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pdfATTACHMENT A
NBS-GENERAL WAVES INSTRUMENT
Mathematica Reference Number: 40160.106
NATIONAL BENEFICIARY SURVEY
June 13, 2014
NATIONAL BENEFICIARY SURVEY
- TABLE OF CONTENTS Section
Page
A.
Screener .......................................................................................... A-1
B.
Disability and Current Work Status .................................................. B-1
C.
Current Employment ........................................................................ C-1
D.
Jobs/Other Jobs During 2014 .......................................................... D-1
E.
Awareness of SSA Work Incentive Programs .................................. E-1
F.
DELETED FROM NBS-GENERAL WAVES .................................... F-1
G.
Employment-Related Services and Supports Used in 2014.............G-1
H.
DELETED FROM NBS-GENERAL WAVES .................................... H-1
I.
Health and Functional Status ............................................................ I-1
J.
Health Insurance ...............................................................................J-1
K.
Income and Other Assistance .......................................................... K-1
L.
Sociodemographic Information......................................................... L-1
M.
Closing Information and Observations ............................................ M-1
SECTION A: SCREENER
PRELOADED INFORMATION
S1
(A01_a)
CLUSTERED SAMPLE
YES = 01
NO = 02
S3
(A01_c)
REGION – VALUES = 01 – 08,
S4
(A01_d)
PSU – VALUES = 01010 – 55018;
S5
(A01_e)
SDATE (DATE SAMPLE PULLED –June 2014)
S6
(A02)
S9
(A04_b)
FIRST NAME (original – may be updated in another block: Current First Name)
S10
(A04_c)
LASTNAME (original – may be updated in another block: Current Last Name)
S11
(A04_d)
BIRTHDATE (original – may be updated in another block: Current Birth Date)
ROUND OF DATA COLLECTION
Round 1 = 01
Round 2 = 02
Round 3 = 03S8 (A04_a) FULLNAME (original – may be updated in another block: Current Full Name)
S11a CURRENT AGE: IF A71 = 02 OR 03, USE A68 OR A69 TO CALCULATE CURRENT AGE
S12
(A04_e)
GENDER
S13
(A04_f)
BSTATUS (Benefit Type)
BSTATUS = 01 – SSI ONLY BENEFITS
BSTATUS = 02 – SSDI ONLY BENEFITS
BSTATUS = 03 – CONCURRENT (BOTH SSI AND SSDI) BENEFITS
S14
(A04_g)
SSIAGE (from SSI records –age first received SSI benefits)
S18
(A04_k)
STATE MED (STATE NAME FOR MEDICAID) (based on state of residence at A67a)
S19
(A04_l)
VRNAME (STATE NAME FOR VRA) (based on state of residence at A67a)
S20
(A04_m)
Sample Member’s Address at time sample was drawn (may be updated in Section A)
S21
(A04_n)
Sample Member’s Phone Number at time sample was drawn
S22
PROXY – FULL NAME
S23
PROXY – PHONE NUMBER
S24
PROXY – ADDRESS 1, ADDRESS 2, CITY, STATE, ZIP
S25
INTERPRETER NAME
INTERPRETER.
A-1
–
RETAIN
SAMPLE
MEMBER
PHONE
NUMBER
ASSOCIATED
WITH
NBS ROUND 4 INSTRUMENT
RTYPE: Set at A110 or A110a.
PROGRAMMER: INSTITUTE A PARALLEL BLOCK THAT ALLOWS THE INTERVIEWER TO SWITCH
RESPONDENT FROM SAMPLE MEMBER TO PROXY OR FROM PROXY TO SAMPLE
MEMBER AT ANY POINT IN THE INTERVIEW. UPDATE RTYPE BASED ON THE PARALLEL
BLOCK.
PROGRAMMER: A CURRENT CONTACT BLOCK WILL STORE ANY UPDATES TO S8, S9, S10, S11, S20, and
S21. UPDATES TO THE OTHER CURRENT CONTACT BLOCK CAN COME FROM THE
SCREENER OR LOCATING.
PROGRAMMER: STORE UPDATED NAME, ADDRESS, AGE, PROXY, ETC. INFORMATION IN ADDRESS
UPDATE BLOCK OR NAME UPDATE BLOCK.
(All)
A0.
A-2
CALL SCREEN. PROGRAMMER, DISPLAY: INTERVIEWER: YOU ARE CALLING…(ONE ONLY) NOTE:
01, 04, 07 THROUGH 15 ARE SET IN OVERNIGHT PROCESSING. 02, 03, 05 AND 06 WOULD BE IN
THE FRONT END FOR THE INTERVIEWER TO SELECT.
SITUATION
DISPLAY, CALLING FOR
GO TO
01
NEW SCREENER FOR NAME
CALL TO {NAME}
A1
02
CATI CALL-IN
{NAME} CALLING IN
A11
03
CAPI INTERVIEW
{NAME – CAPI}
A64
04
CALL NAME AFTER REMAIL
{NAME , AFTER REMAIL}
A1
05
RELAY CALL IN
{NAME} CALLING IN – RELAY
A11
06
TTY CALL IN
{NAME} CALLING IN – TTY
A11
07
CALL NAME USING RELAY
{NAME} – RELAY
A10
08
CALL NAME USING TTY
{NAME} – TTY
A10
09
CALL NAME USING AMPLIFIER
{NAME} – AMPLIFIER
A1
10
CALL TO IDENTIFIED PROXY
PROXY NAME
A56
11
CALLBACK TO PROXY AFTER REMAIL
PROXY NAME
A56
12
INFORMANT/PROXY CALL IN
13
CALL TO NEW PROXY
PROXY NAME
A56
14
CALL INTERPRETER
INTERPRETER NAME
A8
15
CALL TO NEW / UNNAMED
INTERPRETER
INTERPRETER NAME
A4b
A11
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
CALL TO RESPONDENT
(A0 = 01, 04, OR 09)
A1.
Hello, my name is _________, calling on behalf of the Social Security Administration. May I please speak
with {NAME}?
INTERVIEWER: We are not selling anything or asking for a contribution.
SPEAKING .........................................................................
WANTS MORE INFORMATION .........................................
{NAME} COMES TO PHONE .............................................
CALL BACK LATER ...........................................................
{NAME} MOVED.................................................................
POSSIBLE PARTICIPATION PROBLEM ...........................
HOSPITALIZED..................................................................
{NAME} DECEASED ..........................................................
{NAME} INCARCERATED..................................................
LANGUAGE BARRIER (NOT SPANISH) ...........................
INSTITUTIONALIZED ........................................................
MILITARY DUTY ................................................................
SWITCH TO AMPLIFIER / CONTINUE ..............................
NO SUCH PERSON AT THIS NUMBER ............................
OTHER: SUPERVISOR REVIEW NEEDED......................
HUNG UP DURING INTRODUCTION ...............................
UNAVAILABLE DURING FIELD PERIOD ..........................
LIVING OUTSIDE USA ......................................................
REFUSED ..........................................................................
A-1
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
r
(A10)
(A10)
SET A100 = 01 (A100)
(A30)
(A13)
(A27a)
(A103a)
SET A103 = 01(A103)
(A3)
(A27a)
SET A103 = 02 (A103)
(A10)
SET A102 = 01 (A102)
SET A106 = 05 (A106)
SET STATUS = 640 (END)
SET A104 = 06 (A104)
SET A103 = 03 (A103)
SET A105 = 02 (A105)
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
REQUESTS INFORMATION
(A1=02)
A2.
Social Security recently sent {NAME} a letter saying that we would be calling to ask {him/her} to participate
in an important national health study we are conducting for them. I work for Mathematica Policy Research, a
nationally recognized research company based in Princeton, New Jersey. We are conducting a scientific
study. We are not selling anything or asking for contributions.
PROBE:
(IF PREPAY=1): We recently sent a letter which included a $5 gift card as a token of
appreciation. We will send you an additional $15 gift card after you complete the interview.
INTERVIEWER INSTRUCTION (PRE-PAY=1): If sample member says he/she did not receive gift card and
will not complete the interview until we send a gift card, schedule appointment to call back.
NAME SPEAKING ..............................................................
{NAME} COMES TO PHONE .............................................
CALL BACK LATER ...........................................................
{NAME} MOVED.................................................................
POSSIBLE PARTICIPATION PROBLEM ...........................
HOSPITALIZED..................................................................
{NAME} DECEASED ..........................................................
{NAME} INCARCERATED..................................................
LANGUAGE BARRIER (NOT SPANISH) ...........................
INSTITUTIONALIZED ........................................................
MILITARY DUTY ................................................................
SWITCH TO AMPLIFIER / CONTINUE ..............................
NO SUCH PERSON AT THIS NUMBER ............................
OTHER: SUPERVISOR REVIEW NEEDED......................
HUNG UP DURING INTRODUCTION ...............................
UNAVAILABLE DURING FIELD PERIOD ..........................
LIVING OUTSIDE USA ......................................................
DID NOT RECEIVE LETTER .............................................
REFUSED ..........................................................................
01
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
r
(A10)
(A10)
SET A100 = 01 (A100)
(A30)
(A13)
(A27a)
(A103a)
SET A103 = 01 (A103)
(A27a)
SET A103 = 02 (A103)
(A10)
SET A102 = 01 (A102)
SET A106 = 05 (A106)
SET STATUS = 640 (END)
SET A104 = 06 (A104)
SET A103 = 03 (A103)
A22
SET A105 = 02 (A105)
LANGUAGE BARRIER
(A1 = 10) OR (A2 = 10)
A3.
Can someone there speak English?
PERSON COMES TO PHONE........................................... 01
CALL BACK LATER ........................................................... 02 SET A100 = 09 (A100)
NO ONE SPEAKS ENGLISH ............................................. 03 SET A106 = 01 (A106)
REFUSED/HUNG UP .........................................................
r SET A106 = 01 (A106)
POSSIBLE INTERPRETER COMES TO PHONE
(A3 = 01)
A4.
Hello, my name is _____________, calling on behalf of the Social Security Administration. Social Security
recently sent {NAME} a letter saying {he/she} was selected to participate in an important health survey we
are conducting for them. It is called the National Beneficiary Survey. We are looking for someone who is
18 years or older to help {him/her} by interpreting the interview for us. Are you 18 years of age or older?
PROBE (PREPAY=1): We recently sent a letter which included a $5 gift card as a token of appreciation. We
will send you an additional $15 gift card after you complete the interview.
YES .................................................................................... 01 (A4b)
NO ...................................................................................... 00
REFUSED/HUNG UP .........................................................
r SET A106 = 01 (A106)
A-2
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
(A4 = 00)
A4a.
Is there someone else who is 18 years or older who could come to the phone and help with the interview?
YES, PERSON COMES TO PHONE ................................. 01
CALL BACK LATER ........................................................... 02 (A6)
NO ONE SPEAKS ENGLISH ............................................. 03 SET A106 = 01 (A106)
REFUSED/HUNG UP .........................................................
r SET A106 = 01 (A106)
(A0 = 15) OR (A4 = 01) OR (A4a = 01)
A4b.
IF (A0=15) or (A4a=01) FILL {Hello, my name is _____________, calling on behalf of the Social Security
Administration. Social Security recently sent {NAME} a letter saying {he/she} was selected to participate in
an important health survey we are conducting for them. It is called the National Beneficiary Survey. We are
looking for an interpreter who is 18 years or older to help {him/her} with the interview.} Would you be able to
help {NAME} by interpreting the interview?
PROBE: We are not selling anything or asking for contributions.
PROBE (PREPAY=1): We recently sent a letter which included a $5 gift card as a token of appreciation.
We will send you an additional $15 gift card after you complete the interview.
YES ....................................................................................
CALL BACK LATER ...........................................................
NO ONE +18 SPEAKS ENGLISH ......................................
{NAME} MOVED.................................................................
POSSIBLE PARTICIPATION PROBLEM ...........................
HOSPITALIZED..................................................................
{NAME} DECEASED ..........................................................
{NAME} INCARCERATED..................................................
INSTITUTIONALIZED ........................................................
MILITARY DUTY ................................................................
NO SUCH PERSON AT THIS NUMBER ............................
OTHER: SUPERVISOR REVIEW NEEDED......................
UNAVAILABLE DURING FIELD PERIOD ..........................
LIVING OUTSIDE USA ......................................................
REQUESTS IN-PERSON INTERVIEW ..............................
REFUSED ..........................................................................
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
r
(A6)
SET A106 = 01 (A106)
(A30)
(A13)
(A27a)
(A103a)
SET A103 = 01 (A103)
(A27a)
SET A103 = 02 (A103)
SET A102 = 01 (A102)
SET A106 = 05 (A106)
SET A104 = 06 (A104)
SET A103 = 03 (A103)
(A39)
SET A105 = 02 (A105)
(A4b = 01)
A5.
If {NAME} is available and you are ready to interpret, we can begin now. If you or {NAME} get tired or need a
break at any time, please tell me and we will call back later to finish the interview.
CONTINUE ......................................................................... 01
CALL BACK LATER ........................................................... 02
INTERPRETER REFUSED ................................................
r SET A105 = 02 (A105)
A-3
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
(A4a = 02) OR (A4b = 02) OR (A5 = 01 OR 02)
A6.
{IF A5 = 01 DISPLAY Before we begin, please tell me your name.}
{IF A4a = 02 DISPLAY Please tell me that person’s name so we can ask for them when we call back later /
IF A5 = 02 OR A4b = 02 DISPLAY: Please tell me your name so we can ask for you when we call back later}.
PROBE: IF PERSON IS RELUCTANT TO GIVE NAME, SAY: The first name is all we need.
IF NAME IS REFUSED, CODE AS REFUSED AND CONTINUE
FIRST, MIDDLE, LAST
DON’T KNOW ....................................................................
REFUSED ..........................................................................
d
r
PROGRAMMER: STORE INTERPRETER NAME IN S25 AND LOCATOR
(A6 = ANSWER OR r)
A7.
And, what is {IF A5 = 01 OR 2) OR (A4b = 02) FILL your / IF A4a = 02 FILL their} relationship to {NAME}?
{NAME’S} SPOUSE ............................................................
NAME’S} MOTHER ............................................................
{NAME’S} FATHER ............................................................
{NAME’S} CHILD ................................................................
GRANDPARENT OF {NAME} ............................................
BROTHER/SISTER (NATURAL/STEP) OF {NAME} ..........
AUNT/UNCLE OF {NAME} .................................................
OTHER RELATIVE .............................................................
NOT RELATED ..................................................................
STAFF AT RESIDENCE .....................................................
DON’T KNOW ....................................................................
REFUSED ..........................................................................
01
02
03
04
05
06
07
08
09
10
d
r
(A7 = ANSWER OR d OR r)
A7a.
PROGRAMMER:
IF A5 = 01 (CONTINUE) ..................................................... 01 (A10)
ELSE CALLBACK TO INTERPRETER ............................. 02 SET A100 = 03 (A100)
CALLBACK TO NAMED INTERPRETER
(A0=14)
A8.
Hello, my name is ___________________, calling on behalf of the Social Security Administration. May I
please speak to {INTERPRETER’S NAME}?
PROBE:
We are not selling anything or asking for contributions.
SPEAKING .........................................................................
INTERPRETER COMES TO PHONE ................................
CALL BACK LATER ...........................................................
HUNG UP DURING INTRODUCTION ..............................
INTERPRETER REFUSED ................................................
A-4
01
02
03 SET A100 = 03 (A100)
04 SET STATUS = 640 (END)
r SET A105 = 02 (A105)
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
(A8 =01 OR 02)
A9.
{IF A8 = 02 DISPLAY: Hello, my name is ________________, calling on behalf of the Social Security
Administration.} When we spoke with you recently, you said this would be a good time for you to interpret
the National Beneficiary Survey for {NAME}. Are you and {NAME} ready to begin?
PROBE:
If you or {NAME} get tired or need a break at any time, please tell me and we will call back later
to finish the interview.
YES, CONTINUE ................................................................
CALL BACK LATER ...........................................................
HUNG UP DURING INTRODUCTION ...............................
INTERPRETER REFUSED ................................................
SET A105 = 02 (A105)
01
03 SET A100 = 03 (A100)
04 SET STATUS = 640 (END)
05
SPEAKING TO NAME OR INTERPRETER / NAME OR INTERPRETER COMES TO PHONE / TO NAME AFTER
REMAIL
(A0 = 07 OR 08) OR (A1 = 01, 03 OR 13) OR (A2 = 01, 03, OR 13) OR (A7a = 01) OR (A9 = 01)
A10.
{PROGRAMMER, IF A7a = 01 DISPLAY “Please tell {NAME} that I said….”} {(IF A0 = 07 OR 08, OR 09) OR
(A1 = 03) OR (A2 = 03 OR 13) DISPLAY Hello, my name is ________________, calling on behalf of the
Social Security Administration.} Recently, Social Security sent you {PROGRAMMER IF A0 = 04 USE
another} a letter explaining an important survey we are conducting for them. {IF A2 = 01 BEGIN HERE} The
National Beneficiary Survey is about your health, daily activities, any jobs you may have, and any Social
Security programs and services you may use. I’m calling to ask you to participate. The information you and
other participants give us will be used to help evaluate Social Security’s programs for disability beneficiaries.
PROBE:
We are not selling anything or asking for a contribution.
The interview {IF A0 = 08 FILL will take around 2 - 3 hours because we are using TTY / IF A0 = 07 FILL will
take around 2 - 3 hours because we are using Relay. / IF (A0 = 04) OR (A1 = 01, 03 OR 13) OR (A2 = 01
OR 03 OR 13) FILL: will take between 45 and 60 minutes.} IF PRE-PAY=0: {In appreciation for your time,
we will mail you a gift card for $20.00 when we finish the interview}/ IF PRE-PAY=1: {As a token of
appreciation, we recently mailed you a gift card for $5. We will send you an additional $15 gift card after you
complete the interview. The questions are easy. If you get tired or need a break at any time, please tell me
and we will call back later to finish the interview. This interview may be recorded for quality assurance. Let’s
start now.
INTERVIEWER INSTRUCTION (PREPAY=1): If sample member says he/she did not receive gift card and
will not complete the interview until we send a check, schedule appointment to call back.
CONTINUE ....................................................... 01 (A64)
{NAME} WILL CALL MPR ................................ 02 SET A108 = 01 (A108)
CALL BACK LATER ......................................... 03 (IF A1 = 01, 03, 13 OR A2 = 01, 03, A13A;
OR A0 = 07, 08, 09 SET A100 = 01 (A100)
IF A7a = 01 OR A9 = 02 SET A100 = 03
(A100))
DID NOT RECEIVE LETTER/DOES NOT
RECALL LETTER .........................................
REQUESTS PROXY ........................................
REQUESTS IN-PERSON INTERVIEW ............
POSSIBLE PARTICIPATION PROBLEM .........
REFUSED ........................................................
A-5
04
05
06
07
r
(A20)
(A39)
(A39)
(A13)
(IF A1 = 01, 03, 13 OR
A2 = 01, 03, A13A; OR A0 = 07, 08, 09
SET A105 = 01 (A105) / IF A7a = 01 OR
A9 = 01 SET A105 = 02 (A105)
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
NAME OR UNKNOWN INFORMANT CALLS IN
(A0=02, 05, OR 06)
A11.
INTERVIEWER: CODE BASED ON SUPERVISOR INSTRUCTION.
{NAME}.............................................................
{NAME} USING TTY.........................................
{NAME} USING RELAY....................................
INFORMANT / POSSIBLE PROXY ..................
01
02
03
04 (A13a)
(A11 = 01, 02, OR 03)
A12.
Hello, my name is ________________________. I’ll be your interviewer today. The National Beneficiary
Survey is about your health, daily activities, and any jobs you might have. It also asks about your use of
Social Security programs and services. The information you and other participants give us will be used to
help evaluate Social Security’s programs for disability beneficiaries.
The interview {PROGRAMMER, IF A11 = 01 FILL will take between 45 and 60 minutes / IF A11 = 02 USE
will take around 2 - 3 hours because we are using TTY / IF A11 = 03 FILL will take around 2 - 3 hours
because we are using Relay.}IF PRE-PAY=0: {In appreciation for your time, we will mail you a $20.00 gift
card when we finish the interview.}/ IF PREPAY=1: {As a token of appreciation, we recently mailed you a gift
card for $5. We will send you an additional $15 gift card after you complete the interview. The questions are
easy. If you get tired or need a break at any time, please tell me and we will call back later to finish the
interview. This interview may be recorded for quality assurance. Let’s start now.
INTERVIEWER INSTRUCTION (PREPAY=1): If sample member says he/she did not receive gift card and
will not complete the interview until we send a gift card, schedule appointment to call back.
CONTINUE ....................................................... 01 (A64)
WANTS TO SCHEDULE INTERVIEW ............. 02 IF A11 = 01 SET A100 = 01 (A100)
IF A11 = 02 SET A100 = 04 (A100)
IF A11 = 03 SET A100 = 05 (A100)
NEEDS PROXY ............................................... 03
NEEDS IN-PERSON ........................................ 04 (A39)
POSSIBLE PARTICIPATION PROBLEM ......... 05 (A13)
REFUSED ........................................................
r IF A11 = 01, 02, 03 SET A105 = 01 (A105)
IF A11 = 04 SET A105 = 02 (A105)
DIFFICULTY PARTICIPATING (SPEAKING WITH NAME / INFORMANT / UNKNOWN PROXY WHO CALLS IN)
(A1 = 06) OR (A2 = 06) OR (A4b = 05) OR (A10 = 07) OR (A11 = 04) OR (A12 = 05)
A13.
INTERVIEWER: WHO ARE YOU SPEAKING WITH?
{NAME} / INTERPRETER ................................ 01
INFORMANT/POSSIBLE PROXY .................... 02
A-6
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
(A11 = 04) OR (A13 = 01 OR 02)
A13a. INTERVIEWER: IF BARRIER ALREADY STATED, CODE RESPONSE THEN CONFIRM BY READING
APPROPRIATE CATEGORY BELOW.
{PROGRAMMER: IF A11 = 04, USE: PROBE: Thank you very much for calling and offering to help.
IF NEEDED: What problem does {NAME} have that might prevent {him/her} from participating for
{himself/herself}?
IF (A1 = 06) OR (A2 = 06) OR (A4b = 05) OR (A10 = 07) OR (A12 = 05) FILL
PROBE:
Why {IF A13 = 01 FILL would you/ IF A13 = 02 FILL would {NAME}} have a problem
participating in the survey?
INTERVIEWER: PROBE FOR DON’T KNOW. IF MORE THEN ONE PROBLEM, PROBE FOR THE MAIN
PROBLEM.
HEARING DIFFICULTY ...................................
SPEECH DIFFICULTY .....................................
COGNITIVE BARRIER .....................................
PHYSICAL BARRIER .......................................
INCARCERATED .............................................
INSTITUTIONALIZED ......................................
HOSPITALIZED ...............................................
DECEASED ......................................................
SERVING IN MILITARY ...................................
LIVING OUTSIDE USA ....................................
DON’T KNOW ..................................................
REFUSED ........................................................
A-7
01
02
03
04
06
07
08
09
10
11
d
r
(A46)
SET A103 = 01 (A103)
(A27a)
(A27a)
(A103a)
SET A103 = 02 (A103)
SET A103 = 03 (A103)
SET A105 = 02 (A105)
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
(A13a = 01, 02, 04, OR d)
A14.
Recently, Social Security sent {IF A13 = 01 FILL you / IF A13 = 02 FILL {NAME} a letter saying {IF A13 = 01
FILL you were/ IF A13 = 02 FILL {him/her} he/she was} selected to take part in an important health survey
we are conducting for them.} {IF A12 = 05 START HERE} We would like {IF A13 = 01 FILL you to have / IF
A13 = 02 FILL {NAME} to have} the chance to answer the questions for {IF A13 = 01 FILL yourself / IF A13
= 02 FILL himself / herself} if at all possible. I’m going to read some ways that we can arrange for {IF A13 =
01 FILL you / IF A13 = 02 FILL {NAME}} to take part in the study.
PROBE: What would work best?
PROBE (PREPAY=1): We recently sent a letter which included a gift card for $5 as a token of appreciation.
We will send you an additional $15 gift card after you complete the interview.
INTERVIEWER: READ LIST AND CODE ONE ONLY. IF MORE THAN ONE MENTIONED, ASK WHAT IS
EASIEST FOR {NAME}.
We can break the interview into a few short calls to {IF
A13 = 01 FILL you / IF A13 = 02 FILL {NAME} ....... 01 (A64)
We can use Relay or TTY for the interview .................... 02 (A16)
{PROGRAMMER, DISPLAY 03 ONLY IF A13a = 01} I
can switch to a phone amplifier now ....................... 03 (A64)
{PROGRAMMER, DISPLAY 04 ONLY IF A13a = 01}
We can call later using a phone amplifier................ 04 SET A100 = 06 (A100)
{PROGRAMMER, DISPLAY 05 ONLY IF IN
CLUSTERED SAMPLE S1 = 01 We could send
an interviewer to {{IF A13 = 01 FILL your / IF
A13 = 02 FILL {his/her} home ................................. 05 (A42)
{PROGRAMMER DISPLAY 06 ONLY IF A13 = 02}
INFORMANT OFFERS TO BE PROXY .................. 06 (A39)
{PROGRAMMER, DISPLAY 07 ONLY IF SAMPLE
TYPE = UNCLUSTERED, S1 = 02 AND A13
= 01} {NAME} REQUESTS IN-PERSON
INTERVIEW ............................................................ 07 (A40)
{PROGRAMMER DISPLAY 08 ONLY IF A13 = 01}
{NAME} REQUESTS PROXY ................................. 08 (A39)
PHYSICAL PROBLEM: {NAME} UNABLE TO
PARTICIPATE ........................................................ 09 (A46)
SUGGESTS ANOTHER WAY {SPECIFY__) .................. 10
DON’T KNOW .................................................................
d (A39)
REFUSED .......................................................................
r IF A13 = 01 SET A105 = 01 (A105) /
IF A13 = 02 SET A105 = 02 (A105)
(A14 = 10)
A14a. What is that way?
02) OR (A67 = d)
A72
PROGRAMMER CHECK: IS {NAME’S} IDENTITY VERIFIED (NAME VERIFIED {A66 = 01 OR 02} AND IS
BIRTHDATE VERIFIED (A70 = 01) OR (A71 = 01 OR 02)?
YES (VERIFIED) .............................................. 01
NO (FAILED VERIFICATION) .......................... 00 SET A102 = 04 (A102)
PROGRAMMER: CALCULATE AGE AT INTERVIEW (CURRENTAGE) USING DATE OF INTERVIEW - SELFREPORTED DATE OF BIRTH GIVEN IN A68 (TO BE USED IN SECTION E). DO NOT
RE-CALCULATE UPON RE-ENTRY.
A-22
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
NAME/PROXY COGNITIVE TEST
(A72 = 01)
A73.
INTERVIEWER: WHO ARE YOU SPEAKING WITH?
INTERVIEWER: IF YOU ARE SPEAKING WITH AN INTERPRETER, CODE SPEAKING WITH {NAME}.
NAME – CATI OR CAPI INTERVIEW ..............
NAME, TTY INTERVIEW .................................
NAME, RELAY INTERVIEW ............................
PROXY (CATI) .................................................
PROXY (CAPI) .................................................
01
02 SET A110 = 01 (A110)
03 SET A110 = 01 (A110)
04
05
(A73=01, 04 OR 05)
A74.
Next, I will explain some facts about the survey. After I explain, I will ask you three questions so I can be
sure my explanation was clear.
Here’s the first explanation. The survey asks about {IF (A73 = 03) FILL your / IF (A73 = 04 OR 05) FILL
{NAME’s}} health, daily activities, and any jobs {IF (A73 = 03) FILL you / IF (A73 = 04 OR 05) FILL {NAME}}
might have. Please tell me in your own words what the survey is about.
INTERVIEWER: IF RESPONDENT SAYS “DON’T KNOW” RECORD AS “LISTS NONE”
LISTS NONE ....................................................
LISTS ONLY 1 TOPIC ......................................
LISTS ANY 2 TOPICS ......................................
LISTS 3 TOPICS ..............................................
REFUSED ........................................................
00
01
02 (A77)
03 (A77)
r IF A73 = 03 SET A105 = 01 (A105) /
IF A73 = 04 OR 05 SET A105 = 03 (A105)
A75 IS DELETED
(A74 = 00 OR 01)
A76.
INTERVIEWER: YOU ARE ASKING THIS QUESTION FOR THE SECOND AND LAST TIME.
Let’s try that again. The survey asks about {your/NAME}’s health, daily activities , and any jobs {IF (A73 =
03) FILL you / IF (A73 = 04 OR 05) FILL {NAME}} might have. Please tell me in your own words, what the
survey is about.
INTERVIEWER: IF RESPONDENT SAYS “DON’T KNOW” RECORD AS “LISTS NONE”
LISTS NONE ....................................................
LISTS ONLY 1 TOPIC ......................................
LISTS ANY 2 TOPICS ......................................
LISTS 3 TOPICS ..............................................
REFUSED ........................................................
A-23
00 (A80)
01 (A80)
02
03
r IF A73 = 03 SET A105 = 01 (A105) /
IF A73 = 04 OR 05 SET A105 = 03 (A105)
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
(A74 = 02 OR 03) OR (A76=02 OR 03)
A77.
Here is the next explanation. Taking part in the survey is completely voluntary. Completely voluntary means
you can choose whether or not to take part. If you decide to take part, you can refuse to answer any
questions you do not like and you can stop the interview at any time you choose. Whether you choose to
take part or not, {your/NAME’s} disability benefits will not be affected in any way.
When I say your participation is completely voluntary, what does that mean to you?
PROBE: IF RESPONDENT SAYS: It is voluntary, PROBE: What does that mean?
INTERVIEWER: EXAMPLES OF ACCURATE ANSWERS ARE: I can decide to take part or not to take part.
I can refuse to take part if I want. I don’t have to do this. I can do this if I want. No one will take away my
benefits if I refuse, etc.
INTERVIEWER: IF NAME/PROXY SAYS “DON’T KNOW” RECORD AS “INACCURATE ANSWER”
ACCURATE ANSWER ..................................... 01 (A78)
INACCURATE ANSWER ................................. 02
REFUSED ........................................................ r IF A73 = 03 SET A105 = 01 (A105) /
IF A73 = 04 OR 05 SET A105 = 03 (A105)
(A77=02)
A77a. INTERVIEWER: YOU ARE ASKING THIS QUESTION FOR THE SECOND AND LAST TIME.
Let’s try that again. Taking part in the survey is completely voluntary. Completely voluntary means you can
choose whether or not to take part. If you decide to take part, you can refuse to answer any questions you
do not like and you can stop the interview at any time you choose. Whether you choose to take part or not,
{your/NAME’s} disability benefits will not be affected in any way. When I say your participation is completely
voluntary, what does that mean to you?
PROBE: IF RESPONDENT SAYS: It is voluntary, PROBE: What does that mean?
INTERVIEWER: EXAMPLES OF ACCURATE ANSWERS ARE: I can decide to take part or not to take
part. I can refuse to take part if I want. I don’t have to do this. I can do this if I want. No one will take away
my benefits if I refuse, etc.
INTERVIEWER: IF NAME/PROXY SAYS “DON’T KNOW” RECORD AS “INACCURATE ANSWER”
ACCURATE ANSWER ..................................... 01
INACCURATE ANSWER ................................. 02 (A80)
REFUSED ........................................................ r IF A73 = 03 SET A105 = 01 (A105) /
IF A73 = 04 OR 05 SET A105 = 03 (A105)
(A77 = 01 OR A77a = 01)
A78.
Here’s the last explanation. All your answers will be kept confidential and used only for the research
purposes of the study. When I say that your answers will be kept confidential, what does that mean to you?
PROBE: IF RESPONDENT OR PROXY SAYS: It is confidential, PROBE: What does that mean?
INTERVIEWER: EXAMPLES OF ACCURATE ANSWERS ARE: My answers will be secret. Only
researchers will see what I said. What I say will be (kept) private. It will only be used for research; etc.
INTERVIEWER: IF RESPONDENT SAYS: “DON’T KNOW,” RECORD AS “INACCURATE ANSWER”
ACCURATE ANSWER ..................................... 01 (A110)
INACCURATE ANSWER ................................. 02
REFUSED ........................................................ r IF A73 = 03 SET A105 = 01 (A105) /
IF A73 = 04 OR 05 SET A105 = 03 (A105)
A-24
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
(A78 = 02)
A78a. INTERVIEWER: YOU ARE ASKING THIS QUESTION FOR THE SECOND AND LAST TIME.
Let’s try that again. All your answers will be kept confidential and used only for the research purposes of the
study.
When I say that your answers will be kept confidential, what does that mean to you?
PROBE: IF RESPONDENT OR PROXY SAYS: It is confidential, PROBE: What does that mean?
INTERVIEWER: EXAMPLES OF ACCURATE ANSWERS ARE: My answers will be secret. Only
researchers will see what I said. What I say will be (kept) private. It will only be used for
research; etc.
INTERVIEWER: IF RESPONDENT SAYS “DON’T KNOW” RECORD AS “INACCURATE ANSWER”
ACCURATE ANSWER ..................................... 01 IF A73 = 03 SET A110 = 01 (A110) /
IF A73 = 04 OR 05 SET A110 = 02 (A110)
INACCURATE ANSWER - FAILED .................. 02
REFUSED ........................................................ r IF A73 = 03 SET A105 = 01 (A105) /
IF A73 = 04 OR 05 SET A105 = 03 (A105)
A79 IS DELETED
RESPONDENT OR PROXY FAILS COGNITIVE TEST. FIND A PROXY/ANOTHER PROXY
(A76 = 00 OR 01) OR (A77a = 02 OR A78a = 02)
A80.
Thank you. Our study rules say that we need to find {IF (A73 = 03) USE someone / IF (A73 = 04) USE
someone else} who can help {IF (A64 = 01) FILL you / IF (A64 = 02) FILL {NAME}} answer the survey
questions. Is there someone there who could answer questions about {(IF A64 = 01) FILL your / IF (A64 =
02) FILL {NAME’s}} health, daily activities, and any jobs {IF (A64 = 01) FILL you / IF (A64 = 02) FILL he/she}
might have?
PROBE:
This might be someone who lives with {you/NAME}, a friend, or someone like a social worker or
case worker.
YES, PROXY COMES TO PHONE ..................
YES, CALL BACK PROXY LATER...................
YES, PROXY LIVES ELSEWHERE .................
NO PROXY AVAILABLE ..................................
DON’T KNOW ..................................................
REFUSED ........................................................
01
02
03
04
d
r
(A85)
(A82)
SET A106 = 04 (A106)
SET A106 = 04 (A106)
IF A73 = 03 SET A105 = 01 (A105) /
IF A73 = 04 OR 05 SET A105 = 03 (A105)
(A80 = 02)
A81.
What is that person’s name so that we can call back and ask for them?
NAME: PREFIX, FIRST, `MIDDLE, LAST, SUFFIX
PROGRAMMER: RECORD NAME LOCATING DATABASE
SET A100 = 02 (A100)
A-25
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
(A80 = 03)
A82.
Do you have that person’s name and/or telephone number? If you don’t have all the information please tell
me what you can.
YES .................................................................. 01
NO .................................................................... 00 SET A102 = 07 (A102)
(A82 = 01)
A83.
PREFIX, FIRST, MIDDLE, LAST, SUFFIX
DON’T KNOW ..................................................
REFUSED ........................................................
d
r
Please give me the telephone number, area code first.
TELEPHONE NUMBER: | | | |-| | |
DON’T KNOW ..................................................
REFUSED ........................................................
|-|
d
r
|
|
|
|
PROGRAMMER: STORE 3 PROXY NAME AND PHONE NUMBER IN LOCATING
DATABASE.
IF BOTH NAME AND PHONE NUMBER REFUSED, SET A106 = 05 (A106)
(A83 = ANSWER)
A84.
PROGRAMMER: WHAT KIND OF PROXY CONTACT INFORMATION DOES A83 CONTAIN?
VALID PHONE NUMBER ................................. 01 SET A101 = 02 (A101)
INVALID PHONE NUMBER ............................. 02 SET A106 = 05 (A106)
NO PHONE NUMBER ...................................... 03 SET A106 = 05 (A106)
CALL TO NEW PROXY/NEW PROXY COMES TO PHONE
(A1 = 13) OR (A56 = 01 OR O2) OR (A80 = 01)
A85.
{IF (A56 = 01 OR 02) OR (A80 = 01) USE Hello, my name is ________________, calling on behalf of the
Social Security Administration.} Recently, Social Security contacted {NAME} about an important survey we
are conducting for them. The National Beneficiary Survey is about beneficiaries’ health, daily activities, and
any jobs they might have. . I’ve been told that you are knowledgeable about these topics and are the best
person to answer the survey on behalf of {NAME}.
The interview will take from 45 to 60 minutes. IF PREPAY=0: {In appreciation for your time, we will mail you
a gift card for $20.00 when we finish the interview.}/IF PREPAY=1: {As a token of appreciation, we recently
mailed {NAME} a gift card for $5.. We will send you an additional $15 gift card after you complete the
interview. Would you be able to help us?
INTERVIEWER INSTRUCTION (PREPAY=1): If proxy says sample member did not receive gift card and
will not complete interview until we send gift card, schedule appointment.
YES .................................................................. 01
CALL BACK LATER ......................................... 02 SET A100 = 02 (A100)
DON’T KNOW .................................................. d SET A106 = 03 (A106)
REFUSED ........................................................ r SET A105 = 03 (A105)
(A85=01)
A85a. Before we start, please tell me your name.
FIRST, MIDDLE, LAST
DON’T KNOW ..................................................
REFUSED ........................................................
A-26
d
r
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
NEW PROXY / NEW PROXY COMES-TO-PHONE COGNITIVE TEST
(A85 = 01)
A86.
Next, I will explain some facts about the survey. After I explain, I will ask you three questions so I can be
sure my explanation was clear.
Here’s the first explanation. The survey asks about {NAME’s} health, daily activities, and any jobs {he/she}
might have. Please tell me in your own words what the survey is about.
INTERVIEWER: IF RESPONDENT SAYS “DON’T KNOW,” RECORD AS “LISTS NONE”
LISTS NONE ....................................................
LISTS ONLY 1 TOPIC ......................................
LISTS ANY 2 TOPICS ......................................
LISTS 3 TOPICS ..............................................
REFUSED ........................................................
00
01
02 (A89)
03 (A89)
r SET A105 = 03 (A105)
A87 IS DELETED
(A86 = 00 OR 01)
A88.
INTERVIEWER: YOU ARE ASKING THIS QUESTION FOR THE SECOND AND LAST TIME.
Let’s try that again. The survey asks about {NAME}’s health, daily activities, and any jobs {he/she} might
have. Please tell me in your own words what the survey is about.
INTERVIEWER: IF RESPONDENT SAYS “DON’T KNOW” RECORD AS “LISTS NONE”
LISTS NONE ....................................................
LISTS ONLY 1 TOPIC ......................................
LISTS ANY 2 TOPICS ......................................
LISTS 3 TOPICS ..............................................
REFUSED ........................................................
00 (A92)
01 (A92)
02
03
r SET A105 = 03 (A105)
(A86 = 02 OR 03) OR (A88 = 02 OR 03)
A89.
Here is the next explanation. Taking part in the survey is completely voluntary. Completely voluntary means
you can choose whether or not to take part. If you decide to take part, you can refuse to answer any
questions you do not like and you can stop the interview at any time you choose. Whether you choose to
take part or not, {NAME’s} disability benefits will not be affected in any way.
When I say your taking part is completely voluntary, what does that mean to you?
PROBE: IF RESPONDENT SAYS: It is voluntary, PROBE: What does that mean?
INTERVIEWER: EXAMPLES OF ACCURATE ANSWERS ARE: I can decide to take part or not to take
part. I can refuse to take part if I want. I don’t have to do this. I can do this if I want. No one
will take away my benefits if I refuse, etc.
INTERVIEWER: IF RESPONDENT SAYS “DON’T KNOW,” RECORD AS “INACCURATE ANSWER”
ACCURATE ANSWER ..................................... 01 (A90)
INACCURATE ANSWER ................................. 02
REFUSED ........................................................ r SET A105 = 03 (A105)
A-27
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
(A89 = 02)
A89a. INTERVIEWER: YOU ARE ASKING THIS QUESTION FOR THE SECOND AND LAST TIME.
Let’s try that again. Taking part in the survey is completely voluntary. Completely voluntary means you can
choose whether or not to take part. If you decide to take part, you can refuse to answer any questions you
do not like and you can stop the interview at any time you choose. Whether you choose to take part or not,
{NAME’s} disability benefits will not be affected in any way. When I say your taking part is completely
voluntary, what does that mean to you?
PROBE: IF RESPONDENT SAYS: It is voluntary, PROBE: What does that mean?
INTERVIEWER: EXAMPLES OF ACCURATE ANSWERS ARE: I can decide to take part or not to take
part. I can refuse to take part if I want. I don’t have to do this. I can do this if I want. No one
will take away my benefits if I refuse, etc.
INTERVIEWER: IF RESPONDENT SAYS “DON’T KNOW” RECORD AS “INACCURATE ANSWER”
ACCURATE ANSWER ..................................... 01
INACCURATE ANSWER ................................. 02 (A92)
REFUSED ........................................................ r SET A105 = 03 (A105)
(A89a = 01)
A90.
Here’s the last explanation. All your answers will be kept confidential and used only for the research
purposes of the study. When I say that your answers will be kept confidential, what does that mean to you?
PROBE: IF RESPONDENT SAYS: It is confidential, PROBE: What does that mean?
INTERVIEWER: EXAMPLES OF ACCURATE ANSWERS ARE: My answers will be secret. Only
researchers will see what I said. What I say will be (kept) private. It will only be used for
research; etc.
INTERVIEWER: IF RESPONDENT SAYS “DON’T KNOW,” RECORD AS “INACCURATE ANSWER”
ACCURATE ANSWER ..................................... 01 SET A110 = 02 (A110)
INACCURATE ANSWER ................................. 02
REFUSED ........................................................ r SET A105 = 03 (A105)
(A90 = 02)
A90a. INTERVIEWER: YOU ARE ASKING THIS QUESTION FOR THE SECOND AND LAST TIME.
Let’s try that again. All your answers will be kept confidential and used only for the research purposes of the
study.
When I say that your answers will be kept confidential, what does that mean to you?
PROXY: IF RESPONDENT SAYS: It is confidential, PROBE: What does that mean?
INTERVIEWER: EXAMPLES OF ACCURATE ANSWERS ARE: My answers will be secret. Only
researchers will see what I said. What I say will be (kept) private. It will only be used for
research; etc.
INTERVIEWER: IF RESPONDENT SAYS “DON’T KNOW,” RECORD AS “INACCURATE ANSWER”
ACCURATE ANSWER ..................................... 01 SET A110 = 02 (A110)
INACCURATE ANSWER ................................. 02 (A92)
REFUSED ........................................................ r SET A105 = 03 (A105)
A-28
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
A91 IS DELETED
(A88 = 00 OR 01) OR (A89a = 02) OR (A90a = 02)
A92.
Thanks for your patience. There seems to be a problem and I need to check with my supervisor about what
to do next. My supervisor will get back to you.
PROXY FAILED COGNITIVE TEST................. 01 SET A106 = 04 (A106)
CALL BACK LATER TO SAME NUMBER
(INTERIM)
(A1 = 04) OR (A3 = 02) OR (A5 = 02) OR (A7a = 01) OR (A8 = 03) OR (A9=03) OR (A10 = 03) OR (A12 = 02) OR
(A14 = 04) OR (A17 = 01, 02, 03 OR 04) OR (A18=01 or 02 or 03) OR (A20 = 02; OR A27b = 01) OR (A28 =
ANSWER) OR (A47 = ANSWER) OR (A52 = 01) OR (A55 = 02) OR (A56 = 03) OR (A57 = 02) OR (A58 =
02) OR (A81 = ANSWER) OR (A84 = 01) OR (A85 = 02)
A100.
(INTERNAL VARIABLE – NOT DISPLAYED FOR USER – SHOW FOR TESTING PURPOSES ONLY)
PROGRAMMER: DISPLAY ONLY APPROPRIATE TEXT AND VALUE BELOW.
START NEXT SCREENER AT…
{YOUR NAME} ...........................................................................
{PROXY NAME} .........................................................................
{INTERPRETER NAME} ...........................................................
{NAME} using TTY .....................................................................
{NAME} using Relay ...................................................................
{NAME} using a phone amplifier ................................................
{NEW PROXY NAME} AFTER FIRST PROXY FAILED
COGNITIVE TEST ..............................................................
{NAME} at {IF A1 = 07; OR A2 = 07; OR A4b = 07;
OR A13a = 08 FILL HOSPITAL NAME FROM A28/
IF A1 = 11; OR A2 = 11; OR A4b = 09; OR A13a = 07
FILL INSTITUTION NAME FROM A28 ...............................
IF A4a = 02 AND A6 = ANSWER {NEW INTERPRETER
NAME} ................................................................................
01
02
03
04
05
06
A0 = 01
A0 = 10
A0 = 14
A0 = 08
A0 = 07
A0 = 09
07 A0 = 10
08 A0 = 01
09 A0 = 15
PROGRAMMER: SEND TO CALLBACK SCREEN AND INTERVIEWER WILL SET CALL BACK STATUS THERE.
GO TO END
NEW PHONE NUMBER FOR NAME/PROXY/LEAD TO NAME/LEAD TO PROXY
(A36 = 01) OR (A38 = ANSWER) OR (A52 = 01) OR (A62 = 03, 05, OR 09) OR (A84 = 03, 05, OR 09)
A101. Thank you very much; we will be calling {NAME/PROXY/LEAD FROM BELOW} shortly.
PROGRAMMER: DISPLAY ONLY APPROPRIATE TEXT AND 01 OR 02 VALUES BELOW. 03 SHOULD NOT BE
DISPLAYED.
START NEXT SCREENER AT…
{NAME} ...................................................................................... 01 A0 = 01
{PROXY} WHO LIVES ELSEWHERE ........................................ 02 A0 = 10
LEAD .......................................................................................... 03 SET A106 = 06 (A106)
A-29
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
A101a. PROGRAMMER: GO TO END.
SEND TO LOCATING: NAME OR PROXY (INTERIM)
(A1 = 14) OR (A2 = 14) OR (A4b = 11) OR (A24 = 00) OR (A36 = 00) OR (A37 = 00 OR d) OR (A52 = 00) OR (A56 =
07) OR (A62 = 01, OR 02) OR (A72 = 00) OR (A82 = 00) OR (A84 = 01, 02, 04, 05, 07, OR 08)
A102. Thank you very much. Goodbye.
PROGRAMMER: DISPLAY ONLY APPROPRIATE TEXT AND VALUE BELOW.
INTERVIEWER: PRESS 1 TO CONTINUE
START NEXT SCREENER AT…
{NAME}: NO SUCH PERSON HERE .....................
{NAME}: NEED PHONE NUMBER ONLY ..............
{NAME} NEED ALL CONTACT INFORMATION ....
{NAME} FAILED VERIFICATION – FIND NAME ...
{PROXY}: NO SUCH PERSON HERE ...................
{PROXY}: NEED PHONE NUMBER .....................
01
02
03
04
05
06
SET STATUS = 530 (END) A0 = 01
SET STATUS = 530 (END) A0 = 01
SET STATUS = 530 (END) A0 = 01
SET STATUS = 530 (END) A0 = 01
SET STATUS = 380 (END) A0 = 13
SET STATUS = 380 (END) A0 = 13
PROGRAMMER: FOR 05 – 06 SUPERVISOR WILL SET NEXT
STARTING QUESTION AND MAY OVERWRITE CODES
INELIGIBLE (INTERIM / POSSIBLE FINAL)
(A1 = 09, 12, OR 18) OR (A2 = 09, 12, OR 18) OR (A4b = 08,10, OR 14) OR (A13a = 06, 10 OR 11) OR (A26 = 01)
OR
(A33 = 01)
A103. Thank you for explaining. That’s all the questions we have for you. Goodbye.
PROGRAMMER: DISPLAY ONLY APPROPRIATE TEXT AND VALUE BELOW.
NOTE:
PROGRAMMER, THESE CASES ARE INTERIM UNTIL AFTER SUPERVISOR REVIEW.
THEY
WILL
NOT
CYCLE
THROUGH
THE
SCREENER
AGAIN
UNLESS
SUPERVISOR/PROGRAMMER RESETS CASE STATUS.
INTERVIEWER: PRESS ENTER TO CONTINUE
INCARCERATED ...................................................
IN ACTIVE MILITARY ............................................
LIVING OUTSIDE THE USA ..................................
01
02
03
SET STATUS = 421 (END)
SET STATUS = 422 (END)
SET STATUS = 461 (END)
(A1=08) OR (A2=08) 0R (A4b=07) OR (A13a=09)
A103a. I am sorry to hear {NAME} has passed away. I was calling about a study we are conducting for the Social
Security Administration. You might have seen a letter we recently sent [NAME} explaining the study. When
did {NAME} pass away?
|__|__| / |__|__| / |__|__|__|__|
MONTH DAY
YEAR
(1 – 12) (1 – 31) (2000 – 2014)
DON’T KNOW ........................................................
REFUSED ..............................................................
d
r
Thank you. Please accept my condolences. Goodbye.
PROGRAMMER: SET STATUS = 440. GO
TO END
A-30
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
BARRIERS TO PARTICIPATION – (INTERIM NON-RESPONSE / POSSIBLE FINAL NON-RESPONSE)
(A1 = 17) OR (A2 = 17) OR (A4b = 13) OR (A46 = 05, 06, 07, 08, OR 09) OR (A56 = 06)
A104. Thank you very much for explaining. That’s all the questions I have. Thanks for your time. Goodbye.
PROGRAMMER: DISPLAY ONLY APPROPRIATE TEXT AND VALUE BELOW.
PROGRAMMER, THESE CASES ARE INTERIM UNTIL AFTER SUPERVISOR
REVIEW. THEY WILL NOT CYCLE
THROUGH THE SCREENER
RESETS CASE STATUS.
AGAIN
UNLESS
SUPERVISOR/PROGRAMMER
INTERVIEWER: PRESS ENTER TO CONTINUE
HOSPITALIZED ........................................
INSTITUTIONALIZED ...............................
COGNITIVE BARRIER ..............................
HEARING/SPEECH BARRIER .................
PHYSICAL BARRIER ................................
UNAVAILABLE DURING FP .....................
FINAL LANGUAGE BARRIER ..................
01
02
03
04
05
06
07
SET STATUS = 420 (END)
SET STATUS = 420 (END)
SET STATUS = 412 (END)
SET STATUS = 411 (END)
SET STATUS = 410 (END)
SET STATUS = 430 (END)
SET STATUS = 400 (END)
REFUSALS (INTERIM / FINAL)
(IF ANY OF THE FOLLOWING QUESTIONS = r: A1, A2, A4b, A5, A8, A9, A10, A12, A13a, A14, A17, A18, A20,
A21, A22, A27b, A29, A30, A37, A40, A41, A43, A44, A45, A46, A48, A49, A50, A53, A56, A57, A58, A60, A61, A66,
A67, A67a, A68, A74, A76, A77, A78, A78a, A80, A85, A86, A88, A89, A89a, A90, A90a)
A105.
Thank you for your time. Goodbye.
PROGRAMMER:
GO TO REFUSAL SCREEN SO INTERVIEWER CAN RECORD REASON FOR
REFUSAL. WHILE THE CASE IS STILL IN INTERIM STATUS, THESE CASES WILL
BE SUBJECT TO CALL SCHEDULER RULES THAT WILL DETERMINE WHETHER
AND WHEN TO START THE NEXT SCREENER CALL (A0 – 01 OR A0 = 10) OR SET
AS 860 (END) (REVIEW NEEDED FOR FIELD BY SUPERVISOR , AKA HOLD FOR
CAPI)
START NEXT SCREENER AT:
{NAME} REFUSED.................................... 01
{UNKNOWN} REFUSED ........................... 02
{PROXY} REFUSED ................................. 03
SET STATUS = 200 (REFUSAL SCREEN) A0 = 01
SET STATUS = 220 (REFUSAL SCREEN) A0 = 01
SET STATUS = 210 (REFUSAL SCREEN) A0 = 10
INTERVIEWER: PRESS ENTER TO RECORD REASONS FOR REFUSAL IN REFUSAL SCREEN.
SUPERVISOR REVIEW (INTERIM)
(A1 = 15) OR (A2 = 15) OR (A3 = 03 OR r) OR (A4 = r) OR (A4a = 03 OR r) OR (A4b = 03 OR 12) OR (A15 =
ANSWER) OR (A18 = 05 OR d) OR (A24 = r) OR (A26=r) OR (A28 = r) OR (A29 = r) OR (A47 = d OR r) OR
(A50 = 2) OR (A51 = r) OR (A56 = 05 OR 08) OR (A60 = 00 OR d) OR (A80 = 04 OR d) OR (A101 = 03)
A106.
Thank you for your time. Goodbye.
INTERVIEWER: IF CASE NEEDS A SPANISH INTERVIEWER, PLEASE RECORD IN APPOINTMENT OR
EXIT, AS APPROPRIATE.
POSSIBLE LANGUAGE PROBLEM ................
CALL INFORMANT TO SET TTY/RELAY
CALL BACK TIME ....................................
NEED TO LOCATE NEW PROXY ...................
PROXY FAILED COGNITIVE TEST / NO
OTHER PROXY AVAILABLE...................
OTHER SUPERVISOR REVIEW .....................
CALL LEAD FOR NAME/PROXY INFO ...........
A-31
01 SET STATUS = 380 (END)
02 SET STATUS = 380 (END)
03 SET STATUS = 380 (END)
04 SET STATUS = 380 (END)
05 SET STATUS = 380 (END)
06 SET STATUS = 380 (END)
NBS ROUND 4 INSTRUMENT
SECTION A UNIVERSE: ALL
HOLD FOR CAPI (INTERIM - REQUIRES SUPERVISOR REVIEW)
(A29 = ANSWER) OR (A45 = 01,02, OR d)
A107. Thank you very much. Our field interviewer will call to arrange a time for the interview.
PROGRAMMER: IN ADDITION TO THESE CASES BEING HELD FOR CAPI, REFUSALS AND
UNLOCATABLES WILL ALSO BE HELD FOR CAPI UNDER CERTAIN
CIRCUMSTANCES THAT THE SUPERVISORS WILL DECIDE. NOTE ALSO THAT ALL
CAPI CASES WILL START THE CAPI SCREENER AT A0 = 01.
INTERVIEWER:
PRESS 1TO CONTINUE
HOLD FOR CAPI..............................................
0 SET STATUS = 860 (END) A0 = 01
RESPONDENT WILL CALL MPR (INTERIM)
(A10 = 02) OR (A17 = 05 OR 06)
A108. Thanks for offering to call in. Please write down our toll-free number. {IF (A10 = 02 OR A17 = 06) FILL 877293-5740. / IF (A17 = 05) FILL Call 877-293-5741 for a TTY interview.} [CONFIRM NUMBERS] We are
available days, evenings, and weekends. If you call after hours, please leave a message and we will get
back to you the next day.
INTERVIEWER: PRESS ENTER TO CONTINUE
{NAME} WILL CALL ......................................... 01 SET STATUS = 830 (END) A0 = 02
{NAME} WILL CALL/TTY.................................. 02 SET STATUS = 830 (END) A0 = 08
{NAME} WILL CALL/RELAY............................. 03 SET STATUS = 830 (END) A0 = 07
REQUEST FOR LETTER (INTERIM)
(A22 = 01) OR (A25 = 00) OR (A26 = r) OR (A59 = 02)
A109. You should receive the letter in about a week. Thank you for your time. Goodbye.
INTERVIEWER: PRESS 1 TO CONTINUE
START NEXT SCREENER AT…
{NAME} REQUESTS LETTER ......................... 01 SET STATUS = 831 (END) A0 = 04
PROXY REQUESTS LETTER ......................... 02 SET STATUS = 831 (END) A0 = 11
CONTINUE WITH INTERVIEW
(A78a = 01) OR (A90a = 01)
A110. RESPONDENT CHECK SCREEN
INTERVIEWER: WE SHOW THE RESPONDENT IS
(IF A73 = 01, 02; OR A73 = 03 AND A78a = 01 FILL {NAME}
(IF A73 = 04 OR 05 AND A78a = 01; OR A90a = 01 FILL PROXY
INTERVIEWER: IS THIS INFORMATION CORRECT?
YES .................................................................. 01 (B1)
NO ................................................................. 00
(A110 = 00)
A110a. INTERVIEWER: WHO IS THE RESPONDENT?
SAMPLE MEMBER .......................................... 01 (B1)
PROXY ............................................................. 02
A-32
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
SECTION B: DISABILITY AND CURRENT WORK STATUS
DISABILITY STATUS
(All)
B1.
First, I have some questions about how {your/NAME’s} health affects {your/his/her} daily activities. Does a
physical or mental condition limit the kind or amount of work or other daily activities {you/NAME} can do?
PROBE 1: In other words, are there things {you/NAME} can’t do as much or can’t do at all that people the
same age can?
PROBE 2: Daily activities include cooking, shopping, getting around the home, paying bills, or working at a
job.
YES ............................................................................................ 01
NO .............................................................................................. 00 (B5)
DON’T KNOW ............................................................................ d (B5)
REFUSED .................................................................................. r (B5)
(B1=01)
B2.
What physical or mental condition is the main reason {you are/NAME is} limited?
INTERVIEWER: ENTER VERBATIM RESPONSE
PROBE 1: By what name do doctors call {your/NAME’s} health condition?
PROBE 2: What causes this condition?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(B1=01)
B3.
{Do you/Does NAME} have any other physical or mental conditions that limit the kind or amount of work or
other daily activities {you/he/she} can do?
PROBE 1: In other words, are there things {you/NAME} can’t do as much or can’t do at all that people the
same age can?
PROBE 2: Daily activities include cooking, shopping, getting around the home, paying bills, or working at a
job.
YES ............................................................................................ 01
NO .............................................................................................. 00 (B18_age)
DON’T KNOW ............................................................................ d (B18_age)
REFUSED .................................................................................. r (B18_age)
(B1=01 and B3=01)
B4.
What are those conditions?
INTERVIEWER: ENTER VERBATIM RESPONSE
PROBE 1: By what name do doctors call {your/NAME’s} health condition?
PROBE 2: What causes this condition?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
GO TO B18_age
(B1=00, d, r)
B-1
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
B5.
{Are you/Is NAME} currently receiving disability benefits from Social Security?
YES ............................................................................................ 01
NO .............................................................................................. 00 (B9)
DON’T KNOW ............................................................................ d (B9)
REFUSED .................................................................................. r (B9)
(B1=00, d, r and B5=01)
B6.
What physical or mental condition is the main reason {you are/NAME is} eligible for disability benefits?
INTERVIEWER: ENTER VERBATIM RESPONSE
PROBE 1: By what name do doctors call {your/NAME’s} health condition?
PROBE 2: What causes this condition?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(B1=00, d, r and B5=01)
B7.
{Do you/Does NAME} have any other physical or mental conditions that make {you/him/her} eligible for
disability benefits?
YES ............................................................................................ 01
NO .............................................................................................. 00 (B18_age)
DON’T KNOW ............................................................................ d (B18_age)
REFUSED .................................................................................. r (B18_age)
(B1=00, d, r and B5=01 and B7=01)
B8.
What are those conditions?
INTERVIEWER: ENTER VERBATIM RESPONSE
PROBE 1: By what name do doctors call {your/NAME’s} health condition?
PROBE 2: What causes this condition?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
GO TO B18_ age
(B1=00, d, r and B5=00,d, r)
B9.
{Have you/Has NAME} received disability benefits from Social Security at any time during the last five
years?
YES ............................................................................................ 01 (B11)
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(B1=00, d, r and B5=00,d, r and B9=00,d, r)
B10.
We are only interviewing people who have received disability benefits in the past five years. I need to check
with my supervisor and get back to you. Thank you for your help.
PRESS 1 TO CONTINUE ........................................................... 01
END CALL. STATUS ”SUPERVISOR REVIEW 380.”
B-2
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
(B1=00, d, r and B5=00,d, r and B9=01)
B11.
{Do you/Does NAME} still have the physical or mental conditions that made {you/him/her} eligible for Social
Security disability benefits?
YES ............................................................................................ 01
NO .............................................................................................. 00 (B15)
DON’T KNOW ............................................................................ d (B15)
REFUSED .................................................................................. r (B15)
(B1=00, d, r and B5=00,d, r and B9=01 and B11=01)
B12.
What physical or mental condition is the main reason {you were/NAME was} eligible for disability benefits?
INTERVIEWER: ENTER VERBATIM RESPONSE
PROBE 1: By what name do doctors call {your/NAME’s} health condition?
PROBE 2: What causes this condition?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(B1=00, d, r and B5=00, d, r and B9=01 and B11=01)
B13.
{Do you/Does NAME} have any other physical or mental conditions that made {you/him/her} eligible for
disability benefits?
YES ............................................................................................ 01
NO .............................................................................................. 00 (B18_age)
DON’T KNOW ............................................................................ d (B18_age)
REFUSED .................................................................................. r (B18_age)
(B1=00, d, r and B5=00, d, r and B9=01 and B11=01 and B13=01)
B14.
What are those conditions?
INTERVIEWER: ENTER VERBATIM RESPONSE
PROBE 1: By what name do doctors call {your/NAME’s} health condition?
PROBE 2: What causes this condition?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
GO TO B18_age
(B1=00, d, r and B5=00, d, r and B9=01 and B11=00, d, r)
B15.
What physical or mental condition was the main reason {you were/NAME was} limited when {you/he/she}
first started getting disability benefits from Social Security?
INTERVIEWER: ENTER VERBATIM RESPONSE
PROBE 1: By what name did doctors call {your/NAME’s} health condition?
PROBE 2: What caused this condition?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
B-3
d
r
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
(B1=00, d, r and B5=00, d, r and B9=01 and B11=00, d, r)
B16.
Did {you/NAME} have any other physical or mental conditions that limited the kind or amount of work or
other daily activities {you/he/she} could do when {you/he/she} first started getting disability benefits?
YES ............................................................................................ 01
NO .............................................................................................. 00 (B18_age)
DON’T KNOW ............................................................................ d (B18_age)
REFUSED .................................................................................. r (B18_age)
(B1=00, d, r and B5=00, d, r and B9=01 and B11=00, d, r and B16=01)
B17.
What were those conditions?
INTERVIEWER: ENTER VERBATIM RESPONSE
PROBE 1: By what name did doctors call {your/NAME’s} health condition?
PROBE 2: What caused this condition?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
B18_age. How old {were you/was NAME} when {you/he/she} first became limited in the kind or amount of work or
other daily activities {you/he/she} could do? Your best estimate is fine.
INTERVIEWER: IF AGE IS NOT KNOWN, ENTER ‘99’ TO PROBE FOR A YEAR.
INTERVIEWER: IF LESS THAN ONE YEAR OR SINCE BIRTH, ENTER ‘0’ IN AGE.
|
|
| (B20 IF AGE 0-64)
AGE
(0-64) (or ‘99’ to probe for year)
SINCE BIRTH ............................................................................. 00 (B20)
DON’T KNOW ............................................................................ d (B19)
REFUSED .................................................................................. r (B19)
(B18_age=99)
B18_year.
PROBE: READ IF NECESSARY: In what year?
| | | | |
YEAR
(1933-2014) (B20)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(B18_age=d, r) or (B18_age=99 and B18_year=d, r)
B19.
Did {you/NAME} become limited before the age of 18 or after age 18?
PROBE:
Your best guess is fine.
LESS THAN 18 .......................................................................... 01
18 OR OLDER ........................................................................... 02
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
PROGRAMMER: CALCULATE AGE OF ONSET BASED ON B18_AGE AND B18_YEAR:
B-4
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
If B18_age=0-64, then B18_age_calc=B18_age. Else if B18_age=99 and B18_yr
≠ d or r and B18_year=A68b,
B18_age_calc=0. Else if B18_age=99 and B18_yr≠ d or r and B18_year ≠ A68b, B18_age_calc= B18yr - A68b.
Else, if B18_age=99 and B18_yr=d or r, B18_age_calc= B18_yr. Else, if B18_age=d or r, B18_age_calc=B18_age.
B20.
SOFT EDIT: B18_age_calc SHOULD NOT EXCEED CURRENT AGE. IF B18_age_calc>CURRENTAGE_
TRIGGER EDIT AND DISPLAY FOLLOWING TEXT: INTERVIEWER: AGE OF DISABILITY ONSET IS
GREATER THAN CURRENT AGE. CHECK ENTRY. IF NECESSARY READ: I must have recorded an
incorrect answer. I show that {you are/NAME is} now (CURRENTAGE), and {you/he/she} became limited
when {you were/(he/she) was} (B18_age_calc). Should I change {your/NAME’s} the age when {you/NAME}
first became limited?
CHANGE AGE WHEN FIRST BECAME LIMITED ..................... 01
(CHANGE B18_age) SUPPRESS .............................................. 02
B21.
CHECK: HAS {NAME} BEEN LIMITED SINCE ADULTHOOD (B18_age_calc NE D OR R, AND
B18_age_calcIS > OR = 18) OR (IF B18_age_calc=D OR R and B19=02)?
YES ............................................................................................ 01
NO .............................................................................................. 00 (B23_2)
(B21=01)
B22.
{Were you/Was NAME} working at a job for pay when {you/he/she} first became limited?
YES ............................................................................................ 01
NO .............................................................................................. 00 (B23_2)
DON’T KNOW ............................................................................ d (B23_2)
REFUSED .................................................................................. r (B23_2)
(B21=01 and B22=01)
B23.
Did the job {you/NAME} had at that time require {you/him/her} to use a computer?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(ALL)
B23_2. How often do you (IF B23=01 {now}) use a computer to access the Internet?
Never ..........................................................................................
Daily ...........................................................................................
A few times a week.....................................................................
Once a week...............................................................................
Less than once a week ...............................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01 (B24)
02
03
04
05
d (B24)
r (B24)
(B23_2=2, 3, 4, or 5)
B23_3. Have you ever used a computer to access information about your disability, services, or work-related
information via the Internet?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
CURRENT WORK STATUS
B-5
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
(All)
B24.
These next questions are about {your/NAME’s} personal goals and {your/his/her} current work-related
activities. {Are you/Is NAME} currently working at a job or business for pay or profit?
YES ............................................................................................ 01 (B30)
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
B25. ITEM MOVED TO FOLLOW B29_10_Other
B26. ITEM MOVED TO FOLLOW B25
B27. ITEM MOVED TO FOLLOW B26
(B24=00, d, r)
B28.
{Have you/Has NAME} been looking for work during the last four weeks?
YES ............................................................................................ 01
NO .............................................................................................. 00 (B25, new position)
DON’T KNOW ............................................................................ d (B25, new position)
REFUSED .................................................................................. r (B25, new position)
(B28=01)
B28a. Are {you/NAME} looking for part-time or full-time work?
FULL-TIME ................................................................................. 01 (B29)
PART-TIME ................................................................................ 02
DON’T KNOW ............................................................................ d (B29)
REFUSED .................................................................................. r (B29)
(B28=01 and B28a=2)
B28b. About how many hours per week would {you/NAME} like to work?
| | |
HOURS
(1-60)
(1-168)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
B-6
d
r
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
(B28=01)
B29.
Next, I am going to read you a list of things that some people do to look for work. Please tell me whether or
not {you/NAME} did any of these things during the last four weeks. To look for work in the last four weeks
did {you/NAME}:
YES
NO
DON’T
KNOW
REFUSED
00
d
r
a.
Contact {your/NAME’S} state’s unemployment office?
01
b.
Ask friends or relatives?
01
00
d
r
c.
Look through job advertisements in a newspaper or on the
Internet?
01
00
d
r
d.
Contact the State Vocational Rehabilitation Agency or
{VRNAME FROM {NAME’S} CURRENT STATE}?
01
00
d
r
e.
Contact a local independent living center?
01
00
d
r
f.
Contact a private employment agency or program?
01
00
d
r
f1. Contact a former employer in person, by mail or email, or by
phone?
01
00
d
r
g.
Contact any other employers in person, by mail or email, or
by phone?
01
00
d
r
h.
Do anything else that I didn’t mention?
01
00
d
r
PROGRAMMER: IF B29h=01, GO TO B29h_OTHERWISE, GO TO B29_1a.
(B28=01 and B29_h=01)
B29h_Other. What was it?
INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(B28=01)
B29_1a.
d
r
{Have/Has} {you/NAME} received any job offers within the past four weeks?
YES ............................................................................................ 01
NO .............................................................................................. 00 (B29_7)
DON’T KNOW ............................................................................ d (B25, new position)
REFUSED .................................................................................. r (B25, new position)
(B29_1a=01)
B29_1b.
Did {you/NAME} turn any of these job offers down?
YES ............................................................................................ 01
NO .............................................................................................. 00 (B30)
DON’T KNOW ............................................................................ d (B25, new position)
REFUSED .................................................................................. r (B25, new position)
(B29_1a=01 and B29_1b=01)
B-7
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
B29_2. Now, I am going to read you a list of reasons why people sometimes do not accept a job offer. Please tell
me if any of these are reasons why {you/NAME} did not accept a job that {you/he/she} {were/was} offered in
the past four weeks.
YES
NO
DON’T
KNOW
REFUSED
{You/NAME} would have needed special equipment or
medical devices that {you do / he does /s he does} not
currently have in order to do the work
01
00
d
r
[You/NAME} did not have the personal assistance
[you/he/she] needed to get ready for work each day
(Example if needed: This includes things like dressing and
bathing)
01
00
d
r
c.
{You/NAME} could not get the help that {you/he/she] needed
caring for children or others
01
00
d
r
d.
{You/NAME} did not have reliable transportation to and from
the job
01
00
d
r
e.
The job did not offer a flexible enough schedule
01
00
d
r
01
00
d
r
a.
b.
f.
Job did not pay enough.
g.
The job did not offer health insurance benefits
01
00
d
r
h.
{You/NAME} would have lost benefits (you need / he needs /
she needs) like Social Security, disability insurance, workers’
compensation, or Medicaid, if [you/he/she] accepted the job
01
00
d
r
Is there anything else that I did not mention that made
{you/NAME} turn down a recent job offer
01
00
d
r
i.
(B29_2_i=01)
B29_2_i_Oth. What other reasons?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(B29_1a=01 and B29_1b=01)
B29_2CHECK.CHECK: IS {NAME} A PROXY RESPONDENT (RTYPE=2)?
YES ............................................................................................ 01 (B29_5CHECK)
NO .............................................................................................. 00
(B29_1a=01 and B29_1b=01 AND RTYPE=01)
B29_3CHECK: IS PAY A REASON RESPONDENT DID NOT ACCEPT JOB (B29_2f=01)?
YES ............................................................................................ 01 (B29_3a)
NO .............................................................................................. 00 (B29_3b)
B-8
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
(B29_2f=01 AND RTYPE=01)
B29_3a. You said that one of the reasons you did not accept a job you were offered was because it did not pay enough.
What is the lowest wage or salary you would have accepted for this job?
INTERVIEWER: Read only if necessary, otherwise code:
$|
|
|
|,|
|
|
|.|
|
|
DON’T KNOW .........................................
REFUSED ...............................................
B29_3ahop.
d
r
(B29_5CHECK)
(B29_5CHECK)
Is this:
HOURLY ....................... 01 (1-25)
DAILY ............................ 02 (1-384)
WEEKLY ....................... 03 (1-1,923)
BI-WEEKLY................... 04 (1-4,166)
TWICE A MONTH ......... 05 (1-4,166)
MONTHLY ..................... 06 (1-8,333)
ANNUALLY.................... 07 (1-100,000)
(1-300)
(1-1,922)
(1-9,615)
(1-20,833)
(1-20,833)
(1-41,666)
(1-500,000)
DON’T KNOW .........................................
REFUSED ...............................................
d
r
(B29_5CHECK)
(B29_4a)
(B29_4a)
(B29_4a)
(B29_4a)
(B29_4a)
(B29_4a)
(B29_4a)
(B29_4a)
(B29_2f=00, d, OR r AND RTYPE=01)
B29_3b. If you did get a job offer that matched your current needs and abilities, what is the lowest wage or salary you
would be willing to accept for such a job?
INTERVIEWER: If they hesitate or seem to be having difficulty, add: If you have no idea, just say so.
INTERVIEWER: Read only if necessary, otherwise code:
$|
|
|
|,|
|
|
|.|
|
DON’T KNOW .........................................
REFUSED ...............................................
B29_3bhop
|
d
r
(Skip to B29_5CHECK)
(Skip to B29_5CHECK)
Is this:
HOURLY ....................... 01 (1-25)
DAILY ............................ 02 (1-384)
WEEKLY ....................... 03 (1-1,923)
BI-WEEKLY ................... 04 (1-4,166)
TWICE A MONTH ......... 05 (1-4,166)
MONTHLY ..................... 06 (1-8,333)
ANNUALLY.................... 07 (1-100,000)
DON’T KNOW .........................................
REFUSED ...............................................
(1-300)
(1-1,922)
(1-9,615)
(1-20,833)
(1-20,833)
(1-41,666)
(1-500,000)
d
r
(B29_5CHECK)
(B29_4a)
(B29_4a)
(B29_4a)
(B29_4a)
(B29_4a)
(B29_4a)
(B29_4a)
(B29_4a)
PROGRAMMER NOTE: FOLLOWING SOFT CHECK IF B29_3ahop or B29_3bhop OUT OF RANGE
B29_3check:
Soft edit: “Let me make sure I did not make a mistake. You just indicated that the wage or salary
you would have accepted for this job is [insert ((B29_3a and B29_3ahop) OR (B29_3b and
B29_3hop)). Is this correct?”
CHANGE LOWEST WAGE OR SALARY ................................... 01 (CHANGE B29_3a
OR B29_3b)
CHANGE PAY PERIOD ............................................................. 02 (CHANGE B29_3ahop
OR B29_3bhop)
SUPPRESS ................................................................................ 03
B-9
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
(B29_3ahop=02, 03, 04, 05, 06, d or r) or (B29_3bhop=02, 03, 04, 05, 06, d, or r)
B29_4a.
How many hours per week would you expect to work for this amount of pay?
| | |
HOURS
(1-99)
(Skip to B29_5CHECK)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d (B29_4b)
r (B29_4b)
(B29_4a=d or r)
B29_4b.
Would you expect to work full-time or part-time?
FULL-TIME ................................................................................. 01
PART-TIME ................................................................................ 02
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(B29_1a=01 and B29_1b=01)
B29_5CHECK. IS LOSING BENEFITS REASON DID NOT ACCEPT JOB (B29_h=1)?
YES ............................................................................................ 01 (B29_5)
NO .............................................................................................. 00 (B30)
(B29_2 h=1)
B29_5.
You said that one of the reasons {you/NAME} did not accept a job was because (you/he/she) would have
lost benefits (you/he/she) needed such as Social Security, disability insurance, workers’ compensation,
or Medicaid. There are many ways people find out about how working will affect their benefits. For
example, some people call the Social Security office, some search the Internet, and others contact
disability service organizations. Did {you/NAME} contact anyone or do any of these things in order to find
out how [your/his/her] benefits would be affected if {you/he/she} went to work?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(B29_2 h=1)
B29_6. What benefits {were/was} {you/NAME} most worried about losing?
INTERVIEWER: MARK ALL THAT APPLY
PRIVATE DISABILITY INSURANCE ..........................................
WORKERS’ COMPENSATION ..................................................
VETERANS’ BENEFITS .............................................................
MEDICARE.................................................................................
MEDICAID ..................................................................................
SSA DISABILITY BENEFITS......................................................
PUBLIC ASSISTANCE OR WELFARE ......................................
FOOD STAMPS .........................................................................
PERSONAL ASSISTANCE SERVICES (PAS) ...........................
UNEMPLOYMENT BENEFITS ...................................................
OTHER STATE DISABILITY BENEFITS ....................................
OTHER GOVERNMENT PROGRAMS ......................................
OTHER .......................................................................................
B-10
01
02
03
04
05
06
07
08
09
10
11
12
13
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
(B29_6=13)
B29_6_Other: What other benefits?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
GO TO B30
(B29_1a=00)
B29_7. Now, I am going to read you a list of reasons why people are sometimes unable to find a job. Please tell me
if any of these are reasons why {you/NAME} {have/has} not found a job that {you/he/she} {think/thinks} is
right for {you/him/her}.
a.
b.
{You/NAME} would need special equipment or medical
devices to work which {you do /he does /she does} not
currently have
[You/NAME} [do/does] not have the personal assistance
[you/he/she] [need/needs] to get ready for work each day
YES
NO
DON’T
KNOW
REFUSED
01
00
d
r
01
00
d
r
(Example if needed: This includes things like dressing and
bathing)
c.
{You/NAME} cannot get the help that {you need/ he needs/
she needs] caring for children or others
01
00
d
r
d.
{You/NAME] [do/does] not have reliable transportation to and
from work
01
00
d
r
e.
The jobs that are available do not offer a flexible enough
schedule.
01
00
d
r
f.
{You/NAME} cannot find a job {you are/he is/she is} qualified
for.
01
00
d
r
g.
The jobs that are available do not pay enough
01
00
d
r
h.
Employers will not give {you/NAME} a chance to show that
{you/he/she} can work.
01
00
d
r
i.
The jobs that are available do not offer health insurance
benefits.
01
00
d
r
j.
{You/NAME} would lose benefits (you need / he needs / she
needs) like Social Security, disability insurance, workers’
compensation, or Medicaid if {you/he/she} took a job
01
00
d
r
Is there anything else that I did not mention that is a reason
why (you/Name) (have/has) not been able to find a job?
01
00
d
r
k.
(B29_7_k=01)
B29_7_k_Oth. What other reasons?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
B-11
d
r
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
(B29_1a=00)
B29_7CHECK.
CHECK: IS {NAME} A PROXY RESPONDENT (RTYPE=2)?
YES ............................................................................................ 01 (B29_9CHECK)
NO .............................................................................................. 00
(B29_1a=00 AND RTYPE=01)
B29_8CHECK: IS PAY A REASON RESPONDENT DID NOT ACCEPT JOB (B29_7g=1)?
YES ............................................................................................ 01 (B29_8a)
NO .............................................................................................. 00 (B29_8b)
(B29_7g=1 AND RTYPE=01)
B29_8a. You said that one of the reasons you are unable to find a job is that the jobs that are available do not pay
enough. What is the lowest wage or salary you would accept for a job that matched your current needs
and abilities?
INTERVIEWER: Read only if necessary, otherwise code:
$|
|
|
|,|
|
|
|.|
|
|
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d (B29_9CHECK)
r (B29_9CHECK)
B29_8ahop. Is this:
HOURLY
DAILY
WEEKLY
BI-WEEKLY
TWICE A MONTH
MONTHLY
ANNUALLY
01 (1-25)
02 (1-384)
03 (1-1,923)
04 (1-4,166)
05 (1-4,166)
06 (1-8,333)
07 (1-100,000)
(1-300)
(1-1,922)
(1-9,615)
(1-20,833)
(1-20,833)
(1-41,666)
(1-500,000)
(B29_9CHECK)
(B29_8c)
(B29_8c)
(B29_8c)
(B29_8c)
(B29_8c)
(B29_8c)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d (B29_8c)
r (B29_8c)
(B29_7g=00, d, OR r AND RTYPE=01)
B29_8b. If you did get a job offer that matched your current needs and abilities, what is the lowest wage or salary
you would be willing to accept for such a job?
INTERVIEWER: IF R HESITATES OR SEEMS TO BE HAVING DIFFICULTY: If you have no idea, just
say so.
IF R SAYS HAS NO INTEREST IN WORKING, CODE AS DON’T KNOW.
INTERVIEWER: Read only if necessary, otherwise code:
$|
|
|
|,|
|
|
|.|
|
|
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d (B29_9CHECK)
r (B29_9CHECK)
B29_8bhop. Is this:
HOURLY
DAILY
WEEKLY
BI-WEEKLY
TWICE A MONTH
MONTHLY
ANNUALLY
01 (1-25)
02 (1-384)
03 (1-1,923)
04 (1-4,166)
05 (1-4,166)
06 (1-8,333)
07 (1-100,000)
(1-300)
(1-1,922)
(1-9,615)
(1-20,833)
(1-20,833)
(1-41,666)
(1-500,000)
(B29_9CHECK)
(B29_8c)
(B29_8c)
(B29_8c)
(B29_8c)
(B29_8c)
(B29_8c)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
B-12
d (B29_8c)
r (B29_8c)
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
PROGRAMMER NOTE: FOLLOWING SOFT CHECK IF B29_8ahop or B29_8bhop) OUT OF RANGE
B29_8check: Soft edit: “Let me make sure I did not make a mistake. You just indicated that the wage or salary you
would have accepted for this job is [insert ((B29_8a and B29_8ahop) OR (B29_8b and
B29_8hop)). Is this correct?”
CHANGE LOWEST WAGE OR SALARY ................................... 01 (CHANGE B29_8a
OR B29_8b)
CHANGE PAY PERIOD ............................................................. 02 (CHANGE B29_8ahop
OR B29_8bhop)
SUPPRESS ................................................................................ 03
(B28_8ahop=02, 03, 04, 05, 06, d, or r) or (B28_8bhop=02, 03, 04, 05, 06, d, or r)
B29_8c. How many hours per week would you expect to work for this amount of pay?
|
| |
HOURS
(1-99)
(Skip TO B29_9CHECK)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d (B29_8d)
r (B29_8d)
(B29_8c=d or r)
B29_8d. Would you expect to work full-time or part-time?
FULL-TIME ................................................................................. 01
PART-TIME ................................................................................ 02
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(B29_1a=00)
B29_9CHECK.
IS LOSING BENEFITS REASON DID NOT ACCEPT JOB (B29_7=j)?
YES ............................................................................................ 01 (B29_9)
NO .............................................................................................. 00 (B30)
(B29_7=j)
B29_9. You said that one of the reasons {you/NAME} {have/has} not been able to find a job is because {you/he/she}
would lose benefits (you need / he needs / she needs) such as Social Security, disability insurance, workers’
compensation, or Medicaid if {you/he/she} did get a job. There are many ways people find out about how
working will affect their benefits. For example, some people call the Social Security office, some search the
Internet, and others contact disability service organizations. {Have/Has} {you/NAME} contacted anyone or
done any of these things in order to find out how {your/his/her} benefits will be affected if {you/he/she} did go
to work?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
B-13
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
(B29_7=j)
B29_10. What benefits {are/is} {you/NAME} most worried about losing?
INTERVIEWER: MARK ALL THAT APPLY
PRIVATE DISABILITY INSURANCE ..........................................
WORKERS’ COMPENSATION ..................................................
VETERANS’ BENEFITS .............................................................
MEDICARE.................................................................................
MEDICAID ..................................................................................
SSA DISABILITY BENEFITS......................................................
PUBLIC ASSISTANCE OR WELFARE ......................................
FOOD STAMPS .........................................................................
PERSONAL ASSISTANCE SERVICES (PAS) ...........................
UNEMPLOYMENT BENEFITS ...................................................
OTHER STATE DISABILITY BENEFITS ....................................
OTHER GOVERNMENT PROGRAMS ......................................
OTHER .......................................................................................
01
02
03
04
05
06
07
08
09
10
11
12
13
(B29_10=13)
B29_10_Other: What other benefits?
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
GO TO B30
(B28=00, d, or r) OR (B29_1a=d or r) OR (B29_1b=d or r)
B25.
Other beneficiaries have said that they are not working for a number of reasons. I am going to read you a
list of these reasons. For each, please tell me if it is a reason why {you are/NAME is} not currently working.
{Are you/ Is NAME} not working because PROBE: I need to read the entire list even though some of the
reasons may not apply to {you/NAME}. If a reason does not apply to {you/NAME}, please just say so.
INTERVIEWER: IF RESPONDENTS SAYS 'DOES NOT APPLY' CODE AS 'NO'.
B-14
YES
NO
DON’T
KNOW
REFUSED
a.
A physical or mental condition prevents {you/NAME} from
working
01
00
d
r
b.
{You/NAME} cannot find a job that {you are/ he is /she is}
qualified for
01
00
d
r
c.
{You do/NAME does} not have reliable transportation to and
from work
01
00
d
r
d.
{You are/NAME is} caring for children or others
01
00
d
r
e.
ITEM DELETED
01
00
d
r
f.
{You/NAME} cannot find a job {you want / he wants / she
wants}
01
00
d
r
g.
{You are/NAME is} waiting to finish school or a training
program
01
00
d
r
h.
Workplaces are not accessible to people with {your/NAME’s}
disability
01
00
d
r
i.
{You do/NAME does} not want to lose benefits (you need / he
01
00
d
r
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
needs / she needs) like Social Security, disability insurance,
workers’ compensation, or Medicaid
j.
{Your/NAME’s} previous attempts to work have been
discouraging
01
00
d
r
k.
ITEM DELETED
01
00
d
r
l.
Others do not think {you/NAME} can work
01
00
d
r
01
00
d
r
m. Employers will not give {you/NAME} a chance to show that
{you/he/she} can work
n.
{You/NAME} does not have the special equipment or medical
devices that {you/he/she} would need in order to work
01
00
d
r
o.
You/NAME} cannot get the personal assistance [you need /
he needs / she needs] in order to get ready for work each day
(Example if needed: This includes things like dressing and
bathing).
01
00
d
r
B28=00, d, or r) OR (B29_1a=d or r) OR (B29_1b=d or r)
B26.
Are there any other reasons why {you are/NAME is} not working that I did not mention?
YES ............................................................................................ 01
NO .............................................................................................. 00 (B29_11CHECK)
DON’T KNOW ............................................................................ d (B29_11CHECK)
REFUSED .................................................................................. r (B29_11CHECK)
(B26=01)
B27.
What are they?
INTERVIEWER: ENTER VERBATIM RESPONSE
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(B28=00, d, or r) OR (B29_1a=d or r) OR (B29_1b=d or r)
B29_11CHECK. IS LOSING BENEFITS REASON DID NOT ACCEPT JOB (B25i=01)?
YES ............................................................................................ 01 (B29_11a)
NO .............................................................................................. 00 (B29_12CHECK)
(If B25i=01)
B29_11a. You said that one of the reasons {you/he/NAME} {are/is} not working is because {you do / he does / she
does} not want to lose benefits (you need / he needs / she needs) such as Social Security, disability
insurance, workers’ compensation, or Medicaid. There are many ways people find out about how working
will affect their benefits. For example, some people call the Social Security office, some search the
Internet, and others contact disability service organizations. Did {you/NAME} contact anyone or do any of
these things in order to find out how {your/his/her} benefits would be affected if {you/he/she} went to work?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
B-15
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
(If B25i=01)
B29_11b. What benefits {were/was} {you/NAME} most worried about losing?
INTERVIEWER: MARK ALL THAT APPLY.
PRIVATE DISABILITY INSURANCE ..........................................
WORKERS’ COMPENSATION ..................................................
VETERANS’ BENEFITS .............................................................
MEDICARE.................................................................................
MEDICAID ..................................................................................
SSA DISABILITY BENEFITS......................................................
PUBLIC ASSISTANCE OR WELFARE ......................................
FOOD STAMPS .........................................................................
PERSONAL ASSISTANCE SERVICES (PAS) ..........................
UNEMPLOYMENT BENEFITS ...................................................
OTHER STATE DISABILITY BENEFITS ....................................
OTHER GOVERNMENT PROGRAMS ......................................
OTHER .......................................................................................
01
02
03
04
05
06
07
08
09
10
11
12
13
(B29_11b=13)
B29_11b_Other: What other benefits?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(B28=00, d, or r) OR (B29_1a=d or r) OR (B29_1b=d or r)
B29_12CHECK. CHECK: IS {NAME} A PROXY RESPONDENT (RTYPE=2)?
YES ............................................................................................ 01 (B30)
NO .............................................................................................. 00
((B28=00, d, or r) OR (B29_1a= d or r) OR (B29_1b=d or r) AND (RTYPE=01)
B29_8CHECK: DID RESPONDENT GIVE CONDITION AS ONLY REASON NOT WORKING (B25_a=01 and
(B25_b, B25_c, B25_d, B25_f, B25_g, B25_h, B25_i, B25_j, B25_l, B25_m, B25_n, B25_o=00, d, OR r)?
YES ............................................................................................ 01 (B30)
NO .............................................................................................. 00 (B29_12a)
((B25_a=01 and (B25_b, B25_c, B25_d, B25_f, B25_g, B25_h, B25_i, B25_j, B25_l, B25_m, B25_n, or B25_o=01))
AND (RTYPE=01))
B29_12a. If you did get a job offer that matched your current needs and abilities, what is the lowest wage or salary
you would be willing to accept for such a job?
INTERVIEWER: IF R HESITATES OR SEEMS TO BE HAVING DIFFICULTY: If you have no idea, just
say so. IF R SAYS HAS NO INTEREST IN WORKING, CODE AS DON’T KNOW.
INTERVIEWER: Read only if necessary, otherwise code:
$|
|
|
|,|
|
|
|.|
|
|
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d (B30)
r (B30)
B29_12ahop. Is this:
HOURLY
01 (1-25)
(1-300)
(B30)
DAILY
02 (1-384)
(1-1,922)
(B29_12b)
WEEKLY
03 (1-1,923)
(1-9,615)
(B29_12b)
BI-WEEKLY
04 (1-4,166)
(1-20,833)
(B29_12b)
TWICE A MONTH
05 (1-4,166)
(1-20,833)
(B29_12b)
MONTHLY
06 (1-8,333)
(1-41,666)
(B29_12b)
ANNUALLY
07 (1-100,000)
(1-500,000)
(B29_12b)
DON’T KNOW ............................................................................ d (B29_12b)
B-16
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
REFUSED ..................................................................................
r (B29_12b)
PROGRAMMER NOTE: FOLLOWING SOFT CHECK IF B29_12ahop OUT OF RANGE
B29_12check
Soft edit: “Let me make sure I did not make a mistake. You just indicated that the wage or salary
you would have accepted for this job is [insert ((B29_12a and B29_12ahop). Is this correct?”
CHANGE LOWEST WAGE OR SALARY ................................... 01 (CHANGE B29_12a)
CHANGE PAY PERIOD ............................................................. 02 (CHANGE B29_12ahop)
SUPPRESS ................................................................................ 03
(B29_12ahop=02, 03, 04, 05, 06, d, or r)
B29_12b. How many hours per week would you expect to work for this amount of pay?
| | |
(B30)
HOURS
(1-99)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d (B29_12c)
r (B29_12c)
(B29_12b=d or r)
B29_12c. Would you expect to work full-time or part-time?
FULL-TIME ................................................................................. 01
PART-TIME ................................................................................ 02
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
B30.
Did {you/NAME} work at a job or business for pay or profit anytime in 2014?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
PROGRAMMER NOTE: If B24=1 or B30=1, go to B33. Else, go to B30_b.
NEW ITEM
(B24=0, d, r and B30=0, d, r)
B30_b. {Have you/Has NAME} worked for pay since {you/NAME} started receiving disability benefits?
YES ............................................................................................ 01 (B37)
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
B33.
CHECK: WAS {NAME} WORKING WHEN LIMITATION BEGAN (B22=01)?
YES ............................................................................................ 01 (B37)
NO .............................................................................................. 00
(B33=00)
B34
CHECK: IS {NAME} CURRENTLY WORKING (B24=01)?
YES ............................................................................................ 01 (B37)
NO .............................................................................................. 00
(B33=00 and B34=00)
B35.
CHECK: DID {NAME} WORK IN 2014 (B30=01)?
YES ............................................................................................ 01 (B37)
NO .............................................................................................. 00
B-17
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
(B30b=0, d, or r) or (B33=00 and B34=00 and B35=00)
B36.
{Have you/Has NAME} ever worked for pay?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
B37.
Do {your/NAME’s} personal goals include working at a job, moving up in a job or learning new job skills?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
B37a.
Do {your/NAME’s} personal goals include someday working and earning enough to stop receiving Social
Security disability benefits?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
B38.
{Do you/Does NAME} ever discuss work and career goals with family, friends, or anyone else?
YES ............................................................................................ 01
NO .............................................................................................. 00 (B47)
DON’T KNOW ............................................................................ d (B47)
REFUSED .................................................................................. r (B47)
(B38=01)
B39.
Who {do you/does NAME} discuss {your/his/her} work goals with the most?
INTERVIEWER: MARK ONLY ONE.
PARENT/GUARDIAN .................................................................
SPOUSE/PARTNER ..................................................................
FRIEND ......................................................................................
JOB COACH...............................................................................
EMPLOYER/SUPERVISOR .......................................................
OTHER RELATIVE .....................................................................
CASEWORKER/COUNSELOR/PROGRAM STAFF ..................
MEDICAL PROVIDER ................................................................
OTHER NON-RELATIVE ...........................................................
OTHER .......................................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
05
06
07
08
10
09
d
r
(B40)
(B40)
(B40)
(B40)
(B40)
(B40)
(B40)
(B40)
(B47)
(B47)
(B38=01 and B39=09)
B39_oth. Who was it?
INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
B-18
d
r
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
(B38=01 and B39=01-09)
B40.
Please tell me how much you agree or disagree with the following statement. Would you say you strongly
agree, agree, disagree, or strongly disagree? {Your/NAME’s} {RESPONSE FROM B39} thinks
{your/NAME’s} personal goals should include working at a job, moving up in a job, or learning new job skills.
STRONGLY AGREE ..................................................................
AGREE.......................................................................................
DISAGREE .................................................................................
STRONGLY DISAGREE ............................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
d
r
(B38=01 and B39=01-09)
B41.
{Do you/Does NAME} discuss {your/his/her} work goals with anyone else?
YES ............................................................................................ 01
NO .............................................................................................. 00 (B47)
DON’T KNOW ............................................................................ d (B47)
REFUSED .................................................................................. r (B47)
(B38=01 and B39=01-09 and B41=01)
B42.
Who else {do you/does NAME} discuss {your/his/her} work goals with?
INTERVIEWER: MARK ONLY ONE.
PARENT/GUARDIAN .................................................................
SPOUSE/PARTNER ..................................................................
FRIEND ......................................................................................
JOB COACH...............................................................................
EMPLOYER/SUPERVISOR .......................................................
OTHER RELATIVE .....................................................................
CASEWORKER/COUNSELOR/PROGRAM STAFF ..................
MEDICAL PROVIDER ................................................................
OTHER NON-RELATIVE ...........................................................
OTHER .......................................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
05
06
07
08
10
09
d
r
(B43)
(B43)
(B43)
(B43)
(B43)
(B3)
(B43)
(B43)
(B47)
(B47)
(B38=01 and B39=01-09 and B41=01 and B42=09)
B42_oth. Who was it?
INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(B38=01 and B39=01-09 and B41=01 and B42=01-09)
B43.
Please tell me how much you agree or disagree with the following statement. Would you say you strongly
agree, agree, disagree, or strongly disagree? {Your/NAME’s} {RESPONSE FROM B42} thinks
{your/NAME’s} personal goals should include working at a job, moving up in a job, or learning new job skills.
STRONGLY AGREE ..................................................................
AGREE.......................................................................................
DISAGREE .................................................................................
STRONGLY DISAGREE ............................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
B-19
01
02
03
04
d
r
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
(B38=01 and B39=01-09 and B41=01 and B42=01-09)
B44.
{Do you/Does NAME} discuss {your/his/her} work goals with anyone else?
YES ............................................................................................ 01
NO .............................................................................................. 00 (B47)
DON’T KNOW ............................................................................ d (B47)
REFUSED .................................................................................. r (B47)
(B38=01 and B39=01-09 and B41=01 and B42=01-09 and B44=01)
B45.
Who else {do you/does NAME} discuss {your/his/her} work goals with?
INTERVIEWER: MARK ONLY ONE.
PARENT/GUARDIAN .................................................................
SPOUSE/PARTNER ..................................................................
FRIEND ......................................................................................
JOB COACH...............................................................................
EMPLOYER/SUPERVISOR .......................................................
OTHER RELATIVE .....................................................................
CASEWORKER/COUNSELOR/PROGRAM STAFF ..................
MEDICAL PROVIDER ................................................................
OTHER NON-RELATIVE ...........................................................
OTHER .......................................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
05
06
07
08
10
09
d
r
(B46)
(B46)
(B46)
(B46)
(B46)
(B46)
(B46)
(B46)
(B47)
(B47)
(B38=01 and B39=01-09 and B41=01 and B42=01-09 and B44=01 and B45=09)
B45_oth. Who was it?
INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(B38=01 and B39=01-09 and B41=01 and B42=01-09 and B44=01 and B45=01-09)
B46.
Please tell me how much you agree or disagree with the following statement. Would you say you strongly
agree, agree, disagree, or strongly disagree? {Your/NAME’s} {RESPONSE FROM B5} thinks {your/NAME’s}
personal goals should include working at a job, moving up in a job, or learning new job skills.
STRONGLY AGREE ..................................................................
AGREE.......................................................................................
DISAGREE .................................................................................
STRONGLY DISAGREE ............................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
B-20
01
02
03
04
d
r
NBS ROUND 4 INSTRUMENT
SECTION B UNIVERSE: ALL WHO PASSED SECTION A
QUESTIONS NEEDED FROM SECTION A: RTYPE, CURRENT AGE
PRELOADED VARIABLES: NONE
(All)
B47.
Please tell me how much you agree with the following statements. Would you say you strongly agree,
agree, disagree, or strongly disagree?
STRONGLY
AGREE
AGREE
a.
You see {yourself/NAME} {(IF
B24=01) continuing to work/ (IF
B24=00,d, r) working} for pay in
the next year.
DISAGREE
STRONGLY
DISAGREE
DON’T
KNOW
REFUSED
01
02
03
04
d
r
You see {yourself/NAME} working
and earning enough to stop
receiving disability benefits in the
next year.
01
02
03
04
d
r
You see {yourself/NAME} {(IF
B24=01) continuing to work/ (IF
B24=00,d, r) working} for pay in
the next five years.
01
02
03
04
d
r
01
02
03
04
d
r
(ASK B47b IF B47a=01,02,
OTHERWISE GO TO B47c)
b.
c.
{ASK B47d IF B47c=01,02,
OTHERWISE GO TO B48)
d.
You see {yourself/NAME} working
and earning enough to stop
receiving disability benefits in the
next five years
(All)
B48.
CHECK: IS {NAME} CURRENTLY WORKING (B24 = 01)?
YES ............................................................................................ 01 (C1)
NO .............................................................................................. 00
(B48=00)
B49.
CHECK: WAS {NAME} WORKING IN 2014 (B30 = 01)?
YES ............................................................................................ 01 (D1)
NO .............................................................................................. 00
B-21
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
SECTION C: CURRENT EMPLOYMENT
(All)
C1.
Now I am going to ask some questions about the jobs {you/NAME} currently {have/has}. When answering
these questions, please include both part-time and full-time jobs, but only include jobs {you hold/NAME
holds} for pay or profit.
How many jobs {do you/does NAME} currently have?
|__|__| NUMBER OF JOBS (1-5)
(1-15)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
PROGRAMMER: C2 THROUGH C14 ASKED FOR ALL JOBS WHEN C1>01
(All)
C2.
PROGRAMMER: IF MORE THAN ONE JOB (C1>01) AND FIRST JOB:
Let us start with {your/NAME’s} main job – that is, the job at which {you work/(he/she) works} the most
hours.
What kind of work {do you/does NAME} do, that is, what is {your/NAME’s} occupation?
PROGRAMMER: IF MORE THAN ONE JOB (C1>01) AND SECOND, THIRD, FOURTH, ETC. JOB:
Now I would like to ask about {your/NAME’S} {second/third/fourth} job.
What kind of work {do you/does NAME} do, that is, what is {your/NAME’s} occupation?
ELSE (C1=01):
What kind of work {do you/does NAME} do, that is, what is {your/NAME’s} occupation?
INTERVIEWER: ENTER VERBATIM RESPONSE
PROBE 1: For example, a child-care provider at a private preschool; geometry teacher in a public high
school; sales clerk in a women’s shoe store.
PROBE 2: What are {your/NAME’S} main activities or duties? What else {do you/does NAME} do? What
else? {Do you /Does NAME} supervise anyone?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
C-1
d
r
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(All)
C3.
What kind of business is this?
INTERVIEWER: ENTER VERBATIM RESPONSE
PROBE 1: For what type of organization or industry do you work? For example: accounting firm, daycare
center, educational facility, food services.
PROBE 2: What do they make, sell, or do where {you work/NAME works}?
PROBE 3: Is this mainly manufacturing (making a product), wholesale trade (selling to other businesses),
or retail trade (selling to customers) or something else?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(All)
C4mth. In what month and year did {you/NAME} start working there?
INTERVIEWER: ENTER MONTH HERE AND YEAR ON NEXT SCREEN
PROBE: Your best estimate is fine.
|__|__| (1-12)
MO
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
C4yr.
d
r
PROBE 1: In what month and year did {you/NAME} start working there?
INTERVIEWER: ENTER YEAR
PROBE 2: Your best estimate is fine.
|__|__|__|__| (1981-2015)
YEAR
(1951-2015)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
C5.
d
r
SOFT EDIT: YEAR {NAME} STARTED WORKING AT THIS JOB (C4yr) SHOULD BE GREATER THAN
OR EQUAL TO YEAR OF BIRTH (A04_d) PLUS 14 YEARS. IF RESPONDENT FAILS EDIT,
INTERVIEWER READ: I must have recorded an incorrect answer. I show that {you were/NAME was} born
in (A04_d) and {you/NAME} started working at this job in (C4yr), which means {you/NAME} started working
at this job when {you were/he was/she was} (PROGRAMMER CALCULATE AND FILL AGE: C4YR – YEAR
OF BIRTH) years old. Is that correct?
YES ............................................................................................ 01
NO .............................................................................................. 02 (CHANGE C4YR)
SUPPRESS ................................................................................ 03
C-2
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(All)
C5A.
Beneficiaries do not always know that they should report a change in work status to Social Security. Around
that time did {you/NAME} let Social Security know that {you were/ (he/she) was} working?
YES ............................................................................................ 01
NO .............................................................................................. 00 (C6)
DON’T KNOW ............................................................................ d (C6)
REFUSED .................................................................................. r (C6)
(C5a=01)
C5B.
How soon after {you/NAME} started this job did {you/NAME} tell Social Security {you were/(he/she) was}
working?
PROBE: Your best estimate is fine.
INTERVIEWER: IF R TOLD SSA BEFORE STARTED WORKING, CODE AS 1 WEEK.
WEEKS ...................................................................................... 01 (C5BWeek)
MONTHS .................................................................................... 02 (C5BMonth)
DON’T KNOW ............................................................................ d (C6)
REFUSED .................................................................................. r (C6)
(C5a=01 and C5b=01)
C5BWEEK. INTERVIEWER: ENTER NUMBER OF WEEKS
| | | WEEKS
(1-52)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d (C6)
r (C6)
(C5a=01 and C5b=02)
C5BMonth. INTERVIEWER: ENTER NUMBER OF MONTHS
| | | WEEKS/MONTHS
(1-12)
DON’T ........................................................................................
REFUSED ..................................................................................
(All)
C6.
d (C6)
r (C6)
{Are you/Is NAME} self-employed at this job?
PROBE: Self-employed means that you work for yourself/ or own your own business.
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
C-3
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(All)
C7.
There are a number of special work programs available to people with disabilities. Is {your/NAME’s} job part
of a sheltered workshop program, transitional employment program, the Business Enterprise Program for
the blind, or a supported employment program?
PROBE:
A sheltered workshop is a program that provides employment with subsidized wages (or special
wages that would not be available in a regular job) for people with disabilities. A transitional
employment program allows workers with disabilities to work at reduced levels while they ease
back into the workplace.
The Business Enterprise Program for the blind offers legally blind persons the opportunity to
own their own businesses. Supported employment programs provide job coaches or other
on-the-job supports to help individuals with disabilities get and keep jobs.
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
C8.
How many hours per week {do you/does NAME} usually work at this job?
PROBE: Include overtime if {you/he/she} usually {work/works} overtime.
|
| HOURS PER WEEK (1-60)
(1-168)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
C9.
|
|
d
r
How many weeks per year {do you/does NAME} usually work at this job, including paid vacation and
holidays?
PROBE 1: There are 52 weeks in a year.
PROBE 2: Please include time off for vacation and holidays if {you are/NAME is} paid for that time.
PROBE 3: If {you have/NAME has} worked less than a year, please answer for the number of weeks
{you expect/NAME expects} to work.
|
|
| WEEKS PER YEAR (1-52)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
C-4
d
r
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(All)
C10.
PROGRAMMER: IF MORE THAN ONE JOB (C1>01) AND FIRST JOB:
For the purpose of this survey, it is important to obtain some information on how much {you are/NAME is}
paid on this job. On {your/NAME’s} main job {are you/is (he/she} paid by the hour?
PROGRAMMER: IF MORE THAN ONE JOB (C1>01) AND SECOND, THIRD, FOURTH, ETC. JOB:
For the purpose of this survey, it is important to obtain some information on how much {you are/NAME is}
paid on {your/(his/her)} {second/third/fourth} job. On {your/NAME’s} {second/third/fourth} job {are you/is
(he/she} paid by the hour? ELSE (C1=01): For the purpose of this survey, it is important to obtain some
information on how much {you are/NAME is} paid on {your/(his/her)} current job. On {your/NAME’s} current
job {are you/is (he/she} paid by the hour?
PROGRAMMER: USE PROBE IF MORE THAN ONE JOB (C1>01) AND FIRST JOB.
PROBE:
{Your/NAME’s} main job is the job we have been talking about. The one at which {you
work/(he/she) works} the most hours.
YES ............................................................................................ 01
NO .............................................................................................. 00 (C12amt)
DON’T KNOW ............................................................................ d (C12amt)
REFUSED .................................................................................. r (C12amt)
(C10=01)
C11.
What is {your/NAME’s} regular hourly pay, including tips and commissions?
PROBE: IF LESS THAN $5.00 AN HOUR: Does this include tips and commissions?
INTERVIEWER: IF ENTERING AN AMOUNT WITH CENTS, PLEASE ENTER DECIMAL POINT
$|
|
|
|.|
|
| PER HOUR (1 – 25.00) (1 - 300.00)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
GO TO C15
(C10=00, d, or r)
C12amt. Before taxes and other deductions how much {are you/is NAME} paid on this job, including tips and
commissions.
PROBE:
Is that amount paid daily, weekly, bi-weekly, twice a month, monthly, or annually?
INTERVIEWER: ROUND TO NEAREST DOLLAR AND ENTER HOW OFTEN PAID ON NEXT SCREEN
$|
|
|
|.|
|
|
| . 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
C-5
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(C10=00, d, or r)
C12hop. INTERVIEWER: ENTER HOW OFTEN PAID
DAILY .................................................................................
WEEKLY ............................................................................
BI-WEEKLY ........................................................................
TWICE A MONTH ..............................................................
MONTHLY ..........................................................................
ANNUALLY.........................................................................
DON’T KNOW ....................................................................
REFUSED ..........................................................................
01
02
03
04
05
06
d
r
(1-384)
(1-1,923)
(1-4,166)
(1-4,166)
(1-8,333)
(1-100,000)
(1-1,922)
(1-9,615)
(1-20,833)
(1-20,833)
(1-41,666)
(1-500,000)
PROGRAMMER: CALCULATE MONTHLY PRE-TAX PAY BASED ON C12AMT AND C12HOP FOR EACH JOB:
If C10=1, and C11and C8≠d or r, C_JobMnthPay(1)=c11*c8*4.35.
If C10=1 and C8 or C11=d, C_JobMnthPay(1)=d.
If C10=1 and C8 or C11=r and neither are d, C_JobMnthPay(1)=r.
If C10=0, d, or r and C12amt or C12hop=d, C_JobMnthPay(1)=d.
If C10=0, d, or r and C12amt or C12hop=r, and neither are d, C_JobMnthPay(1)=r.
If C10=0, d, or r and c12hop=1, C_JobMnthPay(1)=c12amt*21.74.
If C10=0, d, or r and c12hop=2, C_JobMnthPay(1)=c12amt*4.35.
If C10=0, d, or r and c12hop=3, C_JobMnthPay(1)=c12amt*2.17.
If C10=0, d, or r and c12hop=4, C_JobMnthPay(1)=c12amt*2.
If C10=0, d, or r and c12hop=5, C_JobMnthPay(1)=c12amt.
If C10=0, d, or r and c12hop=6, C_JobMnthPay(1)=c12amt/12.
(C10=00, d, or r)
C13amt. For this job, about how much is left as take-home pay after taxes and other deductions?
PROBE:
Is that amount paid daily, weekly, bi-weekly, twice a month, monthly, or annually?
INTERVIEWER: ROUND TO NEAREST DOLLAR AND ENTER HOW OFTEN PAID ON NEXT SCREEN
$|
|
|
|.|
|
|
| . 00
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(C10=00, d, or r)
C13hop. INTERVIEWER: ENTER HOW OFTEN PAID
DAILY ...................................................................
WEEKLY ..............................................................
BI-WEEKLY ..........................................................
TWICE A MONTH ................................................
MONTHLY ............................................................
ANNUALLY ..........................................................
DON’T KNOW ......................................................
REFUSED ............................................................
C-6
01
02
03
04
05
06
d
r
(1-346)
(1-1,730)
(1-3,750)
(1-3,750)
(1-7,500)
(1-90,000)
(1-1,730)
(1-8,653)
(1-18,750)
(1-18,750)
(1-37,500)
(1-450,000)
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
PROGRAMMER: CALCULATE MONTHLY TAKE HOME PAY FOR EACH JOB BASED ON C13AMT AND C13HOP:
If C10=1 and C11 and C8≠d or r, C_JobMnthPayTH(1)=c11*c8*4.35.
If C10=1 and C8_1 or C11=d, C_JobMnthPayTH(1)=d.
If C10=1 and C8_1 or C11=r and neither are d, C_JobMnthPayTH(1)=r.
If C10=0, d, or r and C13amt or C13hop=d, C_JobMnthPayTH(1)=d.
If C10=0, d, or r and C13amt or C13hop=r, and neither are d, C_JobMnthPayTH(1)=r.
If C10=0, d, or r and c13hop=1, C_JobMnthPayTH(1)=c13amt*21.74.
If C10=0, d, or r and c13hop=2, C_JobMnthPayTH(1) =c13amt*4.35.
If C10=0, d, or r and c13hop=3, C_JobMnthPayTH(1)=c13amt*2.17.
If C10=0, d, or r and c13hop=4, C_JobMnthPayTH(1)=c13amt*2.
If C10=0, d, or r and c13hop=5, C_JobMnthPayTH(1)=c13amt.
If C10=0, d, or r and c13hop=6, C_JobMnthPayTH(1)=c13amt/12.
(C10=00, d, or r) and (C12hop=01, 02, 03, 04, 05, or 06) and (C13hop=01, 02, 03, 04, 05, or 06)
C14.
SOFT EDIT: AMOUNT OF TAKE-HOME PAY MUST BE LESS THAN OR EQUAL T0 PRE-TAX PAY. IF
AMOUNT OF CALCULATED MONTHLY TAKE HOME PAY (C_JobMnthPayTH(1)) NE D OR R, AND
AMOUNT OF CALCULATED MONTHLY PRE-TAX PAY (C_JobMnthPay(1)) NE D OR R, AND
C_JobMnthPayTH(1) > C_JobMnthPay(1), TRIGGER EDIT AND DISPLAY FOLLOWING TEXT:
INTERVIEWER, AMOUNT OF CALCULATED MONTHLY TAKE HOME PAY IS GREATER THAN AMOUNT
OF CALCULATED PRE-TAX PAY. CHECK ENTRY. IF NECESSARY READ: I must have recorded an
incorrect answer. You said that {you are/NAME is} paid (C12amt) per (C12hop) before taxes and other
deductions which would be about (C_JobMnthPay(1) per month and that (C13amt) per (C13hop), or about
(C_JobMnthPayTH(1) per month, is left as take-home pay after taxes and other deductions. Based on what
I recorded, your take home pay is more than your pre-tax pay. Should I change the amount
{you are/NAME is} paid before taxes and other deductions or the amount {you take/NAME takes} home after
taxes and other deductions?
CHANGE AMOUNT PAID BEFORE TAXES AND OTHER
DEDUCTIONS .................................................................... 01 CHANGE C12amt)
CHANGE AMOUNT OF TAKE-HOME PAY ............................... 02 (CHANGE C13amt)
SUPPRESS ................................................................................ 03
C-7
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(C10=00, d, or r) and (C12hop=01, 02, 03, 04, 05, or 06) and (C13hop=01, 02, 03, 04, 05, or 06)
C14a. SOFT EDIT: DIFFERENCE IN AMOUNT OF CALCULATED MONTHLY TAKE HOME PAY AND
CALCULATED MONTHLY PRE-TAX PAY IS GREATER THAN 30%. IF AMOUNT OF TAKE MONTHLY
HOME PAY (C_JobMnthPayTH(1)) NE D OR R, AND AMOUNT OF MONTHLY PRE-TAX PAY
(C_JobMnthPay(1)) NE D OR R, AND (C_JobMnthPay(1) - C_JobMnthPayTH(1) / C_JobMnthPayTH(1) >
.30, TRIGGER EDIT AND DISPLAY FOLLOWING TEXT: INTERVIEWER, DIFFERENCE IN AMOUNT OF
CALCULATED MONTHLY TAKE HOME PAY AND CALCULATED MONTHLY PRE-TAX PAY IS GREATER
THAN 30%. CHECK ENTRY. IF NECESSARY READ: I may have recorded an incorrect answer. You said
that {you are/NAME is} paid (C12amt) per (C12hop) before taxes and other deductions which would be
about (C_JobMnthPay(1) per month and that (C13amt) per (C13hop), or about (C_JobMnthPayTH(1) per
month is left as take-home pay after taxes and other deductions. Is this correct or should I change the
amount {you are/NAME is} paid before taxes and other deductions or the amount {you take/NAME takes}
home after taxes and other deductions?
CHANGE AMOUNT PAID BEFORE TAXES AND OTHER
DEDUCTIONS .................................................................... 01 CHANGE C12amt)
CHANGE AMOUNT OF TAKE-HOME PAY ............................... 02 (CHANGE C13amt)
SUPPRESS ................................................................................ 03
PROGRAMMER: CALCULATE TOTAL MONTHLY PAY FROM ALL JOBS COMBINED (TO BE USED LATER IN
SECTION K):
If C_JobMnthPay(1) or C_JobMnthPay(2) or C_JobMnthPay(3) (for all jobs listed)=d,
C_CurMnthPay=d.
If C_JobMnthPay(1) or C_JobMnthPay(2) or C_JobMnthPay(3) (for all jobs listed)=r, and none=d,
C_CurMnthPay=r. Else, C_CurMnthPay=Sum of (C_JobMnthPay(1) AND C_JobMnthPay(2) AND
C_JobMnthPay(3), etc. (for all jobs listed)).
(All)
C15.
CHECK: IS {NAME} SELF EMPLOYED (C6=01)?
YES ............................................................................................ 01 (C17)
NO .............................................................................................. 00
(C15=00)
C16.
{Have you/Has NAME} received any promotions at this job during the past 12 months?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
C17.
CHECK: IS {NAME} A PROXY RESPONDENT (RTYPE=2)?
YES ............................................................................................ 01 (C19)
NO .............................................................................................. 00
(C17=00)
C18.
Taking all things into account, how satisfied are you with your {main/current} job? Would you say
PROGRAMMER: USE “MAIN” IF C1>01, OTHERWISE USE “CURRENT.”
VERY SATISFIED, ....................................................................
SOMEWHAT SATISFIED, .........................................................
NOT VERY SATISFIED, OR .....................................................
NOT AT ALL SATISFIED? ........................................................
DON’T KNOW ...........................................................................
REFUSED .................................................................................
C-8
01
02
03
04
d
r
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(All)
C19.
CHECK: IS {NAME} SELF EMPLOYED (C6=01)?
YES ............................................................................................ 01 (C21)
NO .............................................................................................. 00
(C19=00)
C20.
Now, I’d like to ask you a few more questions about {your/NAME’s} {main/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/NAME’s} {main/current} employer offers {you/him/her} any of these benefits.
PROGRAMMER: USE “MAIN” IF C1>01, OTHERWISE USE “CURRENT.”
Does {your/NAME’s} employer offer {you/NAME}
PROBE:
(All)
C21.
Please answer ‘yes’ if {you are/NAME is} eligible for the benefit but {haven’t/hasn’t} yet started
to receive it.
YES
NO
DON’T
KNOW
REFUSED
a.
Health care insurance? (IF NECESSARY: medical and/or
hospital)
01
00
d
r
b.
Dental benefits?
01
00
d
r
c.
Sick days with pay?
01
00
d
r
d.
Paid vacation?
01
00
d
r
e.
Free or low-cost childcare?
01
00
d
r
f.
Transportation, a transportation allowance, or transportation
discounts?
01
00
d
r
g.
Long-term disability benefits?
01
00
d
r
h.
Pension or retirement benefits?
01
00
d
r
i.
Flexible health or dependent care spending accounts?
01
00
d
r
CHECK: DOES {NAME} HAVE MORE THAN ONE CURRENT JOB (C1>01)?
YES .................................................... 01 (REPEAT C2 THROUGH C14 FOR EACH JOB)
NO ...................................................... 00
(All)
C22.
{Do you/Does NAME} use any special equipment related to {your/his/her} disability that helps {you/him/her}
work at {your /his/her} job{s}, for example a brace, cane, wheelchair, modified computer hardware or
modified computer software?
YES ............................................................................................ 01
NO .............................................................................................. 00 (C27)
DON’T KNOW ............................................................................ d (C27)
REFUSED .................................................................................. r (C27)
C-9
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(C22=01)
C23.
What kind of special equipment {do you/does NAME} use?
PROBE:
Anything else?
INTERVIEWER: CODE ALL THAT APPLY.
BRACE .......................................................................................
CANE/CRUTCHES/WALKER.....................................................
WHEELCHAIR............................................................................
MODIFIED COMPUTER HARDWARE.......................................
MODIFIED COMPUTER SOFTWARE .......................................
HEARING AID/DEVICE ..............................................................
SPECIAL GLASSES...................................................................
SPECIAL CHAIR/BACK SUPPORT ...........................................
SPECIAL SHOES/STOCKINGS .................................................
OTHER ___________________________________________
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
05
07
08
09
10
06
d
r
(C24)
(C24)
(C24)
(C24)
(C24)
(C24)
(C24)
(C24)
(C24)
(C24)
(C24)
(C22=01 and C23=06)
C23_Other.
What kind of other special equipment?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(C22=01)
C24.
Who paid for the equipment {you use/he/she uses}?
PROBE:
For example, {you or your family/NAME or (his/her) family}, insurance or Medicaid, or someone
else?
INTERVIEWER: CODE ALL THAT APPLY.
{NAME} .......................................................................................
FAMILY ......................................................................................
HEALTH INSURANCE ...............................................................
MEDICARE.................................................................................
MEDICAID ..................................................................................
EMPLOYER................................................................................
STATE VOCATIONAL REHABILITATION AGENCY .................
NON-PROFIT ORGANIZATION SERVING PEOPLE WITH
DISABILITIES .....................................................................
WORKER’S COMPENSATION ..................................................
DISABILITY INSURANCE ..........................................................
OTHER .......................................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
05
06
07
(C26amt)
(C26amt)
(C25)
(C25)
(C25)
(C25)
(C25)
08
09
10
11
d
r
(C25)
(C25)
(C25)
(C25)
(C25)
(C22=01 and C24=11)
C24_Other. Who else paid for the equipment {you use/NAME uses}?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
C-10
d
r
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(C22=01 and C24=03, 04, 05, 06, 07, 08, 09, 10, 11, d, or r)
C25.
{Do you or your/Does NAME or (his/her)} family have to pay for any part of the cost of the equipment {you
use/(he/she) uses}?
YES ............................................................................................ 01
NO .............................................................................................. 00 (C27)
DON’T KNOW ............................................................................ d (C27)
REFUSED .................................................................................. r (C27)
(All)
C27.
{Do you/Does NAME} use any personal assistance services related to {your/his/her} disability that help
{you/him/her} work, for example, a job coach, a sign language interpreter, a reader or interpreter for the
blind, or a personal care attendant?
YES ............................................................................................ 01
NO .............................................................................................. 00 (C32)
DON’T KNOW ............................................................................ d (C32)
REFUSED .................................................................................. r (C32)
(C27=01)
C28.
What kind of personal assistance services {do you/does NAME} use?
PROBE:
Anything else?
INTERVIEWER: CODE ALL THAT APPLY.
JOB COACH...............................................................................
SIGN LANGUAGE INTERPRETER ............................................
READER/INTERPRETER FOR THE BLIND ..............................
PERSONAL CARE ATTENDANT/PERSONAL ASSISTANT .....
OTHER .......................................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
C-11
01
02
03
04
05
d
r
(C29)
(C29)
(C29)
(C29)
(C29)
(C29)
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(C27=01 and C28=05)
C28_Other. What is the other kind of personal assistance services {you/NAME} use?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(C27=01)
C29.
Who paid for the personal assistance services {you use/NAME uses}?
PROBE:
For example, {you or your family/NAME or (his/her) family}, insurance or Medicaid, or someone
else?
INTERVIEWER: READ LIST IF NEEDED.
INTERVIEWER: CODE ALL THAT APPLY.
{NAME} .......................................................................................
FAMILY ......................................................................................
HEALTH INSURANCE ...............................................................
MEDICARE.................................................................................
MEDICAID ..................................................................................
EMPLOYER................................................................................
STATE VOCATIONAL REHABILITATION AGENCY .................
NON-PROFIT ORGANIZATION SERVING PEOPLE WITH
DISABILITIES .....................................................................
WORKER’S COMPENSATION ..................................................
DISABILITY INSURANCE ..........................................................
OTHER .......................................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
05
06
07
(C31amt)
(C31amt)
(C30)
(C30)
(C30)
(C30)
(C30)
08
09
10
11
d
r
(C30)
(C30)
(C30)
(C30)
(C30)
(C27=01 and C29=11)
C29_Other. Who else paid for the personal assistant services {you use/NAME uses}?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(C27=01 and C29=03, 04, 05, 06, 07, 08, 09, 10, 11, d, or r)
C30.
{Do you or your/Does NAME or (his/her)} family have to pay for any part of the cost of the personal
assistance services {you use/(he/she) uses}?
YES ............................................................................................ 01
NO .............................................................................................. 00 (C32)
DON’T KNOW ............................................................................ d (C32)
REFUSED .................................................................................. r (C32)
C-12
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(All)
C32.
CHECK: IS {NAME} SELF EMPLOYED (C6=01)?
YES ............................................................................................ 01 (C34)
NO .............................................................................................. 00
(C32=00)
C33.
PROGRAMMER: USE “MAIN” IF C1>01, OTHERWISE USE “CURRENT.”
Please tell me whether or not {your/NAME’s} {main/current} employer has made any of these changes
because of {your/his/her} physical or mental condition. Has {your/NAME’s} employer because of
{your/his/her} physical or mental condition.
PROGRAMMER: USE PROBE IF MORE THAN ONE JOB (C1>01) AND FIRST JOB.
PROBE:
a.
b.
c.
d.
e.
f.
{Your/NAME’s} main job is the job we have been talking about.
{you work/(he/she) works} the most hours.
The one at which
YES
NO
DON’T
KNOW
REFUSED
Provided {you/NAME} with any special equipment or assistive
technology?
(PROBE: For example special tools or equipment, software,
or devices to accommodate {your/NAME’s} condition in the
workplace.)
01
00
d
r
Made any changes in {your/NAME’s} work schedule?
(PROBE: For example, working fewer hours, changing the
time {you arrive or leave/(he/she) arrives or leaves}, or taking
more breaks to accommodate {your/NAME’s} condition in the
workplace.)
01
00
d
r
Made any changes to the tasks {you were/NAME was}
assigned or how they are performed?
(PROBE: For example, a light duty job or less demanding job
tasks to accommodate {your/NAME’s} condition in the
workplace.)
01
00
d
r
Made any changes to the physical work environment to make
things easier for {you/NAME}?
(PROBE: For example, modifying {your/his/her} work area,
improving accessibility in the building, or providing assigned
parking to accommodate {your/NAME’s} condition in the
workplace.)
01
00
d
r
Arranged for co-workers or others to assist {you/NAME}?
(PROBE: For example, providing a personal care attendant,
interpreter, or job coach while at work.)
01
00
d
r
Made any other changes that I didn’t mention to
accommodate {your/NAME’s} condition in the workplace?
01
00
d
r
PROGRAMMER: IF C33f=01, GO TO C33f_Other, ELSE GO TO C34.
(C32=00 and C33f=01)
C33f_Other. What other changes?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
C-13
d
r
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(All)
C34.
Are there any changes in {your/NAME’s} {main/current} job or workplace related to {your/his/her} physical or
mental condition that {you need/(he/she) needs}, but that have not been made?
PROGRAMMER: USE “MAIN” IF C1>01, OTHERWISE USE “CURRENT.”
PROGRAMMER: USE PROBE IF MORE THAN ONE JOB (C1>01) AND FIRST JOB.
PROBE:
{Your/NAME’s} main job is the job that we have been talking about.
{you work/(he/she) works} the most hours.
The one at which
YES ............................................................................................ 01
NO .............................................................................................. 00 (C38)
DON’T KNOW ............................................................................ d (C38)
REFUSED .................................................................................. r (C38)
(C34=01)
C35.
What are those changes?
PROBE:
Anything else?
INTERVIEWER: ENTER VERBATIM RESPONSE
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
C36.
d
r
CHECK: IS {NAME} SELF EMPLOYED (C6=01)?
YES ............................................................................................ 01 (C38)
NO .............................................................................................. 00
(C34=01 and C36=00)
C37.
Did {you/NAME} or anyone else ask {your/his/her} employer for (any of) these changes?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
C38.
CHECK: IS {NAME} A PROXY RESPONDENT (RTYPE=2)?
YES ............................................................................................ 01 (C39a2)
NO .............................................................................................. 00
C-14
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(RTYPE=1)
C39.
Again, thinking about your {main/current} job, how much do you agree with each of the following
statements? Would you say you strongly agree, agree, disagree, or strongly disagree?
PROGRAMMER: USE “MAIN” IF C1>01, OTHERWISE USE “CURRENT.”
PROGRAMMER: USE PROBE IF MORE THAN ONE JOB (C1>01) AND FIRST JOB.
PROBE:
Your main job is the job that we have been talking about. The one at which you work the most
hours.
STRONGLY
AGREE
AGREE
DISAGREE
STRONGLY
DISAGREE
NA
DON’T
KNOW
REFUSED
a. The pay is good
01
02
03
04
05
d
r
b. The benefits are good
c. IF {NAME} IS NOT SELFEMPLOYED (C6=00, d, or r): The job
security is good.
IF {NAME} IS SELF-EMPLOYED
(C6=01): The work is steady
d. IF {NAME} IS NOT SELFEMPLOYED (C6=00, d, or r): You
have a chance for promotion
ELSE: SKIP TO C39e
e. You have a chance to develop your
abilities
f. You have recognition or respect from
others
g. You can work on your own in your job
if you want to
h. You can work with others in a group
or team if you want to
01
02
03
04
05
d
r
01
02
03
04
05
d
r
01
02
03
04
05
d
r
01
02
03
04
05
d
r
01
02
03
04
05
d
r
01
02
03
04
05
d
r
01
02
03
04
05
d
r
i.
j.
01
02
03
04
05
d
r
01
02
03
04
05
d
r
01
02
03
04
05
d
r
01
02
03
04
05
d
r
01
02
03
04
05
d
r
Your work is interesting or enjoyable
Your work gives you a feeling of
accomplishment or contribution
k. IF {NAME} IS NOT SELFEMPLOYED (C6=00, d, or r): Your
supervisor is supportive
ELSE: SKIP TO C39l
l. Your co-workers are friendly and
supportive
m. You plan to stay at this job for the
next five years
(All)
C39a2. Sometimes people work fewer hours or earn less money than they could in order to care for family
members, keep the cash benefits they need, or just to have more free time. In (your/NAME’s) (main/current
job), (do you/ does he/ does she) work fewer hours or earn less money than (you/he/she) could for any
reason?
YES ............................................................................................ 01
NO .............................................................................................. 00 (C39_1)
DON’T KNOW ............................................................................ d (C39_1)
REFUSED .................................................................................. r (C39_1)
C-15
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(C39a=01)
C39b. (Do you/Does NAME) work fewer hours or earn less money than (you/he/she) could because (you/he/she)…
PROBE:
I need to ask everyone in our study the same questions, even if they don’t seem to apply to
(you/NAME).
YES
NO
DON’T
KNOW
REFUSED
a.
{Are/Is} taking care of children or others?
01
00
d
r
b.
{Are/Is} enrolled in school or a training program?
01
00
d
r
c.
Want(s) to keep Medicare or Medicaid coverage?
01
00
d
r
d.
Want(s) to keep cash benefits (you/he/she) need such as
disability or workers compensation?
01
00
d
r
e.
Just (do/does) not want to work more?
01
00
d
r
f.
Are there any reasons I didn’t mention why (you are/NAME
is) working or earning less than (you/he/she) could?
01
00
d
r
PROGRAMMER: IF C39b_f=01 GO TO C39f_Other, ELSE SKIP TO C39_1
(C39b_f=01)
C39f_Other What other reason?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(All)
C39_1. Have any of {your/NAME’s} disability-related benefits been reduced or ended because of {your/his/her}
(main/current) job?
YES ............................................................................................ 01
NO .............................................................................................. 00 (C39_3)
DON’T KNOW ............................................................................ d (C39_3)
REFUSED .................................................................................. r (C39_3)
(C39_1=01)
C39_2 What benefits have been reduced or ended as a result of {your/NAME’s} (main/current) job]?
INTERVIEWER: MARK ALL THAT APPLY.
PRIVATE DISABILITY INSURANCE ........................................................
WORKERS’ COMPENSATION ................................................................
VETERANS’ BENEFITS ...........................................................................
MEDICARE ...............................................................................................
MEDICAID ................................................................................................
SSA DISABILITY BENEFITS ....................................................................
PUBLIC ASSISTANCE OR WELFARE ....................................................
FOOD STAMPS........................................................................................
PERSONAL ASSISTANCE SERVICES (PAS) .........................................
UNEMPLOYMENT BENEFITS .................................................................
OTHER STATE DISABILITY BENEFITS ..................................................
OTHER GOVERNMENT PROGRAMS .....................................................
OTHER .....................................................................................................
C-16
01
02
03
04
05
06
07
08
09
10
11
12
13
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(All)
C39_3. Now, I am going to read you a list of things that sometimes help people to work more hours or earn more
money. If any of these do not apply to {you/NAME}, please just say so. At [your/NAME’s] (main/current)
job, do you think that [you/she/he] could work or earn more if you/he/she had.
YES
NO
DON’T
KNOW
REFUSED
a.
Help caring for {your/his/her} children or others in the
household?
01
00
d
r
b.
Help with {your/his/her} own personal care such as bathing,
dressing, preparing meals, and doing housework?
01
00
d
r
c.
Reliable transportation to and from work?
01
00
d
r
d.
Better job skills?
01
00
d
r
e.
A job with a flexible work schedule?
01
00
d
r
f.
Help with finding and getting a better job?
01
00
d
r
PROGRAMMER: IF C39_3g=01, GO TO C39_3g_Other,
ELSE GO TO C39_3h.
01
00
d
r
Is there anything else that I didn’t mention that would help
[you/NAME] work or earn more?
01
00
d
r
g.
h.
Any special equipment or medical devices?
PROGRAMMER: IF C39_3h=01, GO TO C39_3h_Other, ELSE GO TO C39_4.
(C39_3g=01)
C39_3g_Other. What other special equipment or medical devices?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(C39_3h=01)
C39_3h_Other
d
r
What else?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
C39_4.
d
r
One last question about (your / NAME’s) (main/current) job. Because of {your/his/her} work, has Social
Security needed to make any changes to the amount of {your/his/her} disability benefits?
PROBE: Did {your/NAME’s} benefit amount decrease or did {you/he/she} lose benefits altogether?
YES ............................................................................................ 01
NO .............................................................................................. 00 (C39_5)
DON’T KNOW ............................................................................ d (C39_5)
REFUSED .................................................................................. r (C39_5)
C-17
NBS ROUND 4 INSTRUMENT
SECTION C UNIVERSE: CURRENTLY WORKING (B24=01)
VARIABLES NEEDED FROM OTHER SECTIONS: CURRENTLY WORKING (B24), WORKED IN 2014 (B30), RTYPE, BIRTH
YEAR (A04_d)
PRELOADED VARIABLES: NONE
(C39_4=01)
C39_4a. Because of these changes has the Social Security Administration paid {you/NAME} the wrong benefit
amount?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
C39_5.
{Were you/Was NAME} asked to re-pay benefits because the Social Security Administration overpaid
{you/him/her}?
YES ............................................................................................ 01
NO .............................................................................................. 00 (C40)
DON’T KNOW ............................................................................ d (C40)
REFUSED .................................................................................. r (C40)
(C39_5=01)
C39_6.
{Were you/Was NAME} asked to re-pay the Social Security Administration because {you were/(he was
/she was} working while receiving benefits?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
C40.
CHECK: WAS {NAME} WORKING IN 2014 (B30=01)?
YES ............................................................................................ 01 (D1)
NO .............................................................................................. 00 (E1)
C-18
NBS ROUND 4 INSTRUMENT
SECTION D UNIVERSE: WORKED IN 2014 (B30=01)
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, WORKED IN 2014 (B30), NUMBER OF CURRENT JOBS (C1),
START DATES OF CURRENT JOBS (C4mth, C4yr), BIRTH YEAR (A04_d)
PRELOADED VARIABLES: NONE
SECTION D: JOBS/OTHER JOBS DURING 2014
(All)
D1.
Now, I will ask you about jobs {you/NAME} had during 2014. When answering these questions, please
include both part-time and full-time jobs, but only include jobs {you/NAME} held for pay or profit for one
month or longer.
PROGRAMMER: IF C1=01 AND C4 YEAR < 2014, ASK:
Other than (your/NAME’s) current job that you already told me about, in 2014 did {you/NAME} work for pay
at any other jobs for longer than a month?
PROGRAMMER: IF C1>01 AND C4 YEAR < 2014 FOR ONE OR MORE CURRENT JOBS IN SECTION C,
ASK:
Other than (your/NAME’s) current jobs that you already told me about, in 2014 did {you/NAME} work for pay
at any other jobs for longer than a month?
ELSE:
In 2014 did {you/NAME} work for pay at any jobs for longer than a month?
YES ............................................................................................ 01 (D3)
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(D1=00, d, or r)
D2.
SOFT EDIT: IF {NAME} WORKED IN 2014 (B30=01) AND {NAME} DID NOT WORK IN 2014 (D1=0, d, r)
INTERVIEWER READ: “Earlier you said that {you/NAME} worked for pay in 2014. Let me repeat the
question I just read and verify your response.”
PROGRAMMER: IF C1=01 AND C4 YEAR < 2014, ASK:
Other than (your/NAME’s) current job that you already told me about, in 2014 did {you/NAME} work for pay
at any other jobs for longer than a month?
PROGRAMMER: IF C1>01 AND C4 YEAR < 2014 FOR ONE OR MORE CURRENT JOBS IN SECTION C,
ASK:
Other than (your/NAME’s) current jobs that you already told me about, in 2014 did {you/NAME} work for pay
at any other jobs for longer than a month?
ELSE:
In 2014 did {you/NAME} work for pay at any jobs for longer than a month?
YES ............................................................................................ 01
NO .............................................................................................. 00 (E1)
DON’T KNOW ............................................................................ d (E1)
REFUSED .................................................................................. r (E1)
D-1
NBS ROUND 4 INSTRUMENT
SECTION D UNIVERSE: WORKED IN 2014 (B30=01)
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, WORKED IN 2014 (B30), NUMBER OF CURRENT JOBS (C1),
START DATES OF CURRENT JOBS (C4mth, C4yr), BIRTH YEAR (A04_d)
PRELOADED VARIABLES: NONE
(D1=01 or D2=01)
D3.
PROGRAMMER: IF C1=01 AND C4 YEAR < 2014, ASK:
Other than (your/NAME’s) current job that you already told me about, how many other jobs did {you/NAME}
hold for at least one month in 2014?
PROGRAMMER: IF C1>01 AND C4 YEAR < 2014 FOR ONE OR MORE CURRENT JOBS IN SECTION C,
ASK:
Other than (your/NAME’s) current jobs that you already told me about, how many other jobs did {you/NAME}
hold for at least one month in 2014?
ELSE:
How many jobs did {you/NAME} hold for at least one month in 2014?
|__|__| NUMBER OF JOBS (1-5)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
PROGRAMMER: D4 THROUGH D23 ASKED FOR ALL JOBS WHEN D3>01
(D1=01 or D2=01)
D4.
PROGRAMMER: IF MORE THAN ONE JOB (D3>01) AND FIRST JOB:
Let us start with {your/NAME’s} main job in 2014 – that is, the job at which {you worked/(he/she) worked} the
most hours.
What kind of work {did you/did NAME} do, that is, what was {your/NAME’s} occupation?
PROGRAMMER: IF MORE THAN ONE JOB (D3>01) AND SECOND, THIRD, FOURTH, ETC. JOB:
Now I would like to ask about {your/NAME’S} {second/third/fourth} job in 2014.
What kind of work {did you/did NAME} do, that is, what was {your/NAME’s} occupation?
ELSE (D3=01):
What kind of work {did you/did NAME} do, that is, what was {your/NAME’s} occupation?
INTERVIEWER: ENTER VERBATIM RESPONSE
PROBE 1: For example, a child-care provider at a private preschool; geometry teacher in a public high
school; sales clerk in a women’s shoe store.
PROBE 2: What are {your/NAME’S} main activities or duties? What else do you do? What else? Do you
supervise anyone?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
D-2
d
r
NBS ROUND 4 INSTRUMENT
SECTION D UNIVERSE: WORKED IN 2014 (B30=01)
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, WORKED IN 2014 (B30), NUMBER OF CURRENT JOBS (C1),
START DATES OF CURRENT JOBS (C4mth, C4yr), BIRTH YEAR (A04_d)
PRELOADED VARIABLES: NONE
(D1=01 or D2=01)
D5.
What kind of business was this?
INTERVIEWER: ENTER VERBATIM RESPONSE
PROBE 1: For what type of organization or industry did you work? For example: accounting firm, daycare
center, educational facility, food services.
PROBE 2: What do they make, sell, or do where {you/NAME} worked?
PROBE 3: Is this mainly manufacturing (making a product), wholesale trade (selling to other businesses) or
retail trade (selling to customers) or something else?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(D1=01 or D2=01)
D6mth. In what month and year did {you/NAME} start working there?
PROBE: Your best estimate is fine.
INTERVIEWER: ENTER MONTH HERE AND YEAR ON NEXT SCREEN
|__|__| (1-12)
MO
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(D1=01 or D2=01)
D6yr.
PROBE 1: In what month and year did {you/NAME} start working there?
PROBE 2: Your best estimate is fine.
INTERVIEWER: ENTER YEAR
|__|__|__|__| (1981-2014)
YEAR
(1951-2014)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(D1=01 or D2=01)
D7.
SOFT EDIT: YEAR {NAME} STARTED WORKING AT THIS JOB (D6 YEAR) SHOULD BE GREATER
THAN OR EQUAL TO YEAR OF BIRTH (A04d) PLUS 14 YEARS. IF RESPONDENT FAILS EDIT,
INTERVIEWER READ: I must have recorded an incorrect answer. I show that {you were/NAME was} born
in (A04d) and {you/NAME} started working at this job in (D6 YEAR), which means {you/NAME} started
working at this job when {you were/he was/she was} (PROGRAMMER CALCULATE AND FILL AGE: D6
YEAR – YEAR OF BIRTH) years old. Is that correct?
YES ............................................................................................ 01
NO .............................................................................................. 02 (CHANGE D6 YEAR)
SUPPRESS ................................................................................ 03
D-3
NBS ROUND 4 INSTRUMENT
SECTION D UNIVERSE: WORKED IN 2014 (B30=01)
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, WORKED IN 2014 (B30), NUMBER OF CURRENT JOBS (C1),
START DATES OF CURRENT JOBS (C4mth, C4yr), BIRTH YEAR (A04_d)
PRELOADED VARIABLES: NONE
(D1=01 or D2=01)
D8mth. In what month and year did {you/NAME} stop working there?
PROBE: Your best estimate is fine.
INTERVIEWER: ENTER MONTH HERE AND YEAR ON NEXT SCREEN
|__|__| (1-12)
MO
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(D1=01 or D2=01)
D8yr.
PROBE 1: In what month and year did {you/NAME} stop working there?
PROBE 2: Your best estimate is fine.
INTERVIEWER: ENTER YEAR
|__|__|__|__|
YEAR
(1981-2015)
(1951-2015)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(D1=01 or D2=01)
D9.
SOFT EDIT: DATE {NAME} STOPPED WORKING AT THIS JOB (D8 MONTH, D8 YEAR) SHOULD BE
LATER THAN DATE {NAME} STARTED WORKING AT THIS JOB (D6 MONTH, D6 YEAR). IF
RESPONDENT FAILS EDIT, INTERVIEWER READ: I must have recorded an incorrect answer. I show that
{you/NAME} started working at this job in (D6 MONTH, D6 YEAR) and that (you/NAME) stopped working at
this job in (D8 MONTH, D8 YEAR). Is that correct?
YES ............................................................................................
NO, CHANGE ANSWER TO D6.................................................
NO, CHANGE ANSWER TO D8.................................................
NO, CHANGE ANSWERS FOR BOTH D6 AND D8 ...................
SUPPRESS ................................................................................
01
02 (CHANGE D6)
03 (CHANGE D8)
04 (CHANGE D6 AND D8)
05
(D1=01 or D2=01)
D10.
SOFT EDIT: IF DATE {NAME} STOPPED WORKING AT THIS JOB (D8 MONTH, D8 YEAR ) AND DATE
{NAME} STARTED WORKING AT THIS JOB (D6 MONTH, D6 YEAR) ARE THE SAME (D8 MONTH, D8
YEAR – D6 MONTH, D6 YEAR = 0), INTERVIEWER READ: You said that {you/NAME} started and stopped
working at this job in (D8 MONTH, D8 YEAR). I’d like to verify that {you/NAME} worked at this job for less
than one month. Is this correct?
YES, WORKED AT JOB FOR LESS THAN ONE MONTH ........ 01
NO, WORKED AT JOB FOR MORE THAN ONE MONTH ......... 02
SUPPRESS ................................................................................ 03
(D1=01 or D2=01)
D11.
SOFT EDIT: IF YEAR {NAME} STOPPED WORKING AT THIS JOB (D8 YEAR) IS BEFORE 2014,
INTERVIEWER READ: You said that {you/NAME} stopped working at this job in (D8 YEAR). I’d like to verify
that this job ended before 2014. Is this correct?
YES, JOB ENDED BEFORE 2014 ............................................. 01
NO, JOB DID NOT END BEFORE 2014 .................................... 02
SUPPRESS ................................................................................ 03
D-4
NBS ROUND 4 INSTRUMENT
SECTION D UNIVERSE: WORKED IN 2014 (B30=01)
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, WORKED IN 2014 (B30), NUMBER OF CURRENT JOBS (C1),
START DATES OF CURRENT JOBS (C4mth, C4yr), BIRTH YEAR (A04_d)
PRELOADED VARIABLES: NONE
(D1=01 or D2=01)
D12.
CHECK: DID {NAME} WORK AT THIS JOB FOR LESS THAN ONE MONTH (D10=01)?
YES ............................................................................................ 01 (D23)
NO .............................................................................................. 00
(D12=00)
D13.
CHECK: DID THIS JOB END BEFORE 2014 (D11=01)?
YES ............................................................................................ 01 (D23)
NO .............................................................................................. 00
((D1=01 or D2=01) and D12=00 and D13=00)
D14.
{Were you/Was NAME} self-employed at this job?
PROBE:
Self-employed means that you work for yourself or own your own business.
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
((D1=01 or D2=01) and D12=00 and D13=00)
D15.
Was this job part of a sheltered workshop, transitional employment program, the Business Enterprise
Program for the blind, or supported employment program?
PROBE:
A sheltered workshop is a program that provides employment with subsidized wages (or special
wages that would not be available in a regular job) for people with disabilities. A transitional
employment program allows workers with disabilities to work at reduced levels while they ease
back into the workplace. The Business Enterprise Program for the Blind offers legally blind
persons for the opportunity to own their own businesses. Supported employment programs
provide job coaches or other on-the-job supports to help individuals with disabilities get and
keep jobs.
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
((D1=01 or D2=01) and D12=00 and D13=00)
D16.
How many hours per week did {you/NAME} usually work at this job?
PROBE:
Include overtime if {you/he/she} usually worked overtime.
|__|__|__| HOURS PER WEEK (1-60)
(1-168)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
((D1=01 or D2=01) and, D12=00 and D13=00)
D17.
How many weeks per year did {you/NAME} usually work at this job, including paid vacation and holidays?
PROBE 1: Please include time off for vacations and holidays if {you were/NAME was} paid for that time.
PROBE 2: There are 52 weeks in a year.
|__|__| WEEKS PER YEAR (1-52)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
D-5
d
r
NBS ROUND 4 INSTRUMENT
SECTION D UNIVERSE: WORKED IN 2014 (B30=01)
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, WORKED IN 2014 (B30), NUMBER OF CURRENT JOBS (C1),
START DATES OF CURRENT JOBS (C4mth, C4yr), BIRTH YEAR (A04_d)
PRELOADED VARIABLES: NONE
((D1=01 or D2=01) and D12=00 and D13=00)
D18.
PROGRAMMER: IF MORE THAN ONE JOB (D3>01) AND FIRST JOB:
For the purpose of this survey, it is important to obtain some information on how much {you were/NAME
was} paid on {your/(his/her)} main job in 2014. On {your/NAME’s} main job {were you/was (he/she} paid by
the hour?
PROGRAMMER: IF MORE THAN ONE JOB (D3>01) AND SECOND, THIRD, FOURTH, ETC. JOB:
For the purpose of this survey, it is important to obtain some information on how much {you were/NAME
was} paid on {your/(his/her)} {second/third/fourth} job in 2014. On {your/NAME’s} {second/third/fourth} job
{were you/was (he/she} paid by the hour?
ELSE (D3=01): For the purpose of this survey, it is important to obtain some information on how much {you
were/NAME was} paid on {your/(his/her)} job in 2014. On {your/NAME’s} job {were you/was (he/she} paid
by the hour?
PROGRAMMER: IF MORE THAN ONE JOB (D3>01) AND FIRST JOB:
PROBE:
{Your/NAME’s} main job in 2014 was the job at which {you worked/(he/she) worked} the most
hours.
YES ............................................................................................ 01
NO .............................................................................................. 00 (D20amt)
DON’T KNOW ............................................................................ d (D20amt)
REFUSED .................................................................................. r (D20amt)
((D1=01or D2=01) and D12=00 and D13=00 and D18=01)
D19.
What was {your/NAME’s} regular hourly pay, including tips and commissions?
PROBE: IF LESS THAN $5.00 AN HOUR: Does this include tips and commissions?
$ |___|___|___| . |___|___| PER HOUR
(1 - 25.00)
(1 - 300.00)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
GO TO D23
((D1=01 or D2=01) and D12=00 and D13=00 and D18=00, d, r)
D20amt. Before taxes and other deductions how much {were you/was NAME} paid on this job, including tips and
commissions?
PROBE: {Were you/Was NAME} paid daily, weekly, bi-weekly, twice a month, monthly, or annually?
INTERVIEWER: ROUND TO NEAREST DOLLAR
$|___|___|___| , |___|___|___| . 00
DON’T KNOW ............................................................................
REFUSED ..................................................................................
D-6
d
r
NBS ROUND 4 INSTRUMENT
SECTION D UNIVERSE: WORKED IN 2014 (B30=01)
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, WORKED IN 2014 (B30), NUMBER OF CURRENT JOBS (C1),
START DATES OF CURRENT JOBS (C4mth, C4yr), BIRTH YEAR (A04_d)
PRELOADED VARIABLES: NONE
((D1=01 or D2=01) and, D12=00 and D13=00 and D18=00, d, r)
D20hop. Before taxes and other deductions how much {were you/was NAME} paid on this job, including tips and
commissions?
PROBE: {Were you/Was NAME} paid daily, weekly, bi-weekly, twice a month, monthly, or annually?
INTERVIEWER: ENTER HOW OFTEN PAID
DAILY .................................................................................
WEEKLY ............................................................................
BI-WEEKLY ........................................................................
TWICE A MONTH ..............................................................
MONTHLY ..........................................................................
ANNUALLY.........................................................................
DON’T KNOW ....................................................................
REFUSED ..........................................................................
01
02
03
04
05
06
d
r
(1-384)
(1-1,923)
(1-4,166)
(1-4,166)
(1-8,333)
(1-100,000)
(1-1,922)
(1-9,615)
(1-20,833)
(1-20,833)
(1-41,666)
(1-500,000)
PROGRAMMER, CALCULATE MONTHLY PRE-TAX PAY BASED ON D20AMT AND D20HOP FOR EACH JOB:
If D18=1, and D19 and D16≠d or r, C_Job2014MnthPay(1)=D19*D16*4.35.
If D18=1 and D19 or D16=d, C_Job2014MnthPay(1)=d.
If D18=1 and D19 or D16=r and neither are d, C_Job2014MnthPay(1)=r.
If D18=0, d, OR r AND D20AMT OR D20HOP=d, C_Job2014MnthPay(1)=d.
If D18=0, d, OR r AND D20AMT OR D20HOP=r AND NEITHER ARE d, C_Job2014MnthPay(1)=r.
If D18=0, d, or r and D20hop=1, C_Job2014MnthPay(1)=D20amt*21.74.
If D18=0, d, or r and D20hop=2, C_Job2014MnthPay(1)=D20amt*4.35.
If D18=0, d, or r and D20hop=3, C_Job2014MnthPay(1)=D20amt*2.17.
If D18=0, d, or r and D20hop=4, C_Job2014MnthPay(1)=D20amt*2.
If D18=0, d, or r and D20hop=5, C_Job2014MnthPay(1)=D20amt.
If D18=0, d, or r and D20hop=6, C_Job2014MnthPay(1)=D20amt/12.
If D18=0, d, or r and D20hop or D20amt=d, then C_Job2014MnthPay(1)=d.
If D18=0, d, or r and D20hop or D20amt=r and none=d, then C_Job2014MnthPay(1)=r.
((D12=00 or D2=01) and D13=00 and D18=00, d, r)
D21amt. For this job, about how much was left as take-home pay after taxes and other deductions?
PROBE: {Were you/Was NAME} paid daily, weekly, bi-weekly, twice a month, monthly, or annually?
INTERVIEWER: ROUND TO NEAREST DOLLAR
$|___|___|___| , |___|___|___| . 00
DON’T KNOW ............................................................................
REFUSED ..................................................................................
D-7
d
r
NBS ROUND 4 INSTRUMENT
SECTION D UNIVERSE: WORKED IN 2014 (B30=01)
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, WORKED IN 2014 (B30), NUMBER OF CURRENT JOBS (C1),
START DATES OF CURRENT JOBS (C4mth, C4yr), BIRTH YEAR (A04_d)
PRELOADED VARIABLES: NONE
((D1=01 or D2=01) and D12=00 and D13=00 and D18=00, d, r)
D21hop. For this job, about how much was left as take-home pay after taxes and other deductions?
PROBE: {Were you/Was NAME} paid daily, weekly, bi-weekly, twice a month, monthly, or annually?
INTERVIEWER: ENTER HOW OFTEN PAID.
DAILY .................................................................................
WEEKLY ............................................................................
BI-WEEKLY ........................................................................
TWICE A MONTH ..............................................................
MONTHLY ..........................................................................
ANNUALLY.........................................................................
DON’T KNOW ....................................................................
REFUSED ..........................................................................
01
02
03
04
05
06
d
r
(1-346)
(1-1,730)
(1-3,750)
(1-3,750)
(1-7,500)
(1-90,000)
(1-1,730)
(1-8,653)
(1-18,750)
(1-18,750)
(1-37,500)
(1-450,000)
PROGRAMMER, CALCULATE MONTHLY TAKE HOME PAY FOR EACH JOB BASED ON D21AMT AND D21HOP:
If D18=1 and D19 and D16≠d or r, C_Job2014MnthPayTH(1)=D19*D16*4.35.
If D18=1 and D19 or D16=d, C_Job2014MnthPayTH(1)=d.
If D18=1 and D19 or D16=r and neither are d, C_Job2014MnthPayTH(1)=r.
If D18_1=0, d, or r and D21amt or D21hop=d, C_Job2014MnthPayTH(1)=d.
If D18_1=0, d, or r and D21amt or D21hop=r, and neither are d, C_Job2014MnthPayTH(1)=r.
If D18=0, d, or r and D21hop=1, C_Job2014MnthPayTH(1)=D21amt*21.74.
If D18=0, d, or r and D21hop=2, C_Job2014MnthPayTH(1) =D21amt*4.35.
If D18=0, d, or r and D21hop=3, C_Job2014MnthPayTH(1)=D21amt*2.17.
If D18=0, d, or r and D21hop=4, C_Job2014MnthPayTH(1)=D21amt*2.
If D18=0, d, or r and D21hop=5, C_Job2014MnthPayTH(1)=D21amt.
If D18=0, d, or r and D21hop=6, C_Job2014MnthPayTH(1)=D21amt/12.
If D18=0, d, or r and D21hop or D21amt=d, then C_Job2014MnthPayTH(1)=d.
If D18=0, d, or r and D21hop or D21amt=r and none=d, then C_Job2014MnthPayTH(1)=r.
((D1=01 or D2=01) and D12=00 and D13=00 and D18=00, d, r) and (D20hop=01, 02, 03, 04, 05, or 06) and
(D21hop=01, 02, 03, 04, 05, or 06)
D22.
SOFT EDIT: AMOUNT OF CALCULATED MONTHLY TAKE-HOME PAY MUST BE LESS THAN OR
EQUAL T0 CALCULATED MONTHLY PRE-TAX PAY. IF AMOUNT OF MONTHLY TAKE HOME PAY
(C_Job2014MnthPayTH(1)) NE D OR R, AND AMOUNT OF PRE-TAX MONTHLY PAY
(C_Job2014MnthPay(1)) NE D OR R, AND C_Job2014MnthPayTH(1) > C_Job2014MnthPay(1), TRIGGER
EDIT AND DISPLAY FOLLOWING TEXT: INTERVIEWER, AMOUNT OF CALCULATED MONTHLY TAKE
HOME PAY IS GREATER THAN AMOUNT OF CALCULATED MONTHLY PRE-TAX PAY. CHECK
ENTRY.
IF NECESSARY READ: I must have recorded an incorrect answer.
You said that
{you were/NAME was} paid (D20) per (D20 AMOUNT), which would be about (C_Job2014MnthPay(1)
before taxes and other deductions and that (D21) per (D21 AMOUNT), or about (C_Job2014MnthPayTH(1)
was left as take-home pay after taxes and other deductions. Based on what I recorded, your take home pay
was more than your pre-tax pay. Should I change the amount {you were/NAME was} paid before taxes and
other deductions or the amount {you took/NAME took} home after taxes and other deductions?
CHANGE AMOUNT PAID BEFORE TAXES AND OTHER
DEDUCTIONS ........................................................................ 01
CHANGE AMOUNT OF TAKE-HOME PAY .................................... 02
SUPPRESS ..................................................................................... 03
D-8
(CHANGE D20amt)
(CHANGE D21amt)
NBS ROUND 4 INSTRUMENT
SECTION D UNIVERSE: WORKED IN 2014 (B30=01)
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, WORKED IN 2014 (B30), NUMBER OF CURRENT JOBS (C1),
START DATES OF CURRENT JOBS (C4mth, C4yr), BIRTH YEAR (A04_d)
PRELOADED VARIABLES: NONE
((D1=01 or D2=01) and D12=00 and D13=00 and D18=00, d, r) and (D20hop=01, 02, 03, 04, 05, or 06) and
(D21hop=01, 02, 03, 04, 05, or 06)
D22a.
SOFT EDIT: DIFFERENCE IN AMOUNT OF CALCULATED MONTHLY TAKE HOME PAY AND
CALCULATED MONTHLY PRE-TAX PAY IS GREATER THAN 30%. IF AMOUNT OF MONTHLY TAKE
HOME PAY (C_Job2014MnthPayTH(1)) NE D OR R, AND AMOUNT OF MONTHLY PRE-TAX PAY
(C_Job2014MnthPay(1)) NE D OR R, AND (C_Job2014MnthPay(1) - C_Job2014MnthPayTH(1) /
C_Job2014MnthPayTH(1) > .30, TRIGGER EDIT AND DISPLAY FOLLOWING TEXT: INTERVIEWER,
DIFFERENCE IN AMOUNT OF TAKE HOME PAY AND PRE-TAX PAY IS GREATER THAN 30%. CHECK
ENTRY. IF NECESSARY READ: I may have recorded an incorrect answer. You said that {you were/NAME
was} paid (D20) per (D20 AMOUNT), which would be about (C_Job2014MnthPay(1) before taxes and other
deductions and that (D21) per (D21 AMOUNT) , or about (C_Job2014MnthPayTH(1) was left as take-home
pay after taxes and other deductions. Is this correct or should I change the amount {you were/NAME was}
paid before taxes and other deductions or the amount {you took/NAME took} home after taxes and other
deductions?
CHANGE AMOUNT PAID BEFORE TAXES AND OTHER
DEDUCTIONS .................................................................... 01 (CHANGE D20amt)
CHANGE AMOUNT OF TAKE-HOME PAY ............................... 02 (CHANGE D21amt)
SUPPRESS ................................................................................ 03
(D1=01 or D2=01)
D23.
Why did {you/NAME} stop working at this job?
INTERVIEWER: ASK ‘Any other reason?’ UNTIL RESPONDENT INDICATES NO OTHER REASONS. IF
RESPONDENT SAYS QUIT, ASK FOR THE REASON.
INTERVIEWER: CODE ALL THAT APPLY.
LAYOFF, FIRED, RETIRED:
LAYOFF, PLANT CLOSED ........................................................
FIRED ........................................................................................
RETIRED/OLD AGE...................................................................
JOB WAS TEMPORARY AND ENDED .....................................
PROBLEMS WITH JOB:
DID NOT LIKE SUPERVISOR OR CO-WORKERS ...................
DID NOT LIKE JOB DUTIES ......................................................
DID NOT LIKE JOB EARNINGS ................................................
DID NOT LIKE BENEFITS .........................................................
DID NOT LIKE OPPORTUNITIES FOR ADVANCEMENT.........
DID NOT LIKE LOCATION ........................................................
DID NOT GET ACCOMMODATIONS THAT WERE NEEDED ..
OTHER PROBLEMS:
TRANSPORTATION PROBLEMS .............................................
DECIDED TO GO TO SCHOOL ................................................
CHILD CARE RESPONSIBILITIES (PREGNANT).....................
OTHER FAMILY OR PERSONAL REASONS ...........................
DISABILITY:
DISABILITY GOT WORSE.........................................................
BECAME DISABLED .................................................................
OTHER.......................................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
D-9
01
02
03
04
(D24)
(D24)
(D24)
(D24)
05
06
07
08
09
10
11
(D24)
(D24)
(D24)
(D24)
(D24)
(D24)
(D24)
12
13
14
15
(D24)
(D24)
(D24)
(D24)
16
17
18
d
r
(D24)
(D24)
(D23_other)
(D24)
(D24)
NBS ROUND 4 INSTRUMENT
SECTION D UNIVERSE: WORKED IN 2014 (B30=01)
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, WORKED IN 2014 (B30), NUMBER OF CURRENT JOBS (C1),
START DATES OF CURRENT JOBS (C4mth, C4yr), BIRTH YEAR (A04_d)
PRELOADED VARIABLES: NONE
((D1=01 or D2=01) and D23=18)
D23_Other. What is the other reason?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(D1=01 or D2=01)
D24.
CHECK: DID {NAME} HOLD MORE THAN ONE JOB DURING 2014 (D3 > 01)?
YES ............................................................................................ 01
(REPEAT D4 THROUGH D23 FOR EACH JOB)
NO .............................................................................................. 00
(D1=01 or D2=01)
D25.
Sometimes people work fewer hours or earn less money than they could in order to care for family
members, keep the cash benefits they need, or just to have more free time. In 2014, did (you/NAME) work
fewer hours or earn less money than (you/he/she) could have for any reason?
YES ............................................................................................ 01
NO .............................................................................................. 00 (D26)
DON’T KNOW ............................................................................ d (D26)
REFUSED .................................................................................. r (D26)
((D1=01 or D2=01) and D25=01)
D25a. Did (you/NAME) work fewer hours or earn less money than (you/he/she) could have because (you/he/she)…
PROBE:
I need to ask everyone in our study the same questions, even if they don’t seem to apply to
(you/NAME).
YES
NO
DON’T
KNOW
REFUSED
a.
{Were/Was} taking care of children or others?
01
00
d
r
b.
{Were/Was} enrolled in school or a training program?
01
00
d
r
c.
Wanted to keep Medicare or Medicaid coverage?
01
00
d
r
d.
Wanted to keep cash benefits (you/he/she) needed such as
disability or workers compensation?
01
00
d
r
e.
Just did not want to work more?
01
00
d
r
f.
Are there any reasons I didn’t mention why {you/NAME}
might have worked or earned less than {you/he/she} could
have during 2014?
01
00
d
r
PROGRAMMER: IF D25f=01 GO TO D25f_Other, ELSE SKIP TO D25_1
((D1=01 or D2=01) and D25=01 and D25f=01)
D25f_Other What other reason?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
((D1=01 or D2=01) and D25=01)
D25_1. Were any of (your/NAME’s) disability-related benefits reduced or ended as a result of {your/his/her} working
in 2014?
YES ............................................................................................ 01
NO .............................................................................................. 00 (D26)
DON’T KNOW ............................................................................ d (D26)
REFUSED .................................................................................. r (D26)
D-10
NBS ROUND 4 INSTRUMENT
SECTION D UNIVERSE: WORKED IN 2014 (B30=01)
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, WORKED IN 2014 (B30), NUMBER OF CURRENT JOBS (C1),
START DATES OF CURRENT JOBS (C4mth, C4yr), BIRTH YEAR (A04_d)
PRELOADED VARIABLES: NONE
(D25_1=01)
D25_2. What benefits were reduced or ended as a result of {your/NAME’s} job in 2014?
INTERVIEWER: MARK ALL THAT APPLY.
PRIVATE DISABILITY INSURANCE ..........................................
WORKERS’ COMPENSATION ..................................................
VETERANS’ BENEFITS .............................................................
MEDICARE.................................................................................
MEDICAID ..................................................................................
SSA DISABILITY BENEFITS......................................................
PUBLIC ASSISTANCE OR WELFARE ......................................
FOOD STAMPS .........................................................................
PERSONAL ASSISTANCE SERVICES (PAS) ...........................
UNEMPLOYMENT BENEFITS ...................................................
OTHER STATE DISABILITY BENEFITS ....................................
OTHER GOVERNMENT PROGRAMS ......................................
OTHER .......................................................................................
01
02
03
04
05
06
07
08
09
10
11
12
13
(D25_2=13)
D25_2_Other: What other benefits?
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(D1=01 or D2=01)
D26.
Now, I am going to read you a list of things that sometimes help people to work more hours or earn more
money. If any of these do not apply to {you/NAME}, please just say so.
In 2014, do you think {you/NAME} could have worked or earned more if {you/he/she} had…
YES
NO
NA
DON’T
KNOW
REFUSED
a.
Help caring for {your/his/her} children or others in the
household?
01
00
02
d
r
b.
Help with {your/his/her} own personal care such as
bathing, dressing, preparing meals, and doing
housework?
01
00
02
d
r
c.
Reliable transportation to and from work?
01
00
02
d
r
d.
Better job skills?
01
00
02
d
r
e.
A job with a flexible work schedule?
01
00
02
d
r
f.
Help with finding and getting a better job?
01
00
02
d
r
g.
Any special equipment or medical devices?
PROGRAMMER: IF D26g=01, GO TO D26g_Other,
ELSE GO TO D26h.
01
00
02
d
r
01
00
02
d
r
h.
Is there anything else that I didn’t mention that would
have helped {you/NAME} to work or earn more during
2014?
PROGRAMMER: IF D26h=01, GO TO D26h_Other,
ELSE GO TO D27
D-11
NBS ROUND 4 INSTRUMENT
SECTION D UNIVERSE: WORKED IN 2014 (B30=01)
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, WORKED IN 2014 (B30), NUMBER OF CURRENT JOBS (C1),
START DATES OF CURRENT JOBS (C4mth, C4yr), BIRTH YEAR (A04_d)
PRELOADED VARIABLES: NONE
((D1=01 or D2=01) and D26g=01)
D26g_Other What other special equipment or medical devices?
(D26h)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d (D26h)
r (D26h)
((D1=01 or D2=01) and D26h=01)
D26h_Other What else?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(D1=01 or D2=01)
D27.
One last question about when {you were/NAME was} working in 2014. Because of {your/his/her} work, did
Social Security need to make any changes to the amount of {your/his/her} disability benefits?
PROBE:
Did {your/NAME’s} benefit amount decrease or did {you/he/she} lose benefits altogether?
YES ............................................................................................ 01
NO .............................................................................................. 00 (D29)
DON’T KNOW ............................................................................ d (D29)
REFUSED .................................................................................. r (D29)
((D1=01 or D2=01) and D27=01)
D28.
Because of these changes did the Social Security Administration pay {you/NAME} the wrong benefit amount
at any time during 2014?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(D1=01 or D2=02=1)
D29.
In 2014, {were you/was NAME} ever asked to re-pay benefits because the Social Security Administration
overpaid {you/him/her}?
YES ............................................................................................ 01
NO .............................................................................................. 00 (E1)
DON’T KNOW ............................................................................ d (E1)
REFUSED .................................................................................. r (E1)
((D1=01 or D2=01) and D29=01)
D30.
{Were you/Was NAME} asked to re-pay the Social Security Administration because {you were/(he/she) was}
working while receiving benefits?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
D-12
NBS ROUND 4 INSTRUMENT
SECTION E UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE
PRELOADED VARIABLES: BSTATUS, SSIAGE, SAMPLE AGE, TSTATUS, ENSAMPLE, SDATE, VRNAME
SECTION E: AWARENESS OF SSA WORK INCENTIVE PROGRAMS AND TICKET TO WORK
(All)
E1.
I’m going to read you a list of incentives and supports that Social Security offers to people getting disability
benefits, to encourage them to work. Please tell me if {you have/NAME has} ever heard of these incentives
or supports .
PRESS 1 TO CONTINUE ........................................................... 01
(All)
E2.
CHECK: IS {NAME} AN SSI BENEFICIARY (BSTATUS = 01,03)?
YES ............................................................................................ 01
NO .............................................................................................. 00 (E14)
(E2=01)
E3.
{Have you/Has NAME} ever heard of a Plan for Achieving Self-Support or a PASS Plan? This is a Social
Security incentive that lets {you/beneficiaries} set aside money to be used to help {you/them} reach a work
goal. The money set aside does not affect {your/their} benefits.
PROBE 1: {Have you/Has NAME} ever heard of this plan?
PROBE 2: If you’re not sure, please just say so.
INTERVIEWER: IF ‘NOT SURE’, CODE AS DON’T KNOW
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(E2=01)
E5.
{Have you/Has NAME} ever heard of the earned income exclusion or the 1 for 2 earnings exclusion? This is
a Social Security incentive where one-half of {your/a beneficiary’s} earnings over $85 are not counted when
Social Security figures {your/the} benefit.
PROBE 1: {Have you/Has NAME} ever heard of this exclusion?
PROBE 2: If you’re not sure, please just say so.
INTERVIEWER: IF ‘NOT SURE’, CODE AS DON’T KNOW
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(E2=01)
E7.
{Have you/Has NAME} ever heard of Property Essential to Self-Support, or PESS? This is a Social Security
incentive where the dollar value of tools, equipment, or other property needed for {your/a beneficiary’s} work
is excluded when Social Security figures {your/the} benefit.
INTERVIEWER: IF ‘NOT SURE’, CODE AS DON’T KNOW
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(E2=01)
E-1
NBS ROUND 4 INSTRUMENT
SECTION E UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE
PRELOADED VARIABLES: BSTATUS, SSIAGE, SAMPLE AGE, TSTATUS, ENSAMPLE, SDATE, VRNAME
E9.
{Have you/Has NAME} ever heard of Continued Medicaid Eligibility or 1619(b) coverage? This is a Social
Security incentive that lets {you/beneficiaries} keep {your/their} Medicaid insurance after {you/they} go to
work, even if {your/their} benefits have stopped.
INTERVIEWER: IF ‘NOT SURE’, CODE AS DON’T KNOW
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(E2=01)
E11. CHECK: IS {NAME} 25 OR YOUNGER {C_Intage < or = 25} AND DID {NAME} RECEIVE SSI BENEFITS
BEFORE AGE 22 {SSIAGE < 22}?
YES ............................................................................................ 01
NO .............................................................................................. 00 (E14)
(E2=01 and E11=01)
E12.
{Have you/Has NAME} ever heard of the student earned-income exclusion? This is a Social Security
incentive where if {you are/a beneficiary is} in school, up to $1,750 of earnings per month are not counted
when Social Security figures {your/the} benefit.
INTERVIEWER: IF ‘NOT SURE’, CODE AS DON’T KNOW
YES ............................................................................................ 01
NO .............................................................................................. 00 (E14)
DON’T KNOW ............................................................................ d (E14)
REFUSED .................................................................................. r (E14)
(All)
E14.
CHECK: IS {NAME} A SSDI BENEFICIARY (BSTATUS=02,03)?
YES ............................................................................................ 01
NO .............................................................................................. 00 (E19)
(E14=01)
E15.
{Have you/Has NAME} ever heard of a Trial Work Period? This is a Social Security incentive that lets
{you/beneficiaries} earn above $770 for nine months without losing {your/their} benefits.
INTERVIEWER: IF ‘NOT SURE’, CODE AS DON’T KNOW
YES ............................................................................................ 01
NO .............................................................................................. 00 (E17)
DON’T KNOW ............................................................................ d (E17)
REFUSED .................................................................................. r (E17)
(E14=01)
E17.
{Have you/Has NAME} ever heard of an Extended Period of Eligibility for Medicare? This is a Social Security
incentive that lets {you/beneficiaries} keep Medicare coverage when {you/they} go to work, even if
{your/their} benefits have stopped.
INTERVIEWER: IF ‘NOT SURE’, CODE AS DON’T KNOW
YES ............................................................................................ 01
NO .............................................................................................. 00 (E19)
DON’T KNOW ............................................................................ d (E19)
REFUSED .................................................................................. r (E19)
E-2
NBS ROUND 4 INSTRUMENT
SECTION E UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE
PRELOADED VARIABLES: BSTATUS, SSIAGE, SAMPLE AGE, TSTATUS, ENSAMPLE, SDATE, VRNAME
(ALL)
E19.
{Have you/Has NAME} ever heard of exclusions for Impairment-Related Work Expenses or Blind Work
Expenses? This is a Social Security incentive where the value of certain impairment-related items is not
counted when figuring {your/a person’s} benefits and eligibility.
INTERVIEWER: IF ‘NOT SURE’, CODE AS DON’T KNOW
YES ................................................................ 01
NO .................................................................. 00 (E20a)
DON’T KNOW ................................................ d (E20a)
REFUSED ......................................................
r (E20a)
(ALL)
E20a.
{Have you/Has NAME} ever heard of Expedited Reinstatement? This is a Social Security incentive that lets
beneficiaries restart their benefits without having to complete a new application if their attempts at work are
not successful.
INTERVIEWER: IF ‘NOT SURE’ ANSWER ‘DON’T KNOW’.
YES ................................................................ 01
NO .................................................................. 00 (E20c)
DON’T KNOW ................................................ d (E20c)
REFUSED ......................................................
r (E20c)
(E20a=01)
E20b. {Have you/Has NAME} ever used Expedited Reinstatement?
INTERVIEWER: IF ‘NOT SURE’, CODE AS DON’T KNOW
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(ALL)
E20c.
{Have you/Has NAME} ever heard of Work Incentive and Planning Assistance programs? These are local
organizations that give beneficiaries information about Ticket to Work and other programs and help them
understand how their Social Security benefits are affected by work.
INTERVIEWER: IF ‘NOT SURE’, ANSWER ‘DON’T KNOW’
PROBE: These are sometimes called WIPAs.
YES ............................................................................................ 01
NO .............................................................................................. 00 (E20e_1)
DON’T KNOW ............................................................................ d (E20e_1)
REFUSED .................................................................................. r (E20e_1)
(E20c=01)
E20d. {Have you/Has NAME} ever used Work Incentive and Planning Assistance program?
INTERVIEWER: IF ‘NOT SURE’ OR ‘NEVER HEARD OF’ CODE AS DON’T KNOW
YES ........................................................................................... 01
NO ............................................................................................. 00
DON’T KNOW ........................................................................... d
REFUSED ................................................................................. r
E-3
NBS ROUND 4 INSTRUMENT
SECTION E UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE
PRELOADED VARIABLES: BSTATUS, SSIAGE, SAMPLE AGE, TSTATUS, ENSAMPLE, SDATE, VRNAME
(ALL)
E20e.
{Have you/Has NAME} ever heard of Protection and Advocacy for Beneficiaries of Social Security or
PABSS? This program is focused on protecting beneficiaries’ rights to obtain services.
INTERVIEWER: IF ‘NOT SURE’, CODE AS DON’T KNOW
YES ................................................................ 01
NO .................................................................. 00
DON’T KNOW ................................................ d
REFUSED ......................................................
r
(E20e=01)
E20f.
{Have you/Has NAME} ever used Protection and Advocacy for Beneficiaries of Social Security or PABSS?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
AWARENESS OF TICKET TO WORK
(All)
E21.
{Have you/Has NAME} ever heard of the Ticket to Work program?
PROBE:
The Ticket to Work program provides services to help disability beneficiaries achieve steady,
long-term employment by providing them greater choices and opportunities to go to work if they
want to.
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
E-4
NBS ROUND 4 INSTRUMENT
SECTION F: REMOVED FROM NBS-GENERAL WAVES
F-1
NBS ROUND 4 INSTRUMENT
SECTION G UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: AGE OF DISABILITY ONSET
PRELOADED VARIABLES: BIRTHYEAR
SECTION G: EMPLOYMENT-RELATED SERVICES AND SUPPORTS USED IN 2014
SERVICE PROVIDERS
(All)
G1.
Next, I will ask about different types of services that people with disabilities sometimes get in order to
improve their ability to work or live independently.
First, I will ask about employment services {you/NAME} may have received.
(IF DISABLED BEFORE AGE 16 (B18_AGE < 16 OR IF BIRTHYEAR – B18_YEAR <16)) Since age 16,
{have you/has NAME} received any employment services to help {you/him/her} get a job?
(IF DISABLED AT AGE 16 OR LATER (B18_AGE
≥ 16 OR IF BIRTHYEAR
- B18_YEAR ≥ 16)) Since
becoming disabled, {have you/has NAME} received any employment services to help {you/him/her} get a
job?
YES ............................................................................................ 01
NO .............................................................................................. 00 (G10)
DON’T KNOW ............................................................................ d (G10)
REFUSED .................................................................................. r (G10)
(G1=01)
G2.
What was the name of the place {you/NAME} went to for those employment services?
PROGRAMMER: DISPLAY Anyplace else? ON SCREEN FOR PROVIDERS 2 THROUGH 8
INTERVIEWER: PRESS ‘ENTER’ FOR NO OTHER PLACE
PROBE 1: IF RESPONDENT DOESN'T KNOW NAME: I need to enter something that will help identify the
place {you/NAME} received these services from in later questions. What could I enter to help
us identify this place later? Street name, address, person spoken with there, even the color of
the building would help identify it.
PROVIDER 1 ___________________________________________
PROVIDER 2 < STRING=240>___________________________________________
PROVIDER 3 < STRING=240>___________________________________________
PROVIDER 4 < STRING=240>___________________________________________
PROVIDER 5 < STRING=240>___________________________________________
PROVIDER 6 < STRING=240>___________________________________________
PROVIDER 7 < STRING=240>___________________________________________
PROVIDER 8 < STRING=240>___________________________________________
REFUSED ................................................................................................................
r
(G1=01)
G7.
PROGRAMMER: A SK G7 THROUGH G9 FOR EACH PLACE LISTED IN G2
Thinking about {PROVIDER FROM G2}, was this place:
A state agency,............................................................. 01 (G8)
A private business, or ................................................... 02 (NEXT PROVIDER OR G10)
Some other type of place?............................................ 03 (G7_oth)
DON’T KNOW .............................................................. d (NEXT PROVIDER OR G10)
REFUSED ....................................................................
r (NEXT PROVIDER OR G10)
(G1=01 and G7=03)
G7_oth. INTERVIEWER: PLEASE SPECIFY
______________________________________________(NEXT PROVIDER OR G10)
DON’T KNOW ..............................................................
REFUSED ....................................................................
G-11
d (NEXT PROVIDER OR G10)
r (NEXT PROVIDER OR G10)
NBS ROUND 4 INSTRUMENT
SECTION G UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: AGE OF DISABILITY ONSET
PRELOADED VARIABLES: BIRTHYEAR
(G1=01 and G7=01)
G8.
CHECK: WAS {PROVIDER FROM G2} A STATE AGENCY (G7 = 01)?
YES .............................................................................. 01
NO ................................................................................ 02 (NEXT PROVIDER OR G10)
(G1=01 and G7=01 and G8=01)
G9.
Was this place a:
A vocational rehabilitation agency, ...............................
A welfare agency, .........................................................
A mental health agency, ...............................................
Some other state agency,.............................................
Workforce center or employment/unemployment
office, ....................................................................
Some other type of place..............................................
DON’T KNOW ..............................................................
REFUSED ....................................................................
*Note:
01
02
03
04
(NEXT PROVIDER OR G10)
(NEXT PROVIDER OR G10)
(NEXT PROVIDER OR G10)
(G9_oth1)
06
05
d
r
(NEXT PROVIDER OR G10)
(G9_oth2)
(NEXT PROVIDER OR G10)
(NEXT PROVIDER OR G10)
G9=6 is a category added at R2 and R3; value of “other” category (G9=5) maintained for comparability
across rounds.
(G1=01 G7=01 and G8=01 and G9=04)
G9_oth1. INTERVIEWER: PLEASE SPECIFY
_________________________________________________(NEXT PROVIDER OR G10)
DON’T KNOW ................................................
REFUSED ......................................................
d (NEXT PROVIDER OR G10)
r (NEXT PROVIDER OR G10)
(G1=01 G7=01 and G8=01 and G9=05)
G9_oth2. INTERVIEWER: PLEASE SPECIFY
_________________________________________________(NEXT PROVIDER OR G10)
DON’T KNOW ................................................
REFUSED ......................................................
(All)
G10.
d (NEXT PROVIDER OR G10)
r (NEXT PROVIDER OR G10)
Sometimes people get training to help them learn new skills so they can get a new job or change careers.
(IF DISABLED BEFORE AGE 16 (B18_AGE < 16 OR IF BIRTHYEAR – B18_YEAR <16)) Since age 16,
{have you/has NAME} received any training to help {you/him/her} get a new job or change careers?
(IF DISABLED AT AGE 16 OR LATER (B18_AGE
≥ 1 6 OR IF BIRTHYEAR - B18_YEAR ≥ 16)) Since
becoming disabled, {have you/has NAME} received any training to help {you/him/her} get a new job or
change careers?
PROBE:
Please do not include places you already told me about.
YES ............................................................................................ 01
NO .............................................................................................. 00 (G15)
DON’T KNOW ............................................................................ d (G15)
REFUSED .................................................................................. r (G15)
G-12
NBS ROUND 4 INSTRUMENT
SECTION G UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: AGE OF DISABILITY ONSET
PRELOADED VARIABLES: BIRTHYEAR
(G10=01)
G11.
What was the name of the place {you/NAME} went to for that training?
PROBE: Please do not include any places you already told me about.
PROGRAMMER: DISPLAY Anyplace else? ON SCREEN FOR PROVIDERS 2 THROUGH 8
INTERVIEWER: PRESS ‘ENTER’ FOR NO OTHER PLACE
PROBE 1: IF RESPONDENT DOESN'T KNOW NAME: I need to enter something that will help identify the
place {you/NAME} received these services from in later questions. What could I enter to help
us identify this place later? Street name, address, person spoken with there, even the color of
the building would help identify it.
PROVIDER 1 ____________________________________________________
PROVIDER 2 < STRING=240>____________________________________________________
PROVIDER 3 < STRING=240>____________________________________________________
PROVIDER 4 < STRING=240>____________________________________________________
PROVIDER 5 < STRING=240>____________________________________________________
PROVIDER 6 < STRING=240>____________________________________________________
PROVIDER 7 < STRING=240>____________________________________________________
PROVIDER 8 < STRING=240>____________________________________________________
REFUSED........................................................................................................................................
r
PROGRAMMER: FOR EACH PROVIDER LISTED IN G11 DISPLAY G12
(G10=01)
G12.
INTERVIEWER: DID THE RESPONDENT MENTION {PROVIDER LISTED IN G11} AT G2?
INTERVIEWER: IF THE LIST OF PROVIDERS ALREADY MENTIONED IS BLANK, NO PROVIDERS
HAVE BEEN MENTIONED YET.
INTERVIEWER: PROVIDERS MENTIONED AT G2 INCLUDE {DISPLAY PROVIDERS FROM G2}:
YES ................................................................ 01 (PROGRAMMER: DELETE ONE MENTION)
NO .................................................................. 00 (NEXT PROVIDER OR G13)
PROGRAMMER: ASK G13 THROUGH G14 FOR EACH NEW PROVIDER LISTED IN G11.
(G10=01)
G13.
Thinking about {NEW PROVIDER FROM G11}, was this place:
A state agency, ..............................................
A private business, .........................................
A school or college ........................................
Some other type of place ..............................
DON’T KNOW ................................................
REFUSED ......................................................
*Note:
01
02
04
03
d
r
(G14)
(NEXT PROVIDER OR G15)
(NEXT PROVIDER OR G15)*
(G13_oth)
(NEXT PROVIDER OR G15)
(NEXT PROVIDER OR G15)
G13=4 is a category added at R2 and R3; value of “other” category (G13=3) maintained for comparability
across rounds.
(G10=01 and G13=03)
G13_oth. INTERVIEWER: PLEASE SPECIFY
____________________________________________________ (NEXT PROVIDER OR G15)
DON’T KNOW ..............................................................
REFUSED ....................................................................
G-13
d (NEXT PROVIDER OR G15)
r (NEXT PROVIDER OR G15)
NBS ROUND 4 INSTRUMENT
SECTION G UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: AGE OF DISABILITY ONSET
PRELOADED VARIABLES: BIRTHYEAR
(G10=01 and G13=01)
G14.
Was this place a:
A vocational rehabilitation agency, ...............................
A welfare agency, .........................................................
A mental health agency ................................................
Some other state agency, or ........................................
None of these ...............................................................
DON’T KNOW ..............................................................
REFUSED ....................................................................
01
02
03
04
05
d
r
(NEXT PROVIDER OR G15)
(NEXT PROVIDER OR G15)
(NEXT PROVIDER OR G15)
(G14_oth)
(NEXT PROVIDER OR G15)
(NEXT PROVIDER OR G15)
(NEXT PROVIDER OR G15)
(G10=01 and G13=01 and G14=04)
G14_oth. INTERVIEWER: PLEASE SPECIFY
______________________________________________ (NEXT PROVIDER OR G15)
DON’T KNOW ..............................................................
REFUSED ....................................................................
(All)
G15.
d (NEXT PROVIDER OR G15)
r (NEXT PROVIDER OR G15)
Sometimes people with disabilities receive medical services to improve their ability to work or help them live
independently. Some examples of these services are physical therapy, surgery, and help getting special
equipment or devices.
(IF DISABLED BEFORE AGE 16 (B18_AGE < 16 OR IF BIRTHYEAR – B18_YEAR <16)) Since age 16,
{have you/has NAME} received any medical services to improve {your/his/her} ability to work or live
independently?
(IF DISABLED AT AGE 16 OR LATER (B18_AGE
≥ 16 OR IF BIRTHYEAR
- B18_YEAR ≥ 16)) Since
becoming disabled, {have you/has NAME} received any medical services to improve {your/his/her} ability to
work or live independently?
PROBE:
Please do not include places you already told me about.
YES ............................................................................................ 01
NO .............................................................................................. 00 (G19)
DON’T KNOW ............................................................................ d (G19)
REFUSED .................................................................................. r (G19)
(G15=01)
G16.
What was the name of the place {you/NAME} went to for those medical services?
PROBE: Please do not include any places you already told me about.
PROGRAMMER: DISPLAY Anyplace else? ON SCREEN FOR PROVIDERS 2 THROUGH 8
INTERVIEWER: PRESS ‘ENTER’ FOR NO OTHER PLACE
PROBE 1:
IF RESPONDENT DOESN'T KNOW NAME: I need to enter something that will help identify
the place {you/NAME} received these services from in later questions. What could I enter to
help us identify this place later? Street name, address, person spoken with there, even the
color of the building would help identify it.
PROVIDER 1 ____________________________________________________
PROVIDER 2 < STRING=240>____________________________________________________
PROVIDER 3 < STRING=240>____________________________________________________
PROVIDER 4 < STRING=240>____________________________________________________
PROVIDER 5 < STRING=240>____________________________________________________
PROVIDER 6 < STRING=240>____________________________________________________
PROVIDER 7 < STRING=240>____________________________________________________
PROVIDER 8 < STRING=240>____________________________________________________
REFUSED........................................................................................................................................
G-14
r
NBS ROUND 4 INSTRUMENT
SECTION G UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: AGE OF DISABILITY ONSET
PRELOADED VARIABLES: BIRTHYEAR
PROGRAMMER: FOR EACH PROVIDER LISTED IN G16 DISPLAY G17.
(G15=01)
G17.
INTERVIEWER: DID THE RESPONDENT MENTION {PROVIDER LISTED IN G16} AT G2 OR G11?
INTERVIEWER: IF THE LIST OF PROVIDERS ALREADY MENTIONED IS BLANK, NO PROVIDERS
HAVE BEEN MENTIONED YET.
INTERVIEWER: PROVIDERS MENTIONED AT G2 OR G11 INCLUDE {DISPLAY PROVIDERS FROM G2
AND G11}:
YES ............................................................... 01
NO ................................................................. 00
(PROGRAMMER: DELETE ONE MENTION)
(NEXT PROVIDER OR G18)
PROGRAMMER: ASK KINDPLACE FOR EACH NEW PROVIDER LISTED IN G16.
(G15=01)
G18.
Thinking about {NEW PROVIDER FROM G16}, was this place:
A clinic, ..........................................................
A hospital.......................................................
A doctor’s office, or ........................................
Some other type of place?.............................
DON’T KNOW ...............................................
REFUSED .....................................................
01
02
03
04
d
r
(NEXT PROVIDER OR G19)
(NEXT PROVIDER OR G19)
(NEXT PROVIDER OR G19)
(G18_oth)
(NEXT PROVIDER OR G19)
(NEXT PROVIDER OR G19)
(G15=01 and G18=04)
G18_oth. INTERVIEWER: PLEASE SPECIFY
______________________________________________ (NEXT PROVIDER OR G19)
DON’T KNOW .................................
REFUSED .......................................
(All)
G19.
d
r
(NEXT PROVIDER OR G19)
(NEXT PROVIDER OR G19)
Sometimes people go to a mental health professional to get therapy or counseling to improve their ability to
work or live independently.
(IF DISABLED BEFORE AGE 16 (B18_AGE < 16 OR IF BIRTHYEAR – B18_YEAR <16)) Since age 16,
{have you/has NAME} received mental health therapy or counseling to improve {your/his/her} ability to work
or live independently? This could include treatment for alcohol or drug abuse.
(IF DISABLED AT AGE 16 OR LATER (B18_AGE
≥ 16 OR IF BIRTHYEAR
- B18_YEAR ≥ 16)) Since
becoming disabled, {have you/has NAME} received mental health therapy or counseling to improve
{your/his/her} ability to work or live independently? This could include treatment for alcohol or drug abuse.
PROBE: Please do not include places you already told me about.
YES ................................................. 01
NO ................................................... 00
DON’T KNOW ................................. d
REFUSED ....................................... r
G-15
(G23)
(G23)
(G23)
NBS ROUND 4 INSTRUMENT
SECTION G UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: AGE OF DISABILITY ONSET
PRELOADED VARIABLES: BIRTHYEAR
(G19=01)
G20.
What was the name of the place {you/NAME} went to for therapy or counseling?
PROBE: Please do not include any places you already told me about.
PROGRAMMER: DISPLAY Anyplace else? ON SCREEN FOR PROVIDERS 2 THROUGH 8
INTERVIEWER: PRESS ‘ENTER’ FOR NO OTHER PLACE
PROBE 1: IF RESPONDENT DOESN'T KNOW NAME: I need to enter something that will help identify the
place {you/NAME} received these services from in later questions. What could I enter to help us
identify this place later? Street name, address, person spoken with there, even the color of the
building would help identify it.
PROVIDER 1
PROVIDER 2 < STRING=240>
PROVIDER 3 < STRING=240>
PROVIDER 4 < STRING=240>
PROVIDER 5 < STRING=240>
PROVIDER 6 < STRING=240>
PROVIDER 7 < STRING=240>
PROVIDER 8 < STRING=240>
REFUSED............................................................................................................................. r
PROGRAMMER: FOR EACH PROVIDER LISTED IN G20 DISPLAY G21.
(G19=01)
G21.
INTERVIEWER: DID THE RESPONDENT MENTION {PROVIDER LISTED IN G20} AT G2, G11 OR G16?
INTERVIEWER: IF THE LIST OF PROVIDERS ALREADY MENTIONED IS BLANK, NO PROVIDERS
HAVE BEEN MENTIONED YET.
INTERVIEWER: PROVIDERS MENTIONED AT G2, G11, OR G16 INCLUDE {DISPLAY PROVIDERS
FROM G2, G11, AND G16}:
YES ............................................................... 01
NO ................................................................. 00
(PROGRAMMER: DELETE ONE MENTION)
{NEXT PROVIDER OR G22}
PROGRAMMER: ASK KINDPLACE FOR EACH NEW PROVIDER LISTED IN G20.
(G19=01)
G22.
Thinking about {NEW PROVIDER FROM G20}, was this place:
A mental health agency, ................................
A clinic, ..........................................................
A hospital,......................................................
A doctor’s office, or ........................................
Some other type of place?.............................
DON’T KNOW ...............................................
REFUSED .....................................................
G-16
01
02
03
04
05
d
r
(NEXT PROVIDER OR G23)
(NEXT PROVIDER OR G23)
(NEXT PROVIDER OR G23)
(NEXT PROVIDER OR G23)
(G22_oth)
(NEXT PROVIDER OR G23)
(NEXT PROVIDER OR G23)
NBS ROUND 4 INSTRUMENT
SECTION G UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: AGE OF DISABILITY ONSET
PRELOADED VARIABLES: BIRTHYEAR
(G19=01 and G22=05)
G22_oth. INTERVIEWER: PLEASE SPECIFY
________________________________________________(NEXT PROVIDER OR G23)
DON’T KNOW ...............................................................
REFUSED .....................................................................
(All)
G23.
d (NEXT PROVIDER OR G23)
r (NEXT PROVIDER OR G23)
PROGRAMMER: (IF DISABLED BEFORE AGE 16 (C_DISAGE <16)) Since age 16, {have you/has NAME}
enrolled in school or taken any classes to help {you/him/her} get a new job or change careers? Please do
not include any training you have already told me about.
(IF DISABLED AT AGE 16 OR LATER (C_DISAGE≥ 16)) Since becoming disabled, {have you/has NAME}
enrolled in school or taken any classes to help {you/him/her} get a new job or change careers? Please do
not include any training you have already told me about.
PROBE 1: This could include vocational training in high school, college classes, or other instructional
programs.
PROBE 2: Please don’t include places you already told me about.
In 2014, did {you/NAME} enroll in school or take any classes to help {you/him/her} get a new job or change
careers?
Please do not include any training you have already told me about.
PROBE 1: This could include vocational training in high school, college classes, or other instructional
programs.
PROBE 2: Please don’t include places you already told me about.
YES ............................................................................... 01
NO ................................................................................. 00 (G29a)
DON’T KNOW ............................................................... d (G29a)
REFUSED .....................................................................
r (G29a)
G-17
NBS ROUND 4 INSTRUMENT
SECTION G UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: AGE OF DISABILITY ONSET
PRELOADED VARIABLES: BIRTHYEAR
(G23=01)
G24.
Where did {you/NAME} enroll in school or take classes?
PROBE:
Please do not include any places you already told me about.
PROGRAMMER: DISPLAY Anyplace else? ON SCREEN FOR PROVIDERS 2 THROUGH 8
INTERVIEWER: PRESS ‘ENTER’ FOR NO OTHER PLACE
PROBE 1: IF RESPONDENT DOESN'T KNOW NAME: I need to enter something that will help identify the
place {you/NAME} received these services from in later questions. What could I enter to help
us identify this place later? Street name, address, person spoken with there, even the color of
the building would help identify it.
PROVIDER 1
PROVIDER 2 < STRING=240>
PROVIDER 3 < STRING=240>
PROVIDER 4 < STRING=240>
PROVIDER 5 < STRING=240>
PROVIDER 6 < STRING=240>
PROVIDER 7 < STRING=240>
PROVIDER 8 < STRING=240>
REFUSED............................................................................................................................. r
PROGRAMMER: FOR EACH PROVIDER LISTED IN G24 DISPLAY G25.
(G23=01)
G25.
INTERVIEWER: DID THE RESPONDENT MENTION {PROVIDER LISTED IN G24} AT G2, G11, G16, OR
G20?
INTERVIEWER: IF THE LIST OF PROVIDERS ALREADY MENTIONED IS BLANK, NO PROVIDERS
HAVE BEEN MENTIONED YET.
INTERVIEWER: PROVIDERS MENTIONED AT G2, G11, G16, OR G20 INCLUDE {DISPLAY
PROVIDERS FROM G2, G11, G16, AND G20}:
YES ................................................. 01
NO ................................................... 00
(PROGRAMMER: DELETE ONE MENTION)
{NEXT PROVIDER OR G26}
(G10=01 or G23=01)
G26.
{Are you/Is NAME} currently enrolled in school or taking any classes?
YES ................................................. 01
NO ................................................... 00
DON’T KNOW ................................. d
REFUSED ....................................... r
(G29a)
(G29a)
(G29a)
(G10=01 or G23=01 and G26=01)
G27.
{Are you/Is NAME} working toward a degree, a certificate or license, or {are you/is (he/she)} just taking
classes?
WORKING TOWARD DEGREE ................................................. 01
WORKING TOWARD CERTIFICATE/ LICENSE ....................... 02
ONLY TAKING CLASSES .......................................................... 03 (G29a)
DON’T KNOW ............................................................................ d (G29a)
REFUSED .................................................................................. r (G29a)
G-18
NBS ROUND 4 INSTRUMENT
SECTION G UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: AGE OF DISABILITY ONSET
PRELOADED VARIABLES: BIRTHYEAR
(G10=01 or G23=01 and G26=01 and G27=01,02)
G28.
PROGRAMMER: IF G27=01 USE “DEGREE” AND IF G27=02 USE “CERTIFICATE OR LICENSE”
Toward what type of {degree/certificate or license} {are you/is NAME} working?
INTERVIEWER: CODE ONE ONLY.
GED OR HIGH SCHOOL EQUIVALENCE
PROGRAM/COURSES ........................................................
VOCATIONAL PROGRAM .........................................................
ASSOCIATE DEGREE PROGRAM (AA DEGREE) ..................
UNDERGRADUATE DEGREE PROGRAM (BA, BS DEGREE)
GRADUATE DEGREE PROGRAM (e.g., MA, MS, MD, EdD)....
OTHER .......................................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
05
06
d
r
(G29)
(G29)
(G29)
(G29)
(G28f_oth)
(G29)
(G29)
(G10=01 or G23=01 and G26=01 and G27=01,02 and G28=02)
G28b_oth. INTERVIEWER: PLEASE SPECIFY
(G29)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d (G29)
r (G29)
(G10=01 or G23=01 and G26=01 and G27=01,02 and G28=06)
G28f_oth. INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(G10=01 or G23=01 and G26=01 and G27=01 or 02)
G29.
{Are you/Is NAME} a full-time or part-time student?
FULL-TIME ................................................................................. 01
PART-TIME ................................................................................ 02
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
DE-DUPLICATION OF THE LIST OF PROVIDERS
(All)
G29a.
CHECK: DID {NAME} RECEIVE ANY SERVICES (G1=1 OR G10=1 OR G15=1 OR G19=1)?
YES ............................................................................................ 01
NO .............................................................................................. 02 (G48)
G30_1. PROGRAMMER: LIST PROVIDERS FROM G2, G11, G16, AND G20.
INTERVIEWER: IF A PROVIDER APPEARS ON THE LIST BELOW MORE THAN ONCE, ENTER THE
NUMBER IN FRONT OF ONE OF THE PROVIDER NAMES TO DELETE IT FROM THE
LIST. DO NOT MARK BOTH PROVIDER NAMES AS DUPLICATES.
INTERVIEWER: ONCE A PROVIDER NAME HAS BEEN DELETED, IT WILL APPEAR IN TEAL.
NONE/DONE .............................................................................. 00
G-19
NBS ROUND 4 INSTRUMENT
SECTION G UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: AGE OF DISABILITY ONSET
PRELOADED VARIABLES: BIRTHYEAR
(G29a=01)
G30_1. You said {you/NAME} received employment, medical, and therapy services from {LIST BELOW}. I want to
be sure that each service provider is listed only once. Are any of these providers the same?
INTERVIEWER: IF A PROVIDER APPEARS ON THE LIST BELOW MORE THAN ONCE, ENTER THE
NUMBER IN FRONT OF ONE OF THE PROVIDER NAMES TO DELETE IT FROM THE
LIST. DO NOT MARK BOTH PROVIDER NAMES AS DUPLICATES.
INTERVIEWER: ONCE A PROVIDER NAME HAS BEEN DELETED, IT WILL APPEAR IN TEAL.
NONE/DONE ............................................................................. 00
PROGRAMMER: IF ALL PROVIDERS DELETED, DISPLAY, YOU HAVE DELETED ALL PROVIDERS.
RETURN TO G30 AND DELETE DUPLICATES ONLY.
ONCE YOU HAVE SELECTED THE APPROPRIATE PROVIDER FOR DELETION (OR SELECTED 'NONE/DONE')
SUPPRESS THE SECOND ERROR MESSAGE TO CONTINUE.
WHEN SERVICES RECEIVED
(G29a=01)
G33_base. Next, I would like to know when {you/NAME} last received services from the places I just read and more
about the kinds of services {you/he/she} received from those places.
INTERVIEWER: PRESS 1 TO CONTINUE...................................................... 01
(G29a=01)
G33.
PROBE:
Next, I would like to know when {you/NAME} last received services from the places I just read
and more about the kinds of services {you/he/she} received from those places.
Think about all the services {you/NAME} received from {PROVIDER FROM G30_1 DE-DUPLICATED LIST}.
In what year did {you/he/she} last receive services from {PROVIDER FROM G30_1 DE-DUPLICATED
LIST}? Was it in 2015, in 2014, or before 2014?
IN 2015 ......................................................................... 01 (NEXT PROVIDER OR G35)
IN 2014 ......................................................................... 02 (NEXT PROVIDER OR G36)
BEFORE 2014 .............................................................. 03 (NEXT PROVIDER OR G48)
DON’T KNOW .............................................................. d
REFUSED ....................................................................
r
(G29a=01 and G33=d, r)
G34.
Was it:
Within the last 2 years ..................................................
2 to 5 years ago,...........................................................
5 to 10 years ago, or.....................................................
More than 10 years ago?..............................................
DON’T KNOW ..............................................................
REFUSED ....................................................................
01
02
03
04
d
r
(NEXT PROVIDER OR G48)
(NEXT PROVIDER OR G48)
(NEXT PROVIDER OR G48)
(NEXT PROVIDER OR G48)
(NEXT PROVIDER OR G48)
(G29a=01 and G33=01,d, r and G34=01)
G35.
Did {you/NAME} receive services from {PROVIDER FROM G30_1 DE-DUPLICATED LIST} at any time in
2014?
YES .............................................................................. 01 (NEXT PROVIDER OR G35a)
NO ................................................................................ 00 (NEXT PROVIDER OR G48)
DON’T KNOW .............................................................. d (NEXT PROVIDER OR G48)
REFUSED ....................................................................
r (NEXT PROVIDER OR G48)
G-20
NBS ROUND 4 INSTRUMENT
SECTION G UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: AGE OF DISABILITY ONSET
PRELOADED VARIABLES: BIRTHYEAR
SPECIFIC SERVICES RECEIVED FROM PROVIDERS AND SERVICE-RELATED EXPERIENCES IN 2014
(G29a=01 and G33=01,d, r and G34=01 and G35=01)
G35a. CHECK: DID {NAME} RECEIVE SERVICES FROM ANY PROVIDER IN 2014 ON DE-DUPLICATED LIST
(G33=02 OR G35=01) OR (THERE ARE DE-DUPLICATED PROVIDERS LISTED IN G30_1) FOR ANY
PROVIDER IN DE- DUPLICATED LIST?
YES .............................................................................. 01
NO ................................................................................ 00 (G48)
PROGRAMMER: ASK G36 THROUGH G40_1 FOR EACH PROVIDER LISTED IN G30_1 (AFTER DEDUPLICATION) IF USED IN 2014 (G33=02 OR G35=01) OR (THERE ARE DE-DUPLICATED
PROVIDERS LISTED IN G30_1)
(G35a=01 or G33=02)
G36.
In 2014, please tell me if {you/NAME} received any of the following services from {PROVIDER FROM G30_1
DE-DUPLICATED LIST IF USED IN 2014}. Did {you/he/she} receive:
PROBE: from {PROVIDER FROM G30_1 DE-DUPLICATED LIST IF USED IN 2014 for G36_a thru
G36_m}.
YES
NO
NA
DON’T
KNOW
REF
01
00
02
d
r (G37)
01
00
02
d
r (G37)
01
00
02
d
r (G37)
e. Special equipment or devices?
01
00
02
d
r (G36e_oth)
f.
01
00
02
d
r (G37)
g. Group therapy?
01
00
02
d
r (G37)
d. Medical services?
01
00
02
d
r (G37)*
h. A work or job assessment?
01
00
02
d
r (G37)
i.
Help to find a job?
01
00
02
d
r (G37)
j.
Training to learn a new job or skill?
01
00
02
d
r (G37)
k.
Advice about modifying {your/his/her} job or
work place?
01
00
02
d
r (G37)
l.
On-the-job training, job coaching, or support
services?
01
00
02
d
r (G37)
01
00
02
d
r (G36m_oth)
a. Physical therapy?
b. Occupational therapy? PROBE: Occupation
therapy is treatment that helps people
achieve independence in all areas of their
lives and can include home and job site
evaluations, skills assessments, equipment
recommendations, and other treatment to
help improve a person’s ability to perform
daily activities
c.
Speech therapy?
Personal counseling or therapy?
m. Anything else that I didn’t mention?
*Note: G36d moved to after G36g at R2 and R3.
(G35a=01 or G33=02 and G36e=01)
G-21
NBS ROUND 4 INSTRUMENT
SECTION G UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: AGE OF DISABILITY ONSET
PRELOADED VARIABLES: BIRTHYEAR
G36e_oth. INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(G35a=01 or G33=02 and G36m=01)
G36m_oth. INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(G35a=01 or G33=02)
G37.
In 2014, how many times did {you/NAME} receive these services from {PROVIDER FROM G30_1 DEDUPLICATED LIST IF USED IN 2014}? You can tell me either the total number of times in 2014 or the total
number of times per week or per month.
PROBE:
How many times did {you/NAME} go to the place or have contact with the service provider in
2014?
TOTAL TIMES IN 2014 .............................................................. 01 (G37_T2014)
TIMES PER WEEK..................................................................... 02 (G37_Tweek)
TIMES PER MONTH .................................................................. 03 (G37_Tmonth)
DON’T KNOW ............................................................................ d (G39)
REFUSED .................................................................................. r (G39)
(G35a=01 or G33=02 and G37=01)
G37_T2014.
PROBE: READ IF NECESSARY: How many times did {you/NAME} go to the place or have contact
with the service provider in 2014?
|__|__|__|
(1-99) (1-999)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
GO TO G39
(G35a=01 or G33=02 and G37=02)
G37_Tweek.
PROBE: READ IF NECESSARY: How many times did {you/NAME} go to the place or have contact
with the service provider per week?
|__|__|__|
(1-7) (1-99)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(G35a=01 or G33=02 and G37=02)
G38_week.
In 2014, about how many weeks did {you/NAME} get these services?
|__|__| WEEKS
(1-52)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
GO TO G39
G-22
NBS ROUND 4 INSTRUMENT
SECTION G UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: AGE OF DISABILITY ONSET
PRELOADED VARIABLES: BIRTHYEAR
(G35a=01 or G33=02 and G37=03)
G37_Tmonth. PROBE: READ IF NECESSARY: How many times did {you/NAME} go to the place or have contact
with the service provider per month?
|__|__|__|
(1-31) (1-99)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(G35a=01 or G33=02 and G37=03)
G38_month.
In 2014, about how many months did {you/NAME} get these services?
|__|__| MONTHS
(1-52) (1-12)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(G35a=01 or G33=02)
G39.
About how long did each service session with {PROVIDER FROM G30_1 DE-DUPLICATED LIST IF USED
IN 2014} last?
MINUTES ................................................................................... 01 (G39_min)
HOURS ...................................................................................... 02 (G39_hr)
DAYS .......................................................................................... 03 (G39_day)
DON’T KNOW ............................................................................ d (G40)
REFUSED .................................................................................. r (G40)
(G35a=01 or G33=02 and G39=01)
G39_min. INTERVIEWER: ENTER NUMBER OF MINUTES.
|__|__|
(1-59) (1-240)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
GO TO G40
(G35a=01 or G33=02 and G39=02)
G39_hr. INTERVIEWER: ENTER NUMBER OF HOURS.
|__|__|
(1-59) (1-24)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
GO TO G40
(G35a=01 or G33=02 and G39=03)
G39_day.
INTERVIEWER: ENTER NUMBER OF DAYS.
|__|__|
(1-3) (1-90)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
G-23
d
r
NBS ROUND 4 INSTRUMENT
SECTION H UNIVERSE:
(G35a=01 or G33=02)
G40.
How useful to {you/NAME} were the services provided by {PROVIDER FROM G30_1 DE-DUPLICATED
LIST IF USED IN 2014}? Would you say they were:
Very useful,.................................................................................
Somewhat useful, .......................................................................
Not very useful, or ......................................................................
Not at all useful? .........................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
d
r
(G49)
(G49)
(G49)
(G49)
NEW ITEM
(G35a=01 or G33=02) and G40=03 or 04)
G40_1. Were the services provided to you by {PROVIDER FROM G30_1 DE-DUPLICATED LIST IF USED IN 2014}
not useful because…
DON’T
a. you had not received all of your services yet?
b. you did not receive enough services?
c.
the services you received did not fit your needs?
d. your medical condition or other personal circumstances kept you
from fully participating in the services?
PROBE: This might include problems such as transportation or
childcare.
e. The services provided were of poor quality.
f.
Are there any other reasons the services provided to you were not
useful?
K
N
O
WREFUSED
YES
NO
01
00
d
r
01
00
d
r
01
00
d
r
01
00
d
r
01
00
d
r
01
00
d
r
(G40_1_f=01)
G40_1_Other. What were the reasons the services were not useful?
______________________________________________________
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
G43 THROUGH G51 DELETED
WHY USED SERVICES IN 2014
(All)
G52.
CHECK: DID {NAME} USE ANY SERVICES IN 2014 (G33=02 OR G35=01) OR (THERE ARE DEDUPLICATED PROVIDERS ON LIST) FOR ANY PROVIDER IN DE-DUPLICATED LIST USED IN 2014)?
YES ............................................................................................ 01
NO .............................................................................................. 00 (G58)
(G52=01)
G53.
The next few questions are about why {you/NAME} decided to use the employment, medical, or therapy
services {you/he/she} used in 2014.
H-13
NBS ROUND 4 INSTRUMENT
SECTION H UNIVERSE:
Thinking only about the services {you/NAME} used in 2014, what are the main reasons {you/he/she} decided
to use these services?
INTERVIEWER: CODE ALL THAT APPLY.
TO FIND A JOB/GET A BETTER JOB .......................................
TO INCREASE INCOME ............................................................
TO IMPROVE HEALTH/ WELL BEING ......................................
TO IMPROVE ABILITY TO DO DAILY ACTIVITIES ...................
TO AVOID A CONTINUING DISABILITY REVIEW ....................
SOMEONE PRESSURED {NAME} TO PARTICIPATE ..............
WANTED ACCESS TO A SPECIFIC PROGRAM/SERVICE/
RESOURCE.........................................................................
OTHER .......................................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
05
06
(G54)
(G54)
(G54)
(G54)
(G54)
(G55)
07 (G54)
08
d (G54)
r (G54)
(G52=01 and G53=08)
G53h_oth. INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(G52=01 and G53=01-05,07,08,d, r)
G54.
Did anybody pressure {you/NAME} to use any services when {you/NAME} did not want to?
YES ............................................................................................ 01
NO .............................................................................................. 00 (G58)
DON’T KNOW ............................................................................ d (G58)
REFUSED .................................................................................. r (G58)
(G52=01 and G54=01)
G55.
Who pressured {you/NAME} to use these services?
INTERVIEWER: CODE ALL THAT APPLY.
PARENT/GUARDIAN ...............................................................................
SPOUSE/PARTNER ................................................................................
OTHER FAMILY MEMBER ......................................................................
FRIEND/CO-WORKER ............................................................................
EMPLOYER/SUPERVISOR .....................................................................
STAFF OF EMPLOYMENT NETWORK ...................................................
VOCATIONAL REHABILITATION CASE MANAGER ..............................
JOB COACH ............................................................................................
SSA LETTER ...........................................................................................
SSA STAFF ..............................................................................................
WORK INCENTIVES PLANNING AND ASSISTANCE PROGRAM OR
BENEFIT SPECIALIST .....................................................................
HEALTH CARE PROFESSIONAL ...........................................................
COURT/POLICE ......................................................................................
OTHER .....................................................................................................
DON’T KNOW ..........................................................................................
REFUSED ................................................................................................
01
02
03
04
05
06
07
08
09
10
(G56)
(G56)
(G56)
(G56)
(G56)
(G56)
(G56)
(G56)
(G56)
(G56)
11
13
14
12
d
r
(G56)
(G56)
(G56)
(G56)
(G56)
(G52=01 and G54=01 and G55=12)
G55_oth. INTERVIEWER: PLEASE SPECIFY
H-14
NBS ROUND 4 INSTRUMENT
SECTION H UNIVERSE:
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(G52=01 and G54=01)
G56.
How did {your/NAME’s} {FILL PERSON(S) FROM G55} pressure {you/him/her} to use these services?
PROBE: What did they say or do that made {you/NAME} feel pressured?
INTERVIEWER: CODE ALL THAT APPLY.
SAID {NAME} WOULD LOSE DISABILITY AND/OR HEALTH
INSURANCE BENEFITS .....................................................
ENCOURAGED/WOULD NOT TAKE “NO” FOR AN
ANSWER .............................................................................
THREATENED TO WITHHOLD SERVICES ..............................
THREATENED TO TAKE AWAY OTHER SUPPORT (E.G.,
KICK OUT OF THE HOUSE) ...............................................
THREATENED HOSPITALIZATION/JAIL ..................................
OTHER .......................................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01 (G57)
02 (G57)
03 (G57)
04
06
05
d
r
(G57)
(G57)
(G57)
(G57)
(G52=01 and G54=01 and G56=05)
G56_oth. INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(G52=01 and G54=01)
G57.
Now that {you have/NAME has} used these services, listen to this statement and tell me if you strongly
agree, agree, disagree, or strongly disagree. Being pressured to use these services was in {my/NAME’s}
best interest.
INTERVIEWER: READ IF NECESSARY.
STRONGLY AGREE ..................................................................
AGREE .......................................................................................
DISAGREE, OR..........................................................................
STRONGLY DISAGREE ............................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
d
r
INFORMATION ABOUT SERVICES IN 2014
(All)
G58.
Now I want to ask you about how easy it is to get information about services. This includes both services
{you/NAME} used and did not use.
Thinking only about 2014, did {you/NAME} or {your/his/her} representative contact anyone to try to get
information about services to help {you/NAME} work or live independently?
YES ............................................................................................ 01
NO .............................................................................................. 00 (G60)
DON’T KNOW ............................................................................ d (G60)
REFUSED .................................................................................. r (G60)
(G58=01)
G59.
In general, how easy was it for {you/NAME} or {your/his/her} representative to get the information {you/they}
wanted about these services? Was it:
Very easy,................................................................................... 01
Somewhat easy, ......................................................................... 02
H-15
NBS ROUND 4 INSTRUMENT
SECTION H UNIVERSE:
Not very easy, or ........................................................................ 03
Not at all easy? ........................................................................... 04
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
SERVICES NEEDED BUT NOT RECEIVED IN 2014
(All)
G60.
In 2014, were there any services, equipment, or other supports that {you/NAME} needed but did not receive
that would have improved {your/his/her} ability to work or live independently?
YES ............................................................................................ 01
NO .............................................................................................. 00 (G62)
DON’T KNOW ............................................................................ d (G62)
REFUSED .................................................................................. r (G62)
(G60=01)
G61.
Why {were you/was NAME} unable to get these services?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
H-16
d
r
NBS ROUND 4 INSTRUMENT
SECTION H UNIVERSE:
SECTION H: REMOVED FROM NBS GENERAL WAVES
H-17
NBS ROUND 4 INSTRUMENT
SECTION I UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: NONE
PRELOADED INFORMATION: THIS MONTH, LAST YEAR
SECTION I: HEALTH AND FUNCTIONAL STATUS
GENERAL HEALTH STATUS
(ITEMS I1 through I8 constitute the SF-8)
(All)
I1.
The next questions are about {your/NAME’s} health.
Overall, how would you rate {your/NAME’s} health during the past 4 weeks?
Excellent, ....................................................................................
Very good, ..................................................................................
Good,..........................................................................................
Fair, ............................................................................................
Poor, or.......................................................................................
Very poor ....................................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
I2.
During the past 4 weeks, how much did physical health problems limit {your/NAME’s} usual physical
activities (such as walking or climbing stairs?)
Not at all, ....................................................................................
Very little, ....................................................................................
Somewhat,..................................................................................
Quite a lot, or ..............................................................................
Could {you/he/she} not do physical activities? ............................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
I3.
01
02
03
04
05
d
r
How much bodily pain {have you/has NAME} had in the past 4 weeks?
None, ..........................................................................................
Very mild,....................................................................................
Mild, ............................................................................................
Moderate, ...................................................................................
Severe, or ...................................................................................
Very severe? ..............................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
I-1
01
02
03
04
05
d
r
During the past 4 weeks, how much difficulty did {you/NAME} have doing {your/his/her} daily work, both at
home and away from home, because of {your/his/her} physical health?
None at all, .................................................................................
A little bit, ....................................................................................
Some, .........................................................................................
Quite a lot, or ..............................................................................
Could {you/he/she} not do daily work? .......................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
I4.
01
02
03
04
05
06
d
r
01
02
03
04
05
06
d
r
NBS ROUND 4 INSTRUMENT
SECTION I UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: NONE
PRELOADED INFORMATION: THIS MONTH, LAST YEAR
(All)
I5.
During the past 4 weeks, how much energy did {you/NAME} have?
Very much, .................................................................................
Quite a lot, ..................................................................................
Some, .........................................................................................
A little, or ....................................................................................
None? .........................................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
I6.
During the past 4 weeks, how much did {your/NAME’s} physical health or emotional problems limit
{your/his/her} usual social activities with family or friends?
Not at all, ....................................................................................
Very little, ....................................................................................
Somewhat,..................................................................................
Quite a lot, or ..............................................................................
Could {you/he/she} not do social activities? ...............................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
I7.
01
02
03
04
05
d
r
Compared to {THIS MONTH, LAST YEAR}, how would you rate {your/NAME’s} health in general now?
Much better now, ........................................................................
Somewhat better now, ................................................................
About the same, .........................................................................
Somewhat worse now, or ...........................................................
Much worse now? .......................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
I-2
01
02
03
04
05
d
r
During the past 4 weeks, how much did personal or emotional problems keep {you/NAME} from doing
{your/his/her} usual work, school or other daily activities?
Not at all, ....................................................................................
Very little, ....................................................................................
Somewhat,..................................................................................
Quite a lot, or ..............................................................................
Could {you/he/she} not do daily activities? .................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
I9.
01
02
03
04
05
d
r
During the past 4 weeks, how much {have you/has NAME} been bothered by emotional problems (such as
feeling anxious, depressed or irritable?)
Not at all, ....................................................................................
Slightly, .......................................................................................
Moderately .................................................................................
Quite a lot, or ..............................................................................
Extremely?..................................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
I8.
01
02
03
04
05
d
r
01
02
03
04
05
d
r
NBS ROUND 4 INSTRUMENT
SECTION I UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: NONE
PRELOADED INFORMATION: THIS MONTH, LAST YEAR
(All)
I10.
{Do you/Does NAME} take any prescription medications for any ongoing physical health conditions?
PROBE: Please do not include over the counter medication such as cold or headache medication.
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I11.
{Do you/Does NAME} take any prescription medications for any ongoing mental or emotional conditions?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I12.
Since {THIS MONTH, LAST YEAR}, {have you/has NAME} received any treatment for a mental or emotional
condition at a hospital, clinic, or doctor’s office?
PROBE: Do not include medications.
YES ............................................................................................ 01 (I17a)
NO .............................................................................................. 00 (I17a)
DON’T KNOW ............................................................................ d (I17a)
REFUSED .................................................................................. r (I17a)
ADL, IADL, AND FUNCTIONAL LIMITATIONS
(All)
I17a.
Now I’d like to ask you some questions about everyday activities and how much difficulty {you have/NAME
has} doing these activities. Our study requires that all beneficiaries be asked these questions. Please give
me your best answer even if the questions don’t seem to apply to {you/NAME}.
(I17a=01,d, r)
I17b.
{Are you/Is NAME} blind or do {you/ does he/she} have serious difficulty seeing even when wearing
glasses? (ACS)
YES ............................................................................................ 01 (I19)
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I17b=01,d, r and I18=01,d, r)
I19.
{Do you/Does NAME} use any devices, special equipment, or other special assistance because of difficulty
seeing, such as telescopic lenses, adapted computer equipment, Braille, a guide dog, or a white cane?
PROBE: Do not include glasses or contact lenses.
YES ............................................................................................ 01
NO .............................................................................................. 00 (I21)
DON’T KNOW ............................................................................ d (I21)
REFUSED .................................................................................. r (I21)
I-3
NBS ROUND 4 INSTRUMENT
SECTION I UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: NONE
PRELOADED INFORMATION: THIS MONTH, LAST YEAR
(I17b=01,d, r and I18=01,d, r and I19=01)
I20.
What devices, equipment, or other types of assistance {do you/does NAME} use?
PROBE:
Anything else?
INTERVIEWER: CODE ALL THAT APPLY.
TELESCOPIC LENSES .............................................................. 01
ADAPTED COMPUTER EQUIPMENT ....................................... 02
BRAILLE ..................................................................................... 03
READERS .................................................................................. 04
GUIDE DOG ............................................................................... 05
WHITE CANE ............................................................................. 06
OTHER SEEING ASSISTANCE ................................................. 07
MAGNIFYING GLASS ................................................................ 08
SCREEN READERS ................................................................... 09
TEXT-TO_VOICE DEVICES ....................................................... 10
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I21)
(I21)
(I21)
(I21)
(I21)
(I21)
(I21)
(I21)
(I21)
(I21)
(I21)
(I17b=01,d, r and I18=01,d, r and I19=01 and I20=07)
I20_Other. What other seeing assistance?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
I21.
d
r
{Are you/is NAME} deaf or do {you/he/she} have serious difficulty hearing? (ACS)
YES ............................................................................................ 01
NO .............................................................................................. 00 (I25)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I21=01,d, r)
I22.
{Are you/Is NAME} able to hear what is said in normal conversation at all?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I21=01,d, r)
I23.
{Do you/Does NAME} use any devices, special equipment, or other special assistance because of difficulty
hearing? This includes a hearing aide, a phone amplifier, TTY or teletype Relay, an assistive listening or
signaling device, or an interpreter.
INTERVIEWER NOTE: If person reports cochlear implant, code ‘01’.
YES ............................................................................................ 01
NO .............................................................................................. 00 (I25)
DON’T KNOW ............................................................................ d (I25)
REFUSED .................................................................................. r (I25)
I-4
NBS ROUND 4 INSTRUMENT
SECTION I UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: NONE
PRELOADED INFORMATION: THIS MONTH, LAST YEAR
(I21=01,d, r and I23=01)
I24.
What devices, equipment, or other types of assistance {do you/does NAME} use?
PROBE:
Anything else?
INTERVIEWER: CODE ALL THAT APPLY.
HEARING AID ............................................................................
PHONE AMPLIFIER ...................................................................
TYY OR TELETYPE / TTD .........................................................
CLOSED CAPTION TV ..............................................................
ASSISTIVE LISTENING/SIGNALING DEVICE ..........................
INTERPRETER ..........................................................................
OTHER HEARING ASSISTANCE ..............................................
INSTANT MESSAGING .............................................................
SKYPE OR OTHER VIDEO MESSAGING .................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
04
05
06
07
08
09
10
d
r
(I25)
(I25)
(I25)
(I25)
(I25)
(I25)
(I25)
(I25)
(I25)
(I25)
(I21=01,d, r and I23=01 and I24=08)
I24_Other. What other hearing assistance?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
I25.
d
r
{Do you/Does NAME} have any difficulty having {your/his/her} speech understood because of a health
condition or problem?
YES ............................................................................................ 01
NO .............................................................................................. 00 (I29)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I25=01,d, r)
I26.
{Are you/Is NAME} able to have {your/his/her} speech understood at all?
PROBE:
This applies only to spoken speech and does not include sign language ‘speech’.
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I25=01,d, r)
I27.
{Do you/Does NAME} use any devices, special equipment, or other special assistance because of difficulty
speaking or having {your/his/her} speech understood, such as a voice synthesizer or voice amplifier?
YES ............................................................................................ 01
NO .............................................................................................. 00 (I29)
DON’T KNOW ............................................................................ d (I29)
REFUSED .................................................................................. r (I29)
I-5
NBS ROUND 4 INSTRUMENT
SECTION I UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: NONE
PRELOADED INFORMATION: THIS MONTH, LAST YEAR
(I25=01,d, r and I27=01)
I28.
What devices, equipment, or other types of assistance {do you/does NAME} use?
PROBE: Anything else?
INTERVIEWER: CODE ALL THAT APPLY.
VOICE SYNTHESIZER ..............................................................
VOICE AMPLIFIER ....................................................................
SIGN LANGUAGE INTERPRETER ............................................
OTHER SPEECH ASSISTANCE................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
d
r
(I29)
(I29)
(I29)
(I29)
(I29)
(I25=01,d, r and I27=01 and I28=04)
I28_Other. What other speech assistance?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
I29.
d
r
{Do you/Does NAME} have serious difficulty walking or climbing stairs? (ACS)
YES ............................................................................................ 01
NO .............................................................................................. 00 (I33)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I29=01,d, r)
I30.
{Are you/Is NAME} able to walke without assistance at all?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I33=01,d, r)
I34.
{Are you/Is NAME} able to climb stairs at all?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I29=01,d, r)
I31.
{Do you/Does NAME} use any devices, special equipment, or other special assistance because of difficulty
walking, such as a cane, walker, wheelchair, scooter, prosthetic device, or a personal care attendant?
YES ............................................................................................ 01
NO .............................................................................................. 00 (I33)
DON’T KNOW ............................................................................ d (I33)
REFUSED .................................................................................. r (I33)
(I29=01,d, r and I31=01)
I32.
What devices, equipment, or other types of assistance {do you/does NAME} use?
PROBE:
Anything else?
INTERVIEWER: CODE ALL THAT APPLY.
BRACES, CRUTCHES, CANE, OR WALKER............................ 01 (I33)
WHEELCHAIR OR SCOOTER................................................... 02 (I33)
PROSTHETIC DEVICE .............................................................. 03 (I33)
I-6
NBS ROUND 4 INSTRUMENT
SECTION I UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: NONE
PRELOADED INFORMATION: THIS MONTH, LAST YEAR
SPECIAL CHAIR (NOT WHEELCHAIR) ....................................
PERSONAL CARE ASSISTANT ................................................
VEHICLE HAND CONTROLS ....................................................
LIFT (HOME OR VEHICLE) .......................................................
SPECIAL SHOES OR INSERTS ................................................
BREATHING DEVICES ..............................................................
OTHER MOBILITY ASSISTANCE..............................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
04
05
06
07
09
10
08
d
r
(I33)
(I33)
(I33)
(I33)
(I33)
(I33)
(I33)
(I33)
(I29=01,d, r and I31=01 and I32=08)
I32_Other. What other mobility assistance?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
I35.
d
r
{Do you/Does NAME} have any difficulty lifting and carrying something as heavy as 10 pounds, such as a
full bag of groceries?
YES ............................................................................................ 01
NO .............................................................................................. 00 (I37)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I35=01,d, r)
I36.
{Are you/Is NAME} able to lift and carry 10 pounds at all?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I37.
{Do you/Does NAME} have any difficulty using {your/his/her} hands and fingers to do things such as picking
up a glass or grasping a pencil?
YES ............................................................................................ 01
NO .............................................................................................. 00 (I39)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I37=01,d, r)
I38.
{Are you/Is NAME} able to use {your/his/her} hands and fingers to grasp and handle at all?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I39.
{Do you/Does NAME} have any difficulty reaching over {your/his/her} head?
YES ............................................................................................ 01
NO .............................................................................................. 00 (I41)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
I-7
NBS ROUND 4 INSTRUMENT
SECTION I UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: NONE
PRELOADED INFORMATION: THIS MONTH, LAST YEAR
(I39=01,d, r)
I40.
{Are you/Is NAME} able to reach over {your/his/her} head at all?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I41.
{Do you/Does NAME} have any difficulty standing or being on {your/his/her} feet for one hour?
YES ............................................................................................ 01
NO .............................................................................................. 00 (I43)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I41=01,d, r)
I42.
{Are you/Is NAME} able to stand on {your/his/her} feet at all?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I43.
{Do you/Does NAME} have any difficulty stooping, crouching or kneeling?
YES ............................................................................................ 01
NO .............................................................................................. 00 (I45)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I43=01,d, r)
I44.
{Are you/Is NAME} able to stoop, crouch, or kneel at all?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I45.
{Do you/Does NAME} have any difficulty getting around inside {your/his/her} home?
YES ............................................................................................ 01
NO .............................................................................................. 00 (I47)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I45=01,d, r)
I46.
{Do you/Does NAME} need the help of another person in order to get around inside {your/his/her} home?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I47.
Because of a physical, mental, or emotional condition, {do you/does NAME} have difficulty doing errands
alone such as visiting a doctor’s office or shopping? (ACS)
YES ............................................................................................ 01
NO .............................................................................................. 00 (I49)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
I-8
NBS ROUND 4 INSTRUMENT
SECTION I UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: NONE
PRELOADED INFORMATION: THIS MONTH, LAST YEAR
(I47=01,d, r)
I48.
{Do you/Does NAME} need the help of another person in order to get around outside {your/his/her} home?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I49.
{Do you/Does NAME} have any difficulty getting into and out of bed or a chair?
YES ............................................................................................ 01
NO .............................................................................................. 00 (I51)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I49=01,d, r)
I50.
{Do you/Does NAME} need the help of another person in order to get into and out of bed or a chair?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I51.
{Do you/Does NAME} have difficulty dressing or bathing? (ACS)
YES ............................................................................................ 01
NO .............................................................................................. 00 (I53)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I51=01,d, r)
I52.
{Do you/Does NAME} need the help of another person in order to bathe or dress?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I53.
{Do you/Does NAME} have any difficulty shopping for personal items, such as toilet items or medicine?
YES ............................................................................................ 01
NO .............................................................................................. 00 (I55)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I53=01,d, r)
I54.
{Do you/Does NAME} need the help of another person in order to shop for personal items?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I55.
{Do you/Does NAME} have any difficulty preparing {your/his/her} own meals?
PROBE: IF {NAME} DOES NOT PREPARE MEALS: If you do not prepare meals, is this because you have
difficulty with this task?
INTERVIEWER: IF RESPONDENT SAYS NO, CODE AS NO.
I-9
NBS ROUND 4 INSTRUMENT
SECTION I UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: NONE
PRELOADED INFORMATION: THIS MONTH, LAST YEAR
YES ............................................................................................ 01
NO .............................................................................................. 00 (I57)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I55=01,d, r)
I56.
{Do you/Does NAME} need the help of another person in order to prepare {your/his/her} meals?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I57.
{Do you/Does NAME} have any difficulty eating?
PROBE: This includes difficulty chewing, swallowing, or using utensils.
YES ............................................................................................ 01
NO .............................................................................................. 00 (I59)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I57=01,d, r)
I58.
{Do you/Does NAME} need the help of another person in order to eat?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I59.
Because of a physical, mental, or emotional condition, {do you/does NAME} have serious difficulty
concentrating, remembering, or making decisions? (ACS)
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I60.
{Do you/Does NAME} have a lot of trouble coping with day-to-day stresses?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
I61.
{Do you/Does NAME} have a lot of trouble getting along with other people and making or keeping
friendships?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
ALCOHOL ABUSE
(All)
I62.
I-10
These next questions are about {your/NAME’s} use of alcohol. Please remember that your answers are
confidential. If {you do/NAME does} not drink alcohol at all, just say so.
NBS ROUND 4 INSTRUMENT
SECTION I UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: NONE
PRELOADED INFORMATION: THIS MONTH, LAST YEAR
In the past 12 months, have {you/ friends or family} ever felt {you/NAME} ought to cut down on {your/his/her}
drinking?
YES ............................................................................................ 01
NO .............................................................................................. 00
IF VOLUNTEERED: I DON’T DRINK ......................................... 02 (I72)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I62=01,00,d, r)
I63.
In the past 12 months, have people annoyed {you/NAME} by criticizing {your/his/her} drinking?
YES ............................................................................................ 01
NO .............................................................................................. 00
IF VOLUNTEERED: I DON’T DRINK ......................................... 02 (I72)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I62=01,00,d, r and I63=01,00,d, r)
I64.
In the past 12 months, {have you/has NAME} ever felt bad or guilty about {your/his/her} drinking?
YES ............................................................................................ 01
NO .............................................................................................. 00
IF VOLUNTEERED: I DON’T DRINK ......................................... 03 (I72)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I62=01,00,d, r and I63=01,00,d, r and I64=01,00,d, r)
I65.
In the past 12 months, {have you/has NAME} ever had a drink first thing in the morning to steady
{your/his/her} nerves, get rid of a hangover, or get the day started?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I62=01,00,d, r and I63=01,00,d, r and I64=01,00,d, r)
I66.
During the past 12 months, has {your/NAME’s} doctor or another health professional advised {you/NAME} to
stop using alcohol or recommended that {you/he/she} participate in a program to help {you/him/her} stop
using alcohol?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I62=01,00,d, r and I63=01,00,d, r and I64=01,00,d, r)
I67.
During the past 12 months, {have you/has NAME} received treatment or counseling for {your/his/her} use of
alcohol?
YES ............................................................................................ 01 (I72)
NO .............................................................................................. 00 (I72)
DON’T KNOW ............................................................................ d (I72)
REFUSED .................................................................................. r (I72)
I-11
NBS ROUND 4 INSTRUMENT
SECTION I UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: NONE
PRELOADED INFORMATION: THIS MONTH, LAST YEAR
DRUG ABUSE
(All)
I72.
The next questions are about the use of prescription and non-prescription drugs. I will be asking if {you
have/NAME has} ever used these drugs on {your/his/her} own. By ‘on {your/his/her} own’ I mean using nonprescription drugs or using prescription drugs in a non-prescribed manner, such as using larger quantities
than prescribed or for longer periods than prescribed. Examples of non-prescription drugs are marijuana or
pot, speed, crack or cocaine, LSD, or Ecstasy.
During the past 12 months, {have you/has NAME} used drugs on {your/his/her} own more than 5 times?
PROBE:
Have you used drugs to get high or used drugs without a prescription or in larger amounts than
prescribed?
YES ............................................................................................ 01
NO .............................................................................................. 00 (J1)
DON’T KNOW ............................................................................ d (J1)
REFUSED .................................................................................. r (J1)
(I72=01)
I73.
During the past 12 months, did {you/NAME} find {you/he/she} needed larger amounts of these drugs to get
an effect or that {you/he/she} could no longer get high on the amount {you/he/she} had used before?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I72=01)
I74.
During the past 12 months, did {you/NAME} have emotional or physical problems from using drugs – such
as withdrawal symptoms, inability to work, feeling crazy, paranoid, depressed or uninterested in things,
craving, or wanting to stop and being unable to?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I72=01)
I75.
During the past 12 months has {your/NAME’s} doctor or another health professional advised {you/NAME} to
stop using non-prescription drugs or recommended that {you/he/she} participate in a program to help
{you/him/her} stop using non-prescription drugs or prescription drugs in a non-prescribed manner?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(I72=01)
I76.
During the past 12 months, {have you/has NAME} received treatment or counseling for {your/his/her} use of
non-prescription drugs or of prescription drugs in a non-prescribed manner?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
I-12
NBS ROUND 4 INSTRUMENT
SECTION J UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE
PRELOADED VARIABLES: STATEMED
SECTION J: HEALTH INSURANCE
(All)
J1.
Now, I’m going to ask you about different types of health insurance coverage {you/NAME} might have.
{Are you/Is NAME} currently covered by Medicare?
PROBE: Medicare is health insurance coverage provided nationally to certain disabled people under age 65,
including Social Security Disability Insurance beneficiaries that have been receiving benefits for more than
24 months.
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
J2.
PROGRAMMER: IF STATEMED IS EQUAL TO “MEDICAID” USE FOLLOWING TEXT:
There is a program called Medicaid that pays for health care for persons in need. {Are you/Is NAME}
currently covered by Medicaid?
OTHERWISE USE:
There is a program called Medicaid that pays for health care for persons in need. In {your/NAME’S} state,
you may also hear it called {STATEMED FROM {NAME’S} CURRENT STATE}. {Are you/Is NAME} currently
covered by Medicaid?
PROBE:
Medicaid is a state medical assistance program that serves low-income people and Social
Security Income recipients with disabilities.
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
J4.
{Are you/Is NAME} currently covered by military health care, through Armed Forces retirement benefits, the
VA, or TRICARE?
PROBE:
TRICARE is a managed health care program for active duty and retired members of the
uniformed services, their families and survivors’
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
J5.
{Are you/Is NAME} currently covered by private health insurance, for example, private insurance that {you
get/(he/she) gets} through an employer, a family member, or that {you purchase/(he/she) purchases} on
{your/his/her} own including private insurance through the Affordable Care Act, sometimes called
HealthCare.gov or ObamaCare?
YES ............................................................................................ 01
NO .............................................................................................. 00 (J7)
DON’T KNOW ............................................................................ d (J7)
REFUSED .................................................................................. r (J7)
J-1
NBS ROUND 4 INSTRUMENT
SECTION J UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE
PRELOADED VARIABLES: STATEMED
(J5=01)
J6.
{Do you/Does NAME} currently receive {your/his/her} private health insurance through a present or former
employer of {yours/his/hers}, through a present or former employer of {your/his/her} spouse, partner or
parent, or some other source?
INTERVIEWER: IF THE RESPONDENT SAYS THAT THEY OR SOMEONE IN THEIR FAMILY PAYS
FOR THEIR HEALTH INSURANCE, CODE ‘PAID BY SELF/FAMILY’.
OWN EMPLOYER ......................................................................
SPOUSE’S/PARTNER’S/PARENT’S EMPLOYER .....................
PAID BY SELF/FAMILY .............................................................
OTHER SOURCE (SPECIFY)
_____________________________________ ...
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01 (J7)
02 (J7)
03 (J7)
04 (J6_Other)
d (J7)
r (J7)
(J5=01 and H6=04)
J6_Other. What is the Other Source?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
J7.
d
r
CHECK: DOES {NAME} HAVE ANY TYPE OF INSURANCE (J1=01 OR J2=01 OR J4=01 OR J5=01)?
YES ............................................................................................ 01 (J10)
NO .............................................................................................. 00
(J7=00)
J8.
It appears that {you do/NAME does} not currently have any health insurance coverage to help pay for
services from hospitals, doctors, and other health professionals. Is that correct?
YES ............................................................................................ 01 (J10)
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d (J10)
REFUSED .................................................................................. r (J10)
(J7=00 and J8=00)
J9.
What kinds of health insurance coverage {do you/does NAME} have?
PROBE: Any other kind?
INTERVIEWER: CODE ALL THAT APPLY.
MEDICAID/{STATEMED} .........................................................................
MEDICARE ..............................................................................................
CHAMPUS/CHAMP-VA, TRICARE, VA, OTHER MILITARY ...................
INDIAN HEALTH SERVICE .....................................................................
MEDI-GAP ................................................................................................
STATE PROGRAM ..................................................................................
PRIVATE INSURANCE THROUGH OWN EMPLOYER ..........................
PRIVATE INSURANCE THROUGH SPOUSE/PARTNER/PARENT........
PRIVATE INSURANCE PAID BY SELF/FAMILY .....................................
OTHER PLAN (SPECIFY) .........................................................
DON’T KNOW ..........................................................................................
REFUSED ................................................................................................
J-2
01
02
03
04
05
06
07
08
09
10
d
r
(J10)
(J10)
(J10)
(J10)
(J10)
(J10)
(J10)
(J10)
(J10)
(J10)
(J10)
NBS ROUND 4 INSTRUMENT
SECTION J UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE
PRELOADED VARIABLES: STATEMED
((J7=00 and J8=00 and J9=10)
J9_Other. What is the Other Plan?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
J10.
d
r
Now, I’d like you to think back to 2014. In 2014, {were you/was NAME} covered by any type of health
insurance?
PROBE:
Answer ‘yes’ if {you were/NAME was} covered for any part of the year.
YES ............................................................................................ 01
NO .............................................................................................. 00 (K1)
DON’T KNOW ............................................................................ d (K1)
REFUSED .................................................................................. r (K1)
(J10=01)
J11.
What kinds of health coverage did {you/NAME} have?
PROBE:
Any other kind?
INTERVIEWER: CODE ALL THAT APPLY.
MEDICAID/{STATMED} ...........................................................................
MEDICARE ..............................................................................................
CHAMPUS/CHAMP-VA, TRICARE, VA, OTHER MILITARY ...................
INDIAN HEALTH SERVICE .....................................................................
MEDI-GAP ................................................................................................
STATE PROGRAM ..................................................................................
PRIVATE INSURANCE THROUGH OWN EMPLOYER ..........................
PRIVATE INSURANCE THROUGH SPOUSE/PARTNER/PARENT........
PRIVATE INSURANCE PAID BY SELF/FAMILY .....................................
PRIVATE INSURANCE, NOT SPECIFIED WHO THROUGH ..................
OTHER PLAN (SPECIFY) .........................................................
DON’T KNOW ..........................................................................................
REFUSED ................................................................................................
01
02
03
04
05
06
07
08
09
11
10
d
r
(K1)
(K1)
(K1)
(K1)
(K1)
(K1)
(K1)
(K1)
(K1)
(K1)
(K1)
(K1)
(J10=01 and J11=10)
J11_Other. What is the other plan?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
J-3
d
r
NBS ROUND 4 INSTRUMENT
SECTION K UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: RTYPE, B22, B24, B30, B36, C4MTH, C4YR
PRELOADED INFORMATION: LAST MONTH, THIS YEAR
SECTION K: INCOME AND OTHER ASSISTANCE
(All)
K1.
The next set of questions is about income {you/NAME} received last month, that is, in [INSERT LAST
MONTH, THIS YEAR]. This includes earnings from work and benefits from different programs. When
answering these questions, please think only about {your/NAME’s} own earnings and benefits, and don’t
include earnings or benefits that other family members may have received.
PRESS 1 TO CONTINUE ........................................................... 01
(All)
K2.
CHECK 1: IS {NAME} CURRENTLY WORKING (B24=01)?
YES ............................................................................................ 01 (K2CHECK2)
NO .............................................................................................. 00 (K2CHECK3)
(K2=01)
K2CHECK2.
CHECK 2: DID {NAME} START AT LEAST ONE JOB PRIOR TO OR DURING LAST MONTH
((C4MTH < OR = LAST MONTH THIS YEAR AND C4YR = 2015) OR (C4YR < 2015))?
YES ............................................................................................ 01 (K3)
NO .............................................................................................. 00 (K2A)
PROGRAMMER: IF {NAME} IS CURRENTLY WORKING (B24=01) AND STARTED JOB AFTER LAST MONTH
THIS YEAR - (C4MTH > LAST MONTH THIS YEAR AND C4YR =2015), GO TO K2A
(K2=00 and K2CHECK2=01)
K2CHECK 3. HAS {NAME} EVER WORKED (B36=01, D, OR R) OR (B22=01, D, OR R) OR (B30=01, D, OR R)
OR IS EVER WORKED MISSING (B36=.)?
YES ............................................................................................ 01 (K2A)
NO .............................................................................................. 00 (K4)
(K2CHECK2=00 and K2CHECK3=01)
K2A.
Did {you/NAME} work last month?
YES ............................................................................................ 01 (K3)
NO .............................................................................................. 00 (K4)
(K2CHECK3=01 and K2A=01)
K3.
First thinking about the jobs {you/NAME} had last month, including all jobs {you/he/she} had, how much did
{you/he/she} earn last month, that is, in [INSERT LAST MONTH, THIS YEAR] before taxes and deductions?
INTERVIEWER:
ROUND TO NEAREST DOLLAR
$|___|___| , |___|___|___| . 00
(0 – 12,500)
(0 – 40,000)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
K-1
d
r
NBS ROUND 4 INSTRUMENT
SECTION K UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: RTYPE, B22, B24, B30, B36, C4MTH, C4YR
PRELOADED INFORMATION: LAST MONTH, THIS YEAR
(K2CHECK3=01 and K2A=01 and K3 > or = 0)
K3b.
SOFT EDIT: LAST MONTH INCOME SHOULD BE WITHIN 30% OF TOTAL CURRENT MONTHLY PAY
AS REPORTED IN SECTION C. IF K3 NE D OR R AND C_CURMNTHPAY NE D OR R, AND THE
ABSOLUTE VALUE OF (K3 - C_CurMnthPay/ K3 >.30) AND THE ABSOLUTE VALUE OF (C_CurMnthPay
- K3/ C_CurMnthPay >.30), TRIGGER EDIT, AND DISPLAY FOLLOWING TEXT: INTERVIEWER, LAST
MONTH INCOME IS AT LEAST 30% HIGHER OR LOWER THAN AMOUNT REPORTED AS TOTAL
MONTHLY PAY IN SECTION C. CHECK ENTRY. IF NECESSARY READ: I may have recorded an
incorrect answer. Earlier we calculated that {you are/NAME is} currently paid about (C_CurMnthPay) on all
jobs combined. Is this correct or should I change the amount {you/NAME} earned last month before taxes
and other deductions?
CHANGE AMOUNT PAID BEFORE TAXES AND OTHER
DEDUCTIONS .................................................................................. 01 (CHANGE K3)
SUPPRESS .............................................................................................. 03
(K2CHECK3=01 and K2A=01 and (K3 > or = 0 or d or r)
K3a.
Including all jobs {you/NAME} had, how much was left last month, that is in [INSERT LAST MONTH, THIS
YEAR], as take-home pay after taxes and other deductions?
INTERVIEWER:
ROUND TO NEAREST DOLLAR
$|___|___| , |___|___|___| . 00
(1 – 11,250)
(1 – 36,000)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(K2CHECK3=01 and K2A=01 and K3 > or = 0 and K3a > 0)
K3b1. SOFT EDIT: AMOUNT OF TAKE-HOME PAY (K3a) MUST BE LESS THAN OR EQUAL TO AMOUNT PAID
BEFORE TAXES AND OTHER DEDUCTIONS (K3). IF K3A NE D OR R AND K3 NE D OR R, AND K3A >
K3, TRIGGER EDIT AND DISPLAY FOLLOWING TEXT: INTERVIEWER, TAKE HOME PAY IS
GREATER THAN PRE-TAX PAY. CHECK ENTRY. IF NECESSARY READ: I must have recorded an
incorrect answer. You said that {you are/NAME is} paid (K3) before taxes and other deductions and that
(K3a) is left as take-home pay after taxes and other deductions. Based on what I recorded, your take home
pay is more than your pre-tax pay. Should I change the amount {you are/NAME is} paid before taxes and
other deductions or the amount {you take/NAME takes} home after taxes and other deductions?
CHANGE AMOUNT PAID BEFORE TAXES AND OTHER
DEDUCTIONS .................................................................... 01 (CHANGE K3)
CHANGE AMOUNT OF TAKE-HOME PAY ............................... 02 (CHANGE K3a)
SUPPRESS ................................................................................ 03
(K2CHECK3=01 and K2A=01 and K3> or = 0 and K3a > 0)
K3b2. SOFT EDIT: IF K3 GREATER THAN 0, K3A SHOULD BE GREATER THAN 0. IF K3 >0 AND K3A =0,
TRIGGER EDIT AND DISPLAY FOLLOWING TEXT: INTERVIEWER: AMOUNT OF TAKE HOME PAY=0,
CHECK ENTRY. IF NECESSARY READ: I may have recorded an incorrect answer. I have recorded that
you are paid (K3) before taxes and deductions but that your take home pay is 0. Should I change the
amount {you are/NAME is} paid before taxes and other deductions or the amount {you take/NAME takes}
home after taxes and other deductions?
CHANGE AMOUNT PAID BEFORE TAXES AND OTHER
DEDUCTIONS .................................................................... 01 (CHANGE K3)
CHANGE AMOUNT OF TAKE-HOME PAY ............................... 02 (CHANGE K3a)
SUPPRESS ................................................................................ 03
K-2
NBS ROUND 4 INSTRUMENT
SECTION K UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: RTYPE, B22, B24, B30, B36, C4MTH, C4YR
PRELOADED INFORMATION: LAST MONTH, THIS YEAR
(K2CHECK3=01 and K2A=01 and K3> 0 and K3a > 0)
K3b3. SOFT EDIT: DIFFERENCE IN AMOUNT OF TAKE HOME PAY AND PRE-TAX PAY IS GREATER THAN
30%. IF AMOUNT OF TAKE HOME PAY (K3A) NE D OR R, AND AMOUNT OF PRE-TAX PAY (K3) NE D
OR R, AND (K3 – K3A) / K3A > .30, TRIGGER EDIT AND DISPLAY FOLLOWING TEXT: INTERVIEWER,
DIFFERENCE IN AMOUNT OF TAKE HOME PAY AND PRE-TAX PAY IS GREATER THAN 30%. CHECK
ENTRY. IF NECESSARY READ: I may have recorded an incorrect answer. You said that {you are/NAME
is} paid (K3) before taxes and other deductions and that (K3A) is left as take-home pay after taxes and other
deductions. Is this correct or should I change the amount {you are/NAME is} paid before taxes and other
deductions or the amount {you take/NAME takes} home after taxes and other deductions
CHANGE AMOUNT PAID BEFORE TAXES AND OTHER
DEDUCTIONS .................................................................... 01 (CHANGE K3)
CHANGE AMOUNT OF TAKE-HOME PAY ............................... 02 (CHANGE K3a)
SUPPRESS ................................................................................ 03
(All)
K4.
Thinking about the benefits {you/NAME} received last month, did {you/he/she} receive any income from
Social Security?
INTERVIEWER:
SHOULD INCLUDE ANY SSI AND SSDI PAYMENTS
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
K5.
K-3
PROGRAMMER: IF {NAME} RECEIVED INCOME FROM ANY SOURCE BELOW (K6a-h=01), ASK K7
THROUGH K10 IMMEDIATELY AFTER EACH ‘YES’. OTHERWISE, ASK ABOUT NEXT SOURCE OF
INCOME IN K6.
NBS ROUND 4 INSTRUMENT
SECTION K UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: RTYPE, B22, B24, B30, B36, C4MTH, C4YR
PRELOADED INFORMATION: LAST MONTH, THIS YEAR
(All)
K6.
Last month did {you/NAME} receive any income from…
INTERVIEWER:
IF RESPONDENT MENTIONS FOOD STAMPS: I will ask you about food stamps in a
separate question. Do {you/he/she} receive any other income on a regular basis that
does not come from jobs or social security?
INTERVIEWER:
Examples include child support, interest from savings or checking accounts, or
dividends?
YES
NO
DON’T
KNOW
REFUSED
Private disability insurance (sometimes called
long-term care disability insurance)?
01
00
d
r
b.
Workers’ compensation?
01
00
d
r
c.
Veterans’ benefits?
01
00
d
r
d.
Public assistance or welfare payments?
01
00
d
r
e.
Unemployment benefits?
01
00
d
r
f.
Private pensions or government employee
pensions?
01
00
d
r
d
r
(K6_g_oth)
d
r
(K6_h_oth)
a.
g.
Other sources on a regular basis but not from
jobs or Social Security?
PROBE: IF RESPONDENT MENTIONS FOOD
STAMPS: I will ask you about food stamps in a
separate question. Do you receive any other
income on a regular basis that does not come
from jobs or Social Security?
PROBE: Examples include child support, interest
from savings or checking accounts, or dividends?
01
h.
Other sources not on a regular basis?
01
00
00
(K6_g=01)
K6_g_oth What were they?
INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(K6_h=01)
K6_h_oth What were they?
INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
K-4
d
r
NBS ROUND 4 INSTRUMENT
SECTION K UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: RTYPE, B22, B24, B30, B36, C4MTH, C4YR
PRELOADED INFORMATION: LAST MONTH, THIS YEAR
(K6=01)
K7.
How much income did {you/NAME} receive last month from {SOURCE FROM K6}?
INTERVIEWER:
ROUND TO NEAREST DOLLAR
$|___|___| , |___|___|___| . 00
(1 – 1,000)
(1 – 15,000)
(GO TO K6 FOR NEXT SOURCE OR K11)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(K6=01 and K7=d, r)
K8.
Was it more than or less than $300?
$300 OR MORE ......................................................................... 01 (K9)
LESS THAN $300 ...................................................................... 02 (K10)
DON’T KNOW ............................................................................ d (K6 FOR NEXT SOURCE
OR K11)
REFUSED .................................................................................. r (K6 FOR NEXT SOURCE
OR K11)
(K6=01 and K7=d, r and K8=01)
K9.
Was it more than or less than $500?
$500 OR MORE ......................................................................... 01
LESS THAN $500....................................................................... 02
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
GO TO K6 FOR NEXT SOURCE OR K11.
(K6=01 and K7=d, r and K8=02)
K10.
Was it more than or less than $150?
$150 OR MORE ......................................................................... 01
LESS THAN $150....................................................................... 02
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
GO TO K6 FOR NEXT SOURCE OR K11.
(All)
K11.
Did {you/NAME} receive any food stamps last month? You may know this as SNAP benefits. Please include
only food stamps {you/NAME} received for {you/NAME} and {your/NAME’s} family. Do not include food
stamps received separately by other members of [your/NAME’s} household.
YES ............................................................................................ 01
NO .............................................................................................. 00 (K13)
DON’T KNOW ............................................................................ d (K13)
REFUSED .................................................................................. r (K13)
K-5
NBS ROUND 4 INSTRUMENT
SECTION K UNIVERSE: ALL
VARIABLES FROM OTHER SECTIONS: RTYPE, B22, B24, B30, B36, C4MTH, C4YR
PRELOADED INFORMATION: LAST MONTH, THIS YEAR
(K11=01)
K12.
What was the dollar value of the food stamps {you/NAME} received last month? Please include only food
stamps {you/NAME} received by {you/NAME} for {your/NAME’s} family.
INTERVIEWER:
ROUND TO NEAREST DOLLAR
$|___| , |___|___|___| . 00
(0 – 400)
(0 – 950)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
K13.
d
r
Did {you/NAME} receive assistance from any other government program last month? For example, housing
or energy assistance.
YES ............................................................................................ 01
NO .............................................................................................. 00 (L1)
DON’T KNOW ............................................................................ d (L1)
REFUSED .................................................................................. r (L1)
(K13=01)
K14.
What other assistance did {you/NAME} receive?
INTERVIEWER:
PROGRAM:
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(K13=01)
K15.
How much income did {you/NAME} receive last month from the assistance you just told me about?
PROBE: Your best estimate is fine.
INTERVIEWER:
ROUND TO NEAREST DOLLAR
$|___|___| , |___|___|___| . 00
(0 – 500)
(0 – 10,000)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
K-6
d
r
NBS ROUND 4 INSTRUMENT
SECTION L UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE
PRELOADED VARIABLES: NONE
SECTION L: SOCIODEMOGRAPHIC INFORMATION
(All)
L1.
I have a few more questions about {you/NAME}.
What is {your/NAME’s} ethnic background? {Are you/Is (he/she)}:
Hispanic or Latino, or.................................................................. 01
Not Hispanic or Latino? .............................................................. 02
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
L2.
What is {your/NAME’s} race? {Are you/Is (he/she)}:
INTERVIEWER:
CODE ALL THAT APPLY.
Alaska Native or American Indian,..............................................
Asian, .........................................................................................
Black or African American, .........................................................
Native Hawaiian or Other Pacific Islander, or .............................
White ..........................................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
L3.
01
02
03
04
05
d
r
What is the highest year or grade {you/NAME} finished in school?
INTERVIEWER:
READ LIST IF NECESSARY. CODE ONE ANSWER.
INTERVIEWER:
IF ATTENDED SCHOOL BUT COMPLETED LESS THAN HIGH SCHOOL, CODE AS 1.
IF NEVER ATTENDED SCHOOL,CODE AS 10.
INTERVIEWER:
IF RESPONDENT SAYS THEY WERE HOME SCHOOLED, PROBE FOR HIGHEST
YEAR, GRADE, DEGREE, OR CERTIFICATE COMPLETED.
DID NOT COMPLETE HIGH SCHOOL OR GED .......................................................
HIGH SCHOOL: GED .................................................................................................
HIGH SCHOOL: DIPLOMA ........................................................................................
HIGH SCHOOL: CERTIFICATE OF COMPLETION ..................................................
SOME COLLEGE/SOME POSTSECONDARY VOCATIONAL COURSES ...............
2-YEAR OR 3-YEAR COLLEGE DEGREE (ASSOCIATE’S DEGREE) OR
VOCATIONAL SCHOOL DIPLOMA ....................................................................
4-YEAR COLLEGE DEGREE (BACHELOR’S DEGREE) ..........................................
SOME GRADUATE WORK/NO GRADUATE DEGREE .............................................
GRADUATE OR PROFESSIONAL DEGREE (e.g., MA, MBA, Ph.D., J.D., M.D.) .....
NEVER ATTENDED SCHOOL ...................................................................................
SPECIAL EDUCATION WITH NO CERTIFICATE OF COMPLETION .......................
DON’T KNOW ............................................................................................................
REFUSED ..................................................................................................................
L-1
01
02
03
04
05
06
07
08
09
10
11
d
r
NBS ROUND 4 INSTRUMENT
SECTION L UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE
PRELOADED VARIABLES: NONE
(All)
L4.
What is the highest year or grade {your/NAME’s} father finished in school?
INTERVIEWER:
READ LIST IF NECESSARY. CODE ONE ANSWER.
INTERVIEWER:
IF ATTENDED SCHOOL BUT COMPLETED LESS THAN HIGH SCHOOL, CODE AS 1.
IF NEVER ATTENDED SCHOOL, CODE AS 10.
INTERVIEWER:
IF RESPONDENT SAYS THEY WERE HOME SCHOOLED, PROBE FOR HIGHEST
YEAR, GRADE, DEGREE, OR CERTIFICATE COMPLETED.
DID NOT COMPLETE HIGH SCHOOL OR GED .......................................................
HIGH SCHOOL: GED .................................................................................................
HIGH SCHOOL: DIPLOMA ........................................................................................
HIGH SCHOOL: CERTIFICATE OF COMPLETION ..................................................
SOME COLLEGE/SOME POSTSECONDARY VOCATIONAL COURSES ...............
2-YEAR OR 3-YEAR COLLEGE DEGREE (ASSOCIATE’S DEGREE) OR
VOCATIONAL SCHOOL DIPLOMA ....................................................................
4-YEAR COLLEGE DEGREE (BACHELOR’S DEGREE) ..........................................
SOME GRADUATE WORK/NO GRADUATE DEGREE .............................................
GRADUATE OR PROFESSIONAL DEGREE (e.g., MA, MBA, Ph.D., J.D., M.D.) .....
NEVER ATTENDED SCHOOL ...................................................................................
SPECIAL EDUCATION WITH NO CERTIFICATE OF COMPLETION .......................
DON’T KNOW ............................................................................................................
REFUSED ..................................................................................................................
(All)
L5.
06
07
08
09
10
11
d
r
What is the highest year or grade {your/NAME’s} mother finished in school?
INTERVIEWER:
READ LIST IF NECESSARY. CODE ONE ANSWER.
INTERVIEWER:
IF ATTENDED SCHOOL BUT COMPLETED LESS THAN HIGH SCHOOL, CODE AS 1.
IF NEVER ATTENDED SCHOOL, CODE AS 10.
INTERVIEWER:
IF RESPONDENT SAYS THEY WERE HOME SCHOOLED, PROBE FOR HIGHEST
YEAR, GRADE, DEGREE, OR CERTIFICATE COMPLETED.
DID NOT COMPLETE HIGH SCHOOL OR GED .......................................................
HIGH SCHOOL: GED .................................................................................................
HIGH SCHOOL: DIPLOMA ........................................................................................
HIGH SCHOOL: CERTIFICATE OF COMPLETION ..................................................
SOME COLLEGE/SOME POSTSECONDARY VOCATIONAL COURSES ...............
2-YEAR OR 3-YEAR COLLEGE DEGREE (ASSOCIATE’S DEGREE) OR
VOCATIONAL SCHOOL DIPLOMA ....................................................................
4-YEAR COLLEGE DEGREE (BACHELOR’S DEGREE) ..........................................
SOME GRADUATE WORK/NO GRADUATE DEGREE .............................................
GRADUATE OR PROFESSIONAL DEGREE (e.g., MA, MBA, Ph.D., J.D., M.D.) .....
NEVER ATTENDED SCHOOL ...................................................................................
SPECIAL EDUCATION WITH NO CERTIFICATE OF COMPLETION .......................
DON’T KNOW ............................................................................................................
REFUSED ..................................................................................................................
(All)
L6ft.
01
02
03
04
05
01
02
03
04
05
06
07
08
09
10
11
d
r
How tall {are you/is NAME}?
INTERVIEWER:
ENTER FEET
|__| FEET
(3-8)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
L-2
d
r
NBS ROUND 4 INSTRUMENT
SECTION L UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE
PRELOADED VARIABLES: NONE
(All)
L6in.
(How tall {are you/is NAME}?)
PROBE: ROUND TO NEAREST WHOLE NUMBER (E.G., ENTER 6 FOR 5 ½ INCHES)
INTERVIEWER:
ENTER INCHES.
|__|__| INCHES
(0-12)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
L7.
d
r
How much {do you/does NAME} weigh?
|__|__|__| POUNDS (50-300)
(50-600)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
L8.
d
r
{Are you/Is NAME} now married, widowed, divorced, separated or {have you/has (he/she)} never been
married?
MARRIED ...................................................................................
WIDOWED .................................................................................
DIVORCED.................................................................................
SEPARATED ..............................................................................
NEVER MARRIED ......................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
05
d
r
(L10)
(L10)
(L10)
(L10)
(L10)
(L10)
(L8=01)
L9.
Do {you/NAME} and {your/his/her} spouse live in the same household?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
GO TO L11
(L8=02,03,04,05,d,r)
L10.
{Do you/Does NAME} have a long-term partner who lives in the same household with {you/him/her} in a
marriage-like relationship?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
L-3
NBS ROUND 4 INSTRUMENT
SECTION L UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE
PRELOADED VARIABLES: NONE
(All)
L11.
Which of the following best describes {your/NAME’s} living situation?
INTERVIEWER:
READ LIST. CODE ONE ANSWER. ‘LIVE WITH CHILDREN’ SHOULD BE CODED
AS ‘2’
PROGRAMMER DISPLAY ONLY IF L9≠01 {You live/NAME lives} alone. .................
{You live/NAME lives} with {your/his/her} parents, guardians, a spouse/partner,
or other relative ...................................................................................................
{You live/NAME lives} with friends or roommates .......................................................
{You live/NAME lives} in another group setting with people not related to
{you/him/her} .......................................................................................................
{You live/NAME lives} in some other living situation ...................................................
DON’T KNOW ............................................................................................................
REFUSED ..................................................................................................................
01 (L11a)
02 (L11a)
03 (L11a)
04 (L11a)
05
d (L11a)
r (L11a)
(L11=05)
L11_Other. What is the other living situation?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
L11a.
d
r
SOFT EDIT: RESPONDENT CANNOT LIVE IN SAME HOUSEHOLD WITH SPOUSE (L9=01) OR LIVE IN
SAME HOUSEHOLD WITH LONG-TERM PARTNER (L10=01) AND LIVE ALONE (L11=01).
IF
RESPONDENT FAILS EDIT, INTERVIEWER READ: I must have recorded an incorrect answer. I show that
{you live/NAME lives} in the same household with {your/his/her} spouse or partner and {you live/NAME lives}
alone? Could you verify which is correct?
LIVE WITH SPOUSE OR PARTNER ......................................... 01 (CHANGE L9 OR L10)
LIVE ALONE............................................................................... 02 (CHANGE L11)
SUPPRESS ................................................................................ 03
(All)
L12.
The next question is about the place {you live/NAME lives}. Is this place a…
INTERVIEWER:
CODE ONE ANSWER.
INTERVIEWER:
IF RESPONDENT SAYS TOWNHOUSE OR CONDO, CODE AS 1.
Single family home .....................................................................
Mobile home ...............................................................................
Regular apartment ......................................................................
Supervised apartment ................................................................
Group home................................................................................
Halfway house ............................................................................
Personal care or board and care home ......................................
Assisted living facility ..................................................................
Nursing or convalescent home ...................................................
Center for Independent Living ....................................................
Some other type of supervised group residence or facility .........
Something else ...........................................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
L-4
01
02
03
04
05
06
07
08
09
10
11
12
d
r
(L12a)
(L12a)
(L12a)
(L12a)
(L12a)
(L12a)
(L12a)
(L12a)
(L12a)
(L12a)
(L12a)
(L12a)
(L12a)
NBS ROUND 4 INSTRUMENT
SECTION L UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE
PRELOADED VARIABLES: NONE
(L12=12)
L12_Other. What is the other type of place?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
L12a.
d
r
SOFT EDIT: RESPONDENT CANNOT LIVE ALONE (L11=01) AND LIVE IN A GROUP SETTING
(L12=04-11). IF RESPONDENT FAILS EDIT, INTERVIEWER READ: I must have recorded an incorrect
answer. I show that {you/NAME} live alone in a {FILL ANSWER FROM L12}? Which is correct?
LIVE ALONE............................................................................... 01 (CHANGE L12)
LIVE IN GROUP SETTING......................................................... 02 (CHANGE L11)
SUPPRESS ................................................................................ 03
(All)
L13.
CHECK: DOES {NAME} LIVE IN A GROUP SETTING (L12 = 04 – 12)?
YES ............................................................................................ 01
NO .............................................................................................. 00 (L14)
(L13=01)
L15.
Is this place primarily for people with hearing or vision impairments, mental illness, intellectual disabilities, or
developmental disabilities?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(All)
L14.
CHECK: DOES {NAME} LIVE ALONE (L11 = 01) OR LIVE IN GROUP SETTING (L12=4-12)?
YES ............................................................................................ 01 (L20)
NO .............................................................................................. 00
(L14=00)
L16.
How many adults 18 years of age or older live in {your/NAME’s} household, including {yourself/NAME}?
PROBE: This includes all adults who usually live there, even if they are temporarily away on business,
vacation, in a hospital, away at school or on military duty.
|__|__| ADULTS
(1-4)
(1-20)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(L14=00)
L17.
How many children under 18 years of age live in {your/NAME’s} household?
PROBE: This includes all children who usually live there, even if they are temporarily away on vacation, in a
hospital, or away at school.
|__|__| CHILDREN
(0-6)
(0-20)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
L-5
d
r
NBS ROUND 4 INSTRUMENT
SECTION L UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE
PRELOADED VARIABLES: NONE
(L14=00)
L18.
CHECK: DO NO CHILDREN LIVE IN THE HOUSEHOLD (L17=0)?
YES ............................................................................................ 01 (L20)
NO .............................................................................................. 00
(L14=00 and L18=00)
L19.
How many of these children are {your/NAME’s} own? Please include biological, adopted, step, and foster
children.
|__|__| CHILDREN
(0-6)
(0-20)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(All)
L20.
{Do you/Does NAME} have children of {your/his/her} own under the age of 18 living outside of {your/his/her}
household?
PROBE: Please include biological, adopted, step, and foster children.
YES ............................................................................................ 01
NO .............................................................................................. 00 (L22a)
DON’T KNOW ............................................................................ d (L22a)
REFUSED .................................................................................. r (L22a)
(L20=01)
L21.
How many children under 18 not living in {your/NAME’s} household {do you/does (he/she)} have?
|__|__| CHILDREN
(1-6)
(1-20)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
L22a.
d
r
CHECK: DOES {NAME} HAVE ANY CHILDREN (L17>=1 AND L19>=1) OR (L21>=1)?
YES ............................................................................................ 01
NO .............................................................................................. 00 (L23Aamt)
(L22a=01)
L22.
Are any of {your/NAME’s} children, either living with {you/him/her} or not, under the age of six?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
L-6
NBS ROUND 4 INSTRUMENT
SECTION L UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE
PRELOADED VARIABLES: NONE
(All)
L23Aamt. PROGRAMMER: IF L11=01, 03, or 04, ASK:
What was {your/NAME’s} total income in 2014, before taxes or other deductions? Please include money
{you/NAME} received from all sources.
PROGRAMMER: IF L11=02, or 05, d, r, ASK:
What was the total combined income of all members of {your/NAME’s} household in 2014, before taxes or
other deductions? Please include money all members of {your/NAME’s} household received from all
sources.
PROBE: IF RESPONDENT CANNOT PROVIDE AN ANNUAL AMOUNT: If it is hard to calculate an
annual amount can you tell me what your income was per day, week, bi-weekly, twice a month
or monthly in 2014.
INTERVIEWER: ROUND TO NEAREST DOLLAR
$|___|___|___| , |___|___|___| . 00 AMOUNT
(10,000-75,000)
(0-500,000)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d (L24)
r (L24)
(L23Aamt = numeric response)
L23Ahop. PROBE: PROGRAMMER: IF L11=01, 03, or 04, DISPLAY:
What was {your/NAME’s} total income in 2014, before taxes or other deductions? Please include money
{you/NAME} received from all sources.
PROBE: PROGRAMMER: IF L11=02, or 05, d, r, DISPLAY:
What was the total combined income of all members of {your/NAME’s} household in 2014, before taxes or
other deductions? Please include money all members of {your/NAME’s} household received from all
sources.
PROBE: IF RESPONDENT CANNOT PROVIDE AN ANNUAL AMOUNT: If it is hard to calculate an
annual amount can you tell me what your household income was per day, week, bi-weekly,
twice a month or monthly in 2014.
PROBE: Is that daily, weekly, bi-weekly, twice a month, or annually?
INTERVIEWER: ENTER HOW OFTEN PAID
ANNUALLY.................................................................................
MONTHLY ..................................................................................
TWICE A MONTH ......................................................................
WEEKLY ....................................................................................
BI-WEEKLY ................................................................................
DAILY .........................................................................................
OTHER .......................................................................................
01
02
03
04
05
06
07
(L25)
(L23b)
(L23b)
(L23b)
(L23b)
(L23b)
(L23Aamt = numeric response and L23Ahop =07)
L23Ahop_Other.
INTERVIEWER: ENTER OTHER
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
GO TO L24
L-7
NBS ROUND 4 INSTRUMENT
SECTION L UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE
PRELOADED VARIABLES: NONE
(L23Aamt = numeric response and L23Ahop = 02, 03, 04, 05, 06)
L23b. PROGRAMMER: USE “{YOUR/NAME’S} HOUSEHOLD” IF L11=02 OR 05, OTHERWISE USE
“{YOUR/NAME}”
How many {days/weeks/months} did {{you/NAME}/{your household/NAME’s household}} receive this income
in 2014?
|__|__|__| DAYS/WEEKS/MONTHS
(1-365) (1-52) (1/12)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
GO TO L25
(L23Aamt =d, r or L23Ahop=07)
L24.
PROGRAMMER: USE “HOUSEHOLD” IF L11=02 OR 05
Could you please tell me if {your/NAME’S} annual (household) income before taxes and other deductions in
2014 was...
$2,500 or less, ............................................................................ 01
$2, 501 to $5,000,....................................................................... 02
$5,001 to $10,000,...................................................................... 03
$10,001 to $20,000,.................................................................... 04
$20,001 to $30,000,.................................................................... 05
$30,001 to $40,000,.................................................................... 06
$40,001 to $50,000,.................................................................... 07
$50,001 to $75,000,.................................................................... 08
$75,001 to $100,000, or ............................................................. 09
More than $100,000? ................................................................. 10
DON’T KNOW ............................................................................ d
REFUSED ..................................................................................
L25.
L26.
r
DELETED
DELETED
GO TO M1
L-8
NBS ROUND 4 INSTRUMENT
SECTION M UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, {NAME’S} ADDRESS FROM SECTION A
PRELOADED VARIABLES: EXPTYPE, TSTATUS
SECTION M: CLOSING INFORMATION AND OBSERVATIONS
(All)
M1.
PROGRAMMER:
IF WE HAVE NAME, ADDRESS, AND PHONE NUMBER FROM EITHER THE
SCREENER OR FROM THE OTHER PRELOADED INFORMATION DISPLAY THAT
NAME, ADDRESS, AND PHONE NUMBER.
That concludes this interview. Can you please verify (your/NAME’S) current contact information?
NAME: {FULL NAME FROM SCREENER OR PRELOADED INFORMATION}
STREET ADDRESS 1: {FIRST LINE OF ADDRESS FROM SCREENER OR
INFORMATION}
STREET ADDRESS 2: {SECOND LINE OF ADDRESS FROM SCREENER OR
INFORMATION}
PRELOADED
PRELOADED
STREET ADDRESS 3: {THIRD LINE OF ADDRESS FROM SCREENER OR PRELOADED
INFORMATION}
CITY OR TOWN: {CITY OR TOWN FROM SCREENER OR PRELOADED INFORMATION}
STATE: {STATE FROM SCREENER OR PRELOADED INFORMATION}
ZIP CODE: {ZIP CODE FROM SCREENER OR PRELOADED INFORMATION}
TELEPHONE NUMBER: {TELEPHONE NUMBER FROM SCREENER OR PRELOADED INFORMATION}
SAME AS PROVIDED................................................................ 00 (M1a)
INCORRECT INFORMATION ABOVE, NEED TO ENTER
NEW INFORMATION ......................................................... 01 (M1_Firstname)
DON’T KNOW ............................................................................ d (M1a)
REFUSED .................................................................................. r (M1a)
M1 {PROVIDE BOX FOR DATA ENTRY. 1, 0, d, r ARE THE ONLY POSSIBLE RESPONSES; IF M1=01,
THEN GO TO QUESTIONS BELOW, OTHERWISE SKIP TO M1a}
(M1=01)
M1_FirstName.
NAME: {DISPLAY FULL NAME FROM SCREENER OR PRELOADED INFORMATION WITH FIRST NAME
BOLDED}
First name?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M1=01)
M1_MiddleName.
NAME: {DISPLAY FULL NAME FROM SCREENER OR PRELOADED INFORMATION WITH MIDDLE
INITIAL BOLDED}
Middle initial?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
M-1
d
r
NBS ROUND 4 INSTRUMENT
SECTION M UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, {NAME’S} ADDRESS FROM SECTION A
PRELOADED VARIABLES: EXPTYPE, TSTATUS
(M1=01)
M1_LastName.
NAME: {DISPLAY FULL NAME FROM SCREENER OR PRELOADED INFORMATION WITH LAST NAME
BOLDED}
Last name?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M1=01)
M1_Confirm.
NAME: {DISPLAY FULL NAME}
INTERVIEWER: PRESS 1 TO CONTINUE
(M1=01)
M1_Address1.
ADDRESS: {DISPLAY ENTIRE ADDRESS FROM SCREENER OR PRELOADED INFORMATION WITH
LINE 1 BOLD}
Street and number?
INTERVIEWER:
REFUSED AND DON’T KNOW ALLOWED, WILL SKIP REST OF ADDRESS
QUESTIONS.
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M1=01)
M1_Address2.
ADDRESS: {DISPLAY ENTIRE ADDRESS FROM SCREENER OR PRELOADED INFORMATION WITH
LINE 2 BOLD}
PROBE: READ IF NECESSARY: Second part of the address.
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M1=01)
M1_Address3.
ADDRESS: {DISPLAY ENTIRE ADDRESS FROM SCREENER OR PRELOADED INFORMATION WITH
LINE 3 BOLD}
PROBE: READ IF NECESSARY: Third part of the address.
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M1=01)
M1_City.
ADDRESS: {DISPLAY ENTIRE ADDRESS FROM SCREENER OR PRELOADED INFORMATION WITH
CITY BOLD}
Town or city?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M1=01)
M-2
NBS ROUND 4 INSTRUMENT
SECTION M UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, {NAME’S} ADDRESS FROM SECTION A
PRELOADED VARIABLES: EXPTYPE, TSTATUS
M1_State.
ADDRESS: {DISPLAY ENTIRE ADDRESS FROM SCREENER OR PRELOADED INFORMATION WITH
STATE BOLD}
State?
INTERVIEWER:
USE TWO CHARACTER ABBREVIATION.
INTERVIEWER:
ENTER ZZ TO ENTER INTERNATIONAL CITY AND COUNTRY BELOW.
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M1=01)
M1_ZipCode.
ADDRESS: {DISPLAY ENTIRE ADDRESS FROM SCREENER OR PRELOADED INFORMATION WITH
ZIP CODE BOLD}
Zip code?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M1=01)
M1_Confirm.
ADDRESS: {DISPLAY FULL ADDRESS}
INTERVIEWER:
PRESS 1 TO CONTINUE
(M1=01)
M1_PhoneNumber.
TELEPHONE: {TELEPHONE NUMBER FROM SCREENER OR PRELOADED INFORMATION}
Please give me the telephone number, area code first?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
PROGRAMMER: ASK M1_TIMEZONE IF TIME ZONE IS NOT CURRENTLY ENTERED
(M1=01)
M1_TimeZone.
What time zone is that in?
INTERVIEWER:
CURRENT TIME ZONE: {DISPLAY TIME ZONE BASED ON}
HAWAII/ALEUTIAN TIME ZONE ................................................
ALASKA TIME ZONE .................................................................
PACIFIC TIME ZONE .................................................................
MOUNTAIN TIME ZONE ............................................................
CENTRAL TIME ZONE ..............................................................
EASTERN TIME ZONE ..............................................................
ATLANTIC TIME ZONE ..............................................................
NEWFOUNDLAND TIME ZONE ................................................
OTHER INTERNATIONAL TIME ZONE .....................................
M-3
02
03
04
05
06
07
08
09
98
NBS ROUND 4 INSTRUMENT
SECTION M UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, {NAME’S} ADDRESS FROM SECTION A
PRELOADED VARIABLES: EXPTYPE, TSTATUS
(M1=01)
M1_Confirm.
TELEPHONE NUMBER: {TELEPHONE NUMBER FROM SCREENER OR PRELOADED INFORMATION}
TIME ZONE: {TIME ZONE FROM SCREENER OR PRELOADED INFORMATION}
INTERVIEWER:
(All)
M1a.
PRESS 1 TO CONTINUE
{Do you have/Does NAME have} an email address?
YES ............................................................................................ 01
NO .............................................................................................. 00 (M2A)
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
(M1a=01)
M2_.
What is {your/NAME’s} email address?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
M2A.
d
r
CHECK: IS INTERVIEWER SPEAKING WITH {NAME} OR A PROXY?
{NAME} ....................................................................................... 01 (M2CHECK)
PROXY ....................................................................................... 02
(M2A=02)
Confirm. What is your first name?
INTERVIEWER:
PRESS 1 TO CONTINUE
(M2A=02)
M2a_FirstName.
NAME: {DISPLAY PROXY’S FULL NAME FROM SCREENER OR PRELOADED INFORMATION WITH
FIRST NAME BOLD}
First name?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2A=02)
M2a_MiddleName.
NAME: {DISPLAY PROXY’S FULL NAME FROM SCREENER OR PRELOADED INFORMATION WITH
MIDDLE INITIAL BOLD}
Middle initial?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
M-4
d
r
NBS ROUND 4 INSTRUMENT
SECTION M UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, {NAME’S} ADDRESS FROM SECTION A
PRELOADED VARIABLES: EXPTYPE, TSTATUS
(M2A=02)
M2a_LastName.
NAME: {DISPLAY PROXY’S FULL NAME FROM SCREENER OR PRELOADED INFORMATION WITH
LAST NAME BOLD}
Last name?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2A=02)
Confirm. NAME: {DISPLAY PROXY’S FULL NAME}
INTERVIEWER:
PRESS 1 TO CONTINUE
(M2A=02)
M2a_Address1.
ADDRESS:
Street and number?
INTERVIEWER:
REFUSED OR DON’T KNOW ALLOWED. WILL SKIP REST OF ADDRESS
QUESTIONS.
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2A=02)
M2a_Address2.
ADDRESS: {DISPLAY ADDRESS1 FROM PREVIOUS QUESTION}
PROBE: READ IF NECESSARY: Second part of the address.
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2A=02)
M2a_Address3.
ADDRESS: {DISPLAY ADDRESS1 AND ADDRESS2 FROM PREVIOUS QUESTIONS}
PROBE: READ IF NECESSARY: Third part of the address.
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2A=02)
M2a_Address4.
ADDRESS: {DISPLAY ADDRESS1, ADDRESS2, AND ADDRESS3 FROM PREVIOUS QUESTIONS}
PROBE: READ IF NECESSARY: Fourth part of the address.
DON’T KNOW ............................................................................
REFUSED ..................................................................................
M-5
d
r
NBS ROUND 4 INSTRUMENT
SECTION M UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, {NAME’S} ADDRESS FROM SECTION A
PRELOADED VARIABLES: EXPTYPE, TSTATUS
(M2A=02)
M2a_City.
ADDRESS: {DISPLAY ADDRESS1, ADDRESS2, ADDRESS3, AND ADDRESS4 FROM PREVIOUS
QUESTIONS}
Town or City?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2A=02)
M2a_State.
ADDRESS: {DISPLAY ADDRESS1, ADDRESS2, ADDRESS3, ADDRESS4, AND TOWN/CITY FROM
PREVIOUS QUESTIONS}
State?
INTERVIEWER:
USE TWO CHARACTER ABBREVIATION.
INTERVIEWER:
ENTER ZZ TO ENTER INTERNATIONAL CITY AND COUNTRY BELOW.
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2A=02)
M2a_ZipCode.
ADDRESS: {DISPLAY ADDRESS1, ADDRESS2, ADDRESS3, ADDRESS4, TOWN/CITY, AND STATE
FROM PREVIOUS QUESTIONS}
Zip code?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2A=02)
Confirm.
NAME: {DISPLAY PROXY’S FULL ADDRESS}
INTERVIEWER:
PRESS 1 TO CONTINUE
(M2A=02)
M2a_PhoneNumber.
TELEPHONE NUMBER:
Please give me the telephone number, area code first?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
PROGRAMMER: ASK M2A_TIMEZONE IF TIME ZONE IS NOT CURRENTLY ENTERED
M-6
NBS ROUND 4 INSTRUMENT
SECTION M UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, {NAME’S} ADDRESS FROM SECTION A
PRELOADED VARIABLES: EXPTYPE, TSTATUS
(M2A=02)
M2A_TimeZone.
What time zone is that in?
INTERVIEWER:
CURRENT TIME ZONE: {DISPLAY TIME ZONE BASED ON}
HAWAII/ALEUTIAN TIME ZONE ................................................
ALASKA TIME ZONE .................................................................
PACIFIC TIME ZONE .................................................................
MOUNTAIN TIME ZONE ............................................................
CENTRAL TIME ZONE ..............................................................
EASTERN TIME ZONE ..............................................................
ATLANTIC TIME ZONE ..............................................................
NEWFOUNDLAND TIME ZONE ................................................
OTHER INTERNATIONAL TIME ZONE .....................................
02
03
04
05
06
07
08
09
98
(M2A=02)
M2A_Confirm.
TELEPHONE NUMBER: {PROXY’S TELEPHONE NUMBER}
TIME ZONE: {PROXY’S TIME ZONE}
INTERVIEWER:
PRESS 1 TO CONTINUE
(M2A=02)
M2a_Rlshp. How are you related to {NAME}?
{NAME’S} SPOUSE ....................................................................
{NAME’S} MOTHER ...................................................................
{NAME’S} FATHER ....................................................................
{NAME’S} CHILD ........................................................................
GRANDPARENT OF {NAME} ....................................................
BROTHER/SISTER (NATURAL/STEP) OF {NAME} ..................
AUNT/UNCLE OF {NAME} .........................................................
FRIEND ......................................................................................
CASEWORKER/CAREGIVER/PAYEE .......................................
GIRLFRIEND/BOYFRIEND/PARTNER ......................................
GUARDIAN/FOSTER/STEP PARENT .......................................
IN-LAW .......................................................................................
OTHER RELATIVE OF {NAME} .................................................
NOT RELATED ..........................................................................
STAFF AT RESIDENCE .............................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
05
06
07
11
12
13
14
15
08
09
10
d
r
(M2a_email)
(M2a_email)
(M2a_email)
(M2a_email)
(M2a_email)
(M2a_email)
(M2a_email)
(M2a_email)
(M2a_email)
(M2a_email)
(M2a_email)
(M2a_email)
(M2a_Rlshp_oth2)
(M2a_email)
(M2a_email)
(M2a_email)
(M2A=02 and M2a_Rlshp=08)
M2a_oth1. INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2A=02 and M2a_Rlshp=09)
M2a_oth2. INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
M-7
d
r
NBS ROUND 4 INSTRUMENT
SECTION M UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, {NAME’S} ADDRESS FROM SECTION A
PRELOADED VARIABLES: EXPTYPE, TSTATUS
(M2A=02)
M2a_email. Do you have an email address?
YES ............................................................................................ 01
NO .............................................................................................. 00 (M2CHECK)
DON’T KNOW ............................................................................ d (M2CHECK)
REFUSED .................................................................................. r (M2CHECK)
(M2A=02 and M2a_email=01)
M2b.
What is your email address?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(All)
M2CHECK. PROGRAMMER: ONLY ASK M2_PREPAY IF PREPAY = 1. ELSE GO TO M3.
IS {NAME} PART OF THE PREPAY GROUP(PREPAY =1)?
YES ............................................................................................ 01
NO .............................................................................................. 00 (M3)
(M2CHECK=01)
M2_PrePay. Did {you/NAME} receive a gift card for $5.00 in the mail that {you/NAME} can cash?
YES ............................................................................................ 01 (M6)
NO, COLLECT ADDRESS AND SEND ANOTHER CHECK ...... 00 (M3)
DON’T KNOW ............................................................................ d (M3)
REFUSED .................................................................................. r (M3)
PROGRAMMER: IF CAPI CASE, THEN DISPLAY TEXT BELOW INSTEAD:
INTERVIEWER: ARE YOU GIVING THE CHECK TO THE RESPONDENT?
YES ............................................................................................ 01 (M6)
NO, COLLECT ADDRESS AND SEND ANOTHER CHECK ...... 00 (M3)
(M2CHECK=01,00 or M2_PrePay=00,d,r)
M3.
Would you like the check made out to {you/NAME} or someone else?
{YOU/NAME} .............................................................................. 01 (M6)
MAKE CHECK OUT TO SOMEONE ELSE ................................ 02
DON’T KNOW ............................................................................ d
REFUSED .................................................................................. r
M-8
NBS ROUND 4 INSTRUMENT
SECTION M UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, {NAME’S} ADDRESS FROM SECTION A
PRELOADED VARIABLES: EXPTYPE, TSTATUS
(M2_PrePay=00,d,r or M3=02,d,r)
M4.
PROGRAMMER: WE WOULD LIKE THE FOLLOWING FORMAT TO BE USED FOR THE DISPLAY ON
TOP HALF OF SCREEN (IF POSSIBLE, THIS DISPLAY SHOULD CHANGE AS THE INTERVIEWER
ENTERS NEW INFORMATION):
What is the name and address of the person to whom we should send the $20 gift card?
NAME: {FULL NAME FROM M1}
STREET ADDRESS 1: {FIRST LINE OF ADDRESS FROM M1}
STREET ADDRESS 2: {SECOND LINE OF ADDRESS FROM M1}
STREET ADDRESS 3: {THIRD LINE OF ADDRESS FROM M1}
CITY OR TOWN: {CITY OR TOWN FROM M1}
STATE: {STATE FROM M1}
ZIP CODE: {ZIP CODE FROM M1}
TELEPHONE NUMBER: {TELEPHONE NUMBER FROM M1}
SAME AS PROVIDED................................................................ 00 (M6)
INCORRECT INFORMATION ABOVE, NEED TO ENTER
NEW INFORMATION ......................................................... 01 (M4Fname)
DON’T KNOW ............................................................................ d (M6)
REFUSED .................................................................................. r (M6)
PROGRAMMER: SEE M1 FOR FORMATTING TO USE FOR BOTTOM OF SCREEN
(M2_PrePay=00,d,r or M3=02,d,r and M4=01)
M4_Firstname.
NAME:
First name?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2_PrePay=00,d,r or M3=02,d,r and M4=01)
M4_Middlename.
NAME: {DISPLAY FIRST NAME FROM QUESTION M4_FIRSTNAME}
Middle initial?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2_PrePay=00,d,r or M3=02,d,r and M4=01)
M4_Lastname.
NAME: {DISPLAY FIRST NAME FROM QUESTION M4_FIRSTNAME AND MIDDLE NAME FROM
M4_MIDDLENAME}
Last name?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2_PrePay=00,d, r or M3=02,d,r and M4=01)
Confirm.
NAME: {DISPLAY NAME FROM PREVIOUS QUESTIONS}
INTERVIEWER:
M-9
PRESS 1 TO CONTINUE
NBS ROUND 4 INSTRUMENT
SECTION M UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, {NAME’S} ADDRESS FROM SECTION A
PRELOADED VARIABLES: EXPTYPE, TSTATUS
(M2_PrePay=00,d,r or M3=02,d,r and M4=01)
M4_Address1.
ADDRESS:
Street and number?
INTERVIEWER:
REFUSED OR DON’T KNOW ALLOWED. WILL SKIP REST OF ADDRESS
QUESTIONS.
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2_PrePay=00,d,r or M3=02,d,r and M4=01)
M4_Address2.
ADDRESS: {DISPLAY ADDRESS1 FROM PREVIOUS QUESTION}
PROBE: READ IF NECESSARY: Second part of the address.
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2_PrePay=00,d,r or M3=02,d,r and M4=01)
M4_Address3.
ADDRESS: {DISPLAY ADDRESS1 AND ADDRESS2 FROM PREVIOUS QUESTIONS}
PROBE: READ IF NECESSARY: Third part of the address.
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2_PrePay=00,d,r or M3=02,d,r and M4=01)
M4_Address4.
ADDRESS: {DISPLAY ADDRESS1, ADDRESS2, AND ADDRESS3 FROM PREVIOUS QUESTIONS}
PROBE: READ IF NECESSARY: Fourth part of the address.
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2_PrePay=00,d, r or M3=02,d,r and M4=01)
M4_City.
ADDRESS: {DISPLAY ADDRESS1, ADDRESS2, ADDRESS3, AND ADDRESS4 FROM PREVIOUS
QUESTIONS}
Town or city?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
M-10
d
r
NBS ROUND 4 INSTRUMENT
SECTION M UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, {NAME’S} ADDRESS FROM SECTION A
PRELOADED VARIABLES: EXPTYPE, TSTATUS
(M2_PrePay=00,d,r or M3=02,d,r and M4=01)
M4_State. ADDRESS: {DISPLAY ADDRESS1, ADDRESS2, ADDRESS3 ADDRESS4, AND TOWN/CITY FROM
PREVIOUS QUESTIONS}
State?
INTERVIEWER:
USE TWO CHARACTER ABBREVIATION.
INTERVIEWER:
ENTER ZZ TO ENTER INTERNATIONAL CITY AND COUNTRY BELOW.
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2_PrePay=00,d,r or M3=02,d,r and M4=01)
M4_Zip. ADDRESS: {DISPLAY ADDRESS1, ADDRESS2, ADDRESS3, ADDRESS4, TOWN/CITY, AND STATE
FROM PREVIOUS QUESTIONS}
Zip code?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M2_PrePay=00,d,r or M3=02,d,r and M4=01)
Confirm. ADDRESS: {DISPLAY FULL ADDRESS}
INTERVIEWER:
PRESS 1 TO CONTINUE
(M2_PrePay=00,d,r or M3=02,d,r and M4=01)
M4_Telephone.
TELEPHONE NUMBER:
Please give me the telephone number, area code first?
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
PROGRAMMER: ASK M4_TIMEZONE IF TIME ZONE IS NOT CURRENTLY ENTERED
(M2_PrePay=00,d,r or M3=02,d,r and M4=01)
M4_TimeZone.
What time zone is that in?
INTERVIEWER:
CURRENT TIME ZONE: {DISPLAY TIME ZONE BASED ON}
HAWAII/ALEUTIAN TIME ZONE ................................................
ALASKA TIME ZONE .................................................................
PACIFIC TIME ZONE .................................................................
MOUNTAIN TIME ZONE ............................................................
CENTRAL TIME ZONE ..............................................................
EASTERN TIME ZONE ..............................................................
ATLANTIC TIME ZONE ..............................................................
NEWFOUNDLAND TIME ZONE ................................................
OTHER INTERNATIONAL TIME ZONE .....................................
M-11
02
03
04
05
06
07
08
09
98
NBS ROUND 4 INSTRUMENT
SECTION M UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, {NAME’S} ADDRESS FROM SECTION A
PRELOADED VARIABLES: EXPTYPE, TSTATUS
(M2_PrePay=00,d,r or M3=02,d,r and M4=01)
M4_Confirm.
TELEPHONE NUMBER: {DISPLAY TELEPHONE NUMBER}
TIME ZONE: {DISPLAY TIME ZONE}
INTERVIEWER:
(All)
M6.
PRESS 1 TO CONTINUE
CHECK: IS {NAME} PART OF THE PARTICIPANT SAMPLE (TSTATUS=01)?
YES ............................................................................................ 01 (M10a)
NO .............................................................................................. 00 (M10a)
M7.
(All)
M10a.
DELETED
Thank you very much for taking part in this survey. Because people like you are such a valued part of what
we do, I’d like you to think about the survey you just participated in. On a scale from 1 to 10 where one
means 'it was not a good use of time' and ten means “it was a good use of time,” which number between
1 and 10 best describes how you feel about your experience today?
|___|___|
(01-10)
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(All)
M11_Thanks.
Thank you for your cooperation. This completes the survey! Thank you again.
PRESS 1 TO CONTINUE .......................................................... 01
INTERVIEWER OBSERVATIONS
NEW ITEM
(All)
M11a.
How was this interview conducted?
Over the telephone .....................................................................
In person ....................................................................................
Using TTY...................................................................................
Other: Specify .............................................................................
(M11a=04)
M11a_Other.
INTERVIEWER:
01
02
03
04
(M11)
(M11)
(M11)
(M11a_Other)
PLEASE SPECIFY
M11.
INTERVIEWER: INTERVIEWER OBSERVATIONS:
Who was the respondent to this interview?
INTERVIEWER:
PLEASE CODE THE PERSON WITH WHOM YOU CONDUCTED MOST OF THE
INTERVIEW.
{NAME} HIMSELF/HERSELF ..................................................... 01
PROXY FOR {NAME} ................................................................. 02 (M13)
M-12
NBS ROUND 4 INSTRUMENT
SECTION M UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, {NAME’S} ADDRESS FROM SECTION A
PRELOADED VARIABLES: EXPTYPE, TSTATUS
(M11=01)
M12.
Was {NAME} assisted by anyone during this interview? That is, did anyone help {NAME} in interpreting the
questions or giving answers?
YES ............................................................................................ 01
NO .............................................................................................. 00 (M15)
(M11=02 or M12=01)
M13.
PROGRAMMER: IFM12=01 FILL “ASSISTANT” AND IF M11=02 FILL “PROXY”
How is the {assistant/proxy} related to (NAME)?
INTERVIEWER:
IF MORE THAN ONE ASSISTANT OR PROXY, INDICATE THE RELATIONSHIP OF
THE ONE YOU CONSIDER TO BE THE MAIN ASSISTANT OR PROXY.
{NAME’S} SPOUSE ....................................................................
{NAME’S} MOTHER ...................................................................
{NAME’S} FATHER ....................................................................
{NAME’S} CHILD ........................................................................
GRANDPARENT OF {NAME} ....................................................
BROTHER/SISTER (NATURAL/STEP) OF {NAME} ..................
AUNT/UNCLE OF {NAME} .........................................................
FRIEND ......................................................................................
CASEWORKER/CAREGIVER/PAYEE .......................................
GIRLFRIEND/BOYFRIEND/PARTNER ......................................
GUARDIAN/FOSTER/STEP PARENT .......................................
IN-LAW .......................................................................................
OTHER RELATIVE OF {NAME} .................................................
NOT RELATED ..........................................................................
STAFF AT RESIDENCE .............................................................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
*Note:
01
02
03
04
05
06
07
11
12
13
14
15
08
09
10
d
r
(M14)
(M14)
(M14)
(M14)
(M14)
(M14)
(M14)
(M14)
(M14)
(M14)
(M14)
(M14)
(M13_h_oth)
(M13_i_oth)
(M14)
(M14)
(M14)
M14=11 is a category added at R2; value of “other” category (M14=10) maintained for comparability across
rounds.
(M11=02 or M12=01 and M13=08)
M13_h_oth. INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
d
r
(M11=02 or M12=01 and M13=09)
M13_i_oth. INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
M-13
d
r
NBS ROUND 4 INSTRUMENT
SECTION M UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, {NAME’S} ADDRESS FROM SECTION A
PRELOADED VARIABLES: EXPTYPE, TSTATUS
(M11=02 or M12=01)
M14.
PROGRAMMER: IFM12=01 FILL “ASSISTANT” AND IF M11=02 FILL “PROXY”
PROGRAMMER: ONLY DISPLAY RESPONSE OPTION 10, IF M11=02
Why was an {assistant/proxy} needed?
INTERVIEWER:
*Note:
CODE ALL THAT APPLY.
{NAME} DIDN’T KNOW HOW TO ANSWER..............................
{NAME} HOSPITALIZED ............................................................
{NAME} INSTITUTIONALIZED ...................................................
{NAME} HAS HEARING PROBLEM...........................................
{NAME} HAS SPEECH PROBLEM ............................................
{NAME} HAS LANGUAGE PROBLEM .......................................
{NAME} HAS POOR MEMORY OR CONFUSION .....................
{NAME} HAS OTHER MENTAL CONDITION ............................
{NAME} HAS PHYSICAL ILLNESS OR DISABILITY .................
{NAME} FAILED COGNITIVE TEST ..........................................
OTHER NON-HEALTH RELATED REASON .............................
DON’T KNOW ............................................................................
REFUSED ..................................................................................
01
02
03
04
05
06
07
08
09
11
10
d
r
(M15)
(M15)
(M15)
(M15)
(M15)
(M15)
(M15)
(M15)
(M15)
(M15)*
(M15)
(M15)
M14=11 is a new category added at R2 and R3; value of “other” category (M14=10) maintained for
comparability across rounds.
(M11=02 or M12=01 and M14=10)
M14_j_oth. INTERVIEWER: PLEASE SPECIFY
DON’T KNOW ............................................................................
REFUSED ..................................................................................
(All)
M15.
d
r
In general, do you feel the respondent was intellectually capable of responding?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
(All)
M16.
In general, do you feel the respondent’s answers were reasonably accurate?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
(All)
M17.
In general, do you feel the respondent understood the questions?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
(All)
M18.
In general, how tiring did the interview seem to be for the respondent?
VERY TIRING............................................................................. 01
A LITTLE TIRING ....................................................................... 02
NOT TIRING ............................................................................... 03
DON’T KNOW ............................................................................ d
M-14
NBS ROUND 4 INSTRUMENT
SECTION M UNIVERSE: ALL
VARIABLES NEEDED FROM OTHER SECTIONS: RTYPE, {NAME’S} ADDRESS FROM SECTION A
PRELOADED VARIABLES: EXPTYPE, TSTATUS
(All)
M19.
In general, did the respondent have difficulty hearing you during the interview?
YES ............................................................................................ 01
NO .............................................................................................. 00 (M21)
DON’T KNOW ............................................................................ d (M21)
(M19=01)
M20.
In general, do you feel the respondent’s hearing difficulty affected the interview?
YES ............................................................................................ 01
NO .............................................................................................. 00
DON’T KNOW ............................................................................ d
(All)
M21.
M-15
INTERVIEWER: Record any special circumstances encountered while interviewing respondent.
NBS ROUND 4 INSTRUMENT
| File Type | application/pdf |
| File Title | National Beneficiary Survey R4 Instrument |
| Subject | CATI |
| Author | Mathematica Staff |
| File Modified | 2014-06-13 |
| File Created | 2014-06-13 |