Current Stage 1 36-Month Survey

BOND Implementation and Evaluation

Appendix D.

Abt Associates Inc.

Contract No. SS00-10-60011

Benefit Offset National Demonstration
Stage 1 36-Month Follow-up Survey Instrument

Appendix D. BOND Stage 1 36-Month Follow-up Survey Instrument

D-1

BOND Implementation and Evaluation

Contract No. SS00-10-60011

Table of Contents

SECTION A: CONFIRMATION OF RESPONDENT / SCREENER / INTRODUCTIONS ..... 1
SECTION B: EDUCATION AND TRAINING......................................................................... 6
SECTION C: CURRENT EMPLOYMENT STATUS............................................................ 10
SECTION D: BARRIERS TO EMPLOYMENT .................................................................... 26
SECTION E: INCOME ........................................................................................................ 29
SECTION F: HEALTH AND FUNCTIONAL STATUS......................................................... 34
SECTION G: HEALTH INSURANCE .................................................................................. 39
SECTION H: FINANCIAL HARDSHIP ................................................................................ 40
SECTION I:

PERSONAL CHARACTERISTICS ................................................................ 43

SECTION J:

RESPONDENT CONTACT INFORMATION ................................................. 45

Abt Associates Inc.

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Contract No. SS00-10-60011

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507,
as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these
questions unless we display a valid Office of Management and Budget control number. The OMB control
number for this information collection is [INSERT NUMBER], expiring [INSERT EXPIRATION DATE]. We
estimate that it will take about 49 minutes to read the instructions, gather the facts, and answer the questions.
You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 212356401. Send only comments relating to our time estimate to this address, not the completed form.

SECTION A: CONFIRMATION OF RESPONDENT / SCREENER /
INTRODUCTIONS
NOTE TO INTERVIEWER: DO NOT READ TEXT IN ALL CAPS.
Hello, my name is _________ I work for Abt Associates Inc., a national research company based in
Cambridge, MA. Thank you for taking the time to speak with me today. You may have received a letter
in the past week or so that explained about this interview.
Treatment Group: we are conducting a study for the Social Security Administration. The study is about a
new program that they are trying called the Benefit Offset National Demonstration or BOND. You may
recall receiving a letter from SSA about this program a couple of years ago.
Control Group: we are conducting a study for the Social Security Administration to find out more about
the experiences of people receiving Social Security Disability Benefits. We are interviewing many
disability beneficiaries across the country for this study.
At this time, we’d like to have you participate in an interview. The purpose of this interview is to learn
more about the types of jobs you and other people who received Social Security disability benefits may
have, and in any schooling or job training you may have participated in over the past 3 years. We are
also interested in learning whether or not you have worked with a benefits counselor over the past 3
years. Your participation in this study is completely voluntary. It will in no way affect your current or
future receipt of benefits. You can stop the interview at any time. If any question makes you feel
uncomfortable, you can refuse to answer that question.
All information you provide is confidential and it will be protected to the fullest extent possible by law,
including the Privacy Act. This means for example, that we may need to notify someone if keeping that
information confidential could harm you or someone else. Three groups of people will see your answers:
the interviewer, the researchers doing the study, and the Social Security Administration that funded the
study. Your name will not be attached to your survey answers in the data files used by these groups.
Answering the questions in this survey will not affect any disability benefits you receive now, or may
receive in the future. Your name will never appear in any report. Research reports will only present
summary information. The researchers will not use names or individual identifying information in any
research report.
Do you have any questions before we begin?
IF YES: Interviewer respond to questions as they arise.
If NO: Alright then, do you mind if we start the interview now? It should take approximately [49
minutes estimated duration]. [IF TELEPHONE: At the end of the interview, I will send you a
check for $25 to thank you for your time. You should receive it within a month] [IF IN-PERSON: At
the end of the interview, I will give you a $25 money order to thank you for your time.]
REVIEWER NOTE: There is also a screener to verify the identity of the respondent that begins by
checking birth date and continues by checking other data (perhaps name of informant) if

Abt Associates Inc.

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Contract No. SS00-10-60011

interviewer cannot verify birth date. To simplify review, verification screeners have been removed
from this draft.
Screeners vary depending upon:
 if a proxy is needed; or
 if there is a language barrier.
Let’s begin with some general questions. We may have asked similar questions in the past. If we repeat
questions you have answered before, it is so we can update our information.
* INDICATES QUESTIONS NOT TO BE ASKED OF PROXIES.

A1.

Are you currently working at a job or business for pay or profit? This includes work you may do
for a business that you own.
IF NEEDED READ: By ‘working at a job for pay or profit’ we mean at a job where you get paid
money for the work you do.
[INTERVIEWER: IF R IS SELF-EMPLOYED, CODE RESPONSE AS YES]
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

A2.

Are you currently enrolled in school or taking any classes?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

A3.

Do you currently do any volunteer work for an organization?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

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A4.

Contract No. SS00-10-60011

In general, would you say your health is . . .

(SF-12)

Excellent,................................................................................................1
Very good,..............................................................................................2
Good, .....................................................................................................3
Fair, or....................................................................................................4
Poor?......................................................................................................5
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

A5.

Compared to {THIS MONTH, LAST YEAR}, how would you rate your health in general now?
Much better now,....................................................................................1
Somewhat better now, ...........................................................................2
About the same, .....................................................................................3
Somewhat worse now, or.......................................................................4
Much worse now? ..................................................................................5
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

A6.

What is your current marital status? Are you now married, widowed, divorced, separated or have
you never been married?
MARRIED...............................................................................................1
WIDOWED .............................................................................................2
DIVORCED ............................................................................................3
SEPARATED .........................................................................................4
NEVER MARRIED .................................................................................5
REFUSED ..............................................................................................7 (SKIP TO SECT B)
DON’T KNOW ........................................................................................8 (SKIP TO SECT B)

A7.

Are you currently living with a spouse or with someone who is like a spouse to you?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

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A8.

Contract No. SS00-10-60011

CHECK FOR ABILITY TO CONTINUE WITH SELF-RESPONSE. HOW MANY ITEMS IN
QUESTIONS A1-A7 ARE ANSWERED REFUSED OR DON’T KNOW?
1 OR 2....................................................................................................1
3 OR MORE ...........................................................................................2

(SKIP TO SECT B)

[INSTRUCTION: IF RESPONDENT FAILS SCREENER, CAPI WILL PROMPT FOR NAME OF A
PROXY RESPONDENT. IF PROXY IS AVAILABLE SCREENERS WILL REPEAT WITH PROXY. IF NO
PROXY AVAILABLE INTERVIEWER WILL TERMINATE]
A9.

It seems like some of these questions are difficult for you. Is there anyone who can help do this
interview you or answer questions for you?
YES ........................................................................................................1
NO ..........................................................................................................2 (THANK/END)
REFUSED ..............................................................................................7 (THANK/END)
DON’T KNOW ........................................................................................8 (THANK/END)

A10.

A9a.

What is his/her first name?

A9b.

What is his/her middle name?

A9c.

What is his/her last name?

A9d.

Does his/her name have a suffix?

What is (his/her) street address?
A10a. Is there a complex/building name?
A10b. Is there an apartment number?
A10c.

In what city?

A10d. In what state?
A10e. What is the zip code?

A11.

What's the best phone number to reach (him/her) at starting with the area code?
Telephone # with area code: (_______) ________-________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

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A12.

Contract No. SS00-10-60011

Is she/he a friend or a relative, or what is (his/her) relationship to you?
ACCEPT ONE RESPONSE ONLY.
FRIEND..................................................................................................1
RELATIVE..............................................................................................2
LEGAL GUARDIAN................................................................................3
CASE MANAGER ..................................................................................4
OTHER (SPECIFY):____________________________ ......................5
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

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Contract No. SS00-10-60011

SECTION B: EDUCATION AND TRAINING
I would like to continue by talking about your education and training experiences

Return to Work Activities—Education and Training
B1.

What is the highest grade in school that you have completed?
INTERVIEWER: ENTER HIGHEST GRADE COMPLETED IN SPACE PROVIDED FOR GRADE.
IF BEYOND GRADE 12, SELECT APPROPRIATE CODE.
GRADE (1-12) ___________________________________
SOME COLLEGE/SOME POSTSECONDARY VOCATIONAL
COURSES .........................................................................................13
2-YEAR OR 3-YEAR COLLEGE DEGREE (ASSOCIATE’S DEGREE)
OR VOCATIONAL SCHOOL DIPLOMA ..........................................14
4-YEAR COLLEGE DEGREE (BACHELOR’S DEGREE) ..................15
SOME GRADUATE WORK/NO GRADUATE DEGREE .....................16
GRADUATE OR PROFESSIONAL DEGREE
(e.g., MA, MBA, Ph.D., J.D., M.D.) ....................................................17
NEVER ATTENDED SCHOOL ............................................................18
SPECIAL EDUCATION WITH NO CERTIFICATE OF
COMPLETION ...................................................................................19
SPECIAL EDUCATION WITH A CERTIFICATE OF
COMPLETION ...................................................................................20
REFUSED ............................................................................................97
DON’T KNOW ......................................................................................98

IF B1 = 1-12 ASK B1a ELSE SKIP TO B2.

B1a.

Do you have a high school diploma or a GED?
GED .......................................................................................................1
HIGH SCHOOL DIPLOMA.....................................................................2
BOTH .....................................................................................................3
NEITHER ...............................................................................................4
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

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B2.

Contract No. SS00-10-60011

INTERVIEWER: CHECK A2 IS SAMPLE MEMBER CURRENTLY ENROLLED IN SCHOOL OR
TAKING ANY CLASSES?
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO B6)
REFUSED ..............................................................................................7 (SKIP TO B6)
DON’T KNOW ........................................................................................8 (SKIP TO B6)

B3.

Are you working toward a degree, a certificate or license, or are you just taking classes?
WORKING TOWARD DEGREE ............................................................1
WORKING TOWARD CERTIFICATE/ LICENSE ..................................2
ONLY TAKING CLASSES .....................................................................3 (SKIP TO B6)
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

B4.

Toward what type of {degree/certificate or license} are you working?
GED OR HIGH SCHOOL EQUIVALENCE PROGRAM/COURSES .....1
VOCATIONAL OR TRAINING PROGRAM ...........................................2
ASSOCIATE DEGREE PROGRAM (AA DEGREE) ..............................3
UNDERGRADUATE DEGREE PROGRAM (BA, BS DEGREE) ...........4
GRADUATE DEGREE PROGRAM (e.g., MA, MS, MD, EdD) ..............5
OTHER_________________________________ ................................6
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

B5.

Are you a full-time or part-time student?
FULL-TIME.............................................................................................1
PART-TIME............................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

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B6.

Contract No. SS00-10-60011

Now I would like to ask you about any [other] training you may have had since [RADATE].
[SINCE RADATE], have you done any additional schooling or other type of training program that
lasted at least two weeks and that was designed to help you find a job, improve your job skills, or
learn a new job?
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO C1)
REFUSED ..............................................................................................7 (SKIP TO C1)
DON’T KNOW ........................................................................................8 (SKIP TO C1)

B7.

[IF CURRENTLY IN TRAINING A2=1 Not including the program(s) you already told me about,
how many other school or training programs have you done since [RADATE]?
[IF NOT CURRENTLY IN TRAINING A2=2] Altogether, how many school or training programs
have you gone to since [RADATE]?
_______# PROGRAMS
REFUSED .............................................................................................-2 (SKIP TO C1)
DON’T KNOW .......................................................................................-1 (SKIP TO C1)

QUESTIONS B8-B11 ARE REPEATED FOR EACH EPISODE OF EDUCATION/TRAINING REPORTED IN B7, TO
COLLECT DETAILED INFORMATION ABOUT EACH SPELL OF EDUCATION OR TRAINING RECEIVED SINCE
RANDOM ASSIGNMENT. CAPI PROGRAMMING WILL ALLOW FOR UP TO 5 SPELLS OF EDUCATION AND
TRAINING.

B8.

You said that you have gone to [Number of trainings from B6] education or training programs
since [RADATE]. Beginning with the most recent program, please tell me the name of the
program you went to
NAME 1___________________________________________________________
B8a.

What is the name of the next training program you went to?
NAME 2___________________________________________________________
NAME 3___________________________________________________________
NAME 4___________________________________________________________
NAME 5___________________________________________________________

Abt Associates Inc.

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Contract No. SS00-10-60011

IF B7>5 THEN TAKE 5 MOST RECENT PROGRAMS.
B9.

Think about [TRAINING PROGRAM NAME1…5], what kind of schooling or training [is/was] that?
REGULAR HIGH SCHOOL, DIRECTED TOWARD A HS DIPLOMA ...1
PREPARATION FOR A GED EXAM .....................................................2
2-YEAR COLLEGE DIRECTED TOWARD A DEGREE........................3
4-YEAR COLLEGE DIRECTED TOWARD A DEGREE........................4
GRADUATE COURSES ........................................................................5
COLLEGE COURSES NOT DIRECTED TOWARD A DEGREE ..........6
VOCATIONAL EDUCATION OUTSIDE A COLLEGE (BUSINESS or
TECHNICAL SCHOOLS, EMPLOYER OR UNION-PROVIDED
TRAINING, AND MILITARY TRAINING IN VOCATIONAL BUT
NOT MILITARY SKILLS OR JTPA ......................................................7
NON-VOCATIONAL ADULT EDUCATION NOT DIRECTED
TOWARD A DEGREE (BASIC EDUCATION, LITERACY TRAINING,
ENGLISH AS A SECOND LANGUAGE ..............................................8
JOB SEARCH ASSISTANCE, JOB FINDING, ORIENTATION
TO THE WORLD OF WORK ...............................................................9
OTHER (SPECIFY) __________________________________ ........96
REFUSED ............................................................................................97
DON’T KNOW ......................................................................................98

B10.

Since [RADATE], how many weeks have you gone to [TRAINING PROGRAM NAME1…5]?
NUMBER OF WEEKS: ______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

B11.

During those weeks, how many hours a week did you usually spend in [TRAINING PROGRAM
NAME 1…5]?
NUMBER OF HOURS: _______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

REPEAT B8-B11 FOR EACH PROGRAM NAME LISTED IN B7

Abt Associates Inc.

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Contract No. SS00-10-60011

SECTION C: CURRENT EMPLOYMENT STATUS
These next questions are about your current work activities.
C1.

INTERVIEWER: CHECK A1 IS SAMPLE MEMBER CURRENTLY WORKING AT A JOB OR
BUSINESS FOR PAY OR PROFIT?
YES ........................................................................................................1 (SKIP TO C4)
NO ..........................................................................................................2

C2.

Have you been looking for work during the last four weeks?
IF NEEDED READ: By looking for work, I mean looking for a job, either full-time or part-time, for
which you will be paid.
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

C3.

When did you last work for pay at a job for at least one month?
|__|__|
MO

|__|__|__|__|
YEAR

REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1
IF A1=2,7,8 (not employed) SKIP TO C26
IF RESPONDENT INDICATES THAT HE/SHE IS CURRENTLY WORKING, CAPI WILL PROBE:
‘I’m sorry, I must have entered something incorrectly. [CHECK QUESTION A1].

Abt Associates Inc.

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BOND Implementation and Evaluation

Contract No. SS00-10-60011

[ASK ONLY OF THOSE EMPLOYED (A1=1)] Now I am going to ask some questions about the jobs you
currently have. When answering these questions, please include both part-time and full-time jobs, but
only include jobs you work at for pay or profit. This could be work you do for a business that you own.
(NBS modified)

C4.

How many jobs do you currently have?
NUMBER OF JOBS: ______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C5.

Now I have a few questions about your [current/main] job. IF MORE THAN ONE JOB [C4>1]
READ: Your main job is the job where you work the most hours. What kind of business or
industry is this? That is, what do they make or do where you work? (RECORD VERBATIM)
(CPS/MTO modified)
_________________________________________
_________________________________________
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

C6.

What kind of work do you do? That is, what is your occupation? For example, plumber, typist,
farmer [RECORD VERBATIM] (CPS/MTO modified)
_________________________________________
_________________________________________
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

C7.

What are your usual duties or activities at this job? For example: typing, keeping account books,
filing, selling cars, operating printing press, laying brick. [RECORD VERBATIM] (CPS/MTO
modified)
_________________________________________
_________________________________________
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

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BOND Implementation and Evaluation

C8.

Contract No. SS00-10-60011

Are you self-employed at this job? (NBS)
PROBE: Self-employed means that you work for yourself or own your own business.
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

C9.

Is this job a temporary or seasonal job? (NEW)
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

C10.

In what month and year did you start working there?
IF SELF-EMPLOYED [C8=01] ASK:
In what month and year did you start this business? (NBS: Modified)
INTERVIEWER: ENTER MONTH HERE AND YEAR ON NEXT SCREEN
PROBE: Your best estimate is fine.
|__|__|
MO

|__|__|__|__|
YEAR

REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1
For this study, we need some information on how much often you work and how much you are paid on
this job. Please remember that we will keep all of your responses private.

C11.

How many hours per week do you typically work at this job?
NUMBER OF HOURS PER WEEK: ______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

[Programming in CAPI will control for main job versus current job, depending on the response to
C4.]

Abt Associates Inc.

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C12.

Contract No. SS00-10-60011

Before taxes and other deductions how much are you paid on this job? (NBS-modified)
$___________.______
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C12a. Is that amount paid daily, weekly, bi-weekly, twice a month, monthly, annually, or per
unit?
HOURLY ................................................................................................1
DAILY.....................................................................................................2
WEEKLY ................................................................................................3
EVERY TWO WEEKS............................................................................4
TWICE A MONTH ..................................................................................5
MONTHLY..............................................................................................6
ANNUALLY ............................................................................................7
PER UNIT OR PIECE ............................................................................8
REFUSED ............................................................................................97
DON’T KNOW ......................................................................................98

C13.

(SKIP TO C16)
(SKIP TO C14)
(SKIP TO C17)
(SKIP TO C17)
(SKIP TO C17)
(SKIP TO C14)
(SKIP TO C15)

[IF RATE OF PAY IS NOT DAILY (C12a2) SKIP TO C14] How many days a week do you
usually work? (CPS; MTO Interim Evaluation)
NUMBER OF DAYS PER WEEK: ______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C14.

[IF RATE OF PAY NOT WEEKLY (C12a3) OR ANNUALLY (C12a7) SKIP TO C15] How
many weeks a year do you get paid for? (CPS; MTO Interim Evaluation)
NUMBER OF WEEK: ______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

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C15.

Contract No. SS00-10-60011

[IF RATE OF PAY NOT PER UNIT (C12a8 SKIP TO C16] For how many [UNIT]s are you
usually paid per week (on this job)?
NUMBER OF UNITS: ______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C16.

[IF RATE OF PAY IS NOT HOURLY (C12a1) SKIP TO C17] How many hours per week are
you paid for at this rate? (CPS; MTO Interim Evaluation)
NUMBER OF HOURS PER WEEK: ______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C17.

Do you usually receive tips, or commissions (at your main job)? (CPS–modified)
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO C18)
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

C17a. (At your main job,) how much do you usually earn in tips or commissions, before taxes or
other deductions? (CPS-modified)
$___________.______
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C18.

I’d like you to think about your earnings in a typical week. How much do you typically earn,
before taxes or other deductions, in a typical week.
PROBE: Your best estimate is fine.
$___________.______
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

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C19.

Contract No. SS00-10-60011

I’d like you to think about the past year. Have you received any promotions at this job during the
past year?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

C19a. I’d like you to think about the past year. Have you received any bonuses or awards at
this job during the past year?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

C20.

(SKIP TO C21 if SELF EMPLOYED [C8=1]). Now, I’d like to ask you a few more questions
about your current job. I am going to read to you a list of benefits that some employers offer their
employees. Please tell me whether or not your current employer offers you any of these benefits.
Does your employer offer you or your co-workers…
PROGRAMMER: USE “MAIN” IF C4>01, OTHERWISE USE “CURRENT.”
IF NECESSARY READ: Please answer ‘yes’ if you are eligible for the benefit even if you haven’t
started to receive it yet. (NBS-Modified)
YES

NO

REF

DK

C20a. Health care insurance? (IF NECESSARY:
medical and/or hospital)

1

2

7

8

C20b. Dental benefits?

1

2

7

8

C20c. Sick days with pay?

1

2

7

8

C20d. Disability benefits?

1

2

7

8

C20e. Workers’ compensation

1

2

7

8

C20f.

1

2

7

8

C20g. Free or low-cost childcare?

1

2

7

8

C20h. Transportation, a transportation allowance, or
transportation discounts?

1

2

7

8

C20i.

1

2

7

8

Paid vacation?

Pension or retirement benefits?

Abt Associates Inc.

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C21.

Contract No. SS00-10-60011

Now I have a few questions about your work related expenses, including transportation to work.
During the typical week, how do you get to work?
Did you drive, ride in someone else's vehicle, take public transportation, use some combination,
or some other way?
ENTER ALL THAT APPLY. READ IF NECESSARY
DRIVE OWN VEHICLE..........................................................................1
RIDE IN SOMEONE ELSE'S VEHICLE/VAN POOL .............................2
PUBLIC TRANSPORTATION (BUS, TRAIN, SUBWAY, ETC.) ............3
WALK OR BICYCLE ..............................................................................4
SOME OTHER WAY (SPECIFY)...........................................................5
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

(SKIP TO C21B)
(SKIP TO C21C)
(SKIP TO C21C)
(SKIP TO C21c)
(SKIP TO C21c)
(SKIP TO C21c)

C21a. Altogether, about how many miles per week do you usually drive your vehicle as part of
your work commute?
____ MILES PER WEEK
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C21b. Do you have to pay for parking or tolls as a part of your work-commuting expenses?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

C21c. During a typical week, about how much are your work commuting expenses?

$ ______ PER WEEK
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

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BOND Implementation and Evaluation

C22.

Contract No. SS00-10-60011

Not counting expenses your employer paid, do you have any work-related expenses such as
licenses, permits, union dues, special tools, or uniforms for your work?
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO C23)
REFUSED ..............................................................................................7 (SKIP TO C23)
DON’T KNOW ........................................................................................8 (SKIP TO C23)
C22a. Altogether, how much do you spend for such items?
$ _____________________________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1
Is that per….
Week ......................................................................................................1
Every other week ...................................................................................2
Month .....................................................................................................3
Quarter ...................................................................................................4
Year........................................................................................................5
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

C23.

During the last four months, did you or your family pay for any child care arrangements for your
child(ren) while you worked? Include cost of preschool and nursery school; but do not include
tuituion for private kindergarten or grade school.
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO C24)
NO CHILDREN/NOT APPLICABLE.......................................................3
REFUSED ..............................................................................................7 (SKIP TO C24)
DON’T KNOW ........................................................................................8 (SKIP TO C24)

Abt Associates Inc.

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Contract No. SS00-10-60011

C23a. How much do you pay for child care while you work?
$ _____________________________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1
Is that per…
WEEK.....................................................................................................1
EVERY OTHER WEEK..........................................................................2
MONTH ..................................................................................................3
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

C24.

Do you use any special equipment related to your disability that helps you work at your job, for
example a brace, cane, wheelchair, modified computer hardware or modified computer software?
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO C25)
REFUSED ..............................................................................................7 (SKIP TO C25)
DON’T KNOW ........................................................................................8 (SKIP TO C25)

C24a. What kinds of special equipment do you/ use? Anything else?
ENTER ALL THAT APPLY. READ IF NECESSARY
BRACE...................................................................................................1
CANE/CRUTCHES/WALKER................................................................2
WHEELCHAIR .......................................................................................3
MODIFIED COMPUTER HARDWARE..................................................4
MODIFIED COMPUTER SOFTWARE ..................................................5
OTHER (SPECIFY)................................................................................6
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

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Contract No. SS00-10-60011

C24b. Who pays or paid for the equipment you use?
PROBE: For example, you or your family, insurance or Medicaid, or someone else?
ENTER ALL THAT APPLY. READ IF NECESSARY
SELF ......................................................................................................1
FAMILY ..................................................................................................2
HEALTH INSURANCE...........................................................................3
MEDICARE ............................................................................................4
MEDICAID..............................................................................................5
EMPLOYER ...........................................................................................6
STATE VOCATIONAL REHABILITATION AGENCY ............................7
NON-PROFIT ORGANIZATION ..............................................................
SERVING PEOPLE WITH DISABILITIES ..........................................8
WORKER’S COMPENSATION .............................................................9
DISABILITY INSURANCE ...................................................................10
OTHER (SPECIFY)..............................................................................11
REFUSED ............................................................................................97
DON’T KNOW ......................................................................................98

C24c. ASK IFC24b = SELF OR FAMILY: How much you or your family have to pay?
READ IF NECESSARY: Is that a one-time payment, per week, per month, per year, or some
other time period?
$_______________________________________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1
ONE TIME PAYMENT.. ........................................................................ 1
PER WEEK ........................................................................................... 2
PER MONTH .........................................................................................3
PER YEAR.......... .................................................................................. 4
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

Appendix D. BOND Stage 1 36-Month Follow-up Survey Instrument

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BOND Implementation and Evaluation

C25.

Contract No. SS00-10-60011

Do you use any personal assistance services related to your/his/her disability that helps you
work, for example, a job coach, a sign language interpreter, a reader or interpreter for the blind,
or a personal care attendant?
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO C26)
REFUSED ..............................................................................................7 (SKIP TO C26)
DON’T KNOW ........................................................................................8 (SKIP TO C26)

C25a. What kind of personal assistance services do you use? Anything else?
ENTER ALL THAT APPLY. READ IF NECESSARY
JOB COACH.......................................... ................................................1
SIGN LANGUAGE INTERPRETER.......................................................2
READER/INTERPRETER FOR THE BLIND ........................................ 3
PERSONAL CARE ATTENDANT/PERSONAL ASSISTANT ................4
OTHER (SPECIFY)................................................................................5
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

C25b. Who pays for the personal assistance services you use?
PROBE: For example, you or your family/ insurance or Medicaid, or someone else?
ENTER ALL THAT APPLY. READ IF NECESSARY
SELF ......................................................................................................1
FAMILY ..................................................................................................2
HEALTH INSURANCE...........................................................................3
MEDICARE ............................................................................................4
MEDICAID..............................................................................................5
EMPLOYER ...........................................................................................6
STATE VOCATIONAL REHABILITATION AGENCY ............................7
NON-PROFIT ORGANIZATION ..............................................................
SERVING PEOPLE WITH DISABILITIES ..........................................8
WORKER’S COMPENSATION .............................................................9
DISABILITY INSURANCE ...................................................................10
OTHER (SPECIFY)..............................................................................11
REFUSED ............................................................................................97
DON’T KNOW ......................................................................................98

Abt Associates Inc.

Appendix D. BOND Stage 1 36-Month Follow-up Survey Instrument

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BOND Implementation and Evaluation

Contract No. SS00-10-60011

C25c. ASK IFC25b = SELF OR FAMILY: How much you or your family have to pay?
READ IF NECESSARY: Is that a one-time payment, per week, per month, per year, or some
other time period?
$________________________________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

ONE TIME PAYMENT.. ........................................................................ 1
OR
PER WEEK ........................................................................................... 2
PER MONTH .........................................................................................3
PER YEAR.......... .................................................................................. 4
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

C26.

Next, I would like to ask you about different types of services or supports that you may have
received to improve your ability to work. For each service I read, please tell me if it is
something you have used since [RADATE], if you needed, but did not use it, or if you did not
need it. [NBS modified]
Yes
Used

Not
Used

Not
Needed

REF

DK

C26a. A work or job assessment?

1

2

3

7

8

C26b. Help to find a job?

1

2

3

7

8

C26c. Training to learn a new job or skill?

1

2

3

7

8

C26d. Advice about modifying your job or work
place?

1

2

3

7

8

C26e. On-the-job training, job coaching, or
support services?

1

2

3

7

8

C26f. Personal care assistance?

1

2

3

7

8

C26g. Transportation assistance?

1

2

3

7

8

C26h. Help in keeping a job?

1

2

3

7

8

C26i. Any kind of assistive device (a piece of
equipment to make it easier for you to live
independently or work?

1

2

3

7

8

C26j. Anything else that I did not mention?
SPECIFY__________________________

1

2

3

7

8

Since [RADATE] did you get…

Abt Associates Inc.

Appendix D. BOND Stage 1 36-Month Follow-up Survey Instrument

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BOND Implementation and Evaluation

C27.

Contract No. SS00-10-60011

[IF C26g=YES ASKC27 ELSE SKIP TO C28] I’d like to know more about the type of
transportation assistance you received. Did the transportation assistance you received include
assistance in transportation costs such as bus tokens, subway passes?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

C27a. Did it (also) include aid for a specific purpose such as modifying an existing vehicle to be
more accessible?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

C28.

[FOR EACH YES IN C26a-hASK:] How many hours of service did you receive in total over the
past 2 years?
NUMBER OF HOURS OF SERVICE [C26 ACTIVITY]: ______________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

C29.

[IF C26c = YES, ASK C29, ELSE SKIP TO C31] Where did you go to receive the training to learn
a new job or skill? Did you go to . . .
Yes

No

REF

DK

C29a. A vocational rehabilitation agency?

1

2

7

8

C29b. A welfare agency?

1

2

7

8

C29c. A mental health agency?

1

2

7

8

C29d. A state agency?

1

2

7

8

C29e. A workforce center or unemployment office

1

2

7

8

C29f. Your employer

1

2

7

8

C29g. OTHER(SPECIFY:_______________)

1

2

7

8

Abt Associates Inc.

Appendix D. BOND Stage 1 36-Month Follow-up Survey Instrument

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BOND Implementation and Evaluation

C30.

Contract No. SS00-10-60011

Who referred you to place(s) that you went for training or to learn a new job skill?
INTERVIEWER: MARK ONLY ONE. IF R INDICATES IT WAS THEIR IDEA CODE WAS NOT
REFERRED HERE.
PARENT/GUARDIAN.............................................................................1
SPOUSE/PARTNER ..............................................................................2
FRIEND..................................................................................................3
JOB COACH ..........................................................................................4
EMPLOYER/SUPERVISOR ..................................................................5
OTHER RELATIVE ................................................................................6
BENEFIT SPECIALIST ..........................................................................7
MEDICAL PROVIDER ...........................................................................8
WAS NOT REFERRED BY ANYONE ...................................................9
OTHER (SPECIFY____________________________________) .....10
REFUSED ............................................................................................97
DON’T KNOW ......................................................................................98

[IF C26e=YES, ASK C31 ELSE SKIP TO C35]
C31.

Where did you go or who provided the on the job training, job coaching, or support services?

Yes

Not
Used

Not
Needed

REF

DK

C31a. A vocational rehabilitation agency?

1

2

3

7

8

C31b. A welfare agency?

1

2

3

7

8

C31c. A mental health agency?

1

2

3

7

8

C31d. A state agency?

1

2

3

7

8

C31e. A workforce center or unemployment office?

1

2

3

7

8

C31f. Your employer?

1

2

3

7

8

C29g. OTHER(SPECIFY:_______________)

1

2

Abt Associates Inc.

7

8

Appendix D. BOND Stage 1 36-Month Follow-up Survey Instrument

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C32.

Contract No. SS00-10-60011

Who referred you to place(s) that you went for on-the-job training, job coaching, or support
services?
INTERVIEWER: MARK ONLY ONE.
IF R INDICATES IT WAS THEIR IDEA CODE WAS NOT REFERRED BY ANYONE.
PARENT/GUARDIAN.............................................................................1
SPOUSE/PARTNER ..............................................................................2
FRIEND..................................................................................................3
JOB COACH ..........................................................................................4
EMPLOYER/SUPERVISOR ..................................................................5
OTHER RELATIVE ................................................................................6
BENEFIT SPECIALIST ..........................................................................7
MEDICAL PROVIDER ...........................................................................8
WAS NOT REFERRED BY ANYONE ...................................................9
OTHER (SPECIFY____________________________________) .....10
REFUSED ............................................................................................97
DON’T KNOW ......................................................................................98

UNEMPLOYED RESPONDENTS (A1 NE 1) SKIP TO C37

C33.

[IF SELF-EMPLOYED SKIP TO C36] Please tell me whether or not your {main/current} employer
has made any accommodations because of your physical or mental condition. Has your
employer ... (NBS-modified)

YES

NO

NOT
NEEDED

REF

DK

C33a.

Provided you with any special equipment or
assistive technology

1

2

3

7

8

C33b.

Kept your job available to you, even though you
have to go out on disability from time to time?

1

2

3

7

8

C33c.

Arranged for co-workers or others to help you
when you need it?
Provided you with any modified computer
hardware?
Provided you with any modified computer
software?
Made any other changes that I didn’t mention to
accommodate your condition in the workplace?
(SPECIFY:_______________)

1

2

3

7

8

1

2

3

7

8

1

2

3

7

8

1

2

3

7

8

C33d.
C33e.
C33f.

Abt Associates Inc.

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Contract No. SS00-10-60011

ASK ALL RESPONDENTS
C34.

* Taking all things into account, how satisfied are you with your [main/current] job? Would you
say you are:
PROGRAMMER: USE “MAIN” IF C4>01, OTHERWISE USE “CURRENT.”
Very satisfied .........................................................................................1
Somewhat satisfied ...............................................................................2
Not very satisfied ...................................................................................3
Not at all satisfied? ................................................................................4
REFUSED ............................................................................................97
DON’T KNOW ......................................................................................98

C35.

Now, I would like to ask you some questions about how you usually spend your time. In an
ordinary week, about how many hours do you spend in each of these activities:
[INTERVIEWER: IF NONE, ENTER 0. IF LESS THAN 1, ENTER 1]
Number of
Hours per Week

C36.

C35a.

Working in a job for which you are paid?

|__|__|__|

C35b.

Doing unpaid work at a family business?

|__|__|__|

C35c.

(if C37a orC37b >0) Commuting to and from work?

|__|__|__|

C35d.

In volunteer work for an organization?

|__|__|__|

C35e.

In school, working toward a degree, or in a training program?

|__|__|__|

C35f.

In home-making or home maintenance activities including caring for
others, housekeeping, food preparation, yard work or house repairs?

|__|__|__|

C35g.

In personal health care and self grooming activities?

|__|__|__|

[IF A3 = 1 OR C35d>0, ASK C36, ELSE SKIP TO D1] Did any of the volunteer or unpaid work
we just discussed lead you to a paid job?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

Appendix D. BOND Stage 1 36-Month Follow-up Survey Instrument

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BOND Implementation and Evaluation

Contract No. SS00-10-60011

SECTION D: BARRIERS TO EMPLOYMENT
Personal Views
Now I am going to read you a few statements. I’m going to ask whether or not you agree with each one.
Please remember that there is no right or wrong answer, the questions are simply asking what you think
about each one.
D1.

* For the following statements, please tell me whether you strongly agree, agree, neither agree
nor disagree, disagree, or strongly disagree. (NBS modified)
Agree

Neither
Agree Nor
Disagree

Disagree

Strongly
Disagree

NA

REF

DK

1

2

3

4

5

6

7

8

D1b. I am limited in my ability to
work because I do not have
reliable transportation to and
from work.

1

2

3

4

5

6

7

8

D1c. I am limited in my ability to
work because I am caring for
children or others

1

2

3

4

5

6

7

8

D1d. It is difficult for me to work
because I am afraid I will lose
my disability benefits

1

2

3

4

5

6

7

8

D1e. I am limited in my ability to
work because I am finishing a
school or training program

1

2

3

4

5

6

7

8

1

2

3

4

5

6

7

8

D1g. I don’t have the skills or
training I need to return to
work.

1

2

3

4

5

6

7

8

D1h. It will be difficult to re-qualify
for Social Security disability
benefits in the future if I work.

1

2

3

4

5

6

7

8

Strongly
Agree
D1a. I am limited in my ability to
work because of a physical or
mental condition.

D1f.

Many workplaces are not
accessible to people with my
disability

Now I am going to read you a few statements. I’m going to ask whether or not you agree with each one.
Please remember that there is no right or wrong answer, the questions are simply asking what you think
about each one.
D2.

* Do your personal goals include [IF A1=2, getting a job], moving up in a job or learning new job
skills?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

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BOND Implementation and Evaluation

D3.

Contract No. SS00-10-60011

Are you currently receiving Social Security disability benefits?
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO D4)
REFUSED ..............................................................................................7 (SKIP TO D4)
DON’T KNOW ........................................................................................8 (SKIP TO D4)

*D3a.

Do your personal goals include someday working and earning enough to stop receiving
Social Security disability benefits?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

INTERVIEWER READS THIS INTRODUCTION: Under the current rules of the Social Security Disability
Insurance program, disability beneficiaries are allowed to earn up to $1000 per month without a change to
your benefits. This limit is called the level of Substantial Gainful Activity or SGA and the Social Security
increases this limit each year to adjust for inflation. When disability beneficiaries go to work while
receiving disability benefits, SSA ignores the cap of $1000 for up to 9 months, no matter how much a
beneficiary earns from work.

D4.

* We’d like to know which of the following things you think would happen to your monthly
disability cash benefits if you were to work and earn more than the SGA limit of $1000 month
after those initial months have passed. Thinking about the amount of your disability cash
benefits, if you earned more than $1,000 after those initial months…
*D4a.

Do you think you would lose your monthly benefits completely? That is, would the
amount of your benefits fall to $0?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

D4b.

* Do you think your benefits would be reduced but that you would be able to keep
receiving some of your monthly disability benefits?
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO D4d)
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

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BOND Implementation and Evaluation

D4c.

Contract No. SS00-10-60011

* [IF D5b=YES] How do you think those benefits would be reduced? Do you think that
they would be reduced…
By the full amount of your benefit? .......................................................1
By half of the amount of your benefits, that is a $1 reduction in benefits
for every $2 you earn from work? ..........................................................2
By some other amount? ........................................................................3
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

D4d.

* Do you think your disability benefits would stay the same? That is, nothing would
happen to your monthly disability benefits if you earned more than $1000 per month after
the initial nine months that SSA allows?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

D5.

Now, we’d like to know which of the following things you think would happen to your eligibility for
disability benefits if you were to work and earn more than the SGA limit of $1000 month after
those initial months have passed. Thinking about your eligibility for disability benefits…
D5a.

* Do you think you would remain eligible for disability benefits in the future, no matter how
much you earn from work? That is, you would never have to re-apply for benefits?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

D5b.

* Do you think you would remain eligible for disability benefits for awhile, but eventually
you would no longer be eligible to receive benefits? That is, do you think eventually you
would have to re-apply for benefits?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

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BOND Implementation and Evaluation

Contract No. SS00-10-60011

SECTION E: INCOME
I’m going to ask you about the income you personally received last month, that is, in [INSERT LAST
MONTH, THIS YEAR]. This includes income and benefits from different programs. When answering
these questions, please think only about your own earnings and benefits, and don’t include earnings
or benefits that other family members may have received.
E1.

IF D3=1, ASK, OTHERWISE, SKIP TO E2A
E1a.

You just told me you get income from Social Security (or SSDI). How much do you get
each month?
INTERVIEWER: ROUND TO NEAREST DOLLAR
$___________.______ (SKIP TO E2)
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

E1b.

Was it more than or less than $300?
$300 OR MORE .....................................................................................1
LESS THAN $300 ..................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

E2.

(In addition to your Social Security or SSDI, last/ Last) month did you receive any income from…
[READ EACH SOURCE. IF RESPONDENT VOLUNTEERS ‘I ONLY GET SSDI or SOCIAL
SECURITY’ SKIP TO E4
YES

NO

REF

DK

E2a. Veterans’ benefits?

1

2

7

8

E2b. Public assistance or welfare payments?

1

2

7

8

E2c. Workers’ compensation?

1

2

7

8

E2d. Private disability insurance?

1

2

7

8

E2e. Unemployment benefits?

1

2

7

8

E2f. Private pensions or government employee pensions?

1

2

7

8

E2g. Disability insurance for a Disabled adult child?

1

2

7

8

E2h. Other sources on a regular basis but not from jobs or
Social Security?

1

2

7

8

E2i. Other sources not on a regular basis?

1

2

7

8

E2j. IF VOLUNTEERED BY RESPONDENT: SSDI ONLY

1

2

7

8

Abt Associates Inc.

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BOND Implementation and Evaluation

E3.

Contract No. SS00-10-60011

How much income did you receive last month from {SOURCE FROM F2}?
INTERVIEWER: ROUND TO NEAREST DOLLAR
$___________.______ (GO TO E2 FOR NEXT SOURCE OR E4 IF NO OTHER
SOURCES OF INCOME)
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1 (ASK E2a)

E3a.

Was it more than or less than $300?
$300 OR MORE .....................................................................................1 (SKIP TO E2b)
LESS THAN $300 ..................................................................................2 (SKIP TO E2c)
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

E3b

Was it more than or less than $500?
$500 OR MORE .....................................................................................1
LESS THAN $500 ..................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

GO TO E2 FOR NEXT SOURCE
OR E4

E3c.

Was it more than or less than $150?
$150 OR MORE .....................................................................................1
LESS THAN $150 ..................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

GO TO E2 FOR NEXT SOURCE
OR E4

Abt Associates Inc.

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E4.

Contract No. SS00-10-60011

Did you or any member of your household receive SNAP benefits (Supplemental Nutrition
Assistance Program) or food stamps last month?
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO E5)
REFUSED ..............................................................................................7 (SKIP TO E5)
DON’T KNOW ........................................................................................8 (SKIP TO E5)

E4a.

What was the dollar value of the SNAP benefit (Supplemental Nutrition Assistance
Program) or food stamps you received last month?
INTERVIEWER: ROUND TO NEAREST DOLLAR
$___________.______
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

E5.

Did you or any member of your household receive assistance from any other government
source? For example: energy assistance or child care assistance.
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO E8)
REFUSED ..............................................................................................7 (SKIP TO E8)
DON’T KNOW ........................................................................................8 (SKIP TO E8)

E6.

What type of other assistance did you receive?
______________________________________________________
REFUSED ............................................................................................97
DON’T KNOW ......................................................................................98

E7.

How much income did you receive last month from this other assistance?
INTERVIEWER: ROUND TO NEAREST DOLLAR
$___________.______
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

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E8.

Contract No. SS00-10-60011

Do you currently receive any governmental housing assistance in paying rent, such as through
public housing or Section 8 or a Housing Choice Voucher? (HOPE VI, MTO)
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Now I’d like you to think about the income of all members in your household.

E9.

What was the total combined income of all members of this household during the [LAST
CALENDAR YEAR]? Please include money from jobs, work on the side, welfare, SSI, help from
your family and friends, and any other money income received by you or any other household
member. (Effects of Housing Choice Vouchers on Welfare Families)
ENTER DOLLAR AMOUNT: $___________.______ ............................ (SKIP TO F1)
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1
E9a.

Would it amount to $10,000 or more?
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO E9e)
REFUSED ..............................................................................................7 (SKIP TO E9e)
DON’T KNOW ........................................................................................8 (SKIP TO E9e)

E9b.

Would it amount to $20,000 or more?
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO E9d)
REFUSED ..............................................................................................7 (SKIP TO E9d)
DON’T KNOW ........................................................................................8 (SKIP TO E9d)

E9c.

Would it amount to $25,000 or more?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

(SKIP TO F1)

Abt Associates Inc.

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E9d.

Contract No. SS00-10-60011

Would it amount to $15,000 or more?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

(SKIP TO F1)

E9e.

Would it amount to $5,000 or more?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

E10.

INTERVIEWER CHECK: IF EITHER A6 OR A7 = 1, ASK E10a. OTHERWISE, SKIP TO F1.
E10a. Did your spouse (or partner) work during the last calendar year?
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO F1)
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

E10b. How much did your spouse earn from work last year?
ENTER DOLLAR AMOUNT: $___________.______
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

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Contract No. SS00-10-60011

SECTION F: HEALTH AND FUNCTIONAL STATUS
The next few questions ask about your health and how well you are able to do your usual activities.
As I read each item, please tell me if your health now limits you a lot, limits you a little, or does not limit
you at all in these activities.

F1.

Does your health now limit you in moderate activities such as moving a table, pushing a vacuum
cleaner, bowling, or playing golf? Does it limit you…

(SF-12)

A lot, ......................................................................................................1
A little, or ...............................................................................................2
Not at all? ...............................................................................................3

F2.

Does your health now limit you in climbing several flights of stairs? Does it limit you…

(SF-12)

A lot, ......................................................................................................1
A little, or ...............................................................................................2
Not at all? ...............................................................................................3

The next two questions ask about your physical health and your daily activities.

F3.

* During the past 4 weeks, how much of the time have you accomplished less than you would
have liked to as a result of your physical health? Would you say…

(SF-12)

All of the time, ........................................................................................1
Most of the time,.....................................................................................2
Some of the time, ...................................................................................3
A little of the time, or ..............................................................................4
None of the time?...................................................................................5

F4.

During the past 4 weeks, how much of the time were you limited in the kind of work or other
regular daily activities you do as a result of your physical health? Would you say…

(SF-12)

All of the time, ........................................................................................1
Most of the time,.....................................................................................2
Some of the time, ...................................................................................3
A little of the time, or ..............................................................................4
None of the time?...................................................................................5

Abt Associates Inc.

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Contract No. SS00-10-60011

Now I will ask about any emotional problems and your daily activities.

F5.

* During the past 4 weeks, how much of the time have you accomplished less than you would
have liked to as a result of any emotional problems, such as feeling depressed or anxious?
Would you say…

(SF-12)

All of the time, ........................................................................................1
Most of the time,.....................................................................................2
Some of the time, ...................................................................................3
A little of the time, or ..............................................................................4
None of the time?...................................................................................5

F6.

* During the past 4 weeks, how much of the time did you not do work or other activities as
carefully as usual as a result of any emotional problems, such as feeling depressed or anxious?
Would you say…

(SF-12)

All of the time, ........................................................................................1
Most of the time,.....................................................................................2
Some of the time, ...................................................................................3
A little of the time, or ..............................................................................4
None of the time?...................................................................................5

F7.

* During the past 4 weeks, how much did pain interfere with your normal work, including both
work outside the home and housework? Did it interfere.

(SF-12)

Not at all, ................................................................................................1
A little bit,................................................................................................2
Moderately, ............................................................................................3
Quite a bit, or..........................................................................................4
Extremely? .............................................................................................5

These next questions are about how you feel and how things have been with you during the past 4
weeks. For each question, please give me the one answer that comes closest to the way you have been
feeling.

F8.

* During the past 4 weeks, how much of the time have you felt calm and peaceful? Would you
say…

(SF-12)

All of the time, ........................................................................................1
Most of the time,.....................................................................................2
Some of the time, ...................................................................................3
A little of the time, or ..............................................................................4
None of the time?...................................................................................5

Abt Associates Inc.

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F9.

Contract No. SS00-10-60011

* During the past 4 weeks, how much of the time did you have a lot of energy? Would you say…

(SF-12)

All of the time, ........................................................................................1
Most of the time,.....................................................................................2
Some of the time, ...................................................................................3
A little of the time, or ..............................................................................4
None of the time?...................................................................................5

F10.

* During the past 4 weeks, how much of the time have you felt downhearted and depressed?
Would you say…

(SF-12)

All of the time, ........................................................................................1
Most of the time,.....................................................................................2
Some of the time, ...................................................................................3
A little of the time, or ..............................................................................4
None of the time?...................................................................................5

F11.

* During the past 4 weeks, how much of the time has your physical health or emotional problems
interfered with your social activities, like visiting with friends or relatives? Would you say…

(SF-12)

All of the time, ........................................................................................1
Most of the time,.....................................................................................2
Some of the time, ...................................................................................3
A little of the time, or ..............................................................................4
None of the time?...................................................................................5

Health Care Service Utilization
F12.

During the past 12 months, have you stayed overnight in a hospital? (HCC)
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO F14)
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

F13.
During the past 12 months, how many nights in total did you stay in the hospital?
(HCC)
|__|__| TIMES
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

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Contract No. SS00-10-60011

Now I’d like to ask some general health related questions.

F14.

How tall are you without shoes? (NHIS 97)
IF NECESSARY READ: Please respond in feet and inches?
|__| FEET
(3-8)

|__|__| INCHES
(1-11)

REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

F15.

How much do you weigh without shoes? (NHIS97)
|__|__|__| POUNDS (50-300)
(50-600)
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Now I’d like to ask you some questions about everyday activities and how much difficulty you have doing
these activities. Please give me your best answer even if the questions don’t seem to apply to you.

F16.

Do you need help with personal care such as bathing, dressing, or getting around the house
because of an impairment or a physical or mental health problem?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

F17.

During the past 12 months, about how many days did illness or an injury keep you in bed more
than half of the day? (Please include days that you were an overnight patient in a hospital.)
NUMBER OF DAYS ____________________
NONE.....................................................................................................0
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

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F18.

Contract No. SS00-10-60011

Do you need the help of another person in order to get around inside your home?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

F19.

Do you need the help of another person in order to get around outside your home?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

F20.

* Do you have a lot of trouble concentrating long enough to finish everyday tasks?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

F21.

* Do you have a lot of trouble coping with day-to-day stresses?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

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Contract No. SS00-10-60011

SECTION G: HEALTH INSURANCE
Now, I’m going to ask you about different types of health insurance coverage you might have.

G1.
Do you have health insurance coverage now?
(HCC)
[INTERVIEWER: PROBE IF NECESSARY: “For instance, are you covered by a plan that
someone else in your family has, or through a health plan your employer provides, or Medicare,
Medicaid, or a plan you bought on your own?”]
YES .......................................................................................................1 (SKIPTO G3)
NO .........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

G2.
So, you are uninsured, is that correct?
(HCC)
[INTERVIEWER: PROBE IF NECESSARY: “This means no Medicaid coverage or any other
government sponsored health insurance coverage.”]
YES .......................................................................................................1 (SKIPTO G5)
NO .........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

G3.

What kinds of health coverage do you have?
PROBE: Any other kind?
INTERVIEWER: CODE ALL THAT APPLY.
MEDICAID/{STATMED}.........................................................................1
MEDICARE ............................................................................................2
CHAMPUS/CHAMP-VA, TRICARE, VA, OTHER MILITARY ................3
INDIAN HEALTH SERVICE...................................................................4
MEDI-GAP .............................................................................................5
STATE PROGRAM ................................................................................6
PRIVATE INSURANCE THROUGH OWN EMPLOYER .......................7
PRIVATE INSURANCE THROUGH SPOUSE/PARTNER/PARENT ....8
PRIVATE INSURANCE PAID BY SELF/FAMILY ..................................9
PRIVATE DISABILITY INSURANCE PAID BY SELF/FAMILY ...........10
OTHER PLAN (SPECIFY)_____________________ .........................95
REFUSED ............................................................................................97
DON’T KNOW ......................................................................................98

Abt Associates Inc.

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Contract No. SS00-10-60011

SECTION H: FINANCIAL HARDSHIP
The next set of questions are about difficulties people sometimes have in meeting their essential
household expenses. Essential household expenses are things such as mortgage or rent payments,
utility bills, or important medical care.

H1.

During the past 12 months, has there been a time when you did not meet all of your essential
expenses?
IF NEEDED: Essential household expenses include such things as mortgage or rent payments,
utility bills or important medical care
.
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

H2.

The following are some of the specific difficulties people experience with household expenses.
Was there any time in the past 12 months when you did not pay the full amount of the rent or
mortgage?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

H3.

In the past 12 months were you evicted from your home or apartment for not paying the rent or
mortgage?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

H4.

Was there a time in the past 12 months when you could not pay the full amount of the gas, oil, or
electricity bills?
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO H6)
REFUSED ..............................................................................................7 (SKIP TO H6)
DON’T KNOW ........................................................................................8 (SKIP TO H6)

Abt Associates Inc.

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H5.

Contract No. SS00-10-60011

In the past 12 months did the gas or electric company turn off service, or the oil company not
deliver oil because you did not pay?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

H6.

Was there a time in the past 12 months when the telephone or cell phone company disconnected
service because you did not pay?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

H7.

Getting enough food can also be a problem for some people. Which of these statements best
describes the food eaten in your household in the last twelve months:
Enough of the kinds of food we want .....................................................1
Enough but not always the kinds of food we want to eat.......................2
Sometimes not enough to eat ................................................................7
Often not enough to eat .........................................................................8
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

H8.

I'm going to read you some statements that people have made about their food situation. For
these statements, please tell me whether it was often true, sometimes true, or never true for you
in the last twelve months.
“The food that I bought just didn't last and I didn't have money to get more." Was that often,
sometimes or never true for you in the last twelve months?
OFTEN TRUE ........................................................................................1
SOMETIMES TRUE...............................................................................2
NEVER TRUE ........................................................................................7
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

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H9.

Contract No. SS00-10-60011

The next statement is: “I couldn't afford to eat balanced meals" Was that often, sometimes or
never true for you in the last twelve months?
OFTEN TRUE ........................................................................................1
SOMETIMES TRUE...............................................................................2
NEVER TRUE ........................................................................................7
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

H10.

The next statement is: I was not eating enough because I couldn't afford enough food." Was that
often, sometimes or never true for you in the last twelve months?
OFTEN TRUE ........................................................................................1
SOMETIMES TRUE...............................................................................2
NEVER TRUE ........................................................................................7
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

H11.

The next questions refer to adults in the household. In the past twelve months did you ever cut
the size of your meals or skip meals because there wasn't enough money for food?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

H12.

In the past twelve months, did you ever eat less than you felt you should because there wasn't
enough money to buy food?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

H13.

In the past twelve months, did you ever not eat for a whole day because there wasn't enough
money for food?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

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SECTION I:

Contract No. SS00-10-60011

PERSONAL CHARACTERISTICS

Demographics
I have a few more questions about you.

I1.

What is your ethnic background? Are you:
Hispanic or Latino, or .............................................................................1
Not Hispanic or Latino?..........................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

I2.

What is your race? Do you think of yourself as:
INTERVIEWER: CODE ALL THAT APPLY.

I3.

YES

NO

REF

DK

I2a.

IF VOLUNTEERED: MULTIRACIAL,

1

2

7

8

I2b.

Alaska Native or American Indian

1

2

7

8

I2c.

Asian

1

2

7

8

I2d.

Black or African American

1

2

7

8

I2e.

Native Hawaiian or Other Pacific Islander

1

2

7

8

I2f.

White

1

2

7

8

I2g.

OTHER (SPECIFY_______________)

1

2

7

8

What is the primary language spoken in your home?
ENGLISH ...............................................................................................1
SPANISH ...............................................................................................2
AMERICAN SIGN LANGUAGE .............................................................3
OTHER(SPECIFY__________________________) ............................4
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

I4.

INTERVIEWER: RECORD RESPONDENT’S GENDER:
MALE / FEMALE .............................. [query or interviewer observation]

Abt Associates Inc.

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Contract No. SS00-10-60011

Current Living Situation
I5.

Thinking about the place you live, would you say that this place is a…
[INTERVIEWER: CODE ONE ANSWER.]
[IF RESPONDENT LIVES IN ONE UNIT WITHIN A TWO- OR THREE-FAMILY HOME, CODE
AS REGULAR APARTMENT (03).]
Single family home ................................................................................1
Mobile home. .........................................................................................2
Regular apartment ................................................................................3
Supervised apartment ...........................................................................4
Group home ..........................................................................................5
Halfway house........................................................................................6
Personal care or board and care home ................................................7
Assisted living facility .............................................................................8
Nursing or convalescent home ..............................................................9
Shelter .................................................................................................10
Some other type of supervised group residence or facility ..................11
Something else________________________________....................12
REFUSED ............................................................................................97
DON’T KNOW ......................................................................................98

I6.

Is this place primarily for people with hearing or vision impairments, mental illness psychiatric
disabilities, mental retardation, or developmental disabilities?
YES ........................................................................................................1
NO ..........................................................................................................2
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

I7.

Not including yourself, how many other people live in your household with you now?
NUMBER OF PEOPLE____________________
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

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Contract No. SS00-10-60011

SECTION J: RESPONDENT CONTACT INFORMATION
Thank you very much for your time today. At this time we’d like to just confirm some information about
you. The information we confirm now will allow us to help us be able to get back in touch with you in the
future. [It will also allow us to ensure that your incentive payment is sent to the correct address.]
J1.

I have your name listed as [READ AND CONFIRM SPELLING OF NAME, FIRST MIDDLE LAST
SUFFIX]. Is that correct?
YES, ALL CORRECT.............................................................................1
NO, CORRECT FIRST NAME ...............................................................2
NO, CORRECT MIDDLE NAME............................................................3
NO, CORRECT LAST NAME ................................................................4
NO, CORRECT SUFFIX ........................................................................5
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

J2.

J3.

(SKIP TO J3)
(GO TO J2A)
(GO TO J2B)
(GO TO J2C)
(GO TO J2D)
(SKIP TO J3)
(SKIP TO J3)

Could you please tell me how to spell your name.?
J2a.

FIRST:

What is your first name?

J2b.

MIDDLE:

What is your middle name?

J2c.

LAST:

What is your last name?

J2d.

SUFFIX:

Is there anything after your last name, like Jr. or Sr.?

I would like to confirm your date of birth. I have your date of birth as [MM/DD/YYYY]. Is that
correct?
YES ........................................................................................................1 (SKIP TO J4)
NO ..........................................................................................................2
REFUSED ..............................................................................................7 (SKIP TO J4)
DON’T KNOW ........................................................................................8 (SKIP TO J4)

J3a.

What is your date of birth?
____/____/________
MM DD
YYYY
REFUSED .............................................................................................-2
DON’T KNOW .......................................................................................-1

Abt Associates Inc.

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J4.

Contract No. SS00-10-60011

Our records show that your current address is (READ FROM SAMPLE SHEET). Is this correct?
YES, ALL OF THAT IS CORRECT).......................................................1
NO–UPDATE STREET ..........................................................................2
NO–UPDATE APARTMENT/UNIT ........................................................3
NO–UPDATE CITY ...............................................................................4
NO–UPDATE STATE.............................................................................5
NO–UPDATE ZIP...................................................................................6
NO–UPDATE TELEPHONE ..................................................................7
REFUSED ............................................................................................97
DON’T KNOW ......................................................................................98

J5.

J4a.

STREET:

What is your current street address?

J4b.

APT:

Is there an apartment number?

J4c.

CITY:

In what city do you live?

J4d.

STATE:

In what state do you live?

J4e.

ZIP:

What is your zip code?

(SKIP TO J5)
(GO TO J4a)
(GO TO J4b)
(GO TO J4c)
(GO TO J4d)
(GO TO J4e)
(GO TO J5)
(SKIP TO J5)
(SKIP TO J5)

IF CAPI: Our records show your phone number as [AREA CODE/PHONE NUMBER]
IF CATI: I called you at [AREA CODE/PHONE NUMBER].
Is this the best number to reach you at?
YES ........................................................................................................1 (SKIP TO J7)
NO ..........................................................................................................2
REFUSED ..............................................................................................7 (SKIP TO J7)
DON’T KNOW ........................................................................................8 (SKIP TO J7)

J6.

What is your home phone number, starting with area code?
(____) _____-________
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Abt Associates Inc.

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J7.

Contract No. SS00-10-60011

Do you have a cell phone number?
YES ........................................................................................................1
NO ..........................................................................................................2 (SKIP TO END)
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

J7a.

What is your cell phone number, starting with area code?
(____) _____-________
REFUSED ..............................................................................................7
DON’T KNOW ........................................................................................8

Thanks so much for your time.

Abt Associates Inc.

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47