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pdfATTACHMENT C
PAPER-BASED NBS INSTRUMENT FOR EXPERIMENT
OMB No. 0960-NEW
Expiration Date: MM/DD/YYYY
NATIONAL BENEFICIARY SURVEY
July 2022
Round 8 Paper Questionnaire
This survey is for:
[FIRSTNAME] [MI] [LASTNAME]
[TELEPHONE NUMBER]
[ADDRESS1]
[ADDRESS2]
[CITY], [STATE] [ZIP]
Need help?
Contact us at 1-XXX-XXX-XXXX with any questions.
STOP! Please read below before starting:
Start at A1, next page. You do not need to answer every question. Each question has
instructions for where to go next based on how you answer. If there are no instructions, go down
to the very next question.
When you complete, please mail the entire survey booklet back to us in the envelope provided.
The envelope already has postage.
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.
SECTION A: SCREENER
A1.
Welcome to the National Beneficiary Survey! Recently, you received a letter and calls about the National
Beneficiary Survey that Mathematica is conducting for the Social Security Administration.
The survey asks about your 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.
This paper survey will take about 25 minutes. If you complete the whole survey, you will receive a $30
gift card.
Some people are not able to take the whole survey and will not receive $30, based on their answers. If
you fall into this group, please return the survey so we can update our records.
Do you understand everything above and wish to continue to the survey?
A2.
1
Yes
0
No
GO TO END AT THE BOTTOM OF THIS PAGE
Before we start, we need to confirm that we reached the right person. Is the name on the cover of this
survey your full name?
MARK ONE ONLY
1
Yes
GO TO A7, PAGE 3
2
Yes, but my name is now changed (please specify correct name and go to A7, page 3)
____________________________________________________________________________
3
No. I don’t know this person. (please specify your name and go to END, bottom of this page)
____________________________________________________________________________
4
No. I’m taking the survey on behalf of the person on the cover (please specify your name)
____________________________________________________________________________
5
No. I’m taking the survey on behalf of the person on the cover and that person’s name is
now changed (please specify their correct name and your name)
Corrected name of the person on cover: ___________________________________________
Your name: __________________________________________________________________
A3.
To take the survey for the person listed on the cover of this survey, you will answer questions about
their 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?
1
Yes
0
No
GO TO A4, PAGE 2
END. Unfortunately, it doesn’t appear you can take this survey. If you would like to call us to discuss, please
call Mathematica at [FILL] and ask to discuss the paper survey. Please mail this survey back to us using
the enclosed envelope. Thank you very much.
1
A4.
Thank you for offering to help by taking the survey for the person listed on the cover of this survey. What
reason(s) might prevent them from taking part for himself/herself?
MARK ALL THAT APPLY
1
2
3
4
5
6
7
8
9
10
A5.
□
□
□
□
□
□
□
□
□
□
Hearing difficulty
Speech difficulty
Cognitive disability
Physical disability
Incarcerated
Institutionalized
Hospitalized
Serving in the military
Living outside the USA
Other (specify) ___________________________________________________________
How are you related to the person listed on the cover?
MARK ONE ONLY
A6.
1
Spouse or partner
2
Mother, father, or legal guardian
3
Child
4
Grandparent
5
Brother or sister
6
Some other relative
7
A friend
8
A caseworker, caregiver, or payee
9
A staff at a residence home
What is your telephone number, area code first? This is your telephone number, not the person listed on
the cover of this survey. We will only call this number if we need to reach you.
Phone Number: | | | | - |
Area Code
|
|
|-| |
Number
|
|
|
STOP! Please read before continuing:
Starting with the next question, A7, all remaining questions are worded to ask about “your”
experiences. However, since you are taking the survey on behalf of the person listed on the front
cover, please answer all remaining questions about the person listed on the cover.
2
A7.
To help verify your identify, the person named on the cover of this survey, we need to make sure your
date of birth matches our records. What is your date of birth?
Date: |
|
Month
A8.
|/|
|
Day
|/|
|
|
|
|
Year
This survey is only for people who have worked recently so, we need to know if you have worked
recently.
Are you currently working at a job or business for pay or profit?
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 disability benefits will not be affected in any way, and we will keep
any answers you provide completely confidential.
A9.
1
Yes
0
No
GO TO B1, PAGE 4
Did you work for pay or profit at any time during the last 6 months?
We are interested in both full-time and part-time work for pay or profit.
1
Yes
0
No
GO TO END, PAGE 1
3
SECTION B: DISABILITY AND CURRENT WORK STATUS
First, we have some questions about how your health affects your daily activities.
B1.
Does a physical or mental condition limit the kind or amount of work or other daily activities you can do?
In other words, are there things you can’t do as much or can’t do at all that people the same age can?
Daily activities include cooking, shopping, getting around the home, paying bills, or working at a job.
1
Yes
What physical or mental condition is the main reason you are limited?
By what name do doctors call your health condition? What causes this condition?
____________________________________________________________________________
0
B2.
No
GO TO B3
How much does this condition limit the kind or amount of work or other daily activities you 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.”
If your condition varies, your best guess for a typical day is fine.
|
B3.
|
|
| NUMBER FROM 0 TO 100, 0=”NOT AT ALL LIMITING” AND 100=”CANNOT
DO WORK OR DAILY ACTIVITIES AT ALL”
GO TO B4
Have you received disability benefits from Social Security at any time during the last five years?
1
Yes
What physical or mental condition is the main reason you were eligible for disability benefits?
By what name do doctors call your health condition? What causes this condition?
____________________________________________________________________________
B4.
0
No
d
Don’t know
GO TO C1
How old were you when you first became limited in the kind or amount of work or other daily activities
you could do? Your best estimate is fine.
|
|
| AGE
0
Since birth
d
Don’t know
r
I do not wish to answer this
4
SECTION C: CURRENT EMPLOYMENT
Now we have some questions about the jobs you currently have. When answering these questions, please
include both part-time and full-time jobs, but only include jobs you hold for pay or profit.
C1.
Are you currently working at a job or business for pay or profit?
We are interested in both full-time and part-time work for pay or profit.
C2.
1
Yes
0
No
GO TO D1
How many jobs do you currently have?
Include both part-time and full-time jobs, but only include jobs you hold for pay or profit.
|
C3.
|
| JOBS
The next few questions are about your current job. If you have more than one job, please answer about
your main job – that is, the job at which you work the most hours.
How many hours per week do you usually work at your current / main job?
Include overtime if you usually work overtime. If your hours vary week-to-week, please provide an average or
typical amount.
|
C4.
C5.
|
| HOURS PER WEEK
For the purpose of this survey, it is important to obtain some information on how much you are paid on
this job. On your main job are you paid by the hour?
1
Yes
0
No
d
Don’t know
r
I do not wish to answer this
GO TO C5
GO TO C6
What is your regular hourly pay at your main job, including tips and commissions?
$|
C6.
|
|
|.|
|
| AMOUNT PER HOUR
d
Don’t know
GO TO C8, PAGE 6
r
I do not wish to answer this
Before taxes and other deductions how much are you paid on this job, including tips and commissions?
$|
|
|
|,|
|
|
| AMOUNT
d
Don’t know
r
I do not wish to answer this
GO TO C8, PAGE 6
5
C7.
Is that amount how much you earn daily, weekly, bi-weekly, twice a month, monthly, or annually?
MARK ONE ONLY
C8.
1
Daily
2
Weekly
3
Bi-weekly (every two weeks)
4
Twice a month
5
Monthly
6
Annually
d
Don’t know
r
I do not wish to answer this
Next is a list of things that some people use or receive to help them find or keep a job. Please report if
you used or received any of them to help find or keep working at your main job. Did you…
MARK ONE RESPONSE
PER ROW
YES
NO
NOT
APPLICABLE
a. …have a job coach to help you learn how to do your job? ...............................
1
0
na
b. …use a sign language interpreter? ..................................................................
1
0
na
c. …use a reader or interpreter for the blind? ......................................................
1
0
na
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. .................................................................................................................
1
0
na
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. ...........................................................................................................
1
0
na
f. …receive on the job training? ...........................................................................
1
0
na
g. …receive counseling about how work will affect your benefits? ......................
1
0
na
h. …receive help with transportation? ..................................................................
1
0
na
i. …receive help with child or family care? ..........................................................
1
0
na
j. …use special equipment or devices? ...............................................................
1
0
na
C9.
At this job, do most of the other workers have disabilities?
1
Yes
0
No
d
Don’t know
C10. Could this job have been taken by anybody who applied for it and was qualified, including someone who
does not have a disability?
1
Yes
0
No
d
Don’t know
6
C11. If you have more than one job currently, please now think about all the jobs you currently have. How
much did you earn from all of these jobs in the last month in total, before taxes and deductions?
$|
|
|,|
|
|
| AMOUNT PER MONTH
1
Does not apply – I only have one job currently
d
Don’t know
r
I do not wish to answer this
STOP! Please read before continuing:
After answering C11, please go to Section F, question F1, page 12. You do not need to answer
any questions in Section D or Section E.
7
SECTION D: NOT CURRENTLY WORKING
D1.
D2.
Have you been looking for paid work during the last four weeks?
1
Yes
0
No
GO TO D3, PAGE 9
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 have not found a job that you think is right for you.
MARK ONE RESPONSE
PER ROW
YES
NO
a. You would need special equipment or medical devices to work which you do not
have ........................................................................................................................
1
0
b. You do not have the help you need to get ready for work each day ......................
1
0
c. You cannot get the help you need to care for children or others ............................
1
0
d. You do not have reliable transportation to and from work ......................................
1
0
e. Available jobs do not offer a flexible enough schedule ..........................................
1
0
f. You cannot find a job you are qualified for .............................................................
1
0
g. Available jobs do not pay enough ...........................................................................
1
0
h. Employers will not give you a chance to show that you can work ..........................
1
0
i. Available jobs do not offer health insurance ...........................................................
1
0
j. You would lose benefits like Social Security, disability insurance, workers’
compensation, or Medicaid if you took a job ..........................................................
1
0
1
0
k. Is there anything else that that is a reason why you have not been able to find a
job? (specify)........................................................................................................
_______________________________________________________________
8
D3.
Other people 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 not currently working.
MARK ONE RESPONSE
PER ROW
YES
NO
a. A physical or mental health condition prevents you from working...........................
1
0
b. You cannot find a job that you are qualified for .......................................................
1
0
c. You do not have reliable transportation to and from work .......................................
1
0
d. You are caring for children or others .......................................................................
1
0
e. You cannot find a job you want................................................................................
1
0
f. You are waiting to finish school or a training program.............................................
1
0
g. Workplaces are not accessible to people with your disability ..................................
1
0
h. You do not want to lose benefits like Social Security, disability insurance, workers’
compensation, or Medicaid ......................................................................................
1
0
i. Your previous attempts to work have been discouraging ........................................
1
0
j. Others do not think you can work ............................................................................
1
0
k. Employers will not give you a chance to show that you can work ...........................
1
0
l. You does not have the special equipment or medical devices that you would need
to work .....................................................................................................................
1
0
m. You cannot get the help you need 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. .....................................................................................................
1
0
n. You cannot get help you need with tasks you would do at work. This includes
having someone help you with things like writing, reading, lifting or reaching. .......
1
0
D4.
Are there any other reasons why you are not working?
1
Yes (specify) _____________________________________________________________
0
No
9
SECTION E: EMPLOYMENT IN PAST 6 MONTHS
Now we are going to ask some questions about the jobs you had during the last 6 months. When
answering these questions, please include both part-time and full-time jobs, but only include jobs you held
for pay or profit.
E1.
Did you work for pay or profit at any time during the last 6 months?
We are interested in both full-time and part-time work for pay or profit.
E2.
1
Yes
0
No
GO TO F1, PAGE 12
How many jobs did you have during the past 6 months?
Please include both part-time and full-time jobs, but only include jobs you held for pay or profit.
|
E3.
|
| JOBS
The next few questions are about your main job held in the past six months – that is, the job at which
you work the most hours. How many hours per week did you usually work at this job?
Include overtime if you usually worked overtime. If your hours vary week-to-week, please provide an average or
typical amount.
|
E4.
E5.
|
| HOURS PER WEEK
For the purpose of this survey, it is important to obtain some information on how much you were paid
for this job. For your main job you held in the past six months were you paid by the hour?
1
Yes
0
No
d
Don’t know
r
I do not wish to answer this
GO TO E6
What was your regular hourly pay, including tips and commissions?
$|
E6.
|
|
|.|
|
| AMOUNT PER HOUR
d
Don’t know
GO TO E8, PAGE 11
r
I do not wish to answer this
Before taxes and other deductions how much were you paid on this job, including tips and commissions.
$|
|
|
|,|
|
|
| AMOUNT
d
Don’t know
r
I do not wish to answer this
10
E7.
Is that amount how much you earned daily, weekly, bi-weekly, twice a month, monthly, or annually?
MARK ONE ONLY
E8.
1
Daily
2
Weekly
3
Bi-weekly (every two weeks)
4
Twice a month
5
Monthly
6
Annually
d
Don’t know
r
I do not wish to answer this
Next is a list of things that some people use or receive to help them find or keep a job. Please report if
you used or received each to help find or work at your main job. Did you…
MARK ONE RESPONSE
PER ROW
YES
NO
NOT
APPLICABLE
a. …have a job coach to help you learn how to do your job? .................................
1
0
na
b. …use a sign language interpreter? ....................................................................
1
0
na
c. …use a reader or interpreter for the blind? ........................................................
1
0
na
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. ...................................................................................................................
1
0
na
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. .............................................................................................................
1
0
na
f. …receive on the job training? .............................................................................
1
0
na
g. …receive counseling about how work will affect your benefits? ........................
1
0
na
h. …receive help with transportation? ....................................................................
1
0
na
i. …receive help with child or family care? ............................................................
1
0
na
j. …use special equipment or devices? .................................................................
1
0
na
E9.
At this job, do most of the other workers have disabilities?
1
Yes
0
No
d
Don’t know
E10. Could this job have been taken by anybody who applied for it and was qualified, including someone who
does not have a disability?
1
Yes
0
No
d
Don’t know
11
SECTION F: JOBS/OTHER JOBS DURING 2022
Now, we will ask you about jobs you had during 2022. When answering these questions, please include
both part-time and full-time jobs, but only include jobs you held for pay or profit for one month or longer.
F1.
F2.
F3.
Did you work at a job or business for pay or profit anytime in 2022?
1
Yes
0
No
GO TO G1, PAGE 13
Other than any jobs that you already reported on this survey, in 2022 did you work for pay at any other
jobs for longer than a month?
1
Yes
0
No
GO TO G1, PAGE 13
Thinking about the job(s) you had during 2022, not including any job(s) you already reported, how much
did you earn from all of these jobs during 2022, before taxes and deductions?
$|
|
|
|,|
|
|
| AMOUNT
d
Don’t know
r
I do not wish to answer this
12
SECTION G: BENEFIT SUSPENSE
Next, we would like to ask you about your experiences working and how working has affected your cash
disability benefits.
G1.
During the past year, did you ever stop receiving cash disability benefits for a time because you were
working?
This includes stopping cash benefits because you were earning too much or working too many hours.
G2.
G3.
1
Yes
GO TO G2
0
No
d
Don’t know
r
I do not wish to answer this
GO TO K1, PAGE 17
Are you currently receiving cash disability benefits?
1
Yes
GO TO H1, PAGE 14
0
No
d
Don’t know
r
I do not wish to answer this
Are you in the process of getting back on cash disability benefits?
1
Yes
0
No
d
Don’t know
r
I do not wish to answer this
13
SECTION H: RECENT SUSPENSE
We would like to ask you about the work that led to your cash benefits ending.
H1.
H2.
Did you know when you started working or earning more that you would stop receiving cash disability
benefits from Social Security?
1
Yes
GO TO THE BOX AT THE BOTTOM OF THIS PAGE
0
No
d
Don’t know
GO TO THE BOX AT THE BOTTOM OF THIS PAGE
If you had known that you were going to stop receiving cash benefits, would you still have started
working or earning more?
1
Yes
0
No
d
Don’t know
STOP! Please read before continuing:
If you answered “NO” to G2 page 13, GO TO I1, page 15
If you answered “YES” to G2 page 13, GO TO J1, page 16
If you did not answer or did not know the answer to G2 page 13, GO TO K1, page 17
14
SECTION I: ADDITIONAL QUESTIONS ABOUT BENEFIT SUSPENSE IF NOT ON BENEFITS
I1.
Next we will ask you about things that might make you have to go back on cash disability benefits in
the future.
Are you likely to go back on cash disability benefits because of…
MARK ONE RESPONSE
PER ROW
YES
NO
I DON’T
KNOW
a. Your health, for example because of worsening illness or the need to go to medical
appointments? (if yes, specify why) ..............................................................................
___________________________________________________________________
1
0
d
1
0
d
1
0
d
b. Your job, for example because of a need for accommodations or problems with your
co-workers? (if yes, specify why) ..................................................................................
___________________________________________________________________
c. Your personal circumstances, for example because you need child care, do not
have reliable transportation, or worry about losing other benefits? (if yes, specify
why) ..............................................................................................................................
___________________________________________________________________
15
SECTION J: ADDITIONAL QUESTIONS ABOUT BENEFIT SUSPENSE IF ON BENEFITS NOW
Earlier you reported that you are back on benefits.
J1.
Did you go or are you going back on benefits because of . . .
MARK ONE RESPONSE
PER ROW
YES
NO
I DON’T
KNOW
a. Your health, for example because of worsening illness or the need to go to medical
appointments? (if yes, specify why) ..............................................................................
___________________________________________________________________
1
0
d
1
0
d
1
0
d
b. Your job, for example because of a need for accommodations or problems with your
co-workers? (if yes, specify why) ..................................................................................
___________________________________________________________________
c. Your personal circumstances, for example because you need child care, do not
have reliable transportation, or worry about losing other benefits? (if yes, specify
why) ..............................................................................................................................
___________________________________________________________________
J2.
Is there anything that could have helped you to keep working and earning enough to stay off benefits?
1
Yes
0
No
d
Don’t know
GO TO J3
J2a. What things might have helped you keep working and earning enough to stay off benefits?
__________________________________________________________________________________
J3.
Do you think you will either go back to work or work and earn enough to stay off benefits in the future?
1
Yes
0
No
d
Don’t know
16
SECTION K: EMPLOYMENT-RELATED SERVICES AND SUPPORTS USED IN 2022
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 received in 2022.
K1.
First, we will ask about employment services you may have received. In 2022, did you receive:
MARK ONE RESPONSE
PER ROW
YES
NO
NOT
APPLICABLE
a. a work or job assessment to determine if a job is a good fit for you?..................
1
0
na
b. help to find a job? ................................................................................................
1
0
na
c. advice about modifying your job or work place?..................................................
1
0
na
d. job coaching or support services? .......................................................................
1
0
na
e. any other employment services to help you get a job? (specify).........................
1
0
na
______________________________________________________________
K2.
Sometimes people get training to help them learn new skills so they can get a new job or change
careers. In 2022, did you receive:
MARK ONE RESPONSE
PER ROW
YES
NO
NOT
APPLICABLE
a. training to learn a new job or skill? ...................................................................
1
0
na
b. on-the-job training? ...........................................................................................
1
0
na
c. any other training or certification to help you learn new skills or get a job?
(specify) ...........................................................................................................
1
0
na
_____________________________________________________________
K3.
At any time in 2022, did you enroll in school or take any classes to help you get a new job or change
careers? Please do not include any training you already reported.
This could include vocational training in high school, college classes, or other instructional programs.
1
Yes
0
No
17
K4.
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 receive:
MARK ONE RESPONSE
PER ROW
NOT
YES
NO
APPLICABLE
a. Physical therapy? .......................................................................................
1
0
na
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. ...............................................................................
1
0
na
c. Speech therapy? .........................................................................................
1
0
na
d. Special equipment or devices? ...................................................................
1
0
na
e. Prescription drugs? These are drugs prescribed by a doctor and do not
include over-the-counter drugs. ..................................................................
1
0
na
1
0
na
f. Any other medical services to improve your ability to work or live
independently? (specify) .............................................................................
__________________________________________________________
K5.
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 receive:
MARK ONE RESPONSE
PER ROW
YES
NO
NOT
APPLICABLE
a. Personal counseling or therapy? ................................................................
1
0
na
b. Group therapy? ...........................................................................................
1
0
na
1
0
na
c. Any other mental health services to help you work or live independently?
(specify) ......................................................................................................
__________________________________________________________
18
SECTION L: HEALTH AND FUNCTIONAL STATUS
The next set of questions are about your health and everyday activities.
L1.
Overall, how would you rate your health during the past 4 weeks?
MARK ONE ONLY
1
Excellent
2
Very good
3
Good
4
Fair
5
Poor, or
6
Very poor
MARK ONE RESPONSE
PER ROW
YES
L2.
NO
Are you blind or do you have serious difficulty seeing even when wearing
glasses?................................................................................................................
1
0
L3.
Are you deaf or do you have serious difficulty hearing? ......................................
1
0
L4.
Do you have serious difficulty walking or climbing stairs? ...................................
1
0
L5.
Because of a physical, mental, or emotional condition, do you have difficulty
doing errands alone such as visiting a doctor’s office or shopping? ....................
1
0
L6.
Do you have difficulty dressing or bathing?..........................................................
1
0
L7.
Because of a physical, mental, or emotional condition, do you have serious
difficulty concentrating, remembering, or making decisions?...............................
1
0
19
SECTION M: HEALTH INSURANCE
Next are some questions about different types of health insurance coverage you might have.
M1.
Are you currently covered by any type of health insurance plan, either private or government, including
Medicare or Medicaid?
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.
M2.
1
Yes
GO TO M2
0
No
GO TO N1, PAGE 21
What kinds of health insurance coverage do you have?
Medicaid is a state medical assistance program that serves low-income people and Social Security Income
recipients with disabilities.
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.
TRICARE is a managed health care program for active duty and retired members of the uniformed services, their
families and survivors’.
Private insurance includes health insurance that you get through an employer, a family member, or that you
purchase on your own including private insurance through the Affordable Care Act, sometimes called
HealthCare.gov or ObamaCare.
MARK ALL THAT APPLY
1
2
3
4
5
6
7
8
9
10
□
□
□
□
□
□
□
□
□
□
Medicaid or your state’s Medicaid program
Medicare
Tricare, VA, or other military insurance
Indian Health Service
Medi-gap insurance
A state program
Private insurance through my own employer
Private insurance through my spouse, partner, or parent
Private insurance that I pay for by myself or that my family pays for
Some other kind of insurance plan (specify)
____________________________________________________________________________
20
SECTION N: INCOME AND OTHER ASSISTANCE
The next set of questions is about income you received last month. This includes earnings from work and
benefits from different programs. When answering these questions, please think only about your own earnings
and benefits, and don’t include earnings or benefits that other family members may have received.
N1.
N2.
Thinking about the benefits you received last month, did you receive any income from Social Security?
1
Yes
0
No
Last month did you receive any income from…
MARK ONE RESPONSE
PER ROW
YES
NO
a. Private disability insurance (sometimes called long-term disability insurance)? ........
1
0
b. Workers’ compensation? ............................................................................................
1
0
c. Veterans’ benefits? .....................................................................................................
1
0
1
0
e. Unemployment benefits? ............................................................................................
1
0
f. Pensions or retirement income? .................................................................................
1
0
1
0
1
0
d. Public assistance or welfare payments? Please include any payments from the
Temporary Assistance for Needy Families, or TANF, program or any public
assistance payments from your state. ........................................................................
g. Other sources on a regular basis but not from jobs or Social Security? Do not count
food stamps here. Examples include child support, interest from savings or
checking accounts, or dividends. (specify) ................................................................
__________________________________________________________________
h. Other sources not on a regular basis? (specify) .........................................................
__________________________________________________________________
N3.
Thinking about all of the income you received last month from benefits and jobs, how much income did
you receive last month before taxes and deductions?
$|
|
|,|
|
|
| LAST MONTH’S INCOME
d
Don’t know
r
I do not wish to answer this
21
SECTION O: INFORMATION ABOUT YOU
We have a few more questions about you.
O1.
O2.
What is your ethnic background? Are you:
1
Hispanic or Latino, or
2
Not Hispanic or Latino?
r
I do not wish to answer this
What is your race? Are you:
MARK ALL THAT APPLY
1
2
3
4
5
r
O3.
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
What is the highest year or grade you finished in school?
1
Never attended school
2
Did not complete high school / Do not have a general education development degree (GED)
3
General education development degree (GED)
4
High school diploma
5
High school certificate of completion
6
Some college courses
7
A 2-year or 3-year college degree (associates degree) or a vocational school diploma
8
A 4-year college degree (Bachelor’s)
9
Some graduate courses
10
r
O4.
□
□
□
□
□
A graduate or professional degree (e.g., MA, MBA, Ph.D., J.D., M.D.)
I do not wish to answer this
Are you now married, partnered (but not married), widowed, divorced, separated, or have you never
been married?
MARK ONE ONLY
1
Married
2
I have a partner but we are not married
3
Widowed
4
Divorced
5
Separated
6
Never married
r
I do not wish to answer this
22
O5.
How many adults 18 years of age or older live in your household, including yourself?
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. If you live in a group home, halfway house, care home, assisted
living facility, or some other type of group residence, only count yourself.
|
|
d
O6.
|
0
| CHILDREN
No children in my household
Don’t know
d
O8.
Don’t know
How many children under 18 years of age live in your household?
This includes all children who usually live there, even if they are temporarily away on vacation, in a hospital, or
away at school.
|
O7.
| ADULTS
Have you ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard?
1
Yes
0
No
What was the total combined income of all members of your household in 2022, before taxes or other
deductions? Please include money all members of your household received from all sources.
Your best estimate is fine.
$|
O9.
|
|
|,|
|
|
| AMOUNT PER YEAR
d
Don’t know
r
I do not wish to answer this
How often do you access the Internet?
This includes accessing the Internet by computer, smart phone, tablet, or any other means.
1
Never
2
Daily
3
A few times a week
4
Once a week
5
Less than once a week
23
O10. That concludes this survey. Can you please verify your current contact information? We will send you a
$30 gift card to this address.
Name:____________________________________________________________________________
Address 1: ________________________________________________________________________
Address 2: ________________________________________________________________________
City, State, Zip Code: ________________________________________________________________
Phone Number: | | | | - |
Area Code
|
|
|-| |
Number
|
|
|
Thank you for your cooperation. This completes the survey! Please
place this survey in the envelope we sent you and return it by mail. We
will mail the $30 gift card and you should receive it in about 3 weeks.
Thank you again.
24
| 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 |