fr
[p. 206]

Section R -- INCOME

Item R1
Refer to Household Composition.

The next questions are about health insurance coverage and the kinds and amounts of income that people receive. For this family, that includes (read names, including Armed Forces members living at home.)

Read if necessary: The answers to these questions will add greatly to our knowledge about the health problems of the American people, the types of health care they receive, and whether they can afford the care that they need. The information will help in planning health care services and finding ways to lower costs of care.

There are several government programs which provide medical care or help pay medical bills.

People covered by Medicare have a card that looks like this. Show Medicare Card.

1a. In (month), was anyone in the family covered by Medicare?
Read if necessary: Medicare is a health insurance program for persons 65 or over and certain disabled persons.

b. Who was this?
Mark "Medicare" box in person's column.

c. Anyone else?

2a. (In (month), was anyone in the family covered by) Medicaid or (local name)?
Read if necessary: Medicaid or (local name) is a public assistance program that pays for medical care.

b. Who was this?
Mark "Medicaid" box in person's column.

c. Anyone else?

3a. (In (month), was anyone in the family covered by) CHAMPUS, CHAMPVA, the VA, or military health care?
Read if necessary: These programs cover active duty and retired career military personnel and their dependents and survivors and also disabled veterans and their dependents and survivors.

b. Who was this?
Mark "Military" box in person's column.

c. Anyone else?

4a. Health insurance can also be obtained privately or through a current or former employer or union. Was anyone in the family covered by private health insurance or by membership in a health maintenance organization in (month)?

b. Who was this?
Mark "HI Plan" box in person's column.

c. Anyone else?

Ask 4d-f for each person with "HI Plan" marked in 4b.

d. Was -- health insurance coverage from a plan in -- own name?

e. Was any of -- health insurance obtained through an employer or union?

f. Did the employer or union pay for all, part, or none of the cost of this plan?

[p. 207]

Section R -- INCOME -- Continued

Mark box or ask for each nondeleted family member, including Armed Forces members living at home:

5a. Did -- have a job or business in (month)?

b. How many hours did -- usually work per week at all jobs in (month)?

6. Was -- working for an employer or was -- self-employed in (month)?
Read if necessary: Examples of self-employment include a business, professional practice, or farm.

7a. How much income did -- receive in (month) BEFORE deductions from ALL jobs? Include any tips, bonuses, overtime pay, or commissions.

b. In how many of the past 12 months did -- have a job?

Ask 8a and b if box 2 or 3 in 6; otherwise, go to NP.

8a. How much income did -- receive in (month) from self-employment? Report NET income, after business expenses.
Read if necessary: For farms, include any earnings as a tenant farmer or sharecropper.

b. In how many of the past 12 months was -- self-employed?

9a. In (month), did anyone in the family receive Social Security or Railroad Retirement payments?
Read if necessary: Social Security checks are either automatically deposited in the bank or mailed to arrive on the 3rd of every month. If mailed, they are sent in a gold colored envelope.

b. Who was this?
Mark 'SS/RR" box in person's column.

c. Anyone else?

Ask 9d for each person with "SS/RR" in 9b.
d. How much income did -- receive in (month) from Social Security or Railroad Retirement?

Ask 9e-f for each person under 65 with "SS/RR" in 9b.
e. Was -- Social Security or Railroad Retirement income received as a disability benefit?

f. Did -- receive this benefit because -- is disabled?

10a. (In (month), did anyone in the family receive) Supplemental Security Income or SSI?
Read if necessary: Federal SSI checks are either automatically deposited in the bank or mailed to arrive on the first of every month. If mailed, they are sent in a blue colored envelope.

b. Who was this?
Mark "SSI" box in person's column.

c. Anyone else?

Ask 10d for each person with "SSI" in 10b.
d. How much income did -- receive in (month) from Supplemental Security Income or SSI?

[p. 208]

Section R -- INCOME -- Continued

11a. (In (month), did anyone in the family receive) Any (other) disability pension (other than Social Security or Railroad Retirement)?

b. Who was this?
Mark "Disability" box in person's column.

c. Anyone else?

Ask 11d for each person with "Disability" marked in 11b.
d. How much did -- receive in (month) BEFORE deductions from a disability pension?

12a. (In (month), did anyone in the family receive) Any (other) retirement or survivor pension (other than (Social Security or Railroad Retirement/(or) disability pension))?

b. Who was this?
Mark "Pension" box in person's column.

c. Anyone else?

Ask 12d for each person with "Pension" marked in 12b.
d. How much income did -- receive BEFORE deductions from retirement or survivor pensions (other than (Social Security or Railroad Retirement/(or) disability pension)) in (month)?

13a. (In (month), did anyone in the family receive) Public assistance or welfare payments from the State or local welfare office? Do not include SSI.

b. Who was this?
Mark "Welfare" box in person's column.

c. Anyone else?

Ask 13d-f for each person with "Welfare" marked in 13b.
d. Did -- receive Aid to Families with Dependent Children, sometimes called AFDC or ADC, or some other type of assistance payments in (month)?

e. In how many of the past 12 months did -- receive these payments?

f. How much income did -- receive from public assistance or welfare in (month)?

14a. In (month), did anyone in the family receive food stamps?

b. Did this food stamp allotment include anyone who lived here who was NOT in your family?

c. How many other persons who lived here in (month) besides your family were included in this food stamp allotment?

d. What was the total value of the food stamp allotment received in (month)?

[p. 209]

Section R -- INCOME -- Continued

15a. In (month), did anyone in the family have money in any kind of savings or other bank account which earned interest? Do not include dividends.
Read if necessary: Include savings accounts, money market funds, treasury notes, IRA's or certificates of deposit, interest earning checking accounts, bonds, or any other investments which earn interest.

b. Who was this?
Mark "Interest" box in person's column.

c. Anyone else?

Ask 15d for each person with "Interest" marked in 15b.
d. What is your best estimate of the total amount of interest that -- earned in (month)?

16a. Did anyone in the family receive dividend income from stocks or mutual funds or income from rental property, royalties, estates, or trusts in (month)?

b. Who was this?
Mark "Dividends" box in person's column.

c. Anyone else?

Ask 16d for each person with "Dividends" marked in 16b.
d. What is your best estimate of the total amount that -- received from dividends, NET rental property income, royalties, estates, or trusts in (month)?

17a. In (month), did anyone in the family receive income from any other sources, such as veterans payments, worker's or unemployment compensation, child support, or alimony? Do not include lump sum payments, such as money from an inheritance or the sale of a home.

b. Who was this?
Mark "Other income" box in person's column.

c. Anyone else?

Ask 17d for each person with "Other income" marked in 17b.
d. How much income did -- receive in (month) from ALL OTHER sources?