Form CMS-10549: GenIC#2 CMS-10549: GenIC#2 - MCBS Cognitive Testing LGBT Instruments

Attachments:

A- Recruitment Message

B- Recruitment Script

C- Medicare Beneficiary 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 testing new questions that may add important information about health disparities among small population groups. The question topics range from access to health care and usual sources of care, to basic demographic questions such as race, and education. We are inviting Medicare beneficiaries to participate in an interview; the interview involves first completing the survey and talking with the interviewer about some of the survey items. Hearing what Medicare beneficiaries have to say about the survey will help us to improve the questions. If you are eligible and choose to participate, 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 Current Beneficiary 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.

If you agree to participate in this interview, we will ask you to answer survey questions asked by a NORC staff member. After you complete the questionnaire, the interviewer will ask you some questions about the survey as well as your understanding of survey concepts that will help us improve the questionnaire. Some people may view some questions as sensitive – the questions you will be asked range from access to health care and usual source of care to demographic questions such as race, and education. The interview will take no more than 60 minutes. You will receive $40 as an incentive for participating in this survey.

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 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 and Puerto Rico. 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, Medicaid, and Child Health Insurance programs as well as the Health Insurance Marketplace. For more information about CMS, please visit the website www.cms.gov.

Why are you testing new questions?

Studying the ways people use the healthcare system in the U.S. population has been a long-standing goal of the U.S. government and in particular the Department of Health and Human Services (DHHS). Your participation in this study will help to improve how these data are collected and analyzed for the MCBS.

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 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 receive an incentive for participating?

An incentive of $40 will be provided to the Medicare beneficiary for participating 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 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: ___________________________

1. Are you male or female?

   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. 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.

4. How old are you?

_______ years

5. 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

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

   1. YES

   2. NO

7. 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

8. Do you, personally, identify as lesbian, gay, bisexual, or transgender?

   1. Yes

   2. No

[IF RESPONDENT ASKS WHAT TRANSGENDER MEANS:

SOME PEOPLE DESCRIBE THEMSELVES AS TRANSGENDER WHEN THEY EXPERIENCE A DIFFERENT GENDER IDENTITY FROM THEIR SEX AT BIRTH. FOR EXAMPLE, A PERSON BORN INTO A MALE BODY, BUT WHO FEELS FEMALE OR LIVES AS A WOMAN WOULD BE TRANSGENDER. SOME TRANSGENDER PEOPLE CHANGE THEIR PHYSICAL APPEARANCE SO THAT IT MATCHES THEIR INTERNAL GENDER IDENTITY. SOME TRANSGENDER PEOPLE TAKE HORMONES AND SOME HAVE SURGERY. ]

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 verify our notes 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. Some questions include sensitive topics. You may skip questions or end the interview at any time. You will receive $40 as an incentive for participating 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), WORKSHEET AND SHOWCARDS

• CONSENT FORM (TWO COPIES)

• ENVELOPE WITH $40 CASH

• RECEIPT FORM

• DIGITAL RECORDER AND EXTRA BATTERIES

• PENS AND PENCILS

STEP 1: INFORMED CONSENT

PROVIDE RESPONDENT WITH A COPY OF THE INFORMED CONSENT FORM. ANSWER ANY QUESTIONS THE BENEFICIARY MAY HAVE, AND HAVE THE BENEFICIARY SIGN A SEPARATE FORM.

• SIGNED CONSENT FORM COLLECTED

• IF THE BENEFICIARY HAS 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. I will complete the survey by asking you questions. 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?

COGNITIVE INTERVIEW SURVEY ITEMS AND PROBES

	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? WRITE NAME ON WORKSHEET
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? WRITE NAME ON WORKSHEET
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 (PLACE 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/ PLACE 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 (PLACE 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 (PLACE 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 (PLACE 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 (PLACEFROM 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)/(PLACE NAME FROM Q19)].] [(PROVIDER NAME FROM Q21) often does/The doctors at (PLACE 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 (PLACE 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 (PLACE 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 (PLACE 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 PLACE).] You have great confidence in [(PROVIDER NAME FROM Q21)/the doctors at (PLACE 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 (PLACE 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
	I would like to get a little information about your background. Are you of Hispanic, Latino, 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 IF RACE AT Q49 NCLUDES NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER, GO TO Q51. ELSE GO TO Q52.
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:
	SHOW CARD DI5 [FOR MALE RESPONDENTS] Which of the following best represents how you think about yourself? (01) Gay (02) Straight, that is, not gay (03) Bisexual (04) Something else (05) I don’t know how to answer [FOR FEMALE RESPONENTS] Which of the following best represents how you think about yourself? (01) Lesbian or Gay (02) Straight, that is, not lesbian or gay (03) Bisexual (04) Something else (05) I don’t know how to answer
Probes What did you think about when I asked that question? What did you think about in deciding on your answer? How did you decide on that answer? Can you tell me more about that? Did you have any trouble deciding on that answer? If YES, What were you concerned about? Were there any words that you were uncertain about? Which ones? How did this affect your answer? What does [Bisexual] mean to you? [IF R ANSWERED: SOMETHING ELSE: ] What else would best represent how you think about yourself? [IF R ANSWERED: I don’t know how to answer: ] What makes it difficult for you to answer this question? Note to Interviewers How does the R interpret these questions and decide on their answer? Are there terms or words that cause any confusion? Even if there are words that they were uncertain about how did they decide which answer to give? For example, some respondents may not be sure about “straight” or “bisexual” or “transgendered”. What process did they use to decide which response to give? If they said that “don’t know,” what would they want to know to be able to choose a response? Observations:
	What sex were you assigned at birth, on your original birth certificate? (01) FEMALE (02) MALE
Observations:
	SHOW CARD DI6 How do you describe yourself? (select one) (01) Female (02) Male (03) Transgendered (04) Do not identify as female, male, or transgendered
Probes What did you think about when I asked that question? What did you think about in deciding on your answer? How did you decide on that answer? Can you tell me more about that? Did you have any trouble deciding on that answer? If YES, What were you concerned about? Were there any words that you were uncertain about? Which ones? How did this affect your answer? IF R ANSWERED “Do not identity as female, male, or transgendered”: How do you describe yourself? Is there some other term that you would use? What does [Transgendered] mean to you? Note to Interviewers How does the R interpret these questions and decide on their answer? Are there terms or words that cause any confusion? Even if there are words that they were uncertain about how did they decide which answer to give? For example, some respondents may not be sure about “straight” or “bisexual” or “transgendered”. What process did they use to decide which response to give? If they said that “don’t know,” what would they want to know to be able to choose a response? Observations:
	The next two questions are about education and income. SHOW CARD DI7 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 DI8 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 as an incentive for participating in this survey.

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

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Participant Signature

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