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pdfATTACHMENT B
WEB-BASED NBS INSTRUMENT FOR EXPERIMENT
OMB No. 0960-NEW
Expiration Date: MM/DD/YYYY
NATIONAL BENEFICIARY SURVEY
July 2022
Round 8
Successful Worker Experimental Web Questionnaire
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 0960-NEW. The time required to complete this information collection is estimated to average 25 minutes per response.
NATIONAL BENEFICIARY SURVEY
- TABLE OF CONTENTS -
Contents
SECTION A: SCREENER ........................................................................................................................2
SECTION B: DISABILITY AND CURRENT WORK STATUS .........................................................................6
SECTION C: CURRENT EMPLOYMENT ................................................................................................ 10
SECTION C_B: EMPLOYMENT IN PAST 6 MONTHS.............................................................................. 13
SECTION D: JOBS/OTHER JOBS DURING 2022 .................................................................................... 16
SECTION SC: BENEFIT SUSPENSE ...................................................................................................... 17
SECTION SA: QUESTIONS APPLICABLE TO ALL EXPERIENCING RECENT SUSPENSE .................. 18
SECTION SS: QUESTIONS APPLICABLE TO SUSPENSE SAMPLE MEMBERS IN SUSPENSE AT
INTERVIEW ................................................................................................................................ 19
SECTION SB: QUESTIONS APPLICABLE TO SAMPLE MEMBERS WITH RECENT SUSPENSE
RECEIVING BENEFITS AT INTERVIEW ........................................................................................ 20
SECTION E: AWARENESS OF SSA PROGRAMS .................................................................................... 22
SECTION F: REMOVED FROM THE NBS .............................................................................................. 23
SECTION G: EMPLOYMENT-RELATED SERVICES AND SUPPORTS USED IN 2022 ................................... 24
SECTION H: REMOVED FROM THE NBS.............................................................................................. 27
SECTION I: HEALTH AND FUNCTIONAL STATUS .................................................................................. 28
SECTION J: HEALTH INSURANCE ........................................................................................................ 29
SECTION K: INCOME AND OTHER ASSISTANCE .................................................................................. 30
SECTION L: SOCIODEMOGRAPHIC INFORMATION ............................................................................. 32
SECTION M: CLOSING INFORMATION AND OBSERVATIONS ............................................................... 35
SECTION A: SCREENER
SECTION A: SCREENER
PROGRAMMER: Do not display Section Titles (i.e. “SECTION A: SCREENER”). Do not display question
numbers. Do not display Subsection Titles (i.e., “PROXY INFORMATION: A46 to M2a_PhoneNumber”)
PRELOADED INFORMATION
S1
(A01_a)
CLUSTERED SAMPLE
YES = 01
NO = 00
S9
(A04_b)
FIRSTNAME (original – may be updated in another block: Current First Name)—CREATE NAME
USING FIRSTNAME AND LASTNAME
S10
(A04_c)
LASTNAME (original – may be updated in another block: Current Last Name)
S11
(A04_d)
BIRTHDATE (original – may be updated in another block: Current Birth Date)
S13
(A04_f)
BSTATUS (Benefit Type)
BSTATUS = 01 – SSI ONLY BENEFITS
BSTATUS = 02 – SSDI ONLY BENEFITS
BSTATUS = 03 – CONCURRENT (BOTH SSI AND SSDI) BENEFITS
S14
(A04_g) SSIAGE (from SSI records –age first received SSI benefits)—CREATE SSIAGE FROM DATE OF
BIRTH AND DATE FIRST RECEIVED SSI
S18
(A04_k)
STATE MED (STATE NAME FOR MEDICAID) (based on state of residence at A67a)
S19
(A04_l)
VRNAME (STATE NAME FOR VRA) (based on state of residence at A67a)
S20
(A04_m)
Sample Member’s Address at time sample was drawn (may be updated in Section A)
S21
(A04_n)
Sample Member’s Phone Number at time sample was drawn
SampGrp
Sample Group (Sample Group Type)
SampGrp=01– Representative Beneficiary Sample
SampGrp=02 – Successful Worker Sample
Prepay
Prepay incentive type
01= received $2 prepay incentive
00= did not receive $2 prepay incentive
SECTION A: SCREENER
(All)
A74.
Welcome to the National Beneficary Survey! Recently, you received a letter about the National Beneficary
Survey that Mathematica is conducting for the Social Security Administration. Before we start the survey, we
want to explain some facts about the survey.
The survey asks about your (NAME) health, daily activities, and any jobs you might have.
Taking part in the survey is completely voluntary. Completely voluntary means you can choose whether or not
to take part. If you decide to take part, you can skip any questions you do not like. You can also stop the
survey at any time. Whether you choose to take part or not, your disability benefits will not be affected in any
way.
All your answers will be kept confidential and used only for the research purposes of the study.
The survey will take about 20 minutes and you will receive a $30 gift card after you complete the survey.
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the
Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget (OMB) control number. The OMB control number for this collection is [0960NEW]; expiration date [MM/DD/YYYY].
Do you understand everything above and wish to continue to the survey?
Yes ................................................................... 01 (A66)
No ..................................................................... 00 (Screenout)
(All)
A66.
Before we start, we need to confirm that we reached the right person. Is {NAME} your full name?
PROGRAMMER: DISPLAY SAMPLE MEMBER’S FULL NAME BELOW FROM S8.
Yes ...................................................................
Yes, but my name is now changed ...................
No .....................................................................
No. I’m taking the survey on behalf of {NAME}.
No. I’m taking the survey on behalf of {NAME}
and {NAME}’s name is now changed ...............
01
02
03
04
(A68)
(A67)
(Screenout)
(A46)
05 (A67)
(A66=02, 05)
A67.
For the record, what is {your/NAME’s} new name?
MISSING .................................................................................... m
PROXY INFORMATION: A46 to M2a_PhoneNumber
(A66=04, 05)
A46.
To take the survey for {NAME}, you will answer questions about {NAME’s} health, daily activities, any jobs
they might have, and their use of Social Security programs or services. Is this something you are able to do?
Yes ................................................................... 01 (A13a)
No ..................................................................... 00 (Screenout)
(A46=1)
A13a.
Thank you very much for offering to help by taking the survey for {NAME}. What problem does {NAME} have
that might prevent {him/her} from taking part for {himself/herself}? Please select all that apply.
Hearing difficulty ............................................... 01
Speech difficulty ............................................... 02
SECTION A: SCREENER
Cognitive barrier ...............................................
Physical barrier.................................................
Incarcerated .....................................................
Institutionalized .................................................
Hospitalized ......................................................
Deceased .........................................................
Serving in the military .......................................
Living outside the USA .....................................
MISSING ..........................................................
(A46=1)
M2a_Rlshp. How are you related to {NAME}?
03
04
06
07
08
09
10
11
m
{NAME’S} spouse or partner.......................................................
{NAME’S} mother, father, or legal guardian ................................
{NAME’S} child ...........................................................................
{NAME’s} grandparent ................................................................
{NAME’S} brother or sister .........................................................
Some other relative of {NAME} ...................................................
A friend .......................................................................................
A caseworker, caregiver, or payee .............................................
A staff at a residence home ........................................................
MISSING ....................................................................................
01
02
04
05
06
07
11
12
10
m
(A46=1)
M2a_Name.
And what is your first and last name?
MISSING .................................................................................... m
(A46=1)
M2a_PhoneNumber.
What is your telephone number, area code first? This is your telephone number, not {NAME’s}. We will only
call this number if we need to reach you.
( |__|__|__| ) |__|__|__| - |__|__|__|__| PHONE NUMBER
MISSING .................................................................................... m
(All)
A68.
To help verify {your/NAME’s} identify, we need to make sure {your/NAME’s} date of birth matches our records.
What is {your/NAME’S} date of birth?
| | |/|
MONTH
(1 – 12)
[A68]
| |/|
DAY
(1 – 31)
[A68a]
|
|
| |
YEAR
(1956 – 2001)
[A68b]
ANSWERED ..................................................... 01 (A71)
MISSING .......................................................... m (Screenout)
(A68 = ANSWER)
A71.
PROGRAMMER CHECK BIRTHDATE: IS MONTH, DAY, YEAR OF BIRTH AT A68 = MONTH, DAY, AND
YEAR OF BIRTH ON RECORD (S11)?
NO MATCH ...................................................... 00 (Screenout)
1 MATCHES ..................................................... 01 (Screenout)
2 MATCH.......................................................... 02 (A73a)
3 MATCH.......................................................... 03 (A73a)
SECTION A: SCREENER
(A71=2,3)
A73a. The survey we are conducting is only for people who have worked recently so, we need to know if {you/NAME}
have worked recently.
{Are you/Is NAME} currently working at a job or business for pay or profit?
PROBE: We are interested in both full-time and part-time work for pay or profit
Please note that answering any question is completely voluntary and you can refuse to answer any question.
Whether you choose to answer or not, {your/NAME’s} disability benefits will not be affected in any way, and
we will keep any answers you provide completely confidential.
Yes ...........................................................................................
No .............................................................................................
MISSING ..................................................................................
01
00
m
(B0)
(A73b)
(A73b)
(A73a = 0, m)
A73b. Did {you/NAME} work for pay or profit at any time during the last 6 months?
PROBE: We are interested in both full-time and part-time work for pay or profit.
Yes ............................................................................................. 01
No ............................................................................................... 00
MISSING .................................................................................... m
(B0)
(Screenout)
(Screenout)
(A74=0 or A66=3 or A46=0 or A68=M or A71=0,1 or A73a=0,m or A73b=0,m)
Screenout.
Unfortunately, we need to check something in our records before you can proceed with the survey.
If you would like to call us to discuss, please call Mathematica at [FILL] and ask to discuss the web
survey. Thank you very much.
END.
SECTION B: DISABILITY AND WORK STATUS
SECTION B: DISABILITY AND CURRENT WORK STATUS
DISABILITY STATUS
(All)
B0.
First, we have some questions about how {your/NAME’s} health affects {your/his/her} daily activities.
PRESS NEXT TO CONTINUE
(All)
B1.
Does a physical or mental condition limit the kind or amount of work or other daily activities {you/NAME} can
do?
PROBE 1: In other words, are there things {you/NAME} can’t do as much or can’t do at all that people the
same age can?
PROBE 2: Daily activities include cooking, shopping, getting around the home, paying bills, or working at a
job.
Yes ............................................................................................. 01
No ............................................................................................... 00 (B9)
MISSING .................................................................................... m (B9)
(B1=01)
B2.
What physical or mental condition is the main reason {you are/NAME is} limited?
PROBE 1: By what name do doctors call {your/NAME’s} health condition?
PROBE 2: What causes this condition?
___________________________________________________ (B2a)
MISSING .................................................................................... m (B2a)
(B1=01)
B2a.
How much does this condition limit the kind or amount of work or other daily activities {you/NAME} can do?
Please provide a number from 0 to 100 to answer this. Where 0 is “not at all limiting” and 100 is “cannot do
work or daily activities at all.”
PROBE: If {your/NAME’s} condition varies, your best guess for a typical day is fine.
|
|
|
|
NUMBER FROM 0 TO 100, 0=”NOT AT ALL LIMITING” AND
100=”CANNOT DO WORK OR DAILY ACTIVITIES AT ALL”
(B18_age)
MISSING .................................................................................... m (B18_age)
(B1=00, m)
B9.
{Have you/Has NAME} received disability benefits from Social Security at any time during the last five years?
Yes ............................................................................................. 01 (B12)
No ............................................................................................... 00 (B10)
I don’t know ................................................................................ d (B10)
MISSING .................................................................................... m (B10)
(B9=00, d, m)
B10.
We are only surveying people who have received disability benefits in the past five years. If you would like to
call us to discuss, please call Mathematica at [FILL] and ask to discuss the web survey. Thank you very much.
6
SECTION B: DISABILITY AND WORK STATUS
END SURVEY. DO NOT ALLOW REENTRY OR GOING BACK
TO PRIOR SCREEN.
(B1=00, m and B9=01)
B12.
What physical or mental condition is the main reason {you were/NAME was} eligible for disability benefits?
PROBE 1: By what name do doctors call {your/NAME’s} health condition?
PROBE 2: What causes this condition?
___________________________________________________ (B18_age)
MISSING .................................................................................... m (B18_age)
(B1=01 or B9=01)
B18_age. How old {were you/was NAME} when {you/he/she} first became limited in the kind or amount of work or
other daily activities {you/he/she} could do? Your best estimate is fine.
|
|
| (B24)
AGE
(0-67)
Since Birth .................................................................................. 00 (B24)
I don’t know ................................................................................ d (B24)
MISSING .................................................................................... m (B24)
CURRENT WORK STATUS
(B1=01 or B9=01)
B24.
These next questions are about {your/NAME’s} personal goals and {your/his/her} current work-related
activities. {Are you/Is NAME} currently working at a job or business for pay or profit?
PROBE: We are interested in both full-time and part-time work for pay or profit
Yes ............................................................................................. 01 (B30)
No ............................................................................................... 00 (B24b)
MISSING .................................................................................... m (B24b)
(B24 = 0, m)
B24b. Did {you/NAME} work for pay or profit at any time during the last 6 months?
PROBE: We are interested in both full-time and part-time work for pay or profit.
Yes ............................................................................................. 01 (B28)
No ............................................................................................... 00 (B24c)
MISSING .................................................................................... m (B24c)
(B24b=00, m)
B24c. I’m sorry, we are only surveying people who are working now or worked in the past 6 months. If you would
like to call us to discuss, please dial Mathematica at [FILL] and ask to discuss the web survey. Thank you very
much.
END SURVEY. STATUS ”INELIGIBLE”: 2460. DO NOT
ALLOW REENTRY OR GOING BACK TO PRIOR SCREEN.
(B24=00, m)
B28.
{Have you/Has NAME} been looking for paid work during the last four weeks?
Yes ............................................................................................. 01 (B29_7)
No ............................................................................................... 00 (B25)
MISSING .................................................................................... m (B25)
7
SECTION B: DISABILITY AND WORK STATUS
(B28=1)
B29_7. Next is a list of reasons why people are sometimes unable to find a job. Please let us know if any of these are
reasons why {you/NAME} {have/has} not found a job that {you/he/she} {think/thinks} is right for {you/him/her}.
SELECT ONE
RESPONSE PER ROW
YES
NO
MISSING
a.
{You/NAME} would need special equipment or medical
devices to work which {you do /he does /she does} not have
01
00
m
b.
[You/NAME} [do/does] not have the help [you/he/she]
[need/needs] to get ready for work each day
01
00
m
c.
{You/NAME} cannot get the help {you need/ he needs/ she
needs] to care for children or others
01
00
m
d.
{You/NAME] [do/does] not have reliable transportation to and
from work
01
00
m
e.
Available jobs do not offer a flexible enough schedule
01
00
m
f.
{You/NAME} cannot find a job {you are/he is/she is} qualified
for
01
00
m
g.
Available jobs do not pay enough
01
00
m
h.
Employers will not give {you/NAME} a chance to show that
{you/he/she} can work
01
00
m
i.
Available jobs do not offer health insurance
01
00
m
j.
{You/NAME} would lose benefits like Social Security,
disability insurance, workers’ compensation, or Medicaid if
{you/he/she} took a job
01
00
m
Is there anything else that that is a reason why (you/Name)
(have/has) not been able to find a job?
01
00
m
k.
(B29_7_k=01)
B29_7_k_Oth. What other reasons?
MISSING .................................................................................... m
(B28=00, m)
B25.
Other beneficiaries have said that they are not working for a number of reasons. Next is a list of these reasons.
For each, please select yes if it is a reason why {you are/NAME is} not currently working.
YES
NO
MISSING
a.
A physical or mental health condition prevents
{you/NAME} from working
01
00
m
b.
{You/NAME} cannot find a job that {you are/ he is
/she is} qualified for
01
00
m
c.
{You do/NAME does} not have reliable transportation
to and from work
01
00
m
d.
{You are/NAME is} caring for children or others
01
00
m
8
SECTION B: DISABILITY AND WORK STATUS
f.
{You/NAME} cannot find a job {you want / he wants /
she wants}
01
00
m
g.
{You are/NAME is} waiting to finish school or a
training program
01
00
m
h.
Workplaces are not accessible to people with
{your/NAME’s} disability
01
00
m
i.
{You do/NAME does} not want to lose benefits like
Social Security, disability insurance, workers’
compensation, or Medicaid
01
00
m
j.
{Your/NAME’s} previous attempts to work have been
discouraging
01
00
m
l.
Others do not think {you/NAME} can work
01
00
m
01
00
m
{You/NAME} does not have the special equipment or
medical devices that {you/he/she} would need to
work
01
00
m
{You/NAME} cannot get the help {you need / he
needs / she needs} with personal care. This includes
things like help dressing and bathing to get ready for
work or eating lunch and using the restroom at work.
01
00
m
{You/NAME} cannot get help {you need/he
needs/she needs} with tasks you would do at work.
This includes having someone help you with things
like writing, reading, lifting or reaching.
01
00
m
m. Employers will not give {you/NAME} a chance to
show that {you/he/she} can work
n.
o.
p.
(B28=00, m)
B26.
Are there any other reasons why {you are/NAME is} not working?
Yes ............................................................................................. 01 (B27)
No ............................................................................................... 00 (B30)
MISSING .................................................................................... M (B30)
(B26=01)
B27.
What are the other reasons why {you are/NAME is} not working?
MISSING .................................................................................... m
(B1=01 or B9=01)
B30.
Did {you/NAME} work at a job or business for pay or profit anytime in 2022?
Yes ............................................................................................. 01
No ............................................................................................... 00
MISSING .................................................................................... m
9
SECTION C: CURRENT EMPLOYMENT
SECTION C: CURRENT EMPLOYMENT
(B24=01)
C0.
Now we are going to ask some questions about the jobs {you/NAME} currently {have/has}. When answering
these questions, please include both part-time and full-time jobs, but only include jobs {you hold/NAME
holds} for pay or profit.
PRESS NEXT TO CONTINUE
(B24=01)
C1.
How many jobs {do you/does NAME} currently have?
PROBE: Include both part-time and full-time jobs, but only include jobs {you hold/NAME holds} for pay or
profit.
|__|__| NUMBER OF JOBS (1-15) (C8)
MISSING .................................................................................... m (C_B0)
(B24=01 and C1>=1)
C8.
IF C1>1: [The next few questions are about {your/NAME’s} current job. If {you have/NAME has} more than
one job, please answer about {your/NAME’s} main job – that is, the job at which {you work/(he/she) works}
the most hours.]
How many hours per week {do you/does NAME} usually work at {your / his/her} {current / main} job?
PROBE: Include overtime if {you/he/she} usually {work/works} overtime.
PROBE: If {your/his/hers} hours vary week-to-week, please provide an average or typical amount.
|
|
|
| HOURS PER WEEK (1-168)
MISSING .................................................................................... m
(B24=01 and C1>=1)
C10.
IF C1>1: For the purpose of this survey, it is important to obtain some information on how much {you are/NAME
is} paid on this job. On {your/NAME’s} main job {are you/is (he/she} paid by the hour?
IF C1=1: For the purpose of this survey, it is important to obtain some information on how much {you are/NAME
is} paid on {your/(his/her)} job. On {your/NAME’s} job {are you/is (he/she)} paid by the hour?
Yes ............................................................................................. 01 (C11)
No ............................................................................................... 00 (C12amt)
I don’t know ................................................................................ d (CP3)
I do not want to answer .............................................................. r (CP3)
MISSING .................................................................................... m (CP3)
(C10=01)
C11.
What is {your/NAME’s} regular hourly pay {at {your/NAME’s} main job}, including tips and commissions?
SOFT CHECK: IF LESS THAN $5.00 AN HOUR: Does this include tips and commissions?
$|
(C10=00)
|
|
|.|
|
| PER HOUR (1 - 300.00) (CP3)
I don’t know ................................................................................ d (CP3)
I do not want to answer .............................................................. r (CP3)
MISSING .................................................................................... m (CP3)
10
SECTION C: CURRENT EMPLOYMENT
C12amt.
Before taxes and other deductions how much {are you/is NAME} paid on this job, including tips and
commissions?
$|___|___|___| , |___|___|___| . 00 (C12hop)
(0 – 999,999)
I don’t know ................................................................................ d (C12hop)
I do not want to answer .............................................................. r (C12hop)
MISSING .................................................................................... m (C12hop)
(C10=00)
C12hop. Is that amount how much {you earn / NAME earns} daily, weekly, bi-weekly, twice a month, monthly, or
annually?
$|___|___|___| , |___|___|___| . 00
(0 – 999,999)
Daily ..................................................................... 01 (1-1,922)
Weekly ................................................................. 02 (1-9,615)
Bi-weekly (every two weeks) ................................ 03 (1-20,833)
Twice a month ...................................................... 04 (1-20,833)
Monthly ................................................................ 05 (1-41,666)
Annually .............................................................. 06 (1-500,000)
I don’t know ................................................................................ d
I do not want to answer .............................................................. r
MISSING .................................................................................... m
PROGRAMMER: CALCULATE MONTHLY PRE-TAX PAY BASED ON C12AMT AND C12HOP FOR JOB:
If C10=01, and C11and C8≠d or r, C_JobMnthPay(1)=c11*c8*4.35.
If C10=01 and C8 or C11=d, C_JobMnthPay(1)=d.
If C10=01 and C8 or C11=r and neither are d, C_JobMnthPay(1)=r.
If C10=00, d, or r and C12amt or C12hop=d, C_JobMnthPay(1)=d.
If C10=00, d, or r and C12amt or C12hop=r, and neither are d, C_JobMnthPay(1)=r.
If C10=00, d, or r and c12hop=1, C_JobMnthPay(1)=c12amt*21.74.
If C10=00, d, or r and c12hop=2, C_JobMnthPay(1)=c12amt*4.35.
If C10=00, d, or r and c12hop=3, C_JobMnthPay(1)=c12amt*2.17.
If C10=00, d, or r and c12hop=4, C_JobMnthPay(1)=c12amt*2.
If C10=00, d, or r and c12hop=5, C_JobMnthPay(1)=c12amt.
If C10=00, d, or r and c12hop=6, C_JobMnthPay(1)=c12amt/12.
(C1=>1)
CP3.
Next is a list of things that some people use or receive to help them find or keep a job. Please report if
{you/NAME} used or received any of them to help find or keep working at {your/his/her} {main/current} job. Did
{you/NAME}…
PROGRAMMER: USE “MAIN” IF C1>01, OTHERWISE USE “CURRENT.”
a.
…have a job coach to help {you/him/her} learn how
to do {your/his/her} job?
YES
NO
NOT
APPLICABLE
MISSING
01
00
02
m
11
SECTION C: CURRENT EMPLOYMENT
YES
NO
NOT
APPLICABLE
MISSING
b.
…use a sign language interpreter?
01
00
02
m
c.
…use a reader or interpreter for the blind?
01
00
02
m
d.
…use an assistant or caregiver for personal care?
This includes help bathing and dressing to get ready
for work and eating lunch or using the restroom at
work.
01
00
02
m
e. …use a personal care assistant or direct support
professional at work to help with job-related tasks?
This includes help with writing, reading, lifting, or
reaching.
01
00
02
m
f.
…receive on the job training?
01
00
02
m
g.
…receive counseling about how work will affect your
benefits?
01
00
h.
…receive help with transportation?
01
00
02
m
i.
…receive help with child or family care?
01
00
02
m
j.
… use special equipment or devices?
01
00
02
m
02
m
(C1=>1)
CP9a.
At this job, do most of the other workers have disabilities?
Yes ............................................................................................. 01
No ............................................................................................... 00
I don’t know ................................................................................ d
MISSING .................................................................................... m
(C1=>1)
CP9b.
Could this job have been taken by anybody who applied for it and was qualified, including someone who
does not have a disability?
Yes ............................................................................................. 01
No ............................................................................................... 00
I don’t know ................................................................................ d
MISSING .................................................................................... m
(C1=>1)
C12amtALL.
IF C1>1: Now, thinking about all the jobs {you/NAME} currently have, how much did {you/he/she}
earn from all of these jobs in the last month in total, before taxes and deductions?
IF C1=1: Now, thinking about the last month, how much did {you/he/she} earn from your job in the
last month in total, before taxes and deductions?
$|___|___|___| , |___|___|___| . 00
(0 – 99,999)
I don’t know ................................................................................ d
I do not want to answer .............................................................. r
MISSING .................................................................................... m
12
SECTION C_B: EMPLOYMENT IN PAST 6 MONTHS
SECTION C_B: EMPLOYMENT IN PAST 6 MONTHS
NOTE: This section asked of those working in the past 6 months but not currently working (B24=00 and
B24b=01)
(B24=00 and B24b=01)
C_B0. Now we are going to ask some questions about the jobs {you/NAME} had during the last 6 months. When
answering these questions, please include both part-time and full-time jobs, but only include jobs {you
/NAME} held for pay or profit.
PRESS NEXT TO CONTINUE
(B24=00 and B24b=01)
C_B1. How many jobs did {you/NAME} have during the past 6 months?
PROBE: Please include both part-time and full-time jobs, but only include jobs {you /NAME} held for pay or
profit.
|__|__| NUMBER OF JOBS (1-15)
MISSING .........................................................................
m (D0)
(C_B1=>1)
C_B8. IF C_B1>1: The next few questions are about {your/NAME’s} main job held in the past six months – that is,
the job at which {you work/(he/she) works} the most hours.
How many hours per week did {you/NAME} usually work at this job?
PROBE: Include overtime if {you/he/she} usually worked overtime.
PROBE: If {your/his/hers} hours vary week-to-week, please provide an average or typical amount.
|
|
|
| HOURS PER WEEK (1-60)
(1-168)
MISSING .................................................................................... m
(C_B1=>1)
C_B10. IF C_B1>1: For the purpose of this survey, it is important to obtain some information on how much {you
were/NAME was} paid for this job. For {your/NAME’s} main job {you/he/she} held in the past six months {were
you/was (he/she} paid by the hour?
IF C_B1=1: For the purpose of this survey, it is important to obtain some information on how much {you
were/NAME was} paid for {your/(his/her)} job. For {your/NAME’s} job {were you/was (he/she} paid by the
hour?
Yes ............................................................................................. 00 (C_B11)
No ............................................................................................... 00 (C_B12amt)
I don’t know ................................................................................ d (C_BP3)
I do not want to answer .............................................................. r (C_BP3)
MISSING .................................................................................... m (C_BP3)
(C_B10=01)
C_B11. What was {your/NAME’s} regular hourly pay, including tips and commissions?
SOFT CHECK: IF LESS THAN $5.00 AN HOUR: Did this include tips and commissions?
$|
|
|
|.|
|
| PER HOUR (1 – 25.00) (1 - 300.00)
I don’t know ................................................................................ d (C_BP3)
I do not want to answer .............................................................. r (C_BP3)
MISSING .................................................................................... m (C_BP3)
13
SECTION C_B: EMPLOYMENT IN PAST 6 MONTHS
(C_B10=00)
C_B12amt.
Before taxes and other deductions how much {were you/was NAME} paid on this job, including tips
and commissions.
PROBE:
Was that amount paid daily, weekly, bi-weekly, twice a month, monthly, or annually?
$| | | |.|
(0 – 999,999)
|
|
| . 00
I don’t know ................................................................................ d
I do not want to answer .............................................................. r
MISSING .................................................................................... m
(C_B10=00)
C_B12hop.
Is that amount how much {you earned / NAME earned} daily, weekly, bi-weekly, twice a month,
monthly, or annually?
Daily .....................................................................
Weekly .................................................................
Bi-weekly (every two weeks) ................................
Twice a month ......................................................
Monthly.................................................................
Annually ...............................................................
I don’t know ..........................................................
I do not want to answer ........................................
MISSING ..............................................................
01
02
03
04
05
06
d
r
m
(1-1,922)
(1-9,615)
(1-20,833)
(1-20,833)
(1-41,666)
(1-500,000)
PROGRAMMER: CALCULATE MONTHLY PRE-TAX PAY BASED ON C_B12AMT AND C12HOP FOR EACH JOB:
If C_B10=01, and C_B11and C_B8≠d or r, C_B _JobMnthPay(1)=c_B11*c_B8*4.35.
If C_B10=01 and C_B8 or C_B11=d, C_B_JobMnthPay(1)=d.
If C_B10=01 and C_B8 or C_B11=r and neither are d, C_B_JobMnthPay(1)=r.
If C_B10=00, d, or r and C_B12amt or C_B12hop=d, C_B_JobMnthPay(1)=d.
If C_B10=00, d, or r and C_B12amt or C_B12hop=r, and neither are d, C_B_JobMnthPay(1)=r.
If C_B10=00, d, or r and c_B12hop=1, C_B_JobMnthPay(1)=c_B12amt*21.74.
If C_B10=00, d, or r and c_B12hop=2, C_B_JobMnthPay(1)=c_B12amt*4.35.
If C_B10=00, d, or r and c_B12hop=3, C_B_JobMnthPay(1)=c_B12amt*2.17.
If C_B10=00, d, or r and c_B12hop=4, C_B_JobMnthPay(1)=c_B12amt*2.
If C_B10=00, d, or r and c_B12hop=5, C_B_JobMnthPay(1)=c_B12amt.
If C_B10=00, d, or r and c_B12hop=6, C_B_JobMnthPay(1)=c_B12amt/12.
(C_B1=>1)
C_BP3. Next is a list of things that some people use or receive to help them find or keep a job. Please report if
{you/NAME} used or received each to help find or work at {your/his/her} [main] job. Did {you/NAME}…
PROGRAMMER: USE “MAIN” IF C_B1>01.
14
SECTION C_B: EMPLOYMENT IN PAST 6 MONTHS
YES
NO
NOT
APPLICABLE
MISSING
01
00
02
m
a.
…have a job coach to help {you/him/her} learn how
to do {your/his/her} job?
b.
…use a sign language interpreter?
01
00
02
m
c.
…use a reader or interpreter for the blind?
01
00
02
m
d.
…use an assistant or caregiver for personal care?
This includes help bathing or dressing to get ready for
work and eating lunch or using the restroom at work.
01
00
02
m
e. …use a personal care assistant or direct support
professional at work to help with job-related tasks?
This includes help with writing, reading, lifting, or
reaching.
01
00
02
m
f.
…receive on the job training?
01
00
02
m
g.
…receive counseling about how work will affect your
benefits?
01
00
02
m
h.
…receive help with transportation?
01
00
02
m
i.
…receive help with child or family care?
01
00
02
m
j.
… use special equipment or devices?
01
00
02
m
(C_B1=>1)
C_BP9a. At this job, do most of the other workers have disabilities?
Yes ............................................................................................. 01
No ............................................................................................... 00
I don’t know ................................................................................ d
MISSING .................................................................................... m
(C_B1=>1)
C_BP9b. Could this job have been taken by anybody who applied for it and was qualified, including someone who
does not have a disability?
Yes ............................................................................................. 01
No ............................................................................................... 00
I don’t know ................................................................................ d
MISSING .................................................................................... m
(C_B1=>1)
C_B40. CHECK: WAS {NAME} WORKING IN 2022 (B30 = 01)?
YES .................................................................................
NO ...................................................................................
15
01
00
(D0)
(SC1CHECK)
SECTION D: JOBS/OTHER JOBS DURING 2022
SECTION D: JOBS/OTHER JOBS DURING 2022
(B30=01)
D0.
Now, we will ask you about jobs {you/NAME} had during 2022. When answering these questions, please
include both part-time and full-time jobs, but only include jobs {you/NAME} held for pay or profit for one
month or longer.
PRESS NEXT TO CONTINUE
(B30=01)
D1.
Other than (your/NAME’s) jobs that you already reported, in 2022 did {you/NAME} work for pay at any other
jobs for longer than a month?
Yes ............................................................................................. 01 (D1a)
No ............................................................................................... 00 (SC1Check1)
MISSING .................................................................................... m (SC1Check1)
(D1=1)
D1a.
Thinking about the job(s) {you/NAME} had during 2022, not including any job(s) you already reported, how
much did {you/he/she} earn from all of these jobs during 2022, before taxes and deductions?
$|___|___|___| , |___|___|___| . 00
(0 – 999,999)
I don’t know ................................................................................ d
I do not want to answer .............................................................. r
MISSING .................................................................................... m
GO TO SC1CHECK1
16
SECTION SC: BENEFIT SUSPENSE
SECTION SC: BENEFIT SUSPENSE
SC1CHECK:
IS {NAME} CURRENTLY WORKING, WORKED IN PAST 6 MONTHS, WORKED IN 2022 (B24=01 OR B24b=01 OR
B30=01)
YES ............................................................................................ 01 (SC0)
NO .............................................................................................. 00 (G0)
(SC1CHECK=01)
SC0.
Next, we would like to ask you about {your/NAME’s} experiences working and how working has affected
{your/NAME’s} cash disability benefits.
PRESS NEXT TO CONTINUE
(SC1CHECK=01)
SC1.
During the past year, did {you/NAME} ever stop receiving cash disability benefits for a time because {you
were/he was/she was} working?
PROBE:
This includes stopping cash benefits because {you were/he was/she was} earning too much or
working too many hours.
Yes. ............................................................................................ 01 (SC2)
No................................................................................. .............. 00 (G0)
I don’t know. ............................................................................... d (G0)
MISSING................................................................................ ..... m (G0)
(SC1=01)
SC2. {Are you/Is NAME} currently receiving cash disability benefits?
Yes. ............................................................................................ 01 (SA7)
No................................................................................. .............. 00 (SC3)
I don’t know. ............................................................................... d (SC3)
MISSING................................................................................ ..... m (SC3)
(SC2 =00, d, m)
SC3.
{Are you/Is NAME} in the process of getting back on cash disability benefits?
Yes. ............................................................................................ 01 (SA7)
No................................................................................. .............. 00 (SA7)
I don’t know. ............................................................................... d (SA7)
MISSING................................................................................ ..... m (SA7)
17
SECTION SA: QUESTIONS APPLICABLE TO ALL EXPERIENCING RECENT SUSPENSE
SECTION SA: QUESTIONS APPLICABLE TO ALL EXPERIENCING RECENT SUSPENSE
(SC1=01)
We would like to ask you about the work that led to {you /his/her} cash benefits ending.
SA7.
Did {you/NAME} know when {you/he/she} started working or earning more that {you/he/she} would stop
receiving cash disability benefits from Social Security?
Yes. ............................................................................................ 01 (SA8CHECK)
No................................................................................. .............. 00 (SA8)
I don’t know. ............................................................................... d (SA8CHECK)
MISSING .................................................................................... m (SA8CHECK)
(SA7=00)
SA8.
If {you/NAME} had known that {you were/ he was / she was} going to stop receiving cash benefits, would
{you/he/she} still have started working or earning more?
Yes. ............................................................................................ 01
No................................................................................. .............. 00
I don’t know. ............................................................................... d
MISSING .................................................................................... m
SA8CHECK:
IS {NAME} STILL IN SUSPENSE AND NOT IN PROCESS OF GETTING BACK ON BENEFITS: SC2=00 AND
SC3=00?
YES ............................................................................................ 01 (SS2)
NO .............................................................................................. 00
IS {NAME} STILL RECEIVING BENEFITS SC2=01 OR IN PROCESS OF GETTING BACK ON BENEFITS
(SC3=01)?
YES ............................................................................................ 01 (SB1)
NO .............................................................................................. 00 (G0)
18
SECTION SS: QUESTIONS APPLICABLE TO SUSPENSE SAMPLE MEMBERS IN SUSPENSE AT INTERVIEW
SECTION SS: QUESTIONS APPLICABLE TO SUSPENSE SAMPLE MEMBERS IN SUSPENSE AT INTERVIEW
(SC2=00 AND SC3=00)
SS2.
Next we will ask you about things that might make {you/NAME} have to go back on cash disability benefits in
the future.
{Are you/Is NAME} likely to go back on cash disability benefits because of…
YES
NO
I DON’T
KNOW
MISSING
a. {Your/his/her} health, for example because of
worsening illness or the need to go to medical
appointments?
01
00
d
m
b. {Your/His/Her} job, for example because of a need for
accommodations or problems with {your/his/her} coworkers?
01
00
d
m
c. {Your/His/Her} personal circumstances, for example
because {you need/he needs/she needs} child care,
{do/does} not have reliable transportation, or
{worry/worries} about losing other benefits?
01
00
d
m
PROGRAMMER NOTE: IF SS2a= 0,D,M and SS2b=00,D,M and SS2c=00, D, M, GO TO G0.
IF SS2a= 1, GO TO SS2a_1.
IF SS2b= 1, GO TO SS2b_1.
IF SS2c= 1, GO TO SS2c_1.
PROGRAMMER NOTE: SS2a_1 SHOULD BE ASKED IMMEDIATELY AFTER SS2a IF =YES. THEN CYCLE
BACK TO SS2b.
(SS2a=01)
SS2a_1. What about {your/NAME’s} health makes {you/NAME} think {you/he/she} might go back on benefits?
Other (SPECIFY)
MISSING .........................................................................
m
PROGRAMMER NOTE: SS2b_1SHOULD BE ASKED IMMEDIATELY AFTER SS2b IF =YES. THEN CYCLE
BACK TO SS2c.
(SS2b=01)
SS 2b_1. What is it about {your/NAME’s} job that makes {you/NAME} think {you/he/she} might go back on benefits?
Other (SPECIFY)
MISSING .........................................................................
m
PROGRAMMER NOTE: SS2c_1 SHOULD BE ASKED IMMEDIATELY AFTER SS2c IF =YES.
(SS2c=01)
SS 2c_1. What is it about {your/NAME’s} personal circumstances that makes {you/NAME} think {you/he/she} might
go back on benefits?
Other (SPECIFY)
MISSING .........................................................................
GO TO SECTION G.
19
m
SECTION SB: QUESTIONS APPLICABLE TO SAMPLE MEMBERS WITH RECENT SUSPENSE RECEIVING BENEFITS AT
INTERVIEW
SECTION SB: QUESTIONS APPLICABLE TO SAMPLE MEMBERS WITH RECENT SUSPENSE RECEIVING
BENEFITS AT INTERVIEW
Earlier you reported that {you are/NAME is} {back on benefits/in the process of getting back} on benefits].
(SC2=01) or (SC3=01)
SB1.
{Did you go/are you going/Did NAME go/Is NAME going} back on benefits because of . . .
YES
NO
I DON’T
KNOW
MISSING
a. {Your/His/Her} health, for example because of
worsening illness or the need to go to medical
appointments?
01
00
d
M
b. {Your/His/Her} job, for example because of the need
for accommodations or problems with {your/his/her}
co-workers?
01
00
d
M
c. {Your/His/Her} personal circumstances, for example
because {you need/he needs/she needs} child care,
{do/does} not have reliable transportation, or
{worry/worries} about losing other benefits?
01
00
d
m
PROGRAMMER NOTE: IF SB1a= 0,D,M and SB1b=00,D,M and SB1c=00,D,M, GO TO SB3.
IF SB1a= 1, GO TO SB1a_1.
IF SB1b= 1, GO TO SB1b_1.
IF SB1c= 1, GO TO SB1c_1.
PROGRAMMER NOTE: SB1a_1 SHOULD BE ASKED IMMEDIATELY AFTER SB1a IF =YES. THEN CYCLE
BACK TO SB1b.
(SB1a=01)
SB1a_1.
What was it about {your/NAME’s} health that made {you/him/her} have to go back on benefits?
Other (SPECIFY)
MISSING .........................................................................
m
PROGRAMMER NOTE: SB1b_1 SHOULD BE ASKED IMMEDIATELY AFTER SB1b IF =YES. THEN CYCLE BACK
TO SB1c.
(SB1b=01)
SB1b_1. What was it about {your/NAME’s} job that made {you/him/her} have to go back on benefits?
Other (SPECIFY)
MISSING .........................................................................
m
PROGRAMMER NOTE: SB1c_1 SHOULD BE ASKED IMMEDIATELY AFTER SB1c IF =YES.
(SB1c=01)
SB1c_1. What was it about {your/NAME’s} personal circumstances that made {you/him/her} have to go back on
benefits?
Other (SPECIFY)
MISSING .........................................................................
m
20
SECTION SB: QUESTIONS APPLICABLE TO SAMPLE MEMBERS WITH RECENT SUSPENSE RECEIVING BENEFITS AT
INTERVIEW
(SC2=01) or (SC3=01)
SB3.
Is there anything that could have helped {you/NAME} to keep working and earning enough to stay off
benefits?
Yes ..................................................................................
No....................................................................................
I don’t know .....................................................................
MISSING .........................................................................
01
00
d
m
(SB4)
(SB4)
(SB4)
(SB3=1)
SB3a_oth. What things might have helped {you/NAME} keep working and earning enough to stay off benefits?
Other (SPECIFY)
MISSING .........................................................................
m
(SC2=01) or (SC3=01)
IF B24=01 (currently working), fill “work and earn enough to stay off benefits”
ELSE, fill “go back to work”
SB4.
{Do you/Does NAME} think {you/he/she} will {go back to work / work and earn enough to stay off benefits} in
the future?
Yes ......................................................................................... 01 (G0)
No ........................................................................................... 00 (G0)
I don’t know .............................................................................. d (G0)
MISSING ................................................................................. m (G0)
21
SECTION E: AWARENESS OF SSA PROGRAMS
SECTION E: AWARENESS OF SSA PROGRAMS
(SECTION REMOVED FOR WEB SURVEY EXPERIMENT)
22
SECTION F: REMOVED FROM THE NBS
23
SECTION G: EMPLOYMENT-RELATED SERVICES AND SUPPORTS USED IN 2022
SECTION G: EMPLOYMENT-RELATED SERVICES AND SUPPORTS USED IN 2022
SERVICE PROVIDERS
(All)
G0.
Next, we will ask about different types of services that people with disabilities sometimes get in order to
improve their ability to work or live independently. Please think only about services {you/NAME} received in
2022.
PRESS NEXT TO CONTINUE
(All)
G2.
First, we will ask about employment services {you/NAME} may have received.
In 2022, did {you/he/she} receive:
YES
NO
NOT
APPLICABLE
MISSING
a. a work or job assessment to
determine if a job is a good fit for
{you/him/her}?
01
00
02
m
b. help to find a job?
01
00
02
m
01
00
02
m
01
00
02
m
01
00
02
m
c.
advice about modifying
{your/his/her} job or work place?
d. job coaching or support services?
e. any other employment services to
help {you/NAME} get a job?
(G2_e=01)
G2_oth.
Please specify what other employment services {you/NAME} received in 2022.
MISSING .................................................................................... m
(All)
G11. Sometimes people get training to help them learn new skills so they can get a new job or change careers. In
2022, did {you/he/she} receive:
a. training to learn a new job or skill?
b. on-the-job training?
c.
any other training or certification to
help {you/NAME} learn new skills or
get a job?
YES
01
NO
00
NOT
APPLICABLE
02
MISSING
m
01
00
02
m
01
00
02
m
(G11c = 01)
G11_oth.
Please specify what other trainings or certifications {you/NAME} received in 2022.
MISSING .................................................................................... m
24
SECTION G: EMPLOYMENT-RELATED SERVICES AND SUPPORTS USED IN 2022
(All)
G23.
At any time in 2022, did {you/ NAME} enroll in school or take any classes to help {you/him/her} get a new job
or change careers? Please do not include any training you already reported.
PROBE:
This could include vocational training in high school, college classes, or other instructional
programs.
Yes ................................................................................ 01
No.................................................................................. 00
MISSING ....................................................................... m
(All)
G16. Sometimes people with disabilities receive medical services to improve their ability to work or help them live
independently. Some examples of these services are physical therapy, surgery, and help getting special
equipment or devices. In 2022, did {you/he/she} receive:
NOT
APPLICABLE MISSING
YES
NO
a. Physical therapy?
01
00
02
m
b. Occupational therapy?
This treatment helps people gain independence
and can include home and job site evaluations,
skills assessments, equipment, and other
treatment to help improve a person’s ability to
perform daily activities
01
00
02
m
c.
01
00
02
m
01
00
02
m
01
00
02
m
01
00
02
m
Speech therapy?
d. Special equipment or devices?
e. Prescription drugs?
f.
(G16f=01)
G16_oth.
These are drugs prescribed by a doctor and
do not include over-the-counter drugs.
Any other medical services to improve
{your/NAME’s} ability to work or live
independently?
Please specify what other medical services {you/NAME} received in 2022.
MISSING .................................................................................... m
(All)
G20.
Sometimes people go to a mental health professional to get therapy or counseling to improve their ability to
work or live independently. In 2022, did {you/he/she} receive:
YES
NO
NOT
APPLICABLE
MISSING
a. Personal counseling or therapy?
01
00
02
m
b. Group therapy?
01
00
02
m
01
00
02
m
c.
Any other mental health services to
help {you/NAME} work or live
independently?
25
SECTION G: EMPLOYMENT-RELATED SERVICES AND SUPPORTS USED IN 2022
(G20c=01)
G20_oth.
Please specify what other mental health services {you/NAME} received in 2022.
MISSING .................................................................................... m
26
SECTION H: REMOVED FROM THE NBS
27
SECTION I: HEALTH AND FUNCTIONAL STATUS
SECTION I: HEALTH AND FUNCTIONAL STATUS
(All)
I0.
The next set of questions are about {your/NAME’s} health and everyday activities.
PRESS NEXT TO CONTINUE
(All)
I1.
(All)
I17b.
Overall, how would you rate {your/NAME’s} health during the past 4 weeks?
Excellent, ....................................................................................
Very good, ..................................................................................
Good,..........................................................................................
Fair, ............................................................................................
Poor, or.......................................................................................
Very poor ....................................................................................
MISSING ....................................................................................
01
02
03
04
05
06
m
{Are you/Is NAME} blind or do {you/ does he/she} have serious difficulty seeing even when wearing
glasses?
Yes ............................................................................................. 01
No ............................................................................................... 00
MISSING .................................................................................... m
(All)
I21.
{Are you/is NAME} deaf or do {you/he/she} have serious difficulty hearing?
Yes ............................................................................................. 01
No ............................................................................................... 00
MISSING .................................................................................... m
(All)
I29.
{Do you/Does NAME} have serious difficulty walking or climbing stairs?
Yes ............................................................................................. 01
No ............................................................................................... 00
MISSING .................................................................................... m
(All)
I47.
(All)
I51.
Because of a physical, mental, or emotional condition, {do you/does NAME} have difficulty doing errands alone
such as visiting a doctor’s office or shopping?
Yes ............................................................................................. 01
No ............................................................................................... 00
MISSING .................................................................................... m
{Do you/Does NAME} have difficulty dressing or bathing?
Yes ............................................................................................. 01
No ............................................................................................... 00
MISSING .................................................................................... m
(All)
I59.
Because of a physical, mental, or emotional condition, {do you/does NAME} have serious difficulty
concentrating, remembering, or making decisions?
Yes ............................................................................................. 01
No ............................................................................................... 00
MISSING .................................................................................... m
28
SECTION J: HEALTH INSURANCE
SECTION J: HEALTH INSURANCE
(All)
J0.
Next are some questions about different types of health insurance coverage {you/NAME} might have.
PRESS NEXT TO CONTINUE
(All)
J1.
{Are you/Is NAME} currently covered by any type of health insurance plan, either private or government,
inlcuidng Medicare or Medicaid?
PROBE: Medicare is health insurance coverage provided nationally to certain disabled people under age 65,
including Social Security Disability Insurance beneficiaries that have been receiving benefits for more than 24
months.
Yes ............................................................................................. 01 (J9)
No ............................................................................................... 00 (K1)
MISSING .................................................................................... m (K1)
(J1=01)
J9.
What kinds of health insurance coverage {do you/does NAME} have?
HOVER OVER DEFINITION:
Medicaid is a state medical assistance program that serves low-income
people and Social Security Income recipients with disabilities.
HOVER OVER DEFINITION:
Medicare is health insurance coverage provided nationally to certain
disabled people under age 65, including Social Security Disability
Insurance beneficiaries that have been receiving benefits for more than
24 months.
HOVER OVER DEFINITION:
TRICARE is a managed health care program for active duty and retired
members of the uniformed services, their families and survivors’.
HOVER OVER DEFINITION:
Private insurance includes health insurance that {you get/(he/she) gets}
through an employer, a family member, or that {you purchase/(he/she)
purchases} on {your/his/her} own including private insurance through the
Affordable Care Act, sometimes called HealthCare.gov or ObamaCare.
Medicaid/{STATEMED} ............................................................................
Medicare...................................................................................................
Tricare, VA, or other military insurance ....................................................
Indian Health Service ...............................................................................
Medi-gap insurance ..................................................................................
A state program ........................................................................................
Private insurance through {your/his/her} own employer ...........................
Private insurance through {your/his/her} spouse, partner, or parent ........
Private insurance that {you pay/he pays/she pays} for by
{yourself/himself/herself} or that {your/his/her} family pays for ..........
Some other kind of insurance plan (SPECIFY) ........................................
MISSING ..................................................................................................
01
02
03
04
05
06
07
08
09 (K1)
10 (J9_Other)
m (K1)
(J7=00 and J8=00 and J9=10)
J9_Other. What is the other kind of insurance plan?
MISSING .................................................................................... m
29
(K1)
(K1)
(K1)
(K1)
(K1)
(K1)
(K1)
(K1)
SECTION K: INCOME AND OTHER ASSISTANCE
SECTION K: INCOME AND OTHER ASSISTANCE
(All)
K1.
The next set of questions is about income {you/NAME} received last month, that is, in [INSERT LAST MONTH,
THIS YEAR]. This includes earnings from work and benefits from different programs. When answering these
questions, please think only about {your/NAME’s} own earnings and benefits, and don’t include earnings or
benefits that other family members may have received.
PRESS NEXT TO CONTINUE
(All)
K4.
Thinking about the benefits {you/NAME} received last month, did {you/he/she} receive any income from Social
Security?
Yes ............................................................................................. 01
No ............................................................................................... 00
MISSING .................................................................................... m
(All)
K6.
Last month did {you/NAME} receive any income from…
YES
NO
MISSING
a.
Private disability insurance (sometimes called longterm disability insurance)?
01
00
m
b.
Workers’ compensation?
01
00
m
c.
Veterans’ benefits?
01
00
m
d.
Public assistance or welfare payments?
PROBE: Please include any payments from the
Temporary Assistance for Needy Families, or TANF,
program or any public assistance payments from
your state.
01
00
m
e.
Unemployment benefits?
01
00
m
f.
Pensions or retirement income?
01
00
m
g.
Other sources on a regular basis but not from jobs
or Social Security? Do not count food stamps here.
01
00
m
(K6_g_oth)
m
(K6_h_oth)
PROBE: Examples include child support, interest
from savings or checking accounts, or dividends?
h.
Other sources not on a regular basis?
01
00
(K6_g=01)
K6_g_oth What were the other sources of income {you/NAME} received on a regular basis?
MISSING .................................................................................... m
(K6_h=01)
K6_h_oth What were the other sources of income {you/NAME} received, not on a regular basis?
MISSING .................................................................................... m
30
SECTION K: INCOME AND OTHER ASSISTANCE
(ALL)
K3.
Thinking about all of the income {you/he/she} received last month from benefits and jobs, how much income
did {you/he/she} receive last month, that is, in [INSERT LAST MONTH, THIS YEAR] before taxes and
deductions?
$|___|___| , |___|___|___| . 00
(0 – 12,500)
(0 – 40,000)
I don’t know ................................................................................ d
I do not want to answer .............................................................. r
MISSING .................................................................................... m
31
SECTION L: SOCIODEMOGRAPHIC INFORMATION
SECTION L: SOCIODEMOGRAPHIC INFORMATION
(All)
L0.
We have a few more questions about {you/NAME}.
PRESS NEXT TO CONTINUE
(All)
L1.
What is {your/NAME’s} ethnic background? {Are you/Is (he/she)}:
Hispanic or Latino, or.................................................................. 01
Not Hispanic or Latino? .............................................................. 02
I do not wish to answer this ........................................................ r
MISSING .................................................................................... m
(All)
L2.
What is {your/NAME’s} race? {Are you/Is (he/she)}:
Alaska Native or American Indian,..............................................
Asian, .........................................................................................
Black or African American, .........................................................
Native Hawaiian or Other Pacific Islander, or .............................
White ..........................................................................................
I do not wish to answer this ........................................................
MISSING ....................................................................................
(All)
L3.
01
02
03
04
05
r
m
What is the highest year or grade {you/NAME} finished in school?
Never attended school ................................................................................. 10
Did not complete high school / Do not have a general education
development degree (GED) ......................................................................... 01
HIGH SCHOOL GRADUATE
General edication development degree (GED) ............................................ 02
High school diploma ..................................................................................... 03
High school certificate of completion ............................................................ 04
COLLEGE OR SOME COLLEGE
Some college courses .................................................................................. 05
A 2-year or 3-year college degree (associates degree) or a vocational
school diploma ............................................................................................. 06
A 4-year college degree (Bachelor’s) ........................................................... 07
GRADUATE SCHOOL OR SOME GRADUATE SCHOOL
Some graduate courses .............................................................................. 08
A graduate or professional degree (e.g., MA, MBA, Ph.D., J.D., M.D.) ........ 09
I do not wish to answer this ..........................................................................
MISSING ......................................................................................................
(All)
L8.
r
m
{Are you/Is NAME} now married, partnered (but not married), widowed, divorced, separated, or {have you/has
(he/she)} never been married?
Married ....................................................................................... 01
{I have/NAME has} a partner but {we/they} are not married ....... 06
Widowed ..................................................................................... 02
32
SECTION L: SOCIODEMOGRAPHIC INFORMATION
Divorced .....................................................................................
Separated ...................................................................................
Never married .............................................................................
I do not wish to answer this ........................................................
MISSING ....................................................................................
(All)
L16.
03
04
05
r
m
How many adults 18 years of age or older live in {your/NAME’s} household, including {yourself/NAME}?
PROBE: This includes all adults who usually live there, even if they are temporarily away on business,
vacation, in a hospital, away at school or on military duty.
PROBE: If {you live/NAME lives} in a group home, halfway house, care home, assisted living facility, or some
other type of group residence, only count {yourself/NAME}.
|__|__| ADULTS
(All)
L17.
(1-4)
(1-20)
I don’t know ................................................................................ d
MISSING .................................................................................... m
How many children under 18 years of age live in {your/NAME’s} household?
PROBE: This includes all children who usually live there, even if they are temporarily away on vacation, in a
hospital, or away at school.
|__|__| CHILDREN
(0-6)
(0-20)
No children in {my/NAME’s} household ...................................... 0
I don’t know ................................................................................ d
MISSING .................................................................................... m
(All)
LP23.
{Have you/Has NAME} ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard?
Yes ............................................................................................. 01
No ............................................................................................... 00
MISSING .................................................................................... m
(All)
L23Aamt. What was the total combined income of all members of {your/NAME’s} household in 2022, before taxes or
other deductions? Please include money all members of {your/NAME’s} household received from all
sources.
PROBE: Your best estimate is fine.
$|___|___|___| , |___|___|___| . 00 AMOUNT PER YEAR
(10,000-75,000)
(0-500,000)
I don’t know ................................................................................ d (M1)
I do not wish to answer this ........................................................ m (M1)
MISSING .................................................................................... m (M1)
33
SECTION L: SOCIODEMOGRAPHIC INFORMATION
(All)
B23_2. How often {do you/does NAME} access the Internet?
Probe: This includes accessing the Internet by computer, smart phone, tablet, or any other means.
Never ..........................................................................................
Daily ...........................................................................................
A few times a week.....................................................................
Once a week...............................................................................
Less than once a week ...............................................................
MISSING ....................................................................................
34
01
02
03
04
05
m
SECTION M: CLOSING INFORMATION AND OBSERVATIONS
SECTION M: CLOSING INFORMATION AND OBSERVATIONS
(All)
M1.
PROGRAMMER:
IF WE HAVE ADDRESS AND PHONE NUMBER FROM THE PRELOADED
INFORMATION DISPLAY THAT ADDRESS AND PHONE NUMBER.
That concludes this survey. Can you please verify {your/NAME’S} current contact information? We will send
you a $30 gift card to this address.
STREET ADDRESS 1: {FIRST LINE OF ADDRESS FROM PRELOADED INFORMATION}
STREET ADDRESS 2: {SECOND LINE OF ADDRESS FROM PRELOADED INFORMATION}
STREET ADDRESS 3: {THIRD LINE OF ADDRESS FROM PRELOADED INFORMATION}
CITY OR TOWN: {CITY OR TOWN FROM PRELOADED INFORMATION}
STATE: {STATE FROM PRELOADED INFORMATION}
ZIP CODE: {ZIP CODE FROM PRELOADED INFORMATION}
TELEPHONE NUMBER: {TELEPHONE NUMBER FROM SCREENER OR PRELOADED INFORMATION}
All information here is correct ..................................................... 00 (M11_Thanks)
Some or all of this is incorrect or missing ................................... 01 (M1_Address)
MISSING .................................................................................... m (M1_Address)
(M1=01)
M1_Address1.
ADDRESS: {DISPLAY ENTIRE ADDRESS FROM SCREENER OR PRELOADED INFORMATION WITH
LINE 1 BOLD}
What is {your/NAME’s} correct street address?
The above information is correct ................................................
MISSING ....................................................................................
1
r
(M1=01)
M1_Address2.
ADDRESS: {DISPLAY ENTIRE ADDRESS FROM SCREENER OR PRELOADED INFORMATION WITH
LINE 2 BOLD}
What is {your/NAME’s} correct second part of the street address?
The above information is correct ................................................ 1
There is no second part of the street address ............................ 2
MISSING .................................................................................... m
(M1=01)
M1_Address3.
ADDRESS: {DISPLAY ENTIRE ADDRESS FROM SCREENER OR PRELOADED INFORMATION WITH
LINE 3 BOLD}
What is {your/NAME’s} correct third part of the street address?
The above information is correct ................................................ 1
There is no third part of the street address ................................. 2
MISSING .................................................................................... m
35
SECTION M: CLOSING INFORMATION AND OBSERVATIONS
(M1=01)
M1_City.
ADDRESS: {DISPLAY ENTIRE ADDRESS FROM PRELOADED INFORMATION WITH CITY BOLD}
What is {your/NAME’s} correct town or city?
The above information is correct ................................................ 1
MISSING .................................................................................... m
(M1=01)
M1_State.
ADDRESS: {DISPLAY ENTIRE ADDRESS FROM PRELOADED INFORMATION WITH STATE BOLD}
What is {your/NAME’s} correct state?
PROGRAMMER: INCLUDE 50-STATE PLUS DC IN DROP DOWN
The above information is correct ................................................ 1
MISSING .................................................................................... m
(M1=01)
M1_ZipCode.
ADDRESS: {DISPLAY ENTIRE ADDRESS FROM SCREENER OR PRELOADED INFORMATION WITH ZIP
CODE BOLD}
What is {your/NAME’s} correct zip code?
|__|__|__|__|__| - |__|__|__|__| ZIP CODE
The above information is correct ................................................ 1
MISSING .................................................................................... m
(M1=01)
M1_PhoneNumber.
TELEPHONE: {TELEPHONE NUMBER FROM SCREENER OR PRELOADED INFORMATION}
What is {your/NAME’s} correct telephone number, area code first?
( |__|__|__| ) |__|__|__| - |__|__|__|__| PHONE NUMBER (M11_Thanks)
The above information is correct ................................................ 1 (M11_Thanks)
MISSING .................................................................................... m (M11_Thanks)
(All)
M11_Thanks.
Thank you for your cooperation. This completes the survey! We will mail the $30 gift card and {you/NAME}
should receive it in about 3 weeks. Thank you again.
36
| File Type | application/pdf |
| File Title | National Beneficiary Survey R4 Instrument |
| Subject | CATI |
| Author | MATHEMATICA STAFF |
| File Modified | 2022-08-17 |
| File Created | 2022-08-17 |