VRFD Enrollment Survey

INTERVIEWER: READ OR PARAPHRASE
For many people with spinal cord injury or brain injury, seeking employment after injury is an
important goal. There are services available to help people with disabilities. However, the best
ways to coordinate and deliver these services are not yet known. This project will compare
two ways of coordinating and delivering services that are designed to help people with spinal
cord injury or brain injury obtain employment.
The Social Security Administration, Kessler Foundation, and Mathematica, a research
organization, are working together on this project. As part of this study, we will interview
Kessler Institute for Rehabilitation patients with spinal cord injuries or brain injuries.
Thank you for agreeing to participate in this survey. Participation is voluntary but very
important. The survey takes about 15 minutes to complete. Your responses will be kept
private and used only for research purposes. You may skip any question you do not wish to
answer. Your responses will be combined and reported with other responses in total; no
individual names or responses will be reported.
If you have any questions about the survey, please contact Mathematica at 1-8XX-XXX-XXXX
(this is a toll-free call) or email us: XXX@mathematica-mpr.com.

DRAFT Kessler Foundation/Mathematica

1

Date

A. Employment
The first questions are about your employment.
A1.

Were you employed or seeking work at the time of your injury?
MARK ONE ONLY

A2.

1

 Employed

2

 Seeking work

3

 Neither employed nor seeking work

How many years did you work before your injury?
|

A3.

A4.

|

| YEARS

During the next 12 months, how likely do you think it is that you will be working at a job for pay or
profit? By ‘working at a job for pay or profit’ we mean at a job where you get paid money for the work
you do.
1

 Very likely

2

 Somewhat likely

3

 Not very likely

4

 Not at all likely

[If Q1=1 and Q3=1 or 2]
Do you expect to return to work at the former job you had prior to your injury?
1

 Yes

0

 No

DRAFT Kessler Foundation/Mathematica

2

Date

A5.

The following are some reasons why it might be difficult to work following a Spinal Cord Injury (SCI)
or Brain Injury (BI). For each of the statements below, please say whether you strongly agree, agree,
disagree, or strongly disagree.
MARK ONE PER ROW
STRONGLY
AGREE

a.

I am limited in my ability to work because my injury is too
severe.

b.

I am worried that my injury will get worse if I work.

c.

AGREE

DISAGREE

STRONGLY
DISAGREE

1

2

3

4

1

2

3

4

I am limited in my ability to work because I do not have reliable
transportation to and from work.

1

2

3

4

d.

I am limited in my ability to work because I do not have help
for daily living activities, such as dressing or bathing.

1

2

3

4

e.

I am limited in my ability to work because I am caring for
children or others.

1

2

3

4

f.

I am limited in my ability to work because I am finishing a
school or training program.

1

2

3

4

g.

I don’t have the skills or training I need to return to work.

1

2

3

4

h.

Employers will not provide supports, accommodations, or the
flexibility I need because of my injury.

1

2

3

4

i.

Work is not available.

1

2

3

4

j.

Other reason not listed (SPECIFY) ___________________

1

2

3

4

A6.

A7.

A8.

Did you receive any job training, job coaching, or support services before the time of your injury?
1

 Yes

0

 No

d

 Unknown

Did you receive any services from the Department of Vocational Rehabilitation Services (DVRS)
before the time of your injury?
1

 Yes

0

 No

d

 Unknown

Had you ever spoken with or received services from a benefit specialist or Work Incentive Planning
Assistance (WIPA) program provider prior to your injury? These are programs funded by Social
Security to provide information to beneficiaries about how their benefits are affected by work.
1

 Yes

0

 No

d

 Unknown

DRAFT Kessler Foundation/Mathematica

3

Date

B. Education
The next questions are about your education.
B1.

Were you a student at the time of your injury?
MARK ONE ONLY

B2.

B3.

1

 Yes

2

 No

Do you expect to attend school in the next 12 months?
1

 Yes

0

 No

What is the highest level of education you have completed?
MARK ONE ONLY
1

 8th grade or less

2

 9th-11th grade

3

 High school diploma or GED

4

 Some college but no degree

5

 2-year college degree or vocational diploma

6

 Completed bachelor's degree or higher

7

 Other

DRAFT Kessler Foundation/Mathematica

4

Date

C. Health
The next questions are about your health.
C1.

Prior to the time of your injury, would you say that your health was excellent, very good, good, fair, or
poor?
MARK ONE ONLY

C2.

1

 Excellent

2

 Very Good

3

 Good

4

 Fair

5

 Poor

What kinds of health coverage do you have?
MARK ONE OR MORE BOXES
1

 Private insurance

2

 Medicaid

3

 Medicare

4

 Other insurance

5

 No insurance

DRAFT Kessler Foundation/Mathematica

5

Date

D. Demographics
The next questions are about you and your background.
This information will be used to ensure
information is collected accurately from state and federal databases. It will be kept private.
D1.

What is your full legal name?
First name
______________________________________________________________________________________
Last name
______________________________________________________________________________________
Preferred first name if different from legal name
______________________________________________________________________________________

D2.

What is your date of birth?
Birthdate: |

D3.

D5.

D6.

|

| |
Year

|

What is your Social Security Number?
|

D4.

| |/| | |/|
Month
Day

|

|

|-|

|

|-|

|

|

|

|

What is your sex?
1

 Male

2

 Female

What is your ethnic background?
1

 Hispanic or Latino

2

 Non-Hispanic or Latino

What is your race?
MARK ONE OR MORE BOXES
1
2
3
4
5
6








American Indian or Alaska Native
Asian
Black or African/American
Native Hawaiian or other Pacific Islander
White
Other

DRAFT Kessler Foundation/Mathematica

6

Date

D7.

What is your marital status?
MARK ONE ONLY

D8.

1

 Single/never married

2

 Married

3

 Separated

4

 Divorced

5

 Widowed

How many adults (age 18 or older) currently live in your household?
|

D9.

|

| ADULTS

In the last 12 months, what was the total income of all members of your household from all sources
before taxes and other deductions? Please include any money from jobs, public assistance programs,
or any other source.
IF NEEDED: Household means people who live in your house on a permanent basis and contribute to the
household financially. Please include your own income and the income of everyone living with you. Do not
include income from people who live in your household temporarily. If you live in a group home, please
include only your own income.
MARK ONE ONLY

D10.

1

 Less than $10,000

2

 $10,000 to less than $20,000

3

 $20,000 to less than $30,000

4

 $30,000 to less than $50,000

5

 $50,000 or more

Do you speak Spanish regularly in your household?
1

 Yes

0

 No

DRAFT Kessler Foundation/Mathematica

7

Date

E.
E1.

Contact Information

What is your mailing address? We will reach out to you in about a year for your second survey.
Address: _______________________________________________________________________________
City, State, Zip Code: _____________________________________________________________________

E2.

What is your cell phone number?
| | | |-|
Area Code

E3.

| |-| |
Number

|

|

|

What is another telephone number to call to reach you?
| | | |-|
Area Code

E4.

|

|

| |-| |
Number

|

|

|

What is the best e-mail address where we may send you study-related information?
______________________________________________________________________________________
To help us get back in touch with you in a year for your second survey, please provide the name,
address, and telephone number of two people who will always know how to reach you. This
information will be kept private and will only be used if we are unable to reach you.

FIRST PERSON
E5.

Please provide the name of someone who will always know how to contact you.
First name
______________________________________________________________________________________
Last name
______________________________________________________________________________________

E6.

What is this person’s address?
Address: _______________________________________________________________________________
City, State, Zip Code: _____________________________________________________________________

DRAFT Kessler Foundation/Mathematica

8

Date

E7.

What is the best telephone number to reach this person?
| | | |-|
Area Code

E8.

E9.

|

| |-| |
Number

|

|

|

Is this number a…
1

 Cell phone

2

 Landline

3

 Work/office

What is this person’s relationship to you?
______________________________________________________________________________________

SECOND PERSON
E10.

Please provide the name of someone else who will always know how to contact you.
First name
______________________________________________________________________________________
Last name
______________________________________________________________________________________

E11.

What is this person’s address?
Address: _______________________________________________________________________________
City, State, Zip Code: _____________________________________________________________________

E12.

What is the best telephone number to reach this person?
| | | |-|
Area Code

E13.

E14.

|

| |-| |
Number

|

|

|

Is this number a…
1

 Cell phone

2

 Landline

3

 Work/office

What is this person’s relationship to you?
______________________________________________________________________________________

Thank you for taking the time to complete this survey.

DRAFT Kessler Foundation/Mathematica

9

Date