSE (MONTHLY) ///GO TO E11M///
98 DON’T KNOW
99 REFUSED
E11Y. Could you please tell me what your total annual household income was from all sources in 20XX.
/IF PROXY=01/ Could you please tell me what was <INSERT NAME>’s total annual household income was from all sources in 20XX.
[IF NECESSARY: I would like to remind you that everything we discuss is confidential, and that your answer to this question will not affect your benefits.]
[IF NECESSARY: Your best guess or estimate is fine.]
[RANGE=1-999,999] ///SKIP TO E11c.///
E11M. Could you please tell me what your total annual household income was from all sources in 20XX.
/IF PROXY=01/ Could you please tell me what was <INSERT NAME>’s total annual household income was from all sources in 20XX.
[IF NECESSARY: I would like to remind you that everything we discuss is confidential, and that your answer to this question will not affect your benefits.]
[IF NECESSARY: Your best guess or estimate is fine.]
[RANGE=1-83,333] ///SKIP TO E11c.///
E11a. This information is critical for VA for planning purposes. Could you please tell me which of the following best describes your 20XX total annual household income from all sources. Would you say it is…..
/IF PROXY=01/ This information is critical for VA for planning purposes. Could you please tell me which of the following best describes <INSERT NAME>’s 20XX total annual household income from all sources. Would you say it is…..
(READ LIST [ROUND UP “999], THEN FOLLOW-UP AS INDICATED)
|
a. |
|
b. Is it…. |
|
|
|
|
|
|
|
Less than $16,000 |
1→ |
Under $11,000, or |
1 |
|
|
|
$11,000 - $15,999? |
2 |
|
$16,000 - $25,999, |
2→ |
$16,000 – $20,999 |
3 |
|
|
|
$21,000 - $25,999? |
4 |
|
$26,000 - $35,999, |
3→ |
$26,000 – $30,999 |
5 |
|
|
|
$31,000 - $35,999? |
6 |
|
$36,000 - $45,999, |
4→ |
$36,000 – $40,999 |
7 |
|
|
|
$41,000 - $45,999? |
8 |
|
$46,000 - $55,999, OR |
5→ |
$46,000 – $50,999 |
9 |
|
|
|
$51,000 - $55,999? |
10 |
|
$56,000 or over? |
6 |
AUTO CODE $56,000+ |
11 |
OR |
Don’t know |
7 |
Don’t know |
12 |
(Do Not Read) |
Refused to answer |
8 |
Refused to answer |
13 |
E11c. Can you please tell me which state you are in?
//National list of two letter abbreviations and PR for Puerto Rico//
98 DON’T KNOW
99 REFUSED
///END TIMER///
///START TIMER///
CLOSE. That’s all I have. Thank you for your participation. The information you have provided will help VA to better serve all veterans in the future. Thank you and goodbye.
TIME ENDED______________
DATE OF INTERVIEW:
(MM/DD/YY)
VA Form 10-20134g
MAR 2009 Page
| File Type | application/msword |
| File Title | INTENDED AUDIENCE: Priority 1 through 8 veterans who have applied or are currently enrolled for VA health care services |
| Last Modified By | cynthia harvey-pryor |
| File Modified | 2009-05-14 |
| File Created | 2009-05-13 |