Form 3f Family Health Insurance--Health Care Reform

Attachment 3f Supplements (18 minutes)
Page 1 of 6

2011 NHIS Questionnaire - Family
Family Health Insurance-Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

FHI.202_01.010

Instrument Variable Name:

PRPOLH

QuestionnaireFileName:

Family

How [fill1:are you/is ALIAS] related to the policyholder for [fill2: plan1/plan2/plan3/plan4]?

QuestionText:

[fill3:You are/ALIAS is} the policyholder’s…
Child (including stepchildren)
Spouse
Former spouse
Some other relationship
Refused
Don't know

1
2
3
4
7
9
UniverseText:

All persons on each plan where the policyholder is outside of the family roster

SkipInstructions:

<1-4,R,D> [goto PLNWRK]
NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a
family. Information on up to 4 plans per family is collected.

Question ID:

FHI.204_01.010

Instrument Variable Name:

PRCOOH

QuestionnaireFileName:

Family

QuestionText:

Does this plan cover anyone who does not live here?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

All private health insurance plans with policyholder on family roster

SkipInstructions:

<1 > [goto PRCTOH]
<2,R,D> [goto PLNWRK]

Question ID:

FHI.205_01.010

QuestionText:
01-30
97
99

Instrument Variable Name:

PRCTOH

QuestionnaireFileName:

Family

How many people does this plan cover who live somewhere else?
1-30 people
Refused
Don't know

UniverseText:

All private health insurance plans with policyholder on family roster that cover someone outside the family roster

SkipInstructions:

<1-30 > [goto PRRELOH]
[goto PLNWRK]

Page 2 of 6

2011 NHIS Questionnaire - Family
Family Health Insurance-Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

FHI.206_01.010

Instrument Variable Name:

PRRELOH

QuestionnaireFileName:

Family

What is the relationship of [fill1: this person/these persons] to the policyholder?

QuestionText:

*Read if necessary: Children includes adult children.
*Enter all that apply, separate with commas.
Child/Children (including stepchildren)
Spouse
Former spouse
Some other relationship
Refused
Don't know

1
2
3
4
7
9

All private health insurance plans with policyholder on family roster that cover someone outside the family roster

UniverseText:
SkipInstructions:

Question ID:

<1 > [goto PRCNUM]
<2-4,R,D> [goto PLNWRK]

FHI.207_01.010

Instrument Variable Name:

PRCNUM

QuestionnaireFileName:

Family

How many children are covered who live elsewhere?

QuestionText:

*If more than 10 children, enter '10'.
1-10 children
Refused
Don’t know

01-10
97
99
UniverseText:

All private health insurance plans with policyholder on family roster that cover a child or children not on the roster

SkipInstructions:

<01-10> [goto PRAGEOH1]
[goto PLNWRK]

Question ID:

FHI.208_01.010

Instrument Variable Name:

PRAGEOH1

QuestionnaireFileName:

Family

How old is {fill1: this child/the first child}?

QuestionText:

0-100 years
Refused
Don't know

000-100
997
999
UniverseText:

All private health insurance plans with policyholder on family roster that cover one or more children not on the roster

SkipInstructions:

<000-100,R,D> if PRCNUM GE 2 [goto PRAGEOH2] else [goto PLNWRK]

Question ID:

FHI.208_02.010

QuestionText:
000-100
997
999

Instrument Variable Name:

PRAGEOH2

QuestionnaireFileName:

Family

How old is the next child?
0-100 years
Refused
Don't know

UniverseText:

All private health insurance plans with policyholder on family roster that cover one or more children not on the roster

SkipInstructions:

<000-100,R,D> if PRCNUM GE 3 [goto PRAGEOH3] (repeat for up to 10 children); else [goto PLNWRK]

Page 3 of 6

2011 NHIS Questionnaire - Family
Family Health Insurance-Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

FHI.235_00.010

QuestionText:

Instrument Variable Name:

EMPPAY

QuestionnaireFileName:

Family

Do you know how much the employer or union is paying for [fill1: plan1/plan2/plan3/plan4]?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

All private health insurance plans paid for by employer or union

SkipInstructions:

<1> [goto EMPCOSTN] <2,R,D> [goto PLNMGD]

Question ID: FHI.237_01.010
QuestionText:

EMPCOSTN

Instrument Variable Name:

QuestionnaireFileName: Family

1 of 2
How much does the employer or union currently pay for health insurance premiums for [fill1: Plan 1/Plan 2/Plan 3/Plan 4]?
*Enter dollar amount for premium payments.
*Enter ‘ZZ’ to go to percentage format.

00001-99995

$1-$99,995

99997 Refused

99999 Don't know

UniverseText: All private health insurance plans where amount of premium employer/union pays is known
SkipInstructions:

<1-99995> [goto EMPCOSTT]
[store "R" in EMPCOSTT and goto PLNMGD] [store "D" in EMPCOSTT and goto PLNMGD] [goto EMPCOSTP]

Question ID: FHI.237_02.020
QuestionText:

Instrument Variable Name:

EMPCOSTT

1 of 2
* Enter time period for premium payments.

01

Once a week

02

Once every 2 weeks

03

Once a month

04

Twice a month

05

Every 2 months

06

Quarterly (every 3 months)

07

Once a year

08

Twice a year
Refused
Don’t know

UniverseText:
SkipInstructions:

All private health insurance plans with a valid response to EMPCOSTN
goto PLNMGD

QuestionnaireFileName: Family

Page 4 of 6

2011 NHIS Questionnaire - Family
Family Health Insurance-Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

FHI.237_03.000

Instrument Variable Name:

EMPCOSTP

QuestionnaireFileName:

Family

What percent of the premiums does the employer or union pay for [fill1: Plan 1/Plan 2/Plan 3/Plan 4]?

QuestionText:

1-100%
Refused
Don't know

001-100
997
999
UniverseText:

All private health insurance plans paid for by employer or union where respondent wanted to report percentage of premium paid

SkipInstructions:

<1-100,R,D> [goto PLNMGD]

Question ID:

FHI.248_05.000

Instrument Variable Name:

PCPREQ

QuestionnaireFileName:

Family

Does this plan REQUIRE [fill1: you/ALIAS/the family members with this plan] to have a primary care doctor or group of
doctors for all routine care?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

All private health insurance plans

SkipInstructions:

<1,2,R,D> [goto PRRXCOV]

Question ID:

FHI.249_03.010

Instrument Variable Name:

FCOVCONF

QuestionnaireFileName:

Family

If [fill1: you/your family] had to buy a health plan on [fill3: your/their] own with no help from [fill 2: your/an] employer, how confident are
you that [fill4: you/your family] would be able to obtain affordable coverage? Would you say…

QuestionText:

*Read categories below.
Very confident
Somewhat confident
Not too confident
Not confident at all
Refused
Don’t know

1
2
3
4
7
9
UniverseText:
SkipInstructions:

Question ID:

All families with a employment-based health plan
<1-4,R,D> [goto STNAME1]

FHI.312_00.010

QuestionText:
1
2
7
9

Instrument Variable Name:

FHICHNG

QuestionnaireFileName:

Did [fill1: you/ALIAS] have [fill2: type of health insurance coverage] for the past 12 months?
Yes
No
Refused
Don't know

UniverseText:

All persons who are currently insured who were continuously covered in the past year

SkipInstructions:

<1,R,D> [goto HCSPFYR]

<2> [goto FHIKDB]

Family

Page 5 of 6

2011 NHIS Questionnaire - Family
Family Health Insurance-Health Care Reform
Document Version Date: 18-Nov-10

Question ID: FHI.315_00.010

Instrument Variable Name:

FHIKDB

QuestionnaireFileName:

Family

(book) F12 and (book) F14

QuestionText:

If person is currently uninsured:
{Think about the last time [fill1: you/ALIAS] had health insurance or health care coverage. What type did [fill1:
you/ALIAS] have?}
If person had a period without coverage in the past year:
{I recorded that [fill1: you/ALIAS] had a period without health insurance in the past year. What type of health insurance or
coverage did [fill1: you/ALIAS] have before this period?}
If person had a change in coverage type in the past year:
{What other types of health insurance or health care coverage did [fill1: you/ALIAS] have?}
*Enter all that apply, separate with commas.
Private health insurance
Medicare
Medi-Gap
Medicaid
CHIP (SCHIP/Children's Health Insurance Program)
Military health care (TRICARE/VA/CHAMP-VA)
Indian Health Service
State-sponsored health plan
Other government program
Single service plan (e.g., dental, vision, prescriptions)
No coverage of any type
Refused
Don't know

01
02
03
04
05
06
07
08
09
10
11
97
99
UniverseText:

All persons who are currently uninsured for less than a year

SkipInstructions:

<1> [goto PWRKB]
<2-11,R,D> [goto HCSPFYR]

Question ID:

FHI.316_00.010

QuestionText:
01
02
03
04
05
06
07
97
99

Instrument Variable Name:

PWRKB

QuestionnaireFileName:

Family

Which one of these categories best describes how [fill1: your/ALIAS’s] private health insurance was obtained?
Through employer
Through union
Through workplace, but don't know if employer or union
Through workplace, self-employed or professional association
Purchased directly
Through a state/local government or community program
Other, specify
Refused
Don’t know

UniverseText:

All persons who had previous private health insurance

SkipInstructions:

<1-7,R,D> [goto HCSPFYR]

Page 6 of 6

DRAFT 2011 NHIS Questionnaire - Family
Family Health Insurance-Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

FHI.317_00.010

PWRKBSP QuestionnaireFileName:

Instrument Variable Name:

Family

*Enter how private health insurance was obtained.

QuestionText:

Verbatim response_____________
All persons who had previous private health insurance obtained from other source

UniverseText:
SkipInstructions:

Question ID:

[goto HCSPFYR]

FHI.325_00.010

Instrument Variable Name:

Family

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

All families

SkipInstructions:

<1,2,7,9> [goto MEDBPAY]

FHI.327_00.010

Instrument Variable Name:

MEDBPAY

QuestionnaireFileName:

Family

[fill 1: Do you/Does anyone in your family] currently have any medical bills that are being paid off over time?
This could include medical bills being paid off with a credit card, through personal loans, or bill paying arrangements
with hospitals or other providers. The bills can be from earlier years as well as this year.

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

All families

SkipInstructions:

<1,2,7,9> if MEDBILL=2 [goto FSA]; else [goto MEDBNOP]

Question ID:

QuestionnaireFileName:

In the past 12 months did [fill1: you/your family] have problems paying or were unable to pay
any medical bills? Include bills for doctors, dentists, hospitals, therapists, medication, equipment,
nursing home or home care.

QuestionText:

Question ID:

MEDBILL

FHI.327_00.020

QuestionText:
1
2
7
9

Instrument Variable Name:

MEDBNOP

QuestionnaireFileName:

Family

[fill 1: Do you/Does anyone in your family] currently have any medical bills that you are unable to pay at all?
Yes
No
Refused
Don't know

UniverseText:

All families other than those who don’t have problems paying medical bills

SkipInstructions:

<1,2,7,9> [goto FSA]

Page 1 of 6

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization-Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

CAU.050_00.010

Instrument Variable Name:

CNOUSLPL

QuestionnaireFileName:

Sample Child

QuestionnaireFileName:

Sample Child

Why doesn’t [fill: alias] have a usual source of medical care?

QuestionText:

*Enter all that apply, separate with commas.
Doesn’t need a doctor/Haven't had any problems
Doesn’t like/trust/believe in doctors
Doesn’t know where to go
Previous doctor is not available/moved
Too expensive/no insurance/cost
Speak a different language
No care available/Care too far away, not convenient
Put it off/Didn't get around to it
Other
Refused
Don't know

01
02
03
04
05
06
07
08
09
97
99

Sample children <18 without a place of usual care

UniverseText:
SkipInstructions:

Question ID:

<1-9,R,D>[goto CPRVTRYR]

CAU.052_00.010 Instrument Variable Name:

CPRVTRYR

DURING THE PAST 12 MONTHS, did you have any trouble finding a general doctor or provider who would see [fill: alias]?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <18

SkipInstructions:

<1> [goto CPRVTRFD ] <2,R,D> [goto CDRNANP]

Question ID:

CAU.053_00.010 Instrument Variable Name:

QuestionText:
1
2
7
9

CPRVTRFD

QuestionnaireFileName:

Were you able to find a general doctor or provider who could see [fill: alias]?
Yes
No
Refused
Don’t know

UniverseText:

Sample children <18 who had trouble finding a provider in the last year

SkipInstructions:

<1,2,R,D> [goto CDRNANP]

Sample Child

Page 2 of 6

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization-Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

CAU.055_00.010

QuestionText:

DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that they would not accept [fill: alias] as a new patient?

Instrument Variable Name:

UniverseText:

Sample children <18

SkipInstructions:

<1,2,R,D>[goto CDRNAI]

CAU.056_00.010 Instrument Variable Name:

CDRNAI

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that they did not accept [fill: alias]'s health care
coverage?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:
SkipInstructions:

Question ID:

Sample Child

Yes
No
Refused
Don't know

1
2
7
9

Question ID:

CDRNANP QuestionnaireFileName:

Sample children <18
<1,2,R,D>[goto CHCDLYR_1]

CAU.133_00.010 Instrument Variable Name:

QuestionText:

1
2
7
9
UniverseText:
SkipInstructions:

CHCAFYRN

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it
because you couldn't afford it...To see a specialist?
Yes
No
Refused
Don't know
Sample children <2
<1,2,R,D> [goto CHCAFYRF]

Question ID:

CAU.133_00.020

Instrument Variable Name: CHCAFYRF

QuestionnaireFileName: Sample Child

QuestionText:

DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it
because you couldn't afford it...
Follow-up care?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children <2

SkipInstructions:

<1,2,R,D> [if AGE <1 goto CHCSYR1_2; else goto CDENLONG]

Page 3 of 6

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization--Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

CAU.135_05.010 Instrument Variable Name:

CHCAFYR1_6

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it
because you couldn't afford it...
To see a specialist?
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children GE 2

SkipInstructions:

<1,2,R,D> [goto CHCAFYR1_7]

Question ID:

CAU.135_06.010 Instrument Variable Name:

QuestionText:

CHCAFYR1_7

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] NEEDED any of the following, but didn't get it
because you couldn't afford it...
Follow-up care?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children GE 2

SkipInstructions:

<1,2,R,D> [goto CDENLONG]

Question ID: CAU.281_00.010 Instrument Variable Name: CERVISND
QuestionText:

1
2
7
9

QuestionnaireFileName:

Sample Child

Thinking about [fill: S.C. name]'s most recent emergency room visit, did [fill: he/she] go to the emergency room either at night
or on the weekend?
Yes
No
Refused
Refused

UniverseText:

Sample children <18 who had at least one ER visit in the past year

SkipInstructions:

<1,2,R,D> [go to CERHOS]

Page 4 of 6

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization--Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

CAU.282_00.010 Instrument Variable Name:

CERHOS

QuestionnaireFileName:

Did this emergency room visit result in a hospital admission?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <18 who had at least one ER visit in the past year

SkipInstructions:

<1,R,D> [goto CHCHYR] < 2> [go to CERREAS1]

Question ID:

Sample Child

CAU.283_01.010 Instrument Variable Name:

QuestionText:

CERREAS1

QuestionnaireFileName:

Sample Child

Tell me which of these apply to [fill: alias] last emergency room visit?
… [fill: alias] didn’t have another place to go

1
2
7
9

Yes
No
Refused
Don’t know

UniverseText:

Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission

SkipInstructions:

<1,2,R,D> [goto CERREAS2]

Question ID:

CAU.283_02.020

Instrument Variable Name: CERREAS2

QuestionText:

*Read lead-in if necessary.

QuestionnaireFileName:

Sample Child

Tell me which of these apply to [fill: alias] last emergency room visit?
… [fill: alias] doctor’s office or clinic was not open
1
2
7
9

Yes
No
Refused
Don’t know

UniverseText:

Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission

SkipInstructions:

<1,2,R,D> [goto CERREAS3]

Page 5 of 6

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization--Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

CAU.283_03.030 Instrument Variable Name:

CERREAS3

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary.

QuestionText:

Tell me which of these apply to [fill: alias] last emergency room visit?
… [fill: alias] health provider advised that [fill: he/she] go
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission

SkipInstructions:

<1,2,R,D> [goto CERREAS4]

Question ID:

CAU.283_04.040 Instrument Variable Name:

CERREAS4

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary.

QuestionText:

Tell me which of these apply to [fill: alias] last emergency room visit?
… The problem was too serious for the doctor’s office or clinic
Yes
No
Refused
Don’t' know

1
2
7
9
UniverseText:

Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission

SkipInstructions:

<1,2,R,D> [goto CERREAS5]

Question ID:

CAU.283_05.050

QuestionText:

Instrument Variable Name:

CERREAS5

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary.
Tell me which of these apply to [fill: alias] last emergency room visit?
… Only a hospital could help [fill: alias]

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission

SkipInstructions:

<1,2,R,D> [goto CERREAS6]

Page 6 of 6

2011 NHIS Questionnaire - Sample Child
Child Access to Health Care & Utilization--Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

CAU.283_06.060 Instrument Variable Name:

CERREAS6

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary.

QuestionText:

Tell me which of these apply to [fill: alias] last emergency room visit?
… the emergency room is [fill: alias]'s closest provider
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission

SkipInstructions:

<1,2,R,D> [goto CERREAS7]

Question ID:

CAU.283_07.070 Instrument Variable Name:

CERREAS7

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary.

QuestionText:

Tell me which of these apply to [fill: alias] last emergency room visit?
…[fill: alias] gets most of [fill: his/her] care at the emergency room
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission

SkipInstructions:

<1,2,R,D> [goto CERREAS8]

Question ID:

CAU.283_08.080 Instrument Variable Name:

QuestionText:

CERREAS8

QuestionnaireFileName:

Sample Child

*Read lead-in if necessary.
Tell me which of these apply to [fill: alias] last emergency room visit?
…[fill: alias] arrived by ambulance or other emergency vehicle

1
2
7
9

Yes
No
Refused
Don’t know

UniverseText:

Sample children <18 who had at least one ER visit in the past year which did not result in a hospital admission

SkipInstructions:

<1,2,R,D> [goto CHCHYR]

Page 1 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization--Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

AAU.050_00.010

ANOUSLPL

Instrument Variable Name:

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

Why don’t you have a usual source of medical care?

QuestionText:

*Enter all that apply, separate with commas.
Doesn’t need a doctor/Haven't had any problems
Doesn’t like/trust/believe in doctors
Doesn’t know where to go
Previous doctor is not available/moved
Too expensive/no insurance/cost
Speak a different language
No care available/Care too far away, not convenient
Put it off/Didn't get around to it
Other
Refused
Don't know

01
02
03
04
05
06
07
08
09
97
99

Sample adults 18+ without a place of usual care

UniverseText:
SkipInstructions:

Question ID:

AAU.051_00.010

Instrument Variable Name: APRVTRYR

DURING THE PAST 12 MONTHS, did you have any trouble finding a general doctor or provider who would see you?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+

UniverseText:
SkipInstructions:

Question ID:

<1-9,R,D>[goto APRVTRYR]

<1> [goto APRVTRFD ] <2,R,D>[goto ADRNANP]

AAU.053_00.010 Instrument Variable Name:

QuestionText:
1
2
7
9
UniverseText:
SkipInstructions:

APRVTRFD

Were you able to find a general doctor or provider who could see you?
Yes
No
Refused
Don't know
Sample adults 18+ who had trouble finding a provider
<1,2,R,D>[goto ADRNANP]

QuestionnaireFileName:

Sample Adult

Page 2 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization--Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

AAU.057_00.010

Sample Adult

Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+

UniverseText:
SkipInstructions:

<1,2,R,D>[goto ADRNAI]

AAU.059_00.010

Instrument Variable Name:

ADRNAI

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that they did not accept your health care coverage?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+

UniverseText:
SkipInstructions:

Question ID:

QuestionnaireFileName:

DURING THE PAST 12 MONTHS, were you told by a doctor’s office or clinic that they would not accept you as a new patient?

QuestionText:

Question ID:

Instrument Variable Name: ADRNANP

<1,2,R,D>[goto AHCDLY_1]

AAU.111_05.010 Instrument Variable Name:

QuestionText:

AHCAFY_5

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
DURING THE PAST 12 MONTHS, was there any time when you needed any of the following, but didn't get it because
you couldn't afford it?
...To see a specialist.

1
2
7
9

Yes
No
Refused
Don’t know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCAFY_6]

Page 3 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization--Health Care Reform
Document Version Date: 18-Nov-10

AAU.111_06.010

Question ID:

Instrument Variable Name: AHCAFY_6

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.

QuestionText:

DURING THE PAST 12 MONTHS, was there any time when you needed any of the following, but didn't get it because
you couldn't afford it?
...Follow-up care.
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AWORPAY]

Question ID:

AAU.113_00.010 Instrument Variable Name:

QuestionnaireFileName:

Sample Adult

If you get sick or have an accident, how worried are you that you will be able to pay your medical bills? Are you very worried, somewhat
worried, or not at all worried?

QuestionText:

Very worried
Somewhat worried
Not at all worried
Refused
Don't know

1
2
3
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,3,R,D>[goto AHICOMP]

Question ID:

AWORPAY

AAU.113_00.020 Instrument Variable Name:

QuestionText:

1
2
3
7
9

AHICOMP

QuestionnaireFileName:

Sample Adult

In regard to your health insurance or health care coverage, how does it compare to a year ago? Is it better, worse, or about the
same?
Better
Worse
About the same
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,3,R,D>[goto ARXPR_1]

Page 4 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization--Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

AAU.127_01.010

Instrument Variable Name: ARXPR_1

QuestionText:

The following questions concern the use of prescription medication DURING THE PAST 12 MONTHS, are any of the
following true for you?

QuestionnaireFileName:

Sample Adult

…You skipped medication doses to save money
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto ARXPR_2]

Question ID:

AAU.127_02.010 Instrument Variable Name:

ARXPR_2

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary

QuestionText:

The following questions concern the use of medication DURING THE PAST 12 MONTHS, are any of the following true for
you?
…you took less medicine to save money
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto ARXPR_3]

Question ID:

AAU.127_03.010 Instrument Variable Name:

QuestionText:

ARXPR_3

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary
The following questions concern the use of medication DURING THE PAST 12 MONTHS, are any of the following true for
you?
…You delayed filling a prescription to save money

1
2
7
9
UniverseText:
SkipInstructions:

Yes
No
Refused
Don't know
Sample adults 18+
<1,2,R,D>[goto ARXPR_4]

Page 5 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization--Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

AAU.127_04.010

Instrument Variable Name:

ARXPR_4

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.

QuestionText:

The following questions concern the use of medication DURING THE PAST 12 MONTHS, are any of the following true for
you?
…You asked your doctor for a lower cost medication to save money.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto ARXPR_5]

Question ID:

AAU.127_05.010 Instrument Variable Name:

ARXPR_5

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.

QuestionText:

The following questions concern the use of medication DURING THE PAST 12 MONTHS, are any of the following true for
you?
…You bought prescription drugs from another country to save money.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto ARXPR_6]

Question ID:

AAU.127_06.010 Instrument Variable Name:

QuestionText:

ARXPR_6

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
The following questions concern the use of medication DURING THE PAST 12 MONTHS, are any of the following true for
you?
…You used alternative therapies to save money.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto ADENLONG]

Page 6 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization--Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

AAU.243_00.010 Instrument Variable Name:

AERVISND

Thinking about your most recent emergency room visit, did you go to the emergency room either at night or on the weekend?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+ who had at least one ER visit in the past year

SkipInstructions:

<1,2,R,D> [go to AERHOS]

Question ID:

AAU.245_00.010 Instrument Variable Name:

AERHOS

QuestionnaireFileName: Sample Adult

Did this emergency room visit result in a hospital admission?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+ who had at least one ER visit in the past year

SkipInstructions:

<1,R,D> [goto AHCHYR] < 2> [go to AERREAS1]

Question ID:

QuestionnaireFileName: Sample Adult

AAU.248_01.010 Instrument Variable Name:

QuestionText:

AERREAS1

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?
… You didn't have another place to go

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital
admission

SkipInstructions:

<1,2,R,D> [goto AERREAS2]

Page 7 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization--Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

AAU.248_02.020 Instrument Variable Name:

AERREAS2

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?

QuestionText:

… Your doctor’s office or clinic was not open
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital
admission

SkipInstructions:

<1,2,R,D> [goto AERREAS3]

Question ID:

AAU.248_03.030 Instrument Variable Name:

AERREAS3

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?

QuestionText:

… Your health provider advised you to go
Yes
No
Refused
Don't know

1
2
7
9

UniverseText:

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital
admission

SkipInstructions:

<1,2,R,D> [goto AERREAS4]

Question ID:

AAU.248_04.040 Instrument Variable Name:

QuestionText:

AERREAS4

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?
… The problem was too serious for the doctor’s office or clinic

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital
admission

SkipInstructions:

<1,2,R,D> [goto AERREAS5]

Page 8 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization--Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

AAU.248_05.050

Instrument Variable Name: AERREAS5

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?

QuestionText:

… Only a hospital could help you
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital
admission

SkipInstructions:

<1,2,R,D> [goto AERREAS6]

Question ID:

AAU.248_06.060 Instrument Variable Name:

AERREAS6

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?

QuestionText:

… the emergency room is your closest provider
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital
admission

SkipInstructions:

<1,2,R,D> [goto AERREAS7]

Question ID:

AAU.248_07.070 Instrument Variable Name:

QuestionText:

AERREAS7

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?
…you get most of your care at the emergency room

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital
admission

SkipInstructions:

<1,2,R,D> [goto AERREAS8]

Page 9 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization--Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

AAU.248_08.080

Instrument Variable Name:

AERREAS8

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?

QuestionText:

…you arrived by ambulance or other emergency vehicle
Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital admission

UniverseText:
SkipInstructions:

Question ID:

<1,2,R,D> [goto AHCHYR]

AAU.306_00.010 Instrument Variable Name:

AVISLAST

QuestionnaireFileName:

Sample Adult

Thinking about your last visit for any type of medical care, where did you go?

QuestionText:

*Read categories if necessary.
Clinic or health center
Doctor's office or HMO
Hospital emergency room
Hospital outpatient department
Urgent care center
Some other place
Refused
Don't know

1
2
3
4
5
6
7
9

UniverseText:
Sample adults 18+ who have ever seen a doctor or other health professional
SkipInstructions:
<3,5> [goto AWAITRMN] <1,2,4,6> [goto ALASTTYP] [goto HIT1A]

Question ID:

AAU.306_00.020 Instrument Variable Name:

QuestionText:
1
2
3
7
9
UniverseText:

SkipInstructions:

ALASTTYP

QuestionnaireFileName:

Sample Adult

Did you see a general doctor, a specialist, or someone else?
General doctor
Specialist
Someone else
Refused
Don't know
Sample adults 18+ who visited a clinic, doctor’s office/HMO, hospital outpatient department or someplace else (not ER or urgent care center)
on their last visit
<1-3,R,D> [goto AVISAPTN]

Page 10 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization--Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

AAU.306_01.030 Instrument Variable Name:

AVISAPTN

QuestionnaireFileName:

Sample Adult

For this visit, how long did you have to wait between the time you made the appointment and the day you actually saw the doctor or other health
professional?

QuestionText:

*Enter ‘0’ for same day, walk-in appointment, or no appointment made.
*Enter number for appointment wait time.
UniverseText:

SkipInstructions:

Question ID:

Sample adults 18+ who visited a clinic, doctor’s office/HMO, hospital outpatient department or someplace else (not ER or urgent care center)
on their last visit
<0-96,D> [goto AVISAPTT] [ AWAITRMN]

AAU.306_02.030 Instrument Variable Name:

AVISAPTT

QuestionnaireFileName:

Sample Adult

*Enter time period for appointment wait time.

QuestionText:

Days
Weeks
Months

1
2
3

7
9

Refused
Don't know

Sample adults 18+ who visited a clinic, doctor’s office/HMO, hospital outpatient department or someplace else (not ER or urgent care center)
on their last visit and did not answer refused to appointment wait time
SkipInstructions:
<1-3,R,D> [goto AWAITRMN]
UniverseText:

Question ID:

AAU.306_01.040 Instrument Variable Name:

AWAITRMN

QuestionnaireFileName:

Sample Adult

How long did you have to wait in the waiting room before you saw a doctor or other health professional for this visit?

QuestionText:

*Enter number for time in waiting room.
UniverseText:
SkipInstructions:

Question ID:
QuestionText:
1
2

Sample adults 18+ who had a place of last medical visit
<0-96,D> [goto AWAITRMT] [goto HIT1A]

AAU.306_02.040 Instrument Variable Name:

AWAITRMT

QuestionnaireFileName:

Sample Adult

*Enter time period for time in waiting room.
Minutes
Hours

7 Refused
9 Don't know

UniverseText:
Sample adults 18+ who had a place of last medical visit and did not refuse number portion of waiting room time
SkipInstructions:
<1,2,R,D> [goto HIT1A]

Page 11 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization--Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

AAU.309_00.010

Instrument Variable Name:

HIT1A

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you ever used computers for any of the following

QuestionText:

…Look up health information on the Internet
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto HIT2A]

Question ID:

AAU.309_00.020

Instrument Variable Name:

HIT2A

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you ever used computers for any of the following

QuestionText:

…Fill a prescription
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto HIT3A]

Question ID:

AAU.309_00.030

QuestionText:

Instrument Variable Name:

HIT3A

DURING THE PAST 12 MONTHS, have you ever used computers for any of the following
…Schedule an appointment with a health care provider

1
2
7
9

QuestionnaireFileName:

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto HIT4A]

Sample Adult

Page 12 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization-Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

AAU.305_00.040

Instrument Variable Name:

HIT4A

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you ever used computers for any of the following

QuestionText:

…Communicate with a health care provider by email
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto HIT5A]

Question ID:

AAU.309_00.050

Instrument Variable Name:

HIT5A

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you ever used computers for any of the following

QuestionText:

…Use online chat groups to learn about health topics
Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+

UniverseText:

Question ID:

SkipInstructions:

AAU.500_00.010 Instrument Variable Name:

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto APSCHCHK]

1
2
7
9
UniverseText:

QuestionnaireFileName:

Sample Adult

Yes
No
Refused
Don't know

1
2
7
9

QuestionText:

APSBPCHK

DURING THE PAST 12 MONTHS, have you had your blood pressure checked by a doctor, nurse, or other health professional?

QuestionText:

Question ID:

<1,2,R,D> [goto SHTFLUYR]

AAU.510_00.010 Instrument Variable Name:

APSCHCHK

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had your blood cholesterol checked by a doctor, nurse, or other health professional?
Yes
No
Refused
Don't know
Sample adults 18+

SkipInstructions: <1,2,R,D> [goto APSBSCHK]

Page 13 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization-Health Care Reform
Document Version Date: 18-Nov-10

AAU.520_00.010

Question ID:

APSBSCHK

QuestionnaireFileName:

Sample Adult

Have you had a fasting test for high blood sugar or diabetes DURING THE PAST 12 MONTHS?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+

UniverseText:
SkipInstructions:

Question ID:

Instrument Variable Name:

<1,2,R,D> and SEX=1 and AGE GE 40 [gotoAPSCOL]
<1,2,R,D> and SEX=1 and AGE < 40 [goto APSDIET]
<1,2,R,D> and SEX=2 [goto APSPAP]

AAU.530_00.010 Instrument Variable Name:

APSPAP

QuestionnaireFileName:

Sample Adult

QuestionText: Have you had a Pap smear or Pap test DURING THE PAST 12 MONTHS?

QuestionText:

*Read if necessary.
A Pap smear or Pap test is a routine test for women in which the doctor examines the cervix, takes a cell sample from the
cervix with a small stick or brush, and sends it to the lab.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Female sample adults 18+

SkipInstructions:

<1,2,R,D> if AGE GE 30 [goto APSMAM];
else [goto APSDIET]

Question ID:

AAU.540_00.010 Instrument Variable Name:

QuestionText:

APSMAM

Have you had a Mammogram DURING THE PAST 12 MONTHS?
*Read if necessary.
A mammogram is an x-ray of each breast to look for breast cancer.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Female sample adults 30+

SkipInstructions:

<1,2,R,D> if AGE GE 40 [gotoAPSCOL]; else [goto APSDIET]

QuestionnaireFileName:

Sample Adult

Page 14 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization-Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

AAU.550_00.010

Instrument Variable Name:APSCOL

QuestionText:

DURING THE PAST 12 MONTHS, have you had any test done for colon cancer?

QuestionnaireFileName:

Sample Adult

*Read if necessary.
Colon cancer tests include blood stool tests, colonoscopy and sigmoidoscopy.
A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood.
A sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer
or other health problems.
Yes
No
Refused
Don’t know

1
2
7
9

Sample adults 40+

UniverseText:
SkipInstructions:

Question ID:

<1,2,R,D> [goto APSDIET]

AAU.560_00.010 Instrument Variable Name:

APSDIET

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, has a doctor or other health professional talked to you about your diet?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> if SMKNOW eq 1, 2 [goto APSSMKC]; if age GE 40 and age LE 65 [goto LTCFAM]; else [goto AINDINS]

Question ID:

AAU.570_00.010 Instrument Variable Name:

QuestionText:
1
2
7
9

APSSMKC

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, has a doctor or other health professional talked to you about your smoking?
Yes
No
Refused
Don’t know

UniverseText:

Sample adults 18+ currently who smoke every day or some days

SkipInstructions:

<1,2,R,D> if age GE 40 and age LE 65 [goto LTCFAM]; else [goto AINDINS]

Page 15 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization-Health Care Reform
Document Version Date: 18-Nov-10

Question ID:

AAU.580_00.010

Instrument Variable Name: LTCFAM

QuestionText:

Do you have a parent, spouse, sibling, or adult child who has needed help for at least a year with everyday needs like bathing, dressing or eating
due to a long term condition?

QuestionnaireFileName:

Sample Adult

*Read if necessary: Due to a chronic illness or disability
Yes
No
Refused
Don’t know

1
2
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

Sample adults 40-65
<1,2,R,D> [goto LTCHELP]

AAU.582_00.010

Instrument Variable Name: LTCHELP

QuestionnaireFileName:

Sample Adult

How likely is it that you may someday need help with daily activities like bathing, dressing, eating, or using the toilet due to a long term
condition? Would you say…
*Read categories below.
Very likely
Somewhat likely
Somewhat unlikely
Very unlikely
Refused
Don’t know

1
2
3
4
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

Sample adults 40-65
<1-4,R,D> [goto LTCWHO]

AAU.584_00.010

Instrument Variable Name: LTCWHO

If you needed such help, who would provide this help?
*Enter all that apply, separate with commas.

1
2
3
4
5
7
9
UniverseText:
SkipInstructions:

My family
Someone I hire
Home health care organization
Nursing home/assisted living
Other
Refused
Don’t know
Sample adults 40-65
<1-5,R,D> [goto LTCPRCH]

QuestionnaireFileName:

Sample Adult

Page 16 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization-Health Care Reform
Document Version Date:18-Nov-10

Question ID:
QuestionText:

AAU.586_00.010

Instrument Variable Name: LTCPRCH

QuestionnaireFileName:

Sample Adult

Health Care Reform establishes a voluntary, government-run insurance program to pay for help with everyday needs like bathing, dressing or
eating. People will be able to enroll, and pay a monthly premium. Once they need care they would receive an average of $50 each day. Would
you be interested in purchasing this insurance?
Yes
No
Refused
Don’t know

1
2
7
9

UniverseText:
SkipInstructions:

Question ID:
QuestionText:

01
02
03
04
05
06
07
97
99
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

Sample adults 40-65
<1,D> [goto LTCPAY] <2,R> [goto AINDINS]

AAU.588_00.010

Instrument Variable Name: LTCPAY

QuestionnaireFileName:

Sample Adult

How much would you be willing to pay per month NOW to receive this benefit later in life?
$1-$24 per month
$25-$49 per month
$50-$74 per month
$75-$99 per month
$100-$124 per month
$125 per month or more
Nothing/Not interested in the program
Refused
Don’t know
Sample adults 40-65 who would be interested in purchasing long-term care insurance or don’t know if they are interested
<1-7,R> [goto AINDINS] [goto LTC100M]

AAU.590_00.010

Instrument Variable Name: LTC100M

QuestionnaireFileName:

Sample Adult

How likely would it be for you to pay $100 per month for this insurance? Would you say…
*Read categories below.

1
2
3
4
7
9
UniverseText:
SkipInstructions:

Very likely
Somewhat likely
Somewhat unlikely
Very unlikely
Refused
Don’t know
Sample adults 40-65 who don’t know how much they would be willing to pay per month for long-term care insurance
<1-4,R,D> [goto AINDINS]

Page 17 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization-Health Care Reform
Document Version Date:18-Nov-10

Question ID:
QuestionText:

1
2
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

1
2
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

1
2
3
7
9
UniverseText:
SkipInstructions:

AAU.600_00.010

Instrument Variable Name: AINDINS

QuestionnaireFileName:

Sample Adult

DURING THE PAST 3 YEARS, did you try to purchase health insurance directly, that is, not through any employer, union, or government
program?
Yes
No
Refused
Don’t know
Sample adults 18+
<1> [goto AINDPRCH> <2,R,D> [goto HIVTST1]

AAU.600_00.020

Instrument Variable Name: AINDPRCH

QuestionnaireFileName:

Sample Adult

Was a plan purchased?
Yes
No
Refused
Don’t know
Sample adults 18+ who tried to purchase health insurance directly in the past 3 years
<1> [goto AINDWHO] <2> [goto AINDNOT] [goto HIVTST1]

AAU.600_00.030

Instrument Variable Name: AINDWHO

QuestionnaireFileName:

Was this plan for yourself, someone else in your family, or both?
Self
Someone else in family
Both
Refused
Don’t know
Sample adults 18+ who purchased health insurance directly in the past 3 years
<1-3,R,D> [goto AINDDIF1]

Sample Adult

Page 18 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization-Health Care Reform
Document Version Date:18-Nov-10

Question ID:
QuestionText:

AAU.600_00.040

Instrument Variable Name: AINDDIF1

QuestionnaireFileName:

Sample Adult

How difficult was it to find a plan with the type of coverage you needed? Would you say…
*Read categories below.

1
2
3
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

Very difficult
Somewhat difficult
Not at all difficult
Refused
Don’t know
Sample adults 18+ who purchased health insurance directly in the past 3 years
<1-3,R,D> [goto AINDDIF2]

AAU.600_00.050

Instrument Variable Name: AINDDIF2

QuestionnaireFileName:

Sample Adult

How difficult was it to find a plan you could afford? Would you say…
*Read categories below.

1
2
3
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:
1
2
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:
1
2
7
9
UniverseText:
SkipInstructions:

Very difficult
Somewhat difficult
Not at all difficult
Refused
Don’t know
Sample adults 18+ who purchased health insurance directly in the past 3 years
<1-3,R,D> [goto AINDENY1]

AAU.600_01.060

Instrument Variable Name: AINDENY1

QuestionnaireFileName:

Sample Adult

Did any company turn you down when you tried to buy coverage on your own?
Yes
No
Refused
Don’t know
Sample adults 18+ who purchased health insurance directly in the past 3 years
<1,2,R,D> [goto AINDENY2]

AAU.600_02.060

Instrument Variable Name: AINDENY2

QuestionnaireFileName:

Sample Adult

Did any company charge a higher price because of {fill: your/your family’s/you or your family’s} health?
Yes
No
Refused
Don’t know
Sample adults 18+ who purchased health insurance directly in the past 3 years
<1,2,R,D> [goto AINDENY3]

Page 19 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization-Health Care Reform
Document Version Date:18-Nov-10

Question ID:
QuestionText:

1
2
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

AAU.600_03.060

Instrument Variable Name: AINDENY3

QuestionnaireFileName:

Sample Adult

Did any company exclude a specific health problem from the coverage?
Yes
No
Refused
Don’t know
Sample adults 18+ who purchased health insurance directly in the past 3 years
<1,2,R,D> [goto HIVTST1]

AAU.601_00.070

Instrument Variable Name: AINDNOT

QuestionnaireFileName:

Sample Adult

Why did you not buy a plan?
*Enter all that apply, separate with commas.

1
2
3
4
5
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

Turned down
Cost
Pre-existing condition
Got health insurance from other source
Other reason (specify)
Refused
Don’t know
Sample adults 18+ who tried to purchase health insurance directly in the past 3 years but did not
<1-4,R,D> [goto HIVTST1] <5> [goto AINDNTSP]

AAU.601_00.080

Instrument Variable Name: AINDNTSP

*Specify other reason plan was not obtained.

Verbatim _____________________

UniverseText:
SkipInstructions:

Sample adults 18+ who had other reason plan was not purchased
[goto HIVTST1]

QuestionnaireFileName:

Sample Adult

Page 1 of 4

DRAFT 2011 NHIS Questionnaire - Family
Family Food Security
Document Version Date:
Question ID:

FFS.010_00.000 Instrument Variable Name:

QuestionText:

19-Nov-10

FSRUNOUT

QuestionnaireFileName:

Family

These next questions are about whether you were always able to afford the food you needed in the last 30 days. I'm going
to read you several statements that people have made about their food situation. For these statements, please tell me
whether the statement was often true, sometimes true, or never true for [fill 1: you/your family] in the last 30 days.
The first statement is "[fill 2: I/We] worried whether [fill 3: my/our] food would run out before [fill 4: I/we] got money to
buy more." Was that often true, sometimes true, or never true for [fill 1: you/your family] in the last 30 days?

1

Often true
Sometimes true
Never true
Refused
Don't know

2
3
7
9
UniverseText:

All families

SkipInstructions:

<1-3,R,D> goto FSLAST

Question ID:

FFS.020_00.000 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Family

"The food that [fill 1: I/we] bought just didn't last, and [fill 1: I/we] didn't have money to get more." Was that often true,
sometimes true, or never true for [fill 2: you/your family] in the last 30 days?

1

Often true
Sometimes true
Never true
Refused
Don't know

2
3
7
9
UniverseText:

All families

SkipInstructions:

<1-3,R,D> goto FSBALANC

Question ID:

FSLAST

FFS.030_00.000 Instrument Variable Name:

QuestionText:

1
2
3
7
9

FSBALANC

QuestionnaireFileName:

Family

"[fill 1: I/We] couldn't afford to eat balanced meals." Was that often true, sometimes true, or never true for [fill 2:
you/your family] in the last 30 days?
Often true
Sometimes true
Never true
Refused
Don't know

UniverseText:

All families

SkipInstructions:

<1,2> [goto FSSKIP]
<3,D,R> [if FSRUNOUT in(1,2) or FSLAST in(1,2), goto FSSKIP; else goto FINJ3M]

Page 2 of 4

DRAFT 2011 NHIS Questionnaire - Family
Family Food Security
Document Version Date:
Question ID:

FFS.040_00.000 Instrument Variable Name:

QuestionText:

19-Nov-10

FSSKIP

QuestionnaireFileName:

Family

In the last 30 days did [fill 1: you/you or other adults in your family] ever cut the size of your meals or skip meals because
there wasn't enough money for food?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Families for whom it was often or sometimes true in the last 30 days that they worried that food would run out
before they got money to buy more, or that food that was bought didn't last and they didn't have money to get
more, or they couldn't afford to eat balanced meals

SkipInstructions:

<1> [goto FSSKDAYS]
<2,R,D> [goto FSLESS]

Question ID:

FFS.050_00.000 Instrument Variable Name:

QuestionText:

FSSKDAYS

QuestionnaireFileName:

Family

In the last 30 days, how many days did this happen?

1-30

Days
Refused
Don't know

97
99
UniverseText:

Adults in the family cut the size of their meals or skipped meals in the last 30 days because there wasn't enough
money for food

SkipInstructions:

<1-30,R,D> [goto FSLESS]

Question ID:

FFS.060_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

FSLESS

QuestionnaireFileName:

Family

In the last 30 days, did you ever eat less than you felt you should because there wasn't enough money for food?
Yes
No
Refused
Don't know

UniverseText:

Families for whom it was often or sometimes true in the last 30 days that they worried that food would run out
before they got money to buy more, or that food that was bought didn't last and they didn't have money to get
more, or they couldn't afford to eat balanced meals

SkipInstructions:

<1,2,R,D> [goto FSHUNGRY]

Page 3 of 4

DRAFT 2011 NHIS Questionnaire - Family
Family Food Security
Document Version Date:
Question ID:

FFS.070_00.000 Instrument Variable Name:

QuestionText:

19-Nov-10

FSHUNGRY

QuestionnaireFileName:

Family

In the last 30 days, were you ever hungry but didn't eat because there wasn't enough money for food?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Families for whom it was often or sometimes true in the last 30 days that they worried that food would run out
before they got money to buy more, or that food that was bought didn't last and they didn't have money to get
more, or they couldn't afford to eat balanced meals

SkipInstructions:

<1,2,R,D> [goto FSWEIGHT]

Question ID:

FFS.080_00.000 Instrument Variable Name:

QuestionText:

FSWEIGHT

QuestionnaireFileName:

Family

In the last 30 days, did you lose weight because there wasn't enough money for food?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Families for whom it was often or sometimes true in the last 30 days that they worried that food would run out
before they got money to buy more, or that food that was bought didn't last and they didn't have money to get
more, or they couldn't afford to eat balanced meals

SkipInstructions:

<1> [goto FSNOTEAT]
<2,R,D> [if FSSKIP=1 or FSLESS=1 or FSHUNGRY=1, goto FSNOTEAT; else goto FINJ3M]

Question ID:

FFS.090_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

FSNOTEAT

QuestionnaireFileName:

Family

In the last 30 days, did [fill 1: you/you or other adults in your family] ever not eat for a whole day because there wasn't
enough money for food?
Yes
No
Refused
Don't know

UniverseText:

All families where adult(s) cut the size of meals or meals were skipped, ate less than they felt they should, were
hungry but didn't eat, or lost weight in the last 30 days because there wasn't enough money for food

SkipInstructions:

<1> [goto FSNEDAYS]
<2,R,D> [goto FINJ3M]

Page 4 of 4

DRAFT 2011 NHIS Questionnaire - Family
Family Food Security
Document Version Date:
Question ID:

FFS.100_00.000 Instrument Variable Name:

QuestionText:
1-30
97
99

19-Nov-10

FSNEDAYS

QuestionnaireFileName:

Family

In the last 30 days, how many days did this happen?
Days
Refused
Don't know

UniverseText:

All families where the adult(s) did not eat for a whole day, in the last 30 days, because there wasn't enough money
for food

SkipInstructions:

<1-30,R,D> [goto FINJ3M]

Page 1 of 3

DRAFT 2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.135_00.010 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Adult

The next questions are about health clubs, wellness programs or fitness facilities, such as the YMCA, community
recreation programs, and employer fitness programs. If you wanted to use one, is there a health club, wellness program or
fitness facility in your area that meets your needs?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,R,D> [goto ALC1YR]
<2> [goto DISHFL02]

Question ID:

DISHFAC

18-Nov-10

AHB.136_01.010 Instrument Variable Name:

QuestionText:

DISHFL02

QuestionnaireFileName:

Sample Adult

Do any of these barriers limit or prevent you from using a health club, wellness program, or fitness facility that meets
your needs? I am going to read a list. Please say yes or no to each one.
…Cost is too high.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who do not have a health club, wellness program or fitness facility in their area that meets their
needs, if they wanted to use one

SkipInstructions:

<1,2,R,D> [goto DISHFL03]

Question ID:

AHB.136_02.020 Instrument Variable Name:

QuestionText:

DISHFL03

QuestionnaireFileName:

Sample Adult

* Read if necessary.
Do any of these barriers limit or prevent you from using a health club, wellness program, or fitness facility that meets
your needs?
…Lack of staff or instructors who understand your needs.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who do not have a health club, wellness program or fitness facility in their area that meets their
needs, if they wanted to use one

SkipInstructions:

<1,2,R,D> [goto DISHFL04]

Page 2 of 3

DRAFT 2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.136_03.030 Instrument Variable Name:

QuestionText:

DISHFL04

18-Nov-10
QuestionnaireFileName:

Sample Adult

* Read if necessary.
Do any of these barriers limit or prevent you from using a health club, wellness program, or fitness facility that meets
your needs?
…Lack of exercise equipment that meets your needs.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who do not have a health club, wellness program or fitness facility in their area that meets their
needs, if they wanted to use one

SkipInstructions:

<1,2,R,D> [goto DISHFL05]

Question ID:

AHB.136_04.040 Instrument Variable Name:

QuestionText:

DISHFL05

QuestionnaireFileName:

Sample Adult

* Read if necessary.
Do any of these barriers limit or prevent you from using a health club, wellness program, or fitness facility that meets
your needs?
…Difficulty getting into or moving around the building.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who do not have a health club, wellness program or fitness facility in their area that meets their
needs, if they wanted to use one

SkipInstructions:

<1,2,R,D> [goto DISHFL06]

Question ID:

AHB.136_05.050 Instrument Variable Name:

QuestionText:

DISHFL06

QuestionnaireFileName:

Sample Adult

* Read if necessary.
Do any of these barriers limit or prevent you from using a health club, wellness program, or fitness facility that meets
your needs?
…Inadequate transportation.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who do not have a health club, wellness program or fitness facility in their area that meets their
needs, if they wanted to use one

SkipInstructions:

<1,2,D,R> [goto DISHFL07]

Page 3 of 3

DRAFT 2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.136_06.060 Instrument Variable Name:

QuestionText:

DISHFL07

18-Nov-10
QuestionnaireFileName:

Sample Adult

* Read if necessary.
Do any of these barriers limit or prevent you from using a health club, wellness program, or fitness facility that meets
your needs?
…Some other barrier.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who do not have a health club, wellness program or fitness facility in their area that meets their
needs, if they wanted to use one

SkipInstructions:

<1,2,R,D> [goto ALC1YR]

Page 1 of 2

DRAFT 2011 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
Question ID:

FSD.020_00.000 Instrument Variable Name:

QuestionText:

19-Nov-10

ARMFVER

QuestionnaireFileName:

Family

Earlier [fill1: you said/it was said] [fill2: you/alias] [fill3: were/was] on full-time active duty with the Armed Forces. Is
this correct?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

All families with a person age 18 or older who were said to be on active duty in the armed forces in the HHC
section

SkipInstructions:

<1> [goto ARMFFC] <2,R,D> [goto ARMFEV]

Question ID:

FSD.021_00.000 Instrument Variable Name:

QuestionText:

ARMFEV

QuestionnaireFileName:

Family

[fill1: Have you/Has alias] ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard?
*Read if necessary. Active duty does not include training for the Reserves or National Guard, but DOES include
activation, for example, for service in the US or in a foreign country, in support of military or humanitarian operations.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

All families with a person age 18 or older

SkipInstructions:

<1> [goto ARMFFC] <2,R,D> [goto DOINGLW]

Question ID:

FSD.022_00.000 Instrument Variable Name:

QuestionText:

ARMFFC

QuestionnaireFileName:

Family

Did [fill1: you/alias] ever serve in a foreign country during a time of armed conflict or on a humanitarian or peacekeeping mission?
*Read if necessary. This would include National Guard or reserve or active duty monitoring or conducting peace keeping
operations in Bosnia Kosovo, in the Sinai between Egypt and Israel, or in response to the 2004 tsunami, or Haiti in 2010.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

All families with a person age 18 or older who has ever served in the armed forces

SkipInstructions:

<1,2,R,D> [goto ARMFTMP]

Page 2 of 2

DRAFT 2011 NHIS Questionnaire - Family
Family Socio-Demographic
Document Version Date:
Question ID:

FSD.023_00.000 Instrument Variable Name:

QuestionText:

19-Nov-10

ARMFTMP

QuestionnaireFileName:

Family

When did [fill1: you/alias] serve on ACTIVE DUTY in the U.S. Armed Forces?
*Enter all that apply, separate with commas.
*Enter all periods in which this person served. Enter the item even if the person served for just part of that period.

01

Sept 2001 or later
August 1990 to August 2001 (including Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
Refused
Don’t know

02
03
04
05
06
07
08
09
10
11
97
99
UniverseText:

All families with a person age 18 or older who has ever served in the armed forces

SkipInstructions:

<1,3-11,R,D> [goto DOINGLW] <2> [goto ARMFDS]

Question ID:

FSD.024_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

ARMFDS

QuestionnaireFileName:

Family

Did [fill1: you/alias] serve in the Persian Gulf during Operation Desert Shield or Operation Desert Storm between August
1990 and April 1991?
Yes
No
Refused
Don't know

UniverseText:

All families with a person age 18 or older who served from August 1990 to August 2001

SkipInstructions:

<1,2,R,D> [goto DOINGLW]

Page 1 of 2

DRAFT 2011 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:

FIN.261_00.000 Instrument Variable Name:

QuestionText:

02-Aug-10

F200PV35

QuestionnaireFileName:

Was your total family income from all sources less than $44,000 or $44,000 or more?

1

Less than $44,000
$44,000 or more
Refused
Don't Know

2
7
9
UniverseText:

The respondent answered More than $35,000 and there are 4 persons in the family

SkipInstructions:

<1,2,R,D> [goto HOUSEOWN]

Question ID:

Family

FIN.268_00.000 Instrument Variable Name:

QuestionText:

F200POV

QuestionnaireFileName:

Family

Was your total family income from all sources less than [fill1: fill based on 200% poverty threshold] or [fill1: fill based on
200% poverty threshold] or more?

1

Less than [Fill 2: fill based on 200% poverty threshold]
[Fill 2: fill based on 200% poverty threshold] or more
Refused
Don't Know

2
7
9
UniverseText:

The respondent answered More than poverty threshold and there are 2 or fewer persons in the family

SkipInstructions:

<1,2,R,D> [goto HOUSEOWN]

Question ID:

FIN.272_00.000 Instrument Variable Name:

QuestionText:

FINC150

Family

Was your total [fill: family] income from all sources less than $150,000 or $150,000 or more?

1

Less than $150,000
$150,000 or more
Refused
Don't know

2
7
9
UniverseText:

The respondent answered $100,000 or more in FINC100

SkipInstructions:

<1,2,R,D> [goto HOUSEOWN]

Question ID:

QuestionnaireFileName:

FIN.276_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

F200PV75

QuestionnaireFileName:

Family

Was your total family income from all sources less than [fill1: fill based on 200% poverty threshold] or [fill1: fill based on
200% poverty threshold] or more?
Less than [fill 2: fill based on 200% poverty threshold]
[fill 2: fill based on 200% poverty threshold] or more
Refused
Don't Know

UniverseText:

The respondent answered More than $75,000 and there are 9 or more persons in the family OR The respondent
answered Less than $75,000 and there are 6-7 persons in the family

SkipInstructions:

<1,2,R,D> [goto HOUSEOWN]

Page 2 of 2

DRAFT 2011 NHIS Questionnaire - Family
Family Income
Document Version Date:
Question ID:

FIN.360_00.000 Instrument Variable Name:

QuestionText:

02-Aug-10

FSNAP

QuestionnaireFileName:

Family

? [F1]
At any time during [fill 1: last calendar year in 4-digit format], did [fill 2: you/any family members living here] receive
[fill 3: food stamp benefits/SNAPNAME] or food stamp benefits?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

All families

SkipInstructions:

<1> [If one person family, store person number in PSNAP [Goto FSNAPMYR]; else goto PSNAP]

Question ID:

FIN.370_00.000 Instrument Variable Name:

QuestionText:

PSNAP

QuestionnaireFileName:

Family

* Ask or verify. Enter applicable line number(s), separate with commas.
Who received [fill 1: food stamp benefits/SNAPNAME or food stamp benefits]?
*Indicate family members who received SNAP or food stamp benefits.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

All families with two or more persons and at least one received SNAP in the last year

SkipInstructions:

goto FSTPMYR
NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the
respondent. As shown above, each eligible person receives an edited response code in subsequent data processing.

Question ID:

FIN.380_00.000 Instrument Variable Name:

QuestionText:

97
99

QuestionnaireFileName:

Family

During [fill1: last year in 4-digit format], about how many months [fill2: did you/did ALIAS] receive [fill2:
SNAPNAME] or food stamp benefits?
* Enter '1' if less than 1 month

01-12

FSNAPMYR

1-12 months
Refused
Don't know

UniverseText:

All persons mentioned in PSNAP

SkipInstructions:

goto FINWIC