Appendix A-8. Exiter and Possible Exiter Survey
Beyond Benefits Survey
Final Questionnaire Version 3-28-23, REV 6-2-23
Resource Needs and Access (RN) 7
Health Insurance Coverage (HC) 15
Thank you for taking the time to complete the survey for the Beyond Benefits Study. The survey will ask questions about your work, income, access to and needs for various employment resources, health status, health insurance coverage, and finally some questions about who you are and challenges you have faced. This survey should take about 45 minutes to complete. When you are done, we will send you a $40 pre-paid Visa gift card in the mail.
Work and Income (WI)
The first few questions are about work.
WI-1. Are you currently working at a job or business for pay? (Source: NBS Questionnaire)
Yes
No [WI-5]
WI-2. On average, about how many hours per week do you usually work on all your jobs? (Source: NBS Questionnaire, modified)
___ ___ Hours per week
If you work at more than one job or business, please think about the job at which you work the most hours.
WI-3. Which of the following best describes your current employment situation? (U.S. Online Survey of Working Arrangements and Attitudes)
I am a wage and salary employee, and my main job accounts for most of my earnings
I am a wage and salary employee who also earns a lot of extra income from side jobs
I am self-employed and run my own business
I earn most of my income as an independent contractor, freelancer, or gig worker
WI-4. Does your main job offer any of the following benefits? (Source: NBS Questionnaire, modified)
Yes No
a. Health care insurance? |
b. Dental benefits? |
c. Sick days with pay? |
d. Employee assistance program/plan? |
e. Paid vacation? |
r. Free or low-cost childcare? |
g. Transportation, a transportation allowance, or transportation discounts? |
h. Long-term disability benefits? |
i. Pension or retirement benefits? |
j. Flexible health or dependent care spending accounts? |
j. Parental leave? |
.
GO TO WI-10.
WI-5. Do you currently want a job, either full or part time? (Source: CPS Labor Force Items)
Yes [WI-7]
Maybe, it depends [WI-7]
No
WI-6. What is the main reason you do not want a job? (Source: CPS Labor Force Items, modified)
Childcare problems
Other family/personal obligations
Health/medical limitations
School/training
Retired
Social Security limit on earnings
Other (Specify): _________________________________________________________________
WI-7. Have you been looking for paid work during the last four weeks? (Source: NBS Questionnaire)
Yes
No
WI-8. Next is a list of reasons why people are sometimes unable to find a job. Are any of these reasons why you have not found a job? (Source: NBS Questionnaire)
Don’t
know/
Yes No Refused
I do not have the assistive technology, special equipment or medical devices I need to work |
I do not have the help I need to get ready for work each day |
I cannot get the help I need to care for children or others |
I do not have reliable transportation to and from work |
Available jobs do not offer a flexible enough work schedule |
I cannot find a job I am qualified for |
Available jobs do not pay enough |
Employers will not give me a chance to show that I can work |
Available jobs do not offer health insurance |
I would lose benefits like Social Security, disability insurance, worker’s compensation, or Medicaid if I took a job |
Some other reason (Specify): __________________________________ |
WI-9. Which of the following best describes your current status? (Source: SED Baseline Survey)
Would you say…
Keeping house or caregiving
Going to school
Doing volunteer work
In vocational training
Retired
Unable to work, or
Something else? (Specify): ________________________________________________________
[For All]
WI-10. Below is a list of things that some people use or receive to help them find or keep a job. Did you use or receive any of the following to help find or keep working at your most recent/last job. (Source: NBS)
Did you…. Yes No
a. … use a job/employment coach? |
b. … use a sign language interpreter? |
c. … use a reader or interpreter for the blind? |
d. … use an assistant or caregiver for personal care, including help bathing and dressing to get ready for work and help eating lunch or using the restroom at work? |
e. … use a personal care assistant at work to help with job-related tasks, including help with writing, reading, lifting, or reaching? |
f. … receive on the job training? |
g. … receive counseling about how work will affect your benefits? |
h. … receive help with transportation? |
i. … receive help with child or family care? |
j. … use special equipment or devices? |
PROGRAMMER INSTRUCTION: IF RESPONDENT USED SPECIAL EQUIPMENT (WI-10j=1), GO TO WI-11.
ELSE, GO TO I-1.
WI-11. Please indicate the special equipment or devices you used. [CHECK ALL THAT APPLY] (Source: NBS)
Brace
Cane/Crutches/Walker
Wheelchair
Modified computer hardware
Modified computer software
Hearing aid/device
Special glasses
Special chair/back support
Special shoes/stockings
Other (Specify): _________________________________________________________________
Income (I)
These next questions ask you about income from all sources, including employment. Your answers will be kept confidential and will not affect your benefits.
I-1. Please indicate how much money you received from the following sources during the past month, that is since {MONTH, DAY}. We will be asking about household income separately. Remember, your answers will be kept confidential. (Source: SED Baseline Survey)
PROGRAMMER INSTRUCTION: ALLOW EACH ITEM I-1A-K TO BE LEFT BLANK.
a. Any earned income or money from all paid employment, including tips or commissions. Please indicate the take home amount.
$ |__|__|,|__|__|__|
b. VA or other armed services disability benefits
$ |__|__|,|__|__|__|
c. Food Stamp Program or SNAP (the Supplemental Nutritional Assistance Program)
$ |__|__|,|__|__|__|
d. Temporary Assistance for Needy Families (TANF), also known as cash welfare
$ |__|__|,|__|__|__|
e. Vocational program such as Vocational Rehabilitation, the Job Training Partnership Act, or Easter Seal
$ |__|__|,|__|__|__|
f. Social Security Retirement or Survivors Benefits
$ |__|__|,|__|__|__|
g. Unemployment compensation
$ |__|__|,|__|__|__|
h. Other state or county social welfare benefits such as general assistance or public aid
$ |__|__|,|__|__|__|
i. Retirement, pension (including military), investing, or savings income that you receive regular payments from
$ |__|__|,|__|__|__|
j. Alimony and child support
$ |__|__|,|__|__|__|
k. Money from family members including gifts, loans, or bill payments
$ |__|__|,|__|__|__|
I-2. Which category represents the total combined income of all members of your HOUSEHOLD during the past month? This includes money from jobs, net income from business, farm or rent, pensions, dividends, interest, social security payments and any other money income received by members of your HOUSEHOLD who are 15 years of age or older. (Source: CPS Labor Force Items, modified)
Less than $500
$500 to $999
$1,000 to $1,499
$1,500 to $1,999
$2,000 to $2,499
$2,500 to $2,999
$3,000 to $3,499
$3,500 to $3,999
$4,000 to $4,499
$4,500 to $4,999
$5,000 to $5,499
$5,500 to $5,999
$6,000 to $6,499
$6,500 to $6,999
$7,000 or more
Resource Needs and Access (RN)
The first questions are about personal or financial difficulties you may or may not have experienced recently, and your experiences receiving support. This information will be used to help improve the disability program. Your responses will be kept confidential and will not affect your status in the program.
RN-1. In the last 12 months … (Source: WellRx Questionnaire) Yes No
Did you or others you live with eat smaller meals or skip meals because you didn’t have money for food? |
Were you homeless or worried that you might be in the future? |
Did you have trouble paying for your utilities (gas, electricity, phone)? |
Did you have trouble finding or paying for a ride (transportation)? |
Did you need daycare, or better daycare, for your kids? |
Did you need help finding a better job? |
Did you need help getting more education? |
Were you concerned about someone in your home using drugs or alcohol? |
Did you feel unsafe in your daily life? |
Did you need help with legal issues? |
Was anyone in your home threatening or abusing you? |
Have you needed medical care that you did not get because you couldn’t afford it? |
RN-2. Some people use programs or services to help meet their needs. Have you used any of these programs or services in the past 12 months? (Source: New)
Yes No
Food assistance programs |
Housing programs |
Assistance for heating or utilities |
Transportation assistance or programs |
Childcare subsidies or pre-school programs |
Work training programs |
Scholarships or student loans |
Domestic violence or sexual assault services |
Medical care assistance programs or free clinics |
Mental health or counseling programs |
Legal aid office/clinics |
Cash assistance programs |
Other (Specify): _________________________________________________ |
Job Training/Help Finding Work
The next set of questions are about your experiences with finding work.
RN-4. In the past month, have you needed help finding or keeping a job? (Source: NEW)
Yes
No [RN-4.2]
RN-4.1. Please indicate the type of supports/services you needed. [CHECK ALL THAT APPLY] (Source: NEW)
Job skills assessment
Further education/job training
Resume/CV preparation
Career planning
Mock interviews
Job leads and job placement
Ongoing job supports (job coaching)
Assistance with requesting and obtaining job accommodations
Benefits counseling
Some other service (Specify): ______________________________________________
RN-4.2. Which of the following programs have you heard about? [CHECK ALL THAT APPLY] (Source: NEW)
Social Security’s Ticket to Work/Employment Networks
SSI’s Plan for Achieving Self-Support or PASS Plan
SSA’s Work Incentive and Planning Assistance programs
State vocational rehabilitation agencies
American Job Centers
Unemployment offices
Community health centers supports (job clubs or support groups)
Supported employment services or Individual Placement and Support (IPS)
Have not heard of any of these programs [HS-1]
RN-4.3. Have you used any job programs in the past 12 months? (Source: NEW)
Yes
No [RN-4.5]
RN-4.4. Tell us which specific programs you have used. (Source: NEW)
Social Security’s Ticket to Work/Employment Networks
SSI’s Plan for Achieving Self-Support or PASS Plan
SSA’s Work Incentive and Planning Assistance programs
State vocational rehabilitation agencies
American Job Centers
Community health centers supports (job clubs or support groups)
Supported employment services or Individual Placement and Support (IPS)
Some other program (Specify): _____________________________________________
PROGRAMMER INSTRUCTION: FOR QUESTION RN-4.4A, ONLY DISPLAY PROGRAMS SELECTED IN RN-4.4.
RN-4.4a. Of the programs you have used, please tell us if they were helpful or not helpful in finding a job. (Source: NEW)
I found I did not
this find
this
helpful helpful
Social Security’s Ticket to Work/Employment Networks |
SSI’s Plan for Achieving Self-Support or PASS Plan |
SSA’s Work Incentive and Planning Assistance programs |
State vocational rehabilitation agencies |
American Job Centers |
Community health centers supports (job clubs or support groups) |
Supported employment services or Individual Placement and Support (IPS) |
Some other program (Specify): _____________________________________ |
PROGRAMMER INSTRUCTION: GO TO HS-1.
RN-4.5. What is the most important reason for not using any job programs? (Source: NEW)
I have never needed this type of help
It is too difficult or takes too long to get this help
I don’t want anyone to know that I need this help
I have tried to use one of these programs but was not successful
I do not have access to transportation
I do not have childcare
I am dealing with legal issues
I am dealing with housing issues
Some other reason (Specify): ______________________________________________
Health Status (HS)
The next questions are about your health and your current daily activities. If you are unsure about how to answer, please give the best answer you can.
HS-1. In general, would you say your health is … (Source: Short Form SF-12)?
Excellent
Very good
Good
Fair
Poor
These next questions ask about activities that you might do during a typical day. As you read each item, please indicate if your health now limits you a lot, limits you a little, or does not limit you at all in these activities.
HS-2. To what extent does your health now limit you in moderate activities such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? (Source: Short Form SF-12)
A lot
A little
Not at all
HS-3. To what extent does your health now limit you in climbing several flights of stairs? (Source: Short Form SF-12)
A lot
A little
Not at all
HS-4. Now think about your physical health. During the past 4 weeks, how much of the time have you accomplished less than you would have liked to as a result of your physical health? (Source: Short Form SF-12)
Would you say…
All of the time
Most of the time
Some of the time
A little of the time
None of the time
HS-5. During the past 4 weeks, how much of the time did you limit the kind of work or other regular daily activities you do because of your physical health? (Source: Short Form SF-12)
Would you say…
All of the time
Most of the time
Some of the time
A little of the time
None of the time
HS-6. During the past 4 weeks, how much of the time did you accomplish less than you would have liked to because of any emotional problems, such as feeling depressed or anxious? (Source: Short Form SF-12)
Would you say…
All of the time
Most of the time
Some of the time
A little of the time
None of the time
HS-7. During the past 4 weeks, how much of the time did you not work or do other activities as carefully as usual because of any emotional problems, such as feeling depressed or anxious? (Source: Short Form SF-12)
Would you say…
All of the time
Most of the time
Some of the time
A little of the time
None of the time
HS-8. During the past 4 weeks, how much did pain interfere with your normal work, including both work outside the home and housework? (Source: Short Form SF-12)
Not at all
A little bit
Moderately
Quite a bit
Extremely
These next questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please select the one answer that comes closest to the way you have been feeling.
HS-9. During the past 4 weeks, how much of the time have you felt calm and peaceful? (Source: Short Form SF-12)
All of the time
Most of the time
Some of the time
A little of the time
None of the time
HS-10. During the past 4 weeks, how much of the time did you have a lot of energy? (Source: Short Form SF-12)
Would you say…
All of the time
Most of the time
Some of the time
A little of the time
None of the time
HS-11. During the past 4 weeks, how much of the time have you felt downhearted and depressed? (Source: Short Form SF-12)
Would you say…
All of the time
Most of the time
Some of the time
A little of the time
None of the time
HS-12. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities, like visiting with friends or relatives? (Source: Short Form SF-12)
Would you say…
All of the time
Most of the time
Some of the time
A little of the time
None of the time
The next questions ask about how your health may limit your activities.
HS-13. Are you deaf, or do you have serious difficulty hearing? (Source: ACS)
Yes
No
HS-14. Are you blind, or do you have serious difficulty seeing, even when wearing glasses? (Source: ACS)
Yes
No
HS-15. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (Source: ACS)
Yes
No
HS-16. Do you have serious difficulty walking or climbing stairs? (Source: ACS)
Yes
No
HS-17. Do you have difficulty dressing or bathing? (Source: ACS)
Yes
No
HS-18. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? (Source: ACS)
Yes
No
HS-18A. Are you currently receiving disability benefits from Social Security Administration’s Social Security Disability Insurance (SSDI) and/or Supplemental Security Income (SSI) programs?
Yes (GO TO HS-19)
No (GO TO HS-18B)
HS-18B. SSA determined that you were no longer eligible to receive Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) because you have medically improved enough to be able to work. Do you agree with SSA’s decision?
Yes
No
Not applicable, benefits ended for a different reason
The next questions ask about tobacco and alcohol use.
HS-19. Have you ever regularly smoked cigarettes, cigars, a pipe, or a hookah or used vape pens, vaporizers, or e-cigarettes? (Source: SED Baseline Survey, modified)
YES, current smoker
YES, but no longer smoke
NO, never
HS-20. In the last three months, on average how many days per week have you had any alcohol to drink? (For example, beer, wine, or any drink containing liquor.) (Source: Health and Retirement Study)
7 (Every day)
6
5
4
3
2
1
0 (None or less than once a week)
Health Insurance Coverage (HC)
HC-1. What types of health insurance or health coverage plans do you currently have? (Source: SED Baseline Survey)
Medicare (for people 65 and older, or people with certain disabilities)
Medicaid, medical assistance, or any kind of government-assistance plan for those with low incomes or a disability
Insurance through healthcare.gov or a state exchange (marketplace)
Insurance through a current or former employer or union (of yours or another family member)
Insurance purchased directly from an insurance company (by you or another family member)
VA (including those who have ever used or enrolled for VA health care)
TRICARE, TRICARE for life or other military health care
Indian Health Services (IHS)
NO HEALTH INSURANCE
Other (Specify): _________________________________________________________________
PROGRAMMER INSTRUCTION: HC-1; “NO HEALTH INSURANCE” CANNOT BE SELECTED WITH ANY OTHER ANSWER OPTION.
PROGRAMMER INSTRUCTION: IF HC-1 = “NO HEALTH INSURANCE”, ASK HC-2.
ELSE, GO TO DEMOGRAPHICS.
HC-2. Just to confirm, you are not currently covered by Medicare, Medicaid, VA, TRICARE, or any other health insurance. Is that correct? (Source: SED Baseline Survey)
Yes, currently I have no health insurance
No, currently I have health insurance [HC-1]
Demographics (DM)
The next questions are about your background. Any personal information that you provide will not be used to identify you. Your answers are confidential. We will use the information to help improve SSA’s services and make sure they are accessible to people of all backgrounds.
DM-1. What is the highest level of education you have completed? (Source: SED Baseline Survey, modified)
Did not graduate high school
Completed high school or GED
Some college or junior college
College graduate
Post-graduate or advanced degree
DM-2. What is your marital status? (Source: SED Baseline Survey)
Never married
Married
Living as married
Separated
Divorced
Widowed
DM-3. Which of following best describes where you have been living during the past 30 days? (Source: SED Baseline Survey)
Would you say…
At one address in an apartment or house
At more than one address in apartments or houses
With the same people at each address
At more than one address in apartments or houses
With different people at each address [DM-7]
In a homeless shelter or homeless with no address, or [DM-7]
Some other place? (Specify): ______________________________________________________
DM-4. Describe who you have been living with during the past 30 days. [SELECT ALL THAT APPLY] (Source: SED Baseline Survey)
Living alone
Living with spouse/significant other only
Living with children only
Living with spouse/significant other and children
Living with parents
Living with other relatives (other than spouse, children, or grandparents)
Living with friends
Living with other non-related adults (group home, rehab facility, etc.)
OTHER (Specify): _______________________________________________________________
PROGRAMMER INSTRUCTION: IF DM-4=LIVING ALONE, GO TO DM-7.
ELSE, GO TO DM-5.
DM-5. How many people, not counting yourself, have you been living with during the past 30 days? Do not include part-time residents. (Source: SED Baseline Survey)
___ ___ Number of people
DM-6. 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 a vacation, in a hospital, or away at school. (Source: NBS)
___ ___ Number of children
DM-7. Are you of Hispanic, Latino, or Spanish origin? (Source: SED Baseline Survey)
Yes
No
DM-8. What race do you consider yourself to be? Please select one or more of the following categories: (Source: SED Baseline Survey)
White
Black or African-American
Asian
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
OTHER (Specify): _______________________________________________________________
DM-9. What languages do you usually speak? (Source: SED Baseline Survey)
English only
Spanish only
Both English and Spanish
Both English and some other language
Some other language only? (Specify): _______________________________________________
DM-10. Which of the following best represents how you think of yourself? (Source: BRFSS)
Gay
Straight, that is, not gay
Bisexual
Something else
DM-11.Are you…(SELECT ALL THAT APPLY)
Male
Female
Transgender
Non-binary
Prefer not to answer
Justice Involvement (JI)
People who have been involved with the justice system may find that their background is a barrier to employment. These final questions are about your background, legal support, and employment experiences. Remember we keep all your information confidential.
JI-1. Have you ever been convicted of any misdemeanors or felonies? (Source: New)
Yes
No [JI-3]
JI-2. Has your criminal record ever prevented you from getting a job? (Source: New)
Yes
No
JI-3. Do you have access to legal support if you need it (for example, money for legal fees, public defender, etc.)? (Source: New)
Yes
No
This is the end of your survey. Thank you for your participation. You will receive a $40 Visa Gift Card by mail.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2024-07-25 |