Form CMS-10549 Cognitive Testing for Limited English Proficiency

Attachments:

A- Recruitment Message

B- Recruitment Script

C- Medicare Beneficiary Language Study Frequently Asked Questions

D- Eligibility Screener Questionnaire

E- Participant Consent Form

F- Cognitive Interview Protocol

G- Participant Receipt Form

Attachment A: Recruitment Message

On behalf of the Centers for Medicare and Medicaid Services (CMS), NORC at the University of Chicago is conducting research to improve the Medicare Current Beneficiary Survey (MCBS). CMS sponsors the MCBS, a nationally representative survey of Medicare beneficiaries. The MCBS collects information on health status, sources of health care, satisfaction with care, and health care expenditures of Medicare beneficiaries. NORC is working on improving the survey by adding questions on the English language proficiency of Medicare beneficiaries and the impact of limited English proficiency on health and health care. We are inviting Medicare beneficiaries who are limited in English proficiency to participate in an interview, [if needed: along with a family member or friend aged 18 or older who can serve as a language assistant. The language assistant will help translate for the beneficiary and should be someone who would normally help the beneficiary participate in an interview or accompany the beneficiary to medical appointments.] The interview involves first completing the survey, and then talking with the interviewer about some of the survey items. Hearing what Medicare beneficiaries [and language assistants] have to say about the survey will help us to improve the questions. If you [and the language assistant] are [both] eligible and choose to participate, [each of] you will receive $40 as an incentive for participating in this study. If you are interested in learning more, please contact the Study Coordinator, NAME at NAME@norc.org.

Attachment B: Recruitment Script

Hello. My name is [NAME] and I work for NORC at the University of Chicago. I’m calling about your interest in the Medicare Beneficiary Language Study. Is this a good time?

[IF YES] Let me tell you a little bit about what we are going to do and then you can let me know if you are still interested. First, are you 18 years or older? [IF NO, let individual know we are only interviewing people aged 18 or older and thank them for interest]

[IF YES] We are conducting this study to improve the way information is collected for the Medicare Current Beneficiary Survey (MCBS), which is a survey sponsored by the Centers for Medicare and Medicaid Services. The MCBS is a national survey of Medicare beneficiaries in the United States. It collects information on health status, sources of health care, satisfaction with care, and health care expenditures.

NORC is working on improving the survey by adding questions on the English language proficiency of Medicare beneficiaries and the impact of limited English proficiency on health and health care. If you agree to participate in this interview, we will ask you to complete a questionnaire with an NORC staff member. After you complete the questionnaire, the interviewer will ask you some questions about the survey that will help us improve the questionnaire. The interview will take no more than 60 minutes. You will receive $40 as an incentive for participating in this survey.

[If needed: Since we are interested in interviewing Medicare beneficiaries who are limited in English proficiency, we are inviting each beneficiary to complete the interview with the help of a family member or friend aged 18 or older who can serve as a language assistant. The language assistant will help translate for the beneficiary and should be someone who would normally help the beneficiary participate in an interview or accompany the beneficiary to medical appointments.]

Would you like to participate?

• [IF YES] Great. I am going to ask you a few background questions to confirm your eligibility. Then we can schedule an appointment time for you.  GO TO ELIGIBILITY SCREENER QUESTIONNAIRE

• [IF NO] That's okay. We appreciate your interest. But for research purposes, we would like to know why you choose not to participate. NOTE TO RECRUITER: IF POTENTIAL RESPONDENT DECIDES AFTER HEARING ABOUT THE STUDY THAT HE/SHE DOES NOT WANT TO PARTICIPATE, ASK WHY NOT AND OFFER TO ANSWER QUESTIONS. RECORD THE RESPONDENT’S REASONS FOR NOT PARTICIPATING BELOW:

Thank you. Have a nice day.

Notes:

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1275.  The time required to complete this information collection is estimated to average 60 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact 1-800-MEDICARE or William Long at 410-786-7927.

Attachment C: Medicare Beneficiary Language Study Frequently Asked Questions

What is the MCBS?

The Medicare Current Beneficiary Survey (MCBS) is a national survey of Medicare beneficiaries in the United States. It collects information on health status, sources of health care, satisfaction with care, and health care expenditures.

What is the study about?

This study is being conducted on behalf of the Centers for Medicare and Medicaid Services (CMS) to try to improve the way information is collected for the MCBS.

What is the Centers for Medicare and Medicaid Services (CMS)?

CMS is a federal agency that is part of the United States Department of Health and Human Services. CMS administers the Medicare program. For more information about CMS, please visit the website www.cms.gov.

Who is NORC?

NORC is a not-for-profit social science research organization affiliated with the University of Chicago. NORC is conducting this study on behalf of the Centers for Medicare and Medicaid Services. You can learn more about NORC at its website, www.norc.org, or by contacting the Study Director, Susan Schechter at schechter-susan@norc.org.

Do I have to participate?

Participation by respondents and language assistants is voluntary. You may choose whether or not you want to be in this study. If you decide to be in the study, you may choose to skip any question you do not want to answer or stop participating at any time. Your Medicare benefits will not be affected in any way by your decision whether to participate.

Will I be compensated for my expenses to travel to your office? Compensation in the amount of $40 will be provided to the Medicare beneficiary [and language assistant] to cover travel and other expenses incurred to participate in the study.

How long will the study take?

The interview will take about one hour.

Why should I participate?

We are testing a new version of the MCBS questionnaire. Input from beneficiaries and language assistants on how the new questionnaire is working will help improve the data we collect. By participating in this study you can help make sure that CMS collects the most complete and accurate data possible on the experiences of Medicare beneficiaries.

Who do I contact if I have questions about my rights as a study participant?

If you have any questions regarding your rights as a study participant, you may call the NORC IRB Manager, toll-free, at 866-309-0542.

How is my privacy protected?

Your answers will always be kept private, and none of the information that you provide will be used for any purpose other than research. Your name or any information that could identify you will never be used.

What information will be shared with the government/with CMS?

Your name will not be associated with any of the responses you give to the survey questions, and we will not provide the names of any participants to CMS. CMS will receive information about this study in a form that will not lead to the identification of any participants.

Attachment D: Eligibility Screener Questionnaire

PARTICIPANT NUMERIC IDENTIFIER: ___________________________

[NOTE: THIS QUESTIONNAIRE IS DIRECTED TOWARD THE MEDICARE BENEFICIARY AS THE RESPONDENT. IF SPEAKING WITH A LANGUAGE ASSISTANT, MODIFY THE LANGUAGE ACCORDINGLY.]

1. ENTER BENEFICIARY GENDER. ASK IF UNSURE.

   1. MALE

   2. FEMALE

2. I need to confirm, do you receive health insurance through Medicare?

   1. YES

   2. NO I am sorry, but only people who receive insurance through Medicare are eligible for this study.

READ IF NECESSARY: Do you have a Medicare card? Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease. Medicare Part A includes coverage for hospital stays and Part B includes coverage for doctor’s services. Part C, Medicare Advantage Plans, is offered through private insurance companies under contract with Medicare. Some people opt to add on Part D, which is prescription drug coverage.

3. Do you speak a language other than English at home?

   1. YES

   2. NO I am sorry, but only Medicare beneficiaries who are limited in English proficiency are eligible for this study.

4. What is this language?

   1. SPANISH

   2. OTHER LANGUAGE _____________________

5. How well do you speak English?

   1. Very well

   2. Well

   3. Not well

   4. Not at all

NOTE: WE WILL INTERVIEW SOME RESPONDENTS WHO SPEAK ENGLISH VERY WELL/WELL TO TEST THE LEP ITEMS WITH BILINGUALS.

6. Would you be able to come in person to one of our offices in Chicago, either downtown or in Hyde Park, to complete an interview?

   1. YES, DOWNTOWN OFFICE

   2. YES, HYDE PARK

   3. NOFIND OUT WHERE RESPONDENT WOULD LIKE TO BE INTERVIEWED; WE WILL DETERMINE IF TRAVEL ARRANGEMENTS CAN BE MADE; CONTINUE SCREENING.

IF SPEAKING WITH A LANGUAGE ASSISTANT AND Q4=OTHER LANGUAGE THAN SPANISH, GO TO Q7; OTHERWISE GO TO Q8.

7. Since we are conducting interviews with Medicare beneficiaries who are not proficient in English, we need to confirm that a language assistant will participate in the interview along with [BENEFICIARY NAME]. The language assistant will help translate for [BENEFICIARY NAME] and should be someone who would normally help [him/her] participate in an interview or accompany [him/her] to medical appointments. The language assistant will also be asked a few questions about the interview experience as well. Are you the person who will be serving as the language assistant for [BENEFICIARY NAME] during this interview?

1. YESGO TO 8

2. NOIF SOMEONE ELSE CAN SERVE AS LANGUAGE ASSISTANT FOR THE INTERVIEW, ASK TO BE PUT IN CONTACT WITH THAT PERSON AND BEGIN AGAIN WITH THE RECRUITMENT SCRIPT. IF NO LANGUAGE ASSISTANT CAN BE IDENTIFIED: I am sorry, in order to participate in the study we need a language assistant to participate along with the Medicare beneficiary.

NOTE: RESPONDENTS WHO SPEAK ENGLISH “WELL” OR “VERY WELL” OR WILL DO THE INTERVIEW IN SPANISH MAY USE A LANGUAGE ASSISTANT AT THEIR DISCRETION. RESPONDENTS WHO SPEAK ENGLISH “NOT WELL” OR “NOT AT ALL” AND WILL NOT DO THE INTERVIEW IN SPANISH MUST HAVE A LANGUAGE ASSISTANT.

8. How old are you?

_______ years

9. What is the highest degree or level of school you have completed?

   1. NO SCHOOLING COMPLETED

   2. NURSERY SCHOOL TO 8TH GRADE

   3. 9TH-12TH GRADE, NO DIPLOMA

   4. HIGH SCHOOL GRADUATE (HIGH SCHOOL DIPLOMA OR THE EQUIVALENT)

   5. VOCATIONAL/TECHNICAL/BUSINESS/TRADE SCHOOL CERTIFICATE OR DIPLOMA (BEYOND THE HIGH SCHOOL LEVEL)

   6. SOME COLLEGE, BUT NO DEGREE

   7. ASSOCIATE DEGREE

   8. BACHELOR'S DEGREE

   9. MASTER'S, PROFESSIONAL OR DOCTORATE DEGREE

   10. DON’T KNOW

   11. REFUSED

10. Are you of Hispanic, Latino, or Spanish origin?

    1. YES

    2. NO

11. What is your race? Please choose one or more.

    1. American Indian or Alaska Native

    2. Asian

    3. Black or African American

    4. Native Hawaiian or other Pacific Islander

    5. White

    6. DON’T KNOW

    7. REFUSED

We would like to audio-record the interview so that we may review our conversation as we prepare a summary of our findings. Is this OK with you? [NOTE TO RECRUITER: THIS QUESTION IS NOT MEANT TO ASK FOR CONSENT. RESPONDENTS WILL BE ASKED AGAIN ABOUT RECORDING DURING THE CONSENT PROCESS. THEY WILL HAVE THE OPPORTUNITY TO DECIDE NOT BE RECORDED AND STILL PARTICIPATE IN THE INTERVIEW. WE PREFER TO RECRUIT RESPONDENTS WHO ARE LIKELY TO CONSENT TO RECORDING.]

1. YES

2. NO

• Ok, let’s schedule an appointment for you to come in for the interview.

• CONFIRM CONTACT INFORMATION AND SCHEDULE APPOINTMENT

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1275.  The time required to complete this information collection is estimated to average 60 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact 1-800-MEDICARE or William Long at 410-786-7927.

Attachment E: Participant Consent Form

PARTICIPANT NUMERIC IDENTIFIER: ___________________________

The Centers for Medicare and Medicaid Services (CMS) is a federal agency that is part of the United States Department of Health and Human Services. CMS administers the Medicare program and conducts the Medicare Current Beneficiary Survey (MCBS), a national survey of Medicare beneficiaries in the United States. To assure that the MCBS obtains the best information possible, CMS sometimes conducts evaluations of the MCBS questionnaire.

You have volunteered to take part in a study to improve the MCBS. In order to have a complete record of your comments, with your permission, your interview session will be audio taped. The recording will be stored electronically on NORC’s secure servers and destroyed at the conclusion of the study. We plan to use the recording to improve the survey. Only staff directly involved in this research project will have access to the recording. Any quotes used in presentations and publications will not include any names or any information that could identify any participant.

Your participation in this interview is voluntary. You may skip questions or end the interview at any time. You will receive $40 in compensation for expenses related to travel and participation in this study. . The information you provide is confidential, consistent with the Privacy Act of 1974. Your Medicare benefits will not be affected in any way by your decision whether to participate. The OMB control number for this study is OMB No. 0938-1275, expiration 05/31/2018.

For questions regarding research subjects’ rights, please contact the NORC IRB Administrator, toll-free at 866-309-0542.

I have volunteered to participate in this study, and I give permission for my tapes to be used for the purposes stated above.

_________________________ ____________________________

Researcher’s Signature Participant’s Signature

_________________________ ____________________________

Printed Name Printed Name

_________________________ ____________________________

Date Date

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1275.  The time required to complete this information collection is estimated to average 60 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact 1-800-MEDICARE or William Long at 410-786-7927.

Attachment F: Cognitive Interview Protocol

PARTICIPANT NUMERIC IDENTIFIER: ___________________________

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1275.  The time required to complete this information collection is estimated to average 60 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact 1-800-MEDICARE or William Long at 410-786-7927.

MATERIALS NEEDED FOR INTERVIEW

• INTERVIEWER PROTOCOL BOOKLET (THIS BOOKLET) AND SHOWCARDS

• CONSENT FORM (FOUR COPIES)

• TWO ENVELOPES WITH $40 CASH IN EACH

• TWO PAYMENT RECEIPTS

• DIGITAL RECORDER AND EXTRA BATTERIES

• PENS AND PENCILS

STEP 1: INFORMED CONSENT

PROVIDE RESPONDENT AND LANGUAGE ASSISTANT EACH WITH A COPY OF THE INFORMED CONSENT FORM. ASK THE LANGUAGE ASSISTANT TO HELP THE BENEFICIARY BY READING AND TRANSLATING THE FORM. ANSWER ANY QUESTIONS THE BENEFICIARY AND LANGUAGE ASSISTANT MAY HAVE, AND HAVE BOTH THE BENEFICIARY AND LANGUAGE ASSISTANT SIGN A SEPARATE FORM. GIVE A SEPARATE COPY OF THE FORM TO THE BENEFICIARY AND TO THE LANGUAGE ASSISTANT.

• SIGNED CONSENT FORMS COLLECTED

• COPY OF CONSENT FORMS GIVEN TO BENEFICIARY AND LANGUAGE ASSISTANT

• IF THE BENEFICIARY AND LANGUAGE ASSISTANT HAVE BOTH CONSENTED TO RECORDING, START THE RECORDER.

STEP 2: COMPLETION OF THE QUESTIONNAIRE

The Medicare Current Beneficiary Survey (MCBS) asks Medicare beneficiaries about their health status, sources of health care, satisfaction with care, and health care expenditures. [IF NEEDED: All the questions are in English, so I would like [LANGUAGE ASSISTANT] to help me translate for [BENEFICIARY NAME]. I will read about a sentence at a time and wait for [LANGUAGE ASSISTANT] to translate before I go on. Then after [BENEFICIARY NAME] answers the question, we will go on to the next question.]

After we have finished the survey, I would like to talk with you about some of the questions in the survey. Getting your feedback on the questions will show me how to make the questions better.

STEP 3: DEBRIEFING

Now I would like to talk with you about some of the survey questions you just answered.

GENERAL PROBES: Suggested general neutral probing for issues that arise.

• How did you decide on that answer?

• Can you tell me more about that?

• Can you give me an example of that?

• Tell me what you are thinking.

• What did you think about when I asked that question?

• What did you think about in deciding on your answer?

• What doctors did you include when you answered this question?

• What does [QUESTION/TERM] mean to you?

OBSERVATIONS ON THE INTERACTION BETWEEN LANGUAGE ASSISTANT AND BENEFICIARY

• Does the language assistant translate the questions for the beneficiary?

• How often does the translator need to translate, repeat or explain a question to the R?

• Does the language assistant appear to be serving as a proxy instead of translator? Does the language assistant appear to be helping the beneficiary decide how to answer?

• What difficulties does the language assistant have in serving as translator?

• Does the respondent answer any questions without the help of the language assistant?

• Ask about items in which language assistant and beneficiary appear to be discussing the question or response, appear uncertain how to answer, or confused by the survey item.

• Did Spanish-speaking respondents require any help from a language assistant? What kind of issues arose that required the language assistant’s help?

LEP COGNITIVE INTERVIEW SURVEY ITEMS AND PROBES

NOTE: THE REFERENCE DATE FOR THE SURVEY WILL BE THE YEAR BEFORE THE INTERVIEW DATE (PAST YEAR).

	The first questions are about health care services you may have used in the past year. In the past year, did you go to a hospital emergency room? (01) YES (02) NO (-8) Don't Know (-9) Refused
Observations:
	In the past year, did you go to a hospital clinic or outpatient department? DO NOT INCLUDE HOSPITAL INPATIENT STAYS. (01) YES (02) NO (-8) Don't Know (-9) Refused
Observations:
	Next, I want to ask about your visits to doctors in the past year. Have you seen a medical doctor in the past year? Please do not include a doctor seen at home, at an emergency room or outpatient department, or while an inpatient at a hospital. [IF NECESSARY, SAY, ‘Please look at show card AC1 for examples of types of medical doctors.’] (01) YES (02) NO (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD AC1 [I have a few more questions about visits that you had in the past.] Think about the most recent time you saw a medical doctor somewhere other than at home or at a hospital. What was the doctor’s specialty? [PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE CARD IF THEY MENTION A 'GENERIC' SPECIALTY LIKE ‘HEART DOCTOR.’ IF RESPONDENT ONLY GIVES A 'GENERIC' SPECIALTY AND THE GENERIC WORD IS SHOWN IN PARENTHESES FOLLOWING ONE OF THE RESPONSES, SELECT THE RESPONSE CATEGORY FOR THAT SPECIALTY (E.G., 'CARDIOLOGY'). OTHERWISE SELECT 'OTHER DR SPECIALTY'.] (01) ALLERGY/IMMUNOLOGY (02) ANESTHESIOLOGY (03) CARDIOLOGY (HEART) (05) DERMATOLOGY (SKIN) (07) ENDOCRINOLOGY/METABOLISM (DIABETES,THYROID) (08) FAMILY PRACTICE (09) GASTROENTEROLOGY (10) GENERAL PRACTICE (11) GENERAL SURGERY (12) GERIATRICS (ELDERLY) (13) GYNECOLOGY - OBSTETRICS (14) HEMATOLOGY (BLOOD) (15) HOSPITAL RESIDENCE (16) INTERNAL MEDICINE (INTERNIST) (17) NEPHROLOGY (KIDNEYS) (18) NEUROLOGY (19) NUCLEAR MEDICINE (20) ONCOLOGY (TUMORS, CANCER) (21) OPHTHALMOLOGY (EYES) (22) ORTHOPEDICS (24) OSTEOPATHY (DO) (25) OTORHINOLARYNGOLOGY (EAR, NOSE, THROAT) (26) PATHOLOGY (27) PHYS MED/REHAB (28) PLASTIC SURGERY (29) PROCTOLOGY (30) PSYCHIATRY/PSYCHIATRIST (31) PULMONARY (LUNGS) (32) RADIOLOGY (33) RHEUMATOLOGY (ARTHRITIS) (34) THORACIC SURGERY (CHEST) (35) UROLOGY (91) OTHER DR SPECIALTY (SPECIFY ________________________________________) (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD SC1 We’re interested in how you feel about the health care you have received over the past year from doctors and hospitals. Please tell me how satisfied you have been with the following: The overall quality of the health care you have received over the past year. (01) VERY SATISFIED (02) SATISFIED (03) DISSATISFIED (04) VERY DISSATISFIED (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD SC1 [Please tell me how satisfied you have been with . . .] The availability of health care at night and on weekends. (01) VERY SATISFIED (02) SATISFIED (03) DISSATISFIED (04) VERY DISSATISFIED (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD SC1 [Please tell me how satisfied you have been with . . .] The ease and convenience of getting to a doctor from where you live. (01) VERY SATISFIED (02) SATISFIED (03) DISSATISFIED (04) VERY DISSATISFIED (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD SC1 [Please tell me how satisfied you have been with . . .] The out-of-pocket costs you paid for health care. (01) VERY SATISFIED (02) SATISFIED (03) DISSATISFIED (04) VERY DISSATISFIED (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD SC1 [Please tell me how satisfied you have been with . . .] The information given to you about what was wrong with you. (01) VERY SATISFIED (02) SATISFIED (03) DISSATISFIED (04) VERY DISSATISFIED (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD SC1 [Please tell me how satisfied you have been with . . .] The follow-up care you received after an initial treatment or operation. (01) VERY SATISFIED (02) SATISFIED (03) DISSATISFIED (04) VERY DISSATISFIED (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD SC1 [Please tell me how satisfied you have been with . . .] The concern of doctors for your overall health rather than just for an isolated symptom or disease. (01) VERY SATISFIED (02) SATISFIED (03) DISSATISFIED (04) VERY DISSATISFIED (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD SC1 [Please tell me how satisfied you have been with . . .] Getting all your health care needs taken care of at the same location. (01) VERY SATISFIED (02) SATISFIED (03) DISSATISFIED (04) VERY DISSATISFIED (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD SC1 [Please tell me how satisfied you have been with . . .] The availability of care by specialists when you feel you need it. (01) VERY SATISFIED (02) SATISFIED (03) DISSATISFIED (04) VERY DISSATISFIED (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD SC1 [Please tell me how satisfied you have been with . . .] The ease of obtaining answers to questions over the telephone about your treatment or prescriptions. (01) VERY SATISFIED (02) SATISFIED (03) DISSATISFIED (04) VERY DISSATISFIED (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD SC1 [Please tell me how satisfied you have been with . . .] The amount you have to pay for your prescribed medicines. (01) VERY SATISFIED (02) SATISFIED (03) DISSATISFIED (04) VERY DISSATISFIED (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	Please think about all of the health care services you receive, including services provided by doctors, hospitals and pharmacies. What things, if anything, about the health care services you receive are you dissatisfied with? (01) RESPONDENT IS NOT DISSATISFIED WITH ANYTHING (91) RESPONDENT IS DISSATISFIED (RECORD VERBATIM BELOW) (-8) Don't Know (-9) Refused RESPONDENT VERBATIM:
Observations:
	Is there a particular medical person or a clinic you usually go to when you are sick or for advice about your health? (01) YES (02) NO GO TO Q40
Observations:
	What kind of place do you usually go to when you are sick or for advice about your health -- is that a managed care plan or HMO center, a clinic, a doctor's office, a hospital, or some other place? IF CLINIC, ASK: Is it a hospital outpatient clinic, or some other kind of clinic? IF SOME OTHER PLACE, ASK: Where is this? (01) DOCTOR'S OFFICE OR GROUP PRACTICE (02) MEDICAL CLINIC (03) MANAGED CARE PLAN CENTER/HMO (04) NEIGHBORHOOD/FAMILY HEALTH CENTER (05) FREESTANDING SURGICAL CENTER (06) RURAL HEALTH CLINIC (07) COMPANY CLINIC (08) OTHER CLINIC (09) WALK-IN URGENT CENTER (10) DOCTOR COMES TO SP'S HOME (11) HOSPITAL EMERGENCY ROOM (12) HOSPITAL OUTPATIENT DEPARTMENT/CLINIC (13) VA FACILITY (14) MENTAL HEALTH CENTER (91) OTHER (SPECIFY ______________________________________________________) (-8) DON'T KNOW (-9) REFUSED
Observations:
	What is the complete name of the place that you go to?
Observations:
	Is there a particular doctor you usually see at this place? (01) YES (02) NO GO TO Q24 (-8) DON'T KNOW (-9) REFUSED
Observations:
	What is the complete name of that doctor?
Observations:
	SHOW CARD AC1 What is (PROVIDER NAME FROM Q21)'s specialty? [PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE CARD IF THEY MENTION A 'GENERIC' SPECIALITY LIKE ‘HEART DOCTOR.’ IF RESPONDENT ONLY GIVES A 'GENERIC' SPECIALTY AND THE GENERIC WORD IS SHOWN IN PARENTHESES FOLLOWING ONE OF THE RESPONSES, SELECT THE RESPONSE CATEGORY FOR THAT SPECIALTY (E.G., 'CARDIOLOGY'). OTHERWISE SELECT 'OTHER DR SPECIALTY'.] (01) ALLERGY/IMMUNOLOGY (02) ANESTHESIOLOGY (03) CARDIOLOGY (HEART) (05) DERMATOLOGY (SKIN) (06) EMERGENCY ROOM PHYSICIAN (07) ENDOCRINOLOGY/ METABOLISM (DIABETES, THYROID) (08) FAMILY PRACTICE (09) GASTROENTEROLOGY (10) GENERAL PRACTICE (11) GENERAL SURGERY (12) GERIATRICS (ELDERLY) (13) GYNECOLOGY - OBSTETRICS (14) HEMATOLOGY (BLOOD) (15) HOSPITAL RESIDENCE (16) INTERNAL MEDICINE (INTERNIST) (17) NEPHROLOGY (KIDNEYS) (18) NEUROLOGY (19) NUCLEAR MEDICINE (20) ONCOLOGY (TUMORS, CANCER) (21) OPHTHALMOLOGY (EYES) (22) ORTHOPEDICS (24) OSTEOPATHY (DO) (25) OTORHINOLARYNGOLOGY (EAR, NOSE, THROAT) (26) PATHOLOGY (27) PHYS MED/REHAB (28) PLASTIC SURGERY (29) PROCTOLOGY (30) PSYCHIATRY/PSYCHIATRIST (31) PULMONARY (LUNGS) (32) RADIOLOGY (33) RHEUMATOLOGY (ARTHRITIS) (34) THORACIC SURGERY (CHEST) (35) UROLOGY (91) OTHER DR SPECIALTY (-8) DON'T KNOW (-9) REFUSED
Observations:
	OTHER DR SPECIALTY (SPECIFY) ________________________________________
	Do you usually have someone accompany you there? (01) YES (02) NO GO TO Q28 (-8) DON'T KNOW (-9) REFUSED
Observations:
	Who usually goes with you? (SPECIFY)________________________
Observations:
	How often is [RESPONSE FROM Q25] with you while you see the doctor or other medical person? Would you say always, sometimes, or never? (01) ALWAYS (02) SOMETIMES (03) NEVER (-8) DON'T KNOW (-9) REFUSED
Observations:
	What are the reasons this person accompanies you there? What does this person do? [PROBE: Any other reason?] CHECK ALL THAT APPLY. (01) WRITES DOWN WHAT DOCTOR SAYS/RECORDS INSTRUCTIONS/TAKES NOTES/REMEMBERS (02) GIVES INFORMATION/EXPLAINS SP'S MEDICAL CONDITION OR NEEDS TO THE DOCTOR (03) EXPLAINS DOCTOR’S INSTRUCTIONS TO SP (04) ASKS QUESTIONS (05) TRANSLATES LANGUAGE (06) SCHEDULES APPOINTMENTS (07) NOTHING/KEEPS SP COMPANY/SITS WITH SP/MORAL SUPPORT (08) TRANSPORTATION (09) SP NEEDS PHYSICAL ASSISTANCE (91) OTHER (SPECIFY ___________________________________________________) (-8) DON'T KNOW (-9) REFUSED
Observations:
	SHOW CARD US1 How long have you been seeing (PROVIDER NAME FROM Q21)/going to (PROVIDER NAME FROM Q19)]? (01) LESS THAN 1 YEAR (02) 1 YEAR TO LESS THAN 3 YEARS (03) 3 YEARS TO LESS THAN 5 YEARS (04) 5 YEARS TO LESS THAN 10 YEARS (05) 10 YEARS OR MORE (-8) DON'T KNOW (-9) REFUSED
Observations:
	SHOW CARD US3 Now I am going to read some statements people have made about their health care. Think about the care you receive from (PROVIDER NAME FROM Q21/ PROVIDER NAME FROM Q19). For each statement, please tell me whether you strongly agree, agree, disagree, or strongly disagree. [(PROVIDER NAME FROM Q21) is/The doctors at (PROVIDER NAME FROM Q19) are] very careful to check everything when examining you. (01) STRONGLY AGREE (02) AGREE (03) DISAGREE (04) STRONGLY DISAGREE (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD US3 [(PROVIDER NAME FROM Q21) is/The doctors at (PROVIDER NAME FROM Q19) are] competent and well-trained. (01) STRONGLY AGREE (02) AGREE (03) DISAGREE (04) STRONGLY DISAGREE (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD US3 [(PROVIDER NAME FROM Q21) has/The doctors at (PROVIDER NAME FROM Q19) have] a complete understanding of the things that are wrong with you. (01) STRONGLY AGREE (02) AGREE (03) DISAGREE (04) STRONGLY DISAGREE (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD US3 [(PROVIDER NAME FROM Q21) often seems/The doctors at ( PROVIDER NAME FROM Q19) often seem] to be in a hurry. (01) STRONGLY AGREE (02) AGREE (03) DISAGREE (04) STRONGLY DISAGREE (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD US3 [Think about the care you receive from [(PROVIDER NAME FROM Q21)/(PROVIDER NAME FROM Q19)].] [(PROVIDER NAME FROM Q21) often does/The doctors at (PROVIDER NAME FROM Q19) often do] not explain your medical problems to you. (01) STRONGLY AGREE (02) AGREE (03) DISAGREE (04) STRONGLY DISAGREE (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD US3 You often have health problems that should be discussed but are not. (01) STRONGLY AGREE (02) AGREE (03) DISAGREE (04) STRONGLY DISAGREE (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD US3 [(PROVIDER NAME FROM Q21) often acts/The doctors at (PROVIDER NAME FROM Q19) often act] as though [(he/she) was/they were] doing you a favor by talking to you. (01) STRONGLY AGREE (02) AGREE (03) DISAGREE (04) STRONGLY DISAGREE (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD US3 [(PROVIDER NAME FROM Q21) tells/The doctors at (PROVIDER NAME FROM Q19) tell] you all you want to know about your condition and treatment. (01) STRONGLY AGREE (02) AGREE (03) DISAGREE (04) STRONGLY DISAGREE (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD US3 [(PROVIDER NAME FROM Q21) answers/The doctors at (PROVIDER NAME FROM Q19) answer] all your questions. (01) STRONGLY AGREE (02) AGREE (03) DISAGREE (04) STRONGLY DISAGREE (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD US3 [Think about the care you receive from (PROVIDER NAME FROM Q21/PROVIDER NAME FROM Q19).] You have great confidence in [(PROVIDER NAME FROM Q21)/the doctors at (PROVIDER NAME FROM Q19)]. (01) STRONGLY AGREE (02) AGREE (03) DISAGREE (04) STRONGLY DISAGREE (05) NOT APPLICABLE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD US3 You depend on [(PROVIDER NAME FROM Q21)/the doctors at (PROVIDER NAME FROM Q19)] in order to feel better both physically and emotionally. (01) STRONGLY AGREE (02) AGREE (03) DISAGREE (04) STRONGLY DISAGREE (05) NOT APPLICABLE (-8) Don't Know (-9) Refused ALL RESPONSES GO TO Q47
Observations:
	[IF NO USUAL SOURCE OF CARE] I am going to read some reasons that people have given for not having a usual source of health care. For each one, please tell me whether or not it is a reason you do not have a usual place for health care. There is no reason to have a usual source of health care because you seldom or never get sick. [Is that a reason you do not have a usual source of health care?] (01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED
Observations:
	You recently moved into the area. [Is that a reason you do not have a usual source of health care?] (01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED
Observations:
	Your usual source of health care in this area is no longer available. [Is that a reason you do not have a usual source of health care?] (01) YES (02) NO GO TO Q44 (-8) DON'T KNOW GO TO Q44 (-9) REFUSED GO TO Q44
Observations:
	Why is your usual source of health care no longer available? (01) PREVIOUS DOCTOR RETIRED (02) PREVIOUS DOCTOR DIED (03) PREVIOUS DOCTOR MOVED (04) RESPONDENT MOVED (05) PREVIOUS DR/PLACE TOO FAR AWAY (91) OTHER (SPECIFY ____________________________________________________) (-8) DON'T KNOW (-9) REFUSED
Observations:
	Thinking about other possible reasons that people have for not having a usual source of health, please tell me if this statement applies to you: You like to go to different places for different health care needs. [Is that a reason you do not have a usual source of health care?] (01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED
Observations:
	The places where you can receive health care are too far away. [Is that a reason you do not have a usual source of health care?] (01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED
Observations:
	The cost of health care is too expensive. [Is that a reason you do not have a usual source of health care?] (01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED
Observations:
	I would like to get a little information about your background. Are you of Hispanic, (Latino/Latina), or Spanish origin? (01) YES (02) NO GO TO Q49 (-8) Don't Know GO TO Q49 (-9) Refused GO TO Q49
Observations:
	SHOW CARD DI1 Looking at this card, are you Mexican, Mexican American, or (Chicano/Chicana), Puerto Rican, Cuban, or of another Hispanic, (Latino/Latina) or Spanish origin? CHECK ALL THAT APPLY. (01) MEXICAN/MEXICAN AMERICAN/CHICANO(A) (02) PUERTO RICAN (03) CUBAN (91) OTHER HISPANIC, LATINO(A), OR SPANISH ORIGIN (SPECIFY _______________) (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD DI2 Looking at this card, what is your race? [ASK IF NECESSARY: Are there any options from this card that you would like me to record?] (01) AMERICAN INDIAN OR ALASKA NATIVE (02) ASIAN (03) BLACK OR AFRICAN AMERICAN (04) NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER (05) WHITE ( (-8) Don't Know (-9) Refused IF RACE INCLUDES ASIAN, GO TO Q50. ELSE IF RACE INCLUDES NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER, GO TO Q51. ELSE GO TO Q52.
Observations:
	SHOW CARD DI3 Looking at this card, are you Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese or some other Asian group? You can choose more than one group. CHECK ALL THAT APPLY. (01) ASIAN INDIAN (02) CHINESE (03) FILIPINO (04) JAPANESE (05) KOREAN (06) VIETNAMESE (91) OTHER ASIAN GROUP (SPECIFY ________________________________________) (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD DI4 Looking at this card, are you Native Hawaiian, Guamanian or Chamorro, Samoan, or some other Pacific Islander group? You can choose more than one group. CHECK ALL THAT APPLY. (01) NATIVE HAWAIIAN (02) GUAMANIAN OR CHAMORRO (03) SAMOAN (91) OTHER PACIFIC ISLANDER GROUP (SPECIFY _____________________________) (-8) Don't Know (-9) Refused
Observations:
	How well do you speak English? Would you say… (01) Very well (02) Well (03) Not Well, or (04) Not at all?
Probes: When I asked “How well do you speak English?” you answered [ANSWER]. How did you decide on your answer? What did you think about when you answered the question? Can you give some examples? Notes to interviewer: Look for difficulty deciding on answer. Do beneficiary and language assistant seem to agree? Did the differences between the question on speaking and reading get conveyed in translation? (For example, it is possible that the language assistant translates too loosely—how well does the beneficiary “know” English instead of “speak” English.) Is there any difficulty explaining the difference between these items to the beneficiary? Observations:
	How well do you read English? Would you say… (01) Very well (02) Well (03) Not Well, or (04) Not at all?
Probes: When I asked “How well do you read English?” you answered [ANSWER]. How did you decide on your answer? What did you think about when you answered the question? Can you give some examples? Notes to interviewer: Look for difficulty deciding on answer. Do beneficiary and language assistant seem to agree? Did the differences between the question on speaking and reading get conveyed in translation? (For example, it is possible that the language assistant translates too loosely—how well does the beneficiary “know” English instead of “read” English.) Is there any difficulty explaining the difference between these items to the beneficiary? Observations:
	Do you speak a language other than English at home? (01) YES (02) NO GO TO Q65 (-8) Don't Know GO TO Q65 (-9) Refused GO TO Q65
Observations:
	What is this language? (01) SPANISH (91) OTHER LANGUAGE, SPECIFY: ________________________ (-8) Don't Know (-9) Refused
Probes: You said you speak LANGUAGE at home. Are there any other languages you speak, at home or elsewhere? What other languages do you speak? In what situations would you use a language other than English? In what situations would you use English? Notes to Interviewer: Q52, Q54, and Q55 are from the ACS and are well tested. However, they appear in a different order here than in the ACS, and with an additional question inserted (in ACS, the order would be Q54, Q55, Q52). Look for issues with question flow or interpretation due to the reordering. Observations:
	In general, in what language do you prefer to receive your medical care? (01) English (02) LANGUAGE FROM Q55, or (03) Both English and LANGUAGE FROM Q55 equally (91) OTHER-specify (-8) Don't Know (-9) Refused
Probes: You answered that you prefer to receive medical care in LANGUAGE. How did you decide on that answer? Tell me more about that. What language(s) do your medical providers use when speaking to you? What language(s) do you use during your medical appointments? Can you give some examples? Notes to Interviewer: Does R choose the language spoken at home as the preferred language for medical care? Do R’s ever interpret the Q to mean what language they do receive care in, rather than the preferred language? Observations:
	In what language do you prefer to read health-related materials? (01) English (02) LANGUAGE FROM Q55, or (03) Both English and LANGUAGE FROM Q55 equally (91) OTHER-specify (-8) Don't Know (-9) Refused
Probes: You answered that you prefer to read health-related materials in LANGUAGE. How did you decide on that answer? Tell me more about that. In what language are the materials that your medical providers give to you? Can you give some examples? Notes to Interviewer: Does R choose the language spoken at home as the preferred language for medical care? Do R’s ever interpret the Q to mean what language they do receive health related materials in, rather than the preferred language? Observations:
	How well can you discuss your symptoms with your medical providers in English? Would you say… (01) Very well (02) Well (03) Not well, or (04) Not at all?
Probes: When I asked how well you can discuss your symptoms with your medical providers in English, you answered [ANSWER]. Can you tell me more about that? How did you decide on your answer? What did you think about when you answered the question? Do you ever speak in English with any medical providers? What language(s) do you use in communicating with your medical providers? Can you give some examples? Notes to Interviewer: How does the R interpret these questions? The question wording may presuppose that Rs do communicate with some of their providers in English (because of the use of the term “your” medical providers). This interpretation may elicit a response that he/she does not communicate with providers in English. The intended interpretation of this question would be, “Would you be able to discuss your symptoms in English?” If R always uses a translator or has a language concordant doctor, are they able to make a judgment on their ability to discuss in English? Observations:
	How well can you discuss your symptoms with your medical providers in [LANGUAGE FROM Q55]? Would you say… (01) Very well (02) Well (03) Not Well, or (04) Not at all?
Probes: [Probe only if answer is inconsistent with expectations. That is, does R indicate difficulty communicating in preferred language for medical care? Does R indicate that they communicate less well in this language than in English? Ask R to provide some examples of how they communicate with providers.] Notes to Interviewer: Does the R indicate higher proficiency in their preferred language for medical care than in English? If not, ask how they decided on answer. Ask for more information on how they communicate with providers. Does this question make sense to Rs who may not have any medical providers who speak their preferred language for medical care? Observations:
	How well can you understand your medical providers’ recommendations in English? Would you say… (01) Very well (02) Well (03) Not Well, or (04) Not at all?
Probes: When I asked how well you can understand your medical providers’ recommendations in English you said [ANSWER]. Can you tell me more about that? How did you decide on your answer? What did you think about when you answered the question? Do you ever speak in English with any medical providers? What language(s) do you use in communicating with your medical providers? Can you give some examples? Notes to Interviewer: How does the R interpret these questions? The question wording may presuppose that Rs do communicate with some of their providers in English (because of the use of the term “your” medical providers). This interpretation may elicit a response that he/she does not communicate with providers in English. The intended interpretation of this question would be, “Would you be able to understand recommendations in English?” If R always uses a translator or has a language concordant doctor, are they able to make a judgment on their ability to discuss in English? Observations:
	How well can you understand your medical providers’ recommendations in [LANGUAGE FROM Q55]? Would you say… (01) Very well (02) Well (03) Not Well, or (04) Not at all?
Probes: [Probe only if answer is inconsistent with expectations. That is, does R indicate difficulty communicating in preferred language for medical care? Does R indicate that they communicate less well in this language than in English? Ask R to provide some examples of how they communicate with providers.] Notes to Interviewer: Does the R indicate higher proficiency in their preferred language for medical care than in English? If not, ask how they decided on answer. Ask for more information on how they communicate with providers. Does this question make sense to Rs who may not have any medical providers who speak their preferred language for medical care? Observations:
SKIP INSTRUCTIONS: IF RESPONDENT NAMED A PROVIDER IN Q21 (USUALDOC=YES), GO TO Q62. ELSE IF USUALDOC=NO AND ((Q58= “VERY WELL” OR “WELL”) AND (Q60=“VERY WELL” OR “WELL”)) THEN GO TO Q65. ELSE GO TO Q64.
	Does [PROVIDER NAME FROM Q21] speak [LANGUAGE FROM Q55]? (01) YES (02) NO (-8) Don't Know (-9) Refused
Probes: Tell me more about the language you prefer to speak with your medical provider. Notes to Interviewer: What language did R indicate as the language preferred for health care? We assume that in most cases R would prefer to receive medical care in a language in which they are fluent. Do Rs who do not communicate well in English ever prefer to receive medical care in English? Why? Are there issues with this item for bilinguals who are fluent in English, or LEP respondents who simply prefer to see providers who speak English? Observations:
	IF (Q58= “VERY WELL” OR “WELL”) AND (Q60=“VERY WELL” OR “WELL”)) THEN GO TO Q65. ELSE IF Q62=YES, GO TO Q64. ELSE CONTINUE. Who helps you communicate with [PROVIDER NAME FROM Q21] – a professional interpreter, a staff person at your doctor's office, a family member, a friend, or do you do the best that you can in English? Professional interpreter Staff person at doctor's office Family member Friend Do the best you can in English Other-specify
Probes: When I asked who helps you communicate with [US5A PROVIDER NAME] you said [ANSWER]. Tell me more about that. Who provides the professional interpreter? What staff person helps to translate? Which family member/friend? Does the same person help you at every visit or do different people help? Notes to Interviewer: Did the R have any difficulty choosing an answer? Who do they think of as a professional interpreter? Staff person? How did the R decide on his/her answer? Are there other ways R communicates with the provider that are not listed as response options? How do Rs whose preferred language for medical care is English respond? How do fluent bilinguals respond? Observations:
	Who helps you communicate with your medical providers who do not speak [LANGUAGE FROM Q55] - a professional interpreter, a staff person at your doctor's office, a family member, a friend, or do you do the best that you can in English? Professional interpreter Staff person at doctor's office Family member Friend Do the best you can in English Other-specify
Probes: When I asked who helps you communicate with your medical providers who do not speak [LANGUAGE FROM Q56], you said [ANSWER]. What medical providers were you thinking of when you answered this question? How did you decide how to answer this question? Observations:
	The next two questions are about education and income. SHOW CARD DI5 What is the highest degree or level of school you have completed? [IF THE SAMPLE PERSON ATTENDED SCHOOL IN A FOREIGN COUNTRY, IN AN UNGRADED SCHOOL, HOME SCHOOLING, OR UNDER OTHER UNIQUE CIRCUMSTANCES, REFER THE RESPONDENT TO THE SHOWCARD AND ASK FOR THE NEAREST EQUIVALENT.] (01) NO SCHOOLING COMPLETED (02) NURSERY SCHOOL TO 8TH GRADE (03) 9TH-12TH GRADE, NO DIPLOMA (04) HIGH SCHOOL GRADUATE (HIGH SCHOOL DIPLOMA OR THE EQUIVALENT) (05) VOCATIONAL/TECHNICAL/BUSINESS/TRADE SCHOOL CERTIFICATE OR DIPLOMA (BEYOND THE HIGH SCHOOL LEVEL) (06) SOME COLLEGE, BUT NO DEGREE (07) ASSOCIATE DEGREE (08) BACHELOR'S DEGREE (09) MASTER'S, PROFESSIONAL OR DOCTORATE DEGREE (-8) Don't Know (-9) Refused
Observations:
	SHOW CARD DI6 Looking at this card, which letter best represents your total income before taxes during the past 12 months? Include income from jobs, Social Security, Railroad Retirement, other retirement income, and the other sources of income we just talked about. [EXPLAIN IF NECESSARY: Income is important in analyzing the information we collect. For example, this information helps us learn whether persons in one income group use certain types of medical care services or have certain medical conditions more or less often than those in another group.] (01) A. Less than $5,000 (02) B. $5,000 - 9,999 (03) C. $10,000 - 14,999 (04) D. $15,000 - 19,999 (05) E. $20,000 - 24,999 (06) F. $25,000 - 29,999 (07) G. $30,000 - 39,999 (08) H. $40,000 - 49,999 (09) I. $50,000 or more (-8) Don't Know (-9) Refused
Observations:

Attachment G: Participant Receipt Form

National Opinion Research Center (NORC)
Participant Receipt Form

Instructions: Please check box below. Sign your name indicating you have read this Receipt and have received $40 compensation for participating in this survey.

□ I have received $40.00 (cash) from an NORC staff member as an incentive for participating in this survey.

_____________________________________________

Participant Signature

|____|____| |____|____| |____|____|

Month Day Year