NHIS 2010 Attachment 3n NHIS 2010 Flashcard Booklet

Attachment 3n NHIS 2010 Flashcard Booklet

54HIS-501(C) (2010)

NATIONAL

HEALTH

INTERVIEW

SURVEY

U.S. Department

of Commerce

BUREAU OF THE

CENSUS

Field

Representative’s

Flashcard and

Information

Booklet (CAPI)

CARD H1

You may choose more than one.

1. Puerto Rican

2. Cuban/Cuban American

3. Dominican (Republic)

4. Mexican

5. Mexican American

6. Central or South American

7. Other Latin American

8. Other Hispanic/Latino/Spanish

CARD H2

You may choose more than one.

1. White

2. Black/African American

3. Indian (American)

4. Alaska Native

5. Native Hawaiian

6. Guamanian

7. Samoan

8. Other Pacific Islander

9. Asian Indian

10. Chinese

11. Filipino

12. Japanese

13. Korean

14. Vietnamese

15. Other Asian

CARD H3

2. Spouse (husband/wife)

3. Unmarried Partner

4. Child (biological/adoptive/in-law/

step/foster)

5. Child of Partner

6. Grandchild

7. Parent (biological/adoptive/in-law/

step/foster)

8. Brother/Sister (biological/adoptive/in-law/

step/foster)

9. Grandparent (Grandmother/Grandfather)

10. Aunt/Uncle

11. Niece/Nephew

12. Other relative

13. Housemate/Roommate

14. Roomer/Boarder

15. Other non-relative

16. Legal Guardian

17. Ward

CARD F1

You may choose more than one.

1. Vision/problem seeing

2. Hearing problem

3. Speech problem

4. Asthma/breathing problem

5. Birth defect

6. Injury

7. Mental retardation

8. Other developmental problem

(e.g., cerebral palsy)

9. Other mental, emotional, or behavioral

problem

10. Bone, joint, or muscle problem

11. Epilepsy or seizures

12. Learning disability

13. Attention Deficit/Hyperactivity

Disorder (ADD/ADHD)

Other impairment/problem

CARD F2

You may choose more than one.

1. Vision/problem seeing

2. Hearing problem

3. Arthritis/rheumatism

4. Back or neck problem

5. Fracture, bone/joint injury

6. Other injury

7. Heart problem

8. Stroke problem

9. Hypertension/high blood pressure

10. Diabetes

11. Lung/breathing problem (e.g., asthma

and emphysema)

12. Cancer

13. Birth defect

14. Mental retardation

15. Other developmental problem (e.g., cerebral palsy)

16. Senility

17. Depression/anxiety/emotional problem

18. Weight problem

Other impairment/problem

CARD F3

Beginning

1	2	3	4	5	6	7
8	9	10

M Middle iddle Middle			11	12	13	14
15	16	17	18	19	20

End						21
22	23	24	25	26	27	28
29	30	31

CARD F4

You may choose up to four.

Insert drawing of injured body parts here

Insert drawing of face here.

CARD F5

You may choose up to two.

4408. Broken bone or fracture

2. Sprain, strain, or twist

3. Cut

4. Scrape

5. Bruise

6. Burn

7. Insect bite

8. Animal bite

9. Other (specify)

CARD F6

4924. Passenger car

4925. Passenger truck, such as a pickup truck, van, or SUV

4926. Bus

4927. Large commercial truck, such as a semi-truck, big rig, or 18-wheeler

4928. Motorcycle (including mopeds, minibikes)

4929. All terrain vehicle or ski/snow-mobile

4930. Farm equipment (such as a tractor)

4931. Industrial or construction vehicle

4932. Other

CARD F7

You may choose up to two.

On, down, from, or into:

1. Stairs, steps, or escalator

2. Floor or level ground

3. Curb (including sidewalk)

4. Ladder or scaffolding

5. Playground equipment

6. Sports field, court, or rink

7. Building or other structure

8. Chair, bed, sofa, or other furniture

9. Bathtub, shower, toilet, or commode

10. Hole or other opening

11. Other

CARD F8

5964. Slipping or tripping

5965. Jumping or diving

5966. Bumping into an object or another person

5967. Being shoved or pushed by another person

5968. Losing balance or having dizziness (becoming faint or having a seizure)

5969. Other

CARD F9

1. Swallowing a drug or medical substance mistakenly or in overdose

2. Swallowing or touching a harmful solid or liquid substance

3. Inhaling harmful gases or vapors

4. Eating a poisonous plant or other substance

mistaken for food

5. Being bitten by a poisonous animal

6. Other (specify)

CARD F10

You may choose up to two.

1. Driving or riding in a motor vehicle

2. Working at a paid job

3. Working around the house or yard

4. Attending school

5. Unpaid work (such as volunteer work)

6. Sports and exercise

7. Leisure activity (excluding sports)

8. Sleeping, resting, eating, or drinking

9. Cooking

10. Being cared for (hands-on care from other person)

11. Other (specify)

CARD F11

You may choose up to two.

1. Home (inside)

2. Home (outside)

3. School (not residential)

4. Child care center or preschool

5. Residential institution (excluding hospital)

6. Health care facility (including hospital)

7. Street or highway

8. Sidewalk

9. Parking lot

10. Sport facility, athletic field, or playground

11. Shopping center, restaurant, store, bank, gas station, or other place of business

12. Farm

13. Park or recreation area (including bike or jog path)

14. River, lake, stream, or ocean

15. Industrial or construction area

16. Other public building

17. Other

CARD F12

You may choose more than one.

1. Private health insurance*

2. Medicare

3. Medi-Gap

4. Medicaid

5. SCHIP (CHIP/Children’s Health

Insurance Program)

5. Military health care

(TRICARE/VA/CHAMP-VA)

5. Indian Health Service

8. State-sponsored health plan

9. Other government program

10. Single service plan (e.g., dental, vision, prescriptions)

10. No coverage of any type

*EXCLUDE private plans that only provide

extra cash while hospitalized.

CARD F13

Insert picture of Medicare card here.

CARD F14

STATE NAMES FOR MEDICAID, CHIP, STATE-/LOCAL-SPONSORED, AND OTHER HEALTH INSURANCE PROGRAMS

Please find your state.

Note: Some Medicaid programs are called “Medical Assistance Program”, “Title 19" or “{State} Medicaid”, such as “Alabama Medicaid”. CHIP or S-CHIP programs can also be under “Title XXI Program” or “{State} CHIP”, such as “Pennsylvania CHIP”. The names provided below offer additional names for the public health insurance programs for each state.

ALABAMA	ALASKA	ARIZONA
Medicaid: Patient 1st; SOBRA,	Medicaid: Alaska Medicaid	Medicaid: AHCCCS; Arizona Health Care Cost Containment System; Baby Arizona; Healthy Arizona; SOBRA
CHIP: AL-Kids, ALL KIDS	CHIP: Denali KidCare,	CHIP: KidsCare
State/Other: Children’s Rehabilitation Service (CRS), Alabama Child Caring Plan, Alabama Health Insurance Plan (AHIP)	State/Other: Chronic and Acute Medical Assistance (CAMA); Health Care Program for Children with Special Health Care Needs (HCP-CSN); Alaska Comprehensive Health Insurance Association ACHIA)	State/Other: Medically Indigent - Medically Needy Program (MI/MN); Office for Children with Special Health Care Needs (CSHCN); Freedom to Work; Young Adults Transitional Insurance (YATI)
ARKANSAS	CALIFORNIA	COLORADO
Medicaid: ConnectCare ; Katie Beckett; TEFRA; ARKids First A; HIFA Waiver Safety Net Benefit Program	Medicaid: Medi-Cal; Health Insurance Premium Payment Program (HIPP)	Medicaid: Primary Care Physician Program (PCPP); BabyCare / KidsCare; Health Colorado
CHIP: ARKids First B	CHIP: Healthy Families Program (HFP)	CHIP: Child Health Plan Plus (CHP+); Childrens Basic Health Plan
State/Other: Arkansas Comprehensive Health Insurance Plan; Children’s Medical Services (CMS)	State/Other: Access for Infants & Mothers (AIM); County Medical Services Program (CMSP); California Children’s Services (CCS); Major Risk Medical Insurance Program (MRMIP); CARE Health Insurance Premium Payment Program; California Major Risk Medical Insurance Program; Healthy Kids Program	State/Other: Health Care Program for Children with Special Needs (HCP); CUHIP - Colorado Uninsurable Health Insurance Plan; CoverColorado; Colorado Indigent Care Program (CICP)

CONNECTICUT	DELAWARE	DISTRICT OF COLUMBIA
Medicaid: Medical Assistance Program; HUSKY Part A	Medicaid: Diamond State Health Plan;	Medicaid: Medical Assistance
CHIP: The HUSKY Plan; HUSKY PLUS, HUSKY Part B	CHIP: Healthy Children; Delaware Healthy Children Program (DHCP)	CHIP: DC Healthy Families; DC Healthy Kids
State/Other: Refugee Medical Assistance; Children with Special Health Care Needs; Connecticut Health Reinsurance Association (HRA); Connecticut Insurance Assistance Program for AIDS Patients (CIAPAP); State-Administered General Assistance Medical Aid (SAGA); Family Health Services Division (BCH)	State/Other: Children with Special Health Care Needs (CSHCN)	State/Other: Medical Charities Program; Health Services for Children with Special Needs; DC Healthcare Alliance
FLORIDA	GEORGIA	HAWAII
Medicaid: MediPass	Medicaid: Right from the Start (RSM); Health Insurance Premium Payment Program (HIPP); Katie Beckett / TEFRA; Georgia Healthy Families	Medicaid: Hawaii-QUEST
CHIP: KidCare ; MediKids; Florida Healthy Kids	CHIP: PeachCare for Kids; Georgia Healthy Families	CHIP: Hawaii CHIP
State/Other: AIDS Insurance Continuation Program (AICP); Florida Comprehensive Health Association; Children’s Medical Services (CMS)	State/Other: Children’s Medical Services (CMS); Indigent Care Trust Fund (ICTF)	State/Other: QUEST-Net; H-COBRA; Children with Special Health Needs

IDAHO	ILLINOIS	INDIANA
Medicaid: Healthy Connections; Medical Assistance	Medicaid: Medical Assistance; Healthy Start; Family Care; Parent Assist; Kidcare Assist; Kidcare Moms and Babies	Medicaid: Hoosier Healthwise; Risk Based Managed Care (RBMC); Medicaid Select
CHIP: Children’s Health Insurance Program; CHIP-A; CHIP-B; Access Card	CHIP: KidCare Share; KidCare Premium; Kidcare Rebate	CHIP: Hoosier Healthwise for Children; Children’s Health Plan; Benefit Package C
State/Other: Catastrophic Fund; Children’s Special Health Program (CSHP); Access to Health Insurance Program; Individual High Risk Reinsurance Pool Plan (HRP)	State/Other: Comprehensive Health Insurance Plan (ICHIP); Specialized Care for Children (DSCC); Health Care for Workers with Disabilities (HBWD); IL – Allkids	State/Other: Children’s Special Health Care Services (CSHCS); Indiana Comprehensive Health Insurance Association (ICHIA);
IOWA	KANSAS	KENTUCKY
Medicaid: Medical Assistance; Health Insurance Premium Payment (HIPP); MediPASS; Iowa Plan	Medicaid: HealthConnect; HealthWave 19; Kansas Medical Assistance Program (KMAP)	Medicaid: Kentucky Patient Access and Care System (KenPAC); KY HealthChoices; Global Choices
CHIP: Health and Well Kids in Iowa (HAWK-i)	CHIP: HealthWave 21	CHIP: Kentucky Children’s Health Insurance Program (KCHIP); Family Choices
State/Other: Children’s Health Specialty Clinics (CHSC); Iowa Comprehensive Health Association ; AIDS/HIV Health Insurance Premium Payment	State/Other: Medi-KAN (MKN); Services for Children with Special Health Care Needs (CSHSN); Kansas Uninsurable Health Insurance Plan; Kansas Health Insurance Association (KHIA)	State/Other: Kentucky HIV Health Insurance Assistance Program; Commission for Children with Special Health Care Needs; Kentucky Access

LOUISIANA	MAINE	MARYLAND
Medicaid: CommunityCARE; LaMoms	Medicaid: MaineCare	Medicaid: Medical Assistance Program; HealthChoice; REM Program; Community Choice
CHIP: LACHIP	CHIP: MaineCare	CHIP: Maryland Children’s Health Program (MCHP); HealthChoice
State/Other: Louisiana Health Plan; Children’s Special Health Services; Louisiana Health Insurance Association	State/Other: Children with Special Health Care Needs Program (CSHNP)	State/Other: AIDS Insurance Assistance Program (MAIAP); Children’s Medical Services (CMS); Primary Adult Care (PAC)
MASSACHUSETTS	MICHIGAN	MINNESOTA
Medicaid: MassHealth;	Medicaid: Medical Assistance Program; Healthy Kids; MICHOICE	Medicaid: Medical Assistance (MA)
CHIP: MassHealth	CHIP: MIChild Program	CHIP: Children’s Health Insurance Program
State/Other: Children’s Medical Security Plan (CMSP); Commonhealth; Medical Security Plan (MSP); Special Kids / Special Care; Insurance Partnership; Division of Special Health Care Needs; Uncompensated Care Pool (UCP)	State/Other: Children’s Special Health Care Services; Trust Fund for Children with Special Health Care Needs	State/Other: Minnesota Care; Minnesota General Assistance Medical Care Program (GAMC); HIV/AIDS Insurance Continuation Program; Minnesota Children with Special Health Care Needs (MCSHN); Minnesota Comprehensive Health Association (MCHA)

MISSISSIPPI	MISSOURI	MONTANA
Medicaid: Medicaid; Medical Assistance Program; Infant Survival Program	Medicaid: MO Healthnet; Managed Care Plus (MC+); MCPlus	Medicaid: Passport to Health
CHIP: Mississippi Children’s Health Insurance Program (CHIP)	CHIP: MO Healthnet for kids with premiums; MC+ for Kids;	CHIP: Montana’s CHIP
State/Other: Mississippi Comprehensive Health Insurance Risk Pool; Children with Special Health Care Needs	State/Other: General Relief Medical Assistance; Children with Special Health Care Needs; Missouri Health Insurance Pool (MHIP)	State/Other: Montana Comprehensive Health Insurance Association (MCHA); Health Insurance Continuum of Coverage Program (HICCP); Children’s Special Health Services (SHS)
NEBRASKA	NEVADA	NEW HAMPSHIRE
Medicaid: Medical Assistance Program; Nebraska Health Connection (NHC);	Medicaid: Nevada Medicaid; Child Assurance Program (CHAP)	Medicaid: New Hampshire Medicaid; Healthy Kids Gold
CHIP: Kids Connection	CHIP: Nevada Check Up	CHIP: Healthy Kids Silver
State/Other: Medically Handicapped Children’s Program (MHCP); Comprehensive Health Insurance Pool	State/Other: Family Health Services Bureau; Children with Special Health Care Needs	State/Other: Special Medical Services (SMSB); Healthy Kids Buy-in; Catastrophic Illness Program
NEW JERSEY	NEW MEXICO	NEW YORK
Medicaid: New Jersey Care 2000+; AIDS Community Care Alternatives (ACCAP);	Medicaid: SALUD!	Medicaid: The Partnership Plan; Medicaid;
CHIP: New Jersey Family Care/ New Jersey Kid Care	CHIP: New MexiKids	CHIP: Child Health Plus
State/Other: Health Insurance Continuation Program (HICP); Special Child Adult and Early Intervention Services (SCAEIS)	State/Other: Insurance Assistance Program; Children’s Medical Services (CMS); New Mexico Medical Insurance Pool (NMMIP); New Mexico Health Insurance Alliance (NMHIA); New Mexico State Coverage Insurance (NMSCI)	State/Other: Family Health Plus; FHPlus; Healthy New York; Physically Handicapped Children’s Program; Children with Special Health Care Needs Program (CSHCN); ADAP Plus Insurance Continuation Program (APIC)

NORTH CAROLINA	NORTH DAKOTA	OHIO
Medicaid: Carolina Access; HealthCare Connection; Access II; Access III; CCNC/CA	Medicaid: Primary Care Provider Program; Primary Care Case Management	Medicaid: Healthy Families, Healthy Start
CHIP: NC CHIP Program; NC Health Choice for Children (NCHC)	CHIP: Healthy Steps Program	CHIP: Healthy Start
State/Other: Title V Services for Children with Special Health Care Needs	State/Other: Comprehensive Health Association of North Dakota (CHAND); Children’s Special Health Services (CSHS)	State/Other: HIV Health Insurance Premium Payment Program (HIPP); Hemophilia Insurance Pilot Program; Bureau for Children with Medical Handicaps (BCMH)
OKLAHOMA	OREGON	PENNSYLVANIA
Medicaid: SoonerCare Plus; SoonerCare Choice	Medicaid: Oregon Health Plan (OHP)	Medicaid: Medical Assistance; Access Card; HealthChoices; Access Plus
CHIP: Oklahoma SCHIP	CHIP: Oregon SCHIP	CHIP: Pa CHIP
State/Other: Children with Special Health Care Needs (CSHCN); Oklahoma Health Insurance High Risk Pool; Oklahoma Employer/Employee Partnership for Insurance Coverage (O-EPIC)	State/Other: CareAssist; Oregon Services for Children with Special Health Needs; Oregon Medical Insurance Pool (OMIP); Family Health Insurance Assistance Program (FHIAP); Insurance Purchasing Cooperative; Child Development and Rehabilitation Center	State/Other: Title V Program; Bureau of Family Health; Health Insurance Premium Payment Program; Adult Basic

RHODE ISLAND	SOUTH CAROLINA	SOUTH DAKOTA
Medicaid: RIte Care; RI Medical Assistance; Katie Beckett	Medicaid: Healthy Connections; Healthy Options Program (HOP); Physicians Enhanced Program (PEP); South Carolina Partners for Health; Partners for Healthy Children (PHC);	Medicaid: Medical Assistance; Medicaid
CHIP: RIte Care	CHIP: Healthy Connections Kids	CHIP: CHIP
State/Other: Subsidy for Health Insurance for Center-Based Child-Care Providers; Office of Children with Special Health Care Needs (OCSHN); RIte share Premium Assistance Program; Child Care Provider Rite Care Program (CCPRC)	State/Other: South Carolina Health Insurance Pool; Children’s Rehabilitative Services (CRS); Medically Indigent Assistance Program (MIAP); Medically Fragile Children’s Program	State/Other: Catastrophic County-Poor Relief Program (CCPR); Continuation of Health Insurance; Children’s Special Health Services (CSHS); Refugee Medical Assistance; South Dakota Risk Pool; Disabled Children’s Program
TENNESSEE	TEXAS	UTAH
Medicaid: TennCare Medicaid	Medicaid: State of Texas Access Reform (STAR); Star+Plus	Medicaid: Medicaid
CHIP: TennCare Standard	CHIP: Texas CHIP	CHIP: Children’s Health Insurance Program
State/Other: Children’s Special Services (CSS); Tenncare Standard; Tenncare Assist	State/Other: Texas Health Insurance Risk Pool; State Kid Insurance Program (SKIP); Children with Special Health Care Needs (CSHCN)	State/Other: Utah’s Primary Care Network (PCN); Custody Medical Care Program; Children with Special Health Care Needs (CSHCN); Comprehensive Health Insurance Pool (HIPUtah); Health Insurance Continuation Program; Utah’s Premium Partnership for Health Insurance (UPP)

VERMONT	VIRGINIA	WASHINGTON
Medicaid: Medicaid; Primary Care Plus	Medicaid: Medicaid; Virginia Medallion; Medallion II	Medicaid: Apple Health for Kids; Family Medicaid; Healthy Options
CHIP: Dr. Dynasaur	CHIP: Family Access to Medical Insurance Security Plan (FAMIS); FAMIS Select	CHIP: Apple Health for Kids with premium
State/Other: Vermont Health Access Plan (VHAP); HIV Insurance Continuation Program (ICAP); Children with Special Health Needs (CSHN); Catamount Health (Premium Assistance Program)	State/Other: State and Local Hospitalization (SLH) Program; Care Connection for Children; Children with Special Health Care Needs (CSHCN)	State/Other: Basic Health; Children with Special Health Care Needs (CSHCN); Washington State Health Insurance Pool; Children’s Health Program (CHP); General Assistance Unemployable (GA-U); Healthcare for Workers with Disabilities (HWD)
WEST VIRGINIA	WISCONSIN	WYOMING
Medicaid: Medical Assistance; Mountain Health Trust (MHT); Mountain Health Choices; Physician Assured Access System (PAAS)	Medicaid: Medical Assistance MA, Wisconsin Medicaid, Healthy Start	Medicaid: Wyoming Medicaid; EqualityCare
CHIP: Children’s Health Insurance Program (CHIP); WVCHIP	CHIP: BadgerCare	CHIP: Wyoming Kid Care
State/Other: Children with Special Health Care Needs; Health Insurance Premium Payment Program (HIPP)	State/Other: Health Insurance Risk Sharing Program (HIRSP); Wisconsin AIDS/HIV Health Insurance Premium Subsidy Program; Children with Special Health Needs (CSHN); Children and Youth with Special Health Care Needs (CYSHCN)	State/Other: Wyoming Health Insurance Pool (WHIP); Children’s Special Health Services (CSH), Caring Program for Children

CARD F15

You may choose more than one.

8612. Accidents

8613. AIDS care

8614. Cancer treatment

8615. Catastrophic care

8616. Dental care

8617. Disability insurance (cash payments

when unable to work for health reasons)

8618. Hospice care

8619. Hospitalization only

8620. Long-term care (nursing home care)

8621. Prescriptions

8622. Vision care

8623. Other (specify)

CARD F16

1. Through employer

2. Through union

3. Through workplace, but don’t know if

employer or union

4. Through workplace, self-employed or

professional association

5. Purchased directly

6. Through a state/local government or

community program

7. Other (specify)

CARD F17

1. 6 months or less

2. More than 6 months, but not more than 1 year ago

3. More than 1 year, but not more than 3

years ago

4. More than 3 years

5. Never

CARD F18

You may choose up to five.

1. Person in family with health insurance

lost job or changed employers

2. Got divorced or separated/death

of spouse or parent

3. Became ineligible because of

age/left school

4. Employer does not offer coverage/

or not eligible for coverage

5. Cost is too high

6. Insurance company refused

coverage

7. Medicaid/Medical plan stopped

after pregnancy

8. Lost Medicaid/Medical plan

because of new job or increase

in income

9. Lost Medicaid (Other reason for losing Medicaid)

10. Other (specify)

CARD F19

0. Zero

1. Less than $500

2. $500 - $1,999

3. $2,000 - $2,999

4. $3,000 - $4,999

5. $5,000 or more

CARD F20

1. Yes, born in one of the 50 United States, or the District of Columbia

2. Yes, born in Puerto Rico, Guam, American Virgin Islands, or other U.S. territory

3. Yes, born abroad to American parent(s)

4. Yes, U.S. citizen by naturalization

4. No, not a citizen of the United States

CARD F21

0. Never attended/kindergarten only

1. 1st grade

2. 2nd grade

3. 3rd grade

4. 4th grade

5. 5th grade

6. 6th grade

7. 7th grade

8. 8th grade

9. 9th grade

10. 10th grade

11. 11th grade

12. 12th grade, no diploma

13. GED or equivalent

14. HIGH SCHOOL GRADUATE

15. Some college, no degree

16. Associate’s degree: occupational,

technical, or vocational program

17. Associate’s degree: academic program

18. Bachelor’s degree (Example: BA, AB, BS, BBA)

19. Master’s degree (Example: MA, MS, MEng, MEd, MBA)

20. Professional School degree (Example: MD, DDS, DVM, JD)

21. Doctoral degree (Example: Phd, EdD)

CARD F22

1. Working for pay at a job or business

2. With a job or business but not at work

3. Looking for work

4. Working, but not for pay, at a family-owned job or business

5. Not working at a job or business and not looking for work

F23

CARD F23-AL

ALABAMA

Note: Where there is more than one program,

an asterisk* denotes which most resembles TANF.

Family Assistance (FA) Program*

JOBS

CARD F23-AK

ALASKA

Alaska Temporary Assistance Program (ATAP)

CARD F23-AZ

ARIZONA

Cash Assistance Program

CARD F23-AR

ARKANSAS

Transitional Employment Assistance (TEA)

CARD F23-CA

CALIFORNIA

California Work Opportunity and Responsibility to Kids (CALWORKS)

CARD F23-CO

COLORADO

Colorado Works

CARD F23-CT

CONNECTICUT

Note: Where there is more than one program,

an asterisk* denotes which most resembles TANF.

Temporary Family Assistance (TFA)*

Jobs First

CARD F23-DE

DELAWARE

Temporary Assistance for Needy Families (TANF)

CARD F23-DC

DISTRICT OF COLUMBIA

Temporary Assistance for Needy Families (TANF)

CARD F23-FL

FLORIDA

Welfare Transition Program

CARD F23-GA

GEORGIA

Temporary Assistance for Needy Families (TANF)

CARD F23-HI

HAWAII

Temporary Assistance for Needy Families (TANF)

Temporary Assistance for Other Needy Families (TAONF)

CARD F23-ID

IDAHO

Temporary Assistance for Families in Idaho (TAFI)

CARD F23-IL

ILLINOIS

Temporary Assistance for Needy Families (TANF)

CARD F23-IN

INDIANA

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Temporary Assistance for Needy Families (TANF)*

Indiana Manpower Placement and Comprehensive Training (IMPACT)

CARD F23-IA

IOWA

Note: Where there is more than one program,

an asterisk* denotes which most resembles TANF.

Family Investment Program (FIP)*

PROMISE JOBS

CARD F23-KS

KANSAS

Note: Where there is more than one program,

an asterisk* denotes which most resembles TANF.

Temporary Assistance for Families (TAF)*

KansasWorks

CARD F23-KY

KENTUCKY

Kentucky Transitional Assistance Program (K-TAP)

CARD F23-LA

LOUISIANA

Note: Where there is more than one program,

an asterisk* denotes which most resembles TANF.

Family Independence Temporary Assistance Program (FITAP)*

Kinship Care Subsidy Program (KCSP)*

Strategies to Empower People (STEP)

CARD F23-ME

MAINE

Note: Where there is more than one program,

an asterisk* denotes which most resembles TANF.

Temporary Assistance for Needy Families (TANF)*

Additional Support for People in Retraining and Employment (ASPIRE)

CARD F23-MD

MARYLAND

Family Investment Program (FIP)

CARD F23-MA

MASSACHUSETTS

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Transitional Aid to Families with Dependent Children (TAFDC)*

Employment Services Program (ESP)

CARD F23-MI

MICHIGAN

Family Independence Program (FIP)

CARD F23-MN

MINNESOTA

Minnesota Family Investment Program (MFIP)

CARD F23-MS

MISSISSIPPI

Temporary Assistance for Needy Families (TANF)

CARD F23-MO

MISSOURI

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Temporary Assistance*

Beyond Welfare

CARD F23-MT

MONTANA

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Temporary Assistance for Needy Families (TANF)*

JOBS

CARD F23-NE

NEBRASKA

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Aid to Dependent Children (ADC)*

Employment First

CARD F23-NV

NEVADA

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Temporary Assistance for Needy Families (TANF)*

New Employees of Nevada (NEON)

CARD F23-NH

NEW HAMPSHIRE

Family Assistance Program (FAP)

New Hampshire Employment Program (NHEP)

CARD F23-NJ

NEW JERSEY

Work First New Jersey (WFNJ)

CARD F23-NM

NEW MEXICO

NMWorks

CARD F23-NY

NEW YORK

Family Assistance (FA) Program

CARD F23-NC

NORTH CAROLINA

Work First

CARD F23-ND

NORTH DAKOTA

Temporary Assistance for Needy Families (TANF)

Training, Employment, Education Management (TEEM)

CARD F23-OH

OHIO

Ohio Works First (OWF)

CARD F23-OK

OKLAHOMA

Temporary Assistance for Needy Families (TANF)

CARD F23-OR

OREGON

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Temporary Assistance for Needy Families (TANF)*

Jobs for Oregon’s Future (JOBS)

CARD F23-PA

PENNSYLVANIA

Temporary Assistance for Needy Families (TANF)

CARD F23-RI

RHODE ISLAND

Family Independence Program (FIP)

CARD F23-SC

SOUTH CAROLINA

Family Independence

CARD F23-SD

SOUTH DAKOTA

Temporary Assistance for Needy Families (TANF)

CARD F23-TN

TENNESSEE

Families First

CARD F23-TX

TEXAS

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Temporary Assistance for Needy Families (TANF)*

CARD F23-UT

UTAH

Family Employment Program (FEP)

CARD F23-VT

VERMONT

Aid to Needy Families with Children (ANFC)*

Reach UP

CARD F23-VA

VIRGINIA

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Temporary Assistance for Needy Families (TANF)*

Virginia Initiative for Employment not Welfare (VIEW)

CARD F23-WA

WASHINGTON

Note: Where there is more than one program, an

asterisk* denotes which most resembles TANF.

Temporary Assistance for Needy Families (TANF)*

WorkFirst

CARD F23-WV

WEST VIRGINIA

West Virginia Works

CARD F23-WI

WISCONSIN

Wisconsin Works (W-2)

CARD F23-WY

WYOMING

Personal Opportunities with Employment Responsibility (POWER)

CARD C1

1. Parent (Biological, adoptive or step)

2. Grandparent

3. Aunt/Uncle

4. Brother/Sister

5. Other relative

6. Legal Guardian

7. Foster parent

8. Other non-relative

CARD C2

You may choose more than one.

1. Down syndrome

2. Cerebral palsy

3. Muscular dystrophy

4. Cystic fibrosis

5. Sickle cell anemia

6. Autism

7. Diabetes

8. Arthritis

9. Congenital heart disease

10. Other heart condition

CARD C3

0. Not true

1. Sometimes true

2. Often true

CARD C4

0. Never

1. 6 months or less

2. More than 6 months, but not more than 1 year ago

3. More than 1 year, but not more than 2 years ago

4. More than 2 years, but not more than 5 years ago

5. More than 5 years ago

CARD C5

0. None

1. 1

2. 2 - 3

3. 4 - 5

4. 6 - 7

5. 8 - 9

6. 10 - 12

7. 13 - 15

8. 16 or more

CARD C6

1. 1

2. 2 - 3

3. 4 - 5

4. 6 - 7

5. 8 - 9

6. 10 - 12

7. 13 - 15

8. 16 or more

CARD C7

1. Not true

2. Somewhat true

3. Certainly true

CARD C8

Overall, do you think that this child has difficulties in any of the following areas: emotions, concentration, behavior, or being able to get along with other people?

1. No

2. Yes, minor difficulties

3. Yes, definite difficulties

4. Yes, severe difficulties

CARD C9

1. School counselor, school nurse or school social worker

2. Speech, occupational or physical therapist

3. Psychiatrist, psychologist, social worker, psychiatric nurse

4. Pediatrician or family doctor

5. Acupuncturist, massage therapist, chiropractor

6. Religious or spiritual counselor

7. Probation or juvenile corrections officer of court counselor

8. Other

CARD A1

1. Working for pay at a job or business

2. With a job or business but not at work

3. Looking for work

4. Working, but not for pay, at a family-owned job or business

5. Not working at a job or business and not looking for work

CARD A2

1. An employee of a PRIVATE company,

business, or individual for wages,

salary, or commission

2. A FEDERAL government employee

3. A STATE government employee

4. A LOCAL government employee

5. Self-employed in OWN business,

professional practice or farm

6. Working WITHOUT PAY in

family-owned business or farm

CARD A3

1. 1-9 employees

2. 10-24 employees

3. 25-49 employees

4. 50-99 employees

5. 100-249 employees

6. 250-499 employees

7. 500-999 employees

8. 1000 employees or more

Card A4

You may choose more than one.

Place drawing of joints here.

CARD A5

1. ALL of the time

2. MOST of the time

3. SOME of the time

4. A LITTLE of the time

5. NONE of the time

CARD A6

0. Not at all difficult

1. Only a little difficult

2. Somewhat difficult

3. Very difficult

4. Can't do at all

6. Do not do this activity

CARD A7

You may choose more than one.

1. Vision/problem seeing

2. Hearing problem

3. Arthritis/rheumatism

4. Back or neck problem

5. Fracture, bone/joint injury

6. Other injury

7. Heart problem

8. Stroke problem

9. Hypertension/high blood pressure

10. Diabetes

11. Lung/breathing problem (e.g., asthma and

emphysema)

12. Cancer

13. Birth defect

14. Mental retardation

15. Other developmental problem

(e.g., cerebral palsy)

16. Senility

17. Depression/anxiety/emotional problem

18. Weight problem

Other impairment/problem

CARD A8

0. Never

1. 6 months or less

2. More than 6 months, but not more than 1 year ago.

3. More than 1 year, but not more than 2 years ago

4. More than 2 years, but not more than 5 years ago

5. More than 5 years ago

CARD A9

0. None

1. 1

2. 2-3

3. 4-5

4. 6-7

5. 8-9

6. 10-12

7. 13-15

8. 16 or more

CARD A10

1. 1

2. 2-3

3. 4-5

4. 6-7

5. 8-9

6. 10-12

7. 13-15

8. 16 or more

CARD A11

1. It's unlikely you've been exposed to HIV

2. You were afraid to find out if you were HIV positive (that you had HIV)

3. You didn't want to think about HIV or about being HIV positive

4. You were worried your name would be reported to the government if you tested positive

5. You didn't know where to get tested

6. You don't like needles

7. You were afraid of losing job, insurance, housing, friends, family, if people knew you were

positive for AIDS infection

8. Some other reason (specify)

9. No particular reason

CARD A12

1. Someone suggested you should be tested

2. You might have been exposed through sex or drug use

3. You might have been exposed through your work or at work

4. You just wanted to find out if you were infected or not

5. For part of a routine medical check-up, or for

hospitalization or surgical procedure

6. You were sick or had a medical problem

7. You were pregnant or delivered a baby

8. For health or life insurance coverage

9. For military induction, separation, or

military service

10. For immigration

11. For marriage license or to get married

12. You were concerned you could give HIV

to someone

13. You wanted medical care or new

treatments if you tested positive

14. Some other reason (specify)

15. No particular reason

CARD A13

1. Private doctor/HMO

2. AIDS clinic/counseling/testing site

3. Hospital, emergency room,

outpatient clinic

4. Other type of clinic

5. Public health department

6. At home

7. Drug treatment facility

8. Military induction or military

service site

9. Immigration site

10. In a correctional facility (jail or

prison)

11. Other location (specify)

CARD A14

a. You have hemophilia and have

received clotting factor

concentrations

b. You are a man who has had sex with

other men, even just one time

c. You have taken street drugs by

needle, even just one time

d. You have traded sex for money or

drugs, even just one time

e. You have tested positive for HIV,

(the virus that causes AIDS)

f. You have had sex (even just one

time) with someone who would

answer "yes" to any of these

statements

CARD A15

You may choose more than one.

1. Breathing the air around a person

who is sick with TB

2. Sharing eating/drinking utensils

3. Through semen or vaginal

secretions shared during sexual

intercourse

4. From smoking

5. From mosquito or other insect bites

6. Other