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[p.188]

Part D - Income and Assets


Mark (X) box or ask for each non-deleted family member, including Armed Forces members living at home.

1a. In (month), did -- have a job or business?
0[] Under 14 (NP, or 6 on page 38)
1[] Yes (1b)
2[] No (NP, or 6 on page 38)
9[] DK (NP, or 6 on page 38)


b. In (month), was -- working for an employer, was -- self-employed, or both?
Read if necessary: Examples of self-employment include business, professional practice, or farm.
Mark (x) only one.

1[] Employer only (2a)
2[] Self-employed only (3 on page 34)
3[] Both (4 on page 36)
9[] DK (NP, or 6 on page 38)


2a. In (month), how many hours per week did -- usually work in -- MAIN job?

________ Hours per week
(Number)
99[] DK


b. Was -- paid by the hour at this MAIN job?

1[] Yes
2[] No
9[] DK


c. In (month), how much income did -- receive before deductions from -- MAIN job?
Include any tips, bonuses, overtime pay, and commissions.

$______
(Dollars)

9999999[] DK


d. How long has -- worked at this MAIN job?
Mark (x) only one.

1[] One year or less
2[] More than a year, but not more than 3 years
3[] More than 3 years, but not more than 5 years
4[] More than 5 years, but not more than 10 years
5[] More than 10 years
9[] DK


e. In (month), how many hours per week did -- usually work at any OTHER jobs?

________ Hours per week (2f)
(Number)

88[] None, only worked one job (2g)
99[] DK (2f)


f. In (month), how much income did -- receive before deductions in all OTHER jobs?
Include any tips, bonuses, overtime pay, and commissions.

$______
(Dollars)

9999999[] DK


g. In how many of the past 12 months did -- have AT LEAST ONE job or business?

________ Months (D1 on page 36)
(Number)

12[] All (D1 on page 36)
99[] DK (D1 on page 36)

[p.189]

Part D - Income and Assets - Continued


3a. In (month), how many hours per week did -- usually work in -- MAIN business?

_______ Hours per week
(Number)

99[] DK


b. In (month), how much income did -- receive from -- MAIN business? Report NET income, after business expenses
Read if necessary: For farms, include any earnings as a tenant farmer or share cropper.

1[] Already included
0[] Loss

$________
(Dollars)

9999999[] DK


c. How long has -- worked at this MAIN business?
Mark (x) only one.

1[] One year or less
2[] More than a year, but not more than 3 years
3[] More than 3 years, but not more than 5 years
4[] More than 5 years, but not more than 10 years
5[] More than 10 years
9[] DK


d. In (month), how many hours per week did -- usually work at all OTHER businesses?

________ Hours per week (3e)
(Number)

88[] None, only worked at one business (3g)
99[] DK (3e)


e. In (month), how much income did -- receive from all OTHER business? Report NET income, after business expenses

1[] Already included
0[] loss

$_______
(Dollars)

9999999[] DK


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

________ Months (if 01-11 (3g); if 12 (D1 on page 36))
(Number)

12[] All (D1 on page 36)
99[] DK (D1 on page 36)


g. In how many of the past 12 months did -- have AT LEAST ONE job or business?

________ Months (D1 on page 36)
(Number)

12[] All (D1 on page 36)
99[] DK (D1 on page 36)

[p.190]

Part D - Income and Assets - Continued


4a. In (month), how many hours per week did -- usually work in -- MAIN job in business?

________ Hours per week
(Number)

99[] DK


b. Was this a job or business?

1[] Job (4c)
2[] Business (4e)
9[] DK (4c)


c. Was -- paid by the hour at this MAIN job?

1[] Yes
2[] No
9[] DK


d. In (month), how much income did -- receive BEFORE deductions from -- MAIN job? Include any tips, bonuses, overtime pay and commissions

$_______ (4f)
(Dollars)

9999999[] DK (4f)


e. In (month), how much income did -- receive from -- MAIN business? Report NET income, after business expenses
Read if necessary: For farms, include any earnings as a tenant farmer or share cropper.

1[] Already included
0[] Loss

$________
(Dollars)

9999999[] DK


f. How long has -- worked at this MAIN [job/business]
Mark (x) only one.

1[] One year or loss
2[] More than a year, but not more than 3 years
3[] More than 3 years, but not more than 5 years
4[] More than 5 years, but not more than 10 years
5[] More than 10 years
9[] DK


g. In (month), how many hours per week did -- usually work at all OTHER jobs or businesses?

________ hours per week
(Number)

99[] DK


h. In (month), how much income did -- receive from all OTHER businesses? Report NET income, after business expenses
Read if necessary: For farms, include any earnings as a tenant farmer or share cropper.

1[] Already included
0[] Loss

$________
(Dollars)

9999998[] No other business
9999999[] DK


i. In (month), how much income did -- receive BEFORE deductions from all OTHER jobs? Include any tips, bonuses, overtime pay, and commissions.

$_______
(Dollars)

9999998[] No other job
9999999[] DK


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

________ Months (If 01 - 11 (4k). If 12 (D1))
(Number)

12[] All (D1)
99[] DK (D1)


k. In how many of the past 12 months did -- have AT LEAST ONE job or business?

________ Months
(Number)

12[] All
99[] DK

ITEM D1
Refer to age.

1[] 18+ (5 on page 38)
8[] Other (1a on page 32 for NP, or 6 on page 38)
[p.191]

Part D - Income and Assets - Continued


Hand Card FD1. Read categories if telephone interview.
CARD FD1

1[] 1-9 employees
2[] 10-24 employees
3[] 25-49 employees
4[] 50-99 employees
5[] 100-499 employees
6[] 500-999 employees
7[] 1,000 or more employees

5a. Thinking about -- (MAIN) job or business in (month), how many people are employed full and part time, including employees at all locations?
Mark (x) only one.

1[] 1-9 (1a on page 32 for NP, or 6)
2[] 10-24 (1a on page 32 for NP, or 6)
3[] 25-49 (1a on page 32 for NP, or 6)
4[] 50-99 (1a on page 32 for NP, or 6)
5[] 100-499 (1a on page 32 for NP, or 6)
6[] 500-999 (1a on page 32 for NP, or 6)
7[] 1,000 or more (1a on page 32 for NP, or 6)
9[] DK (5b)

b. Thinking about the particular location where -- worked in (month), how many people are employed THERE full and part time?
Mark (x) only one.

1[] 1-9 (1a on page 32 for NP, or 6)
2[] 10-24 (1a on page 32 for NP, or 6)
3[] 25-49 (1a on page 32 for NP, or 6)
4[] 50-99 (1a on page 32 for NP, or 6)
5[] 100-499 (1a on page 32 for NP, or 6)
6[] 500-999 (1a on page 32 for NP, or 6)
7[] 1,000 or more (1a on page 32 for NP, or 6)
9[] DK


6a. 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.

1[] Yes (6b)
2[] No (7)
9[] DK (7)

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

1[] SS/RR

c. Anyone else?

[] Yes (Reask 6b and c)
[] No (6d)
[] DK (6d)


Ask 6d-g as appropriate for each person with "SS/RR" marked in 6b.
d. How much income did -- receive in (month), from Social Security or Railroad Retirement?

1[] Already included

$______
(Dollars)

9999[] DK


e. How long has -- received Social Security or Railroad Retirement income?

________
(Number)
1[] Months
2[] Years


99[] DK


Ask 6f-g only if person is under 65;otherwise, go to 6d for NP with "SS/RR" in 6b,or 7
f. Was -- Social Security or Railroad Retirement income received as a disability benefit?

1[] Yes (6g)
2[] No (6d for NP with "SS/RR" in 6d, or 7)
9[] DK (6d for NP with "SS/RR" in 6d, or 7)


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

1[] Yes (6d for NP with "SS/RR" in 6b, or 7)
2[] No (6d for NP with "SS/RR" in 6b, or 7)
9[] DK


7a. (Besides --) Has anyone in the family EVER APPLIED for disability benefits from Social Security? This includes people who applied for benefits even if the claim was denied?

1[] Yes (7b)
2[] No ( 8 on page 40)
9[] DK (8 on page 40)

b. Who was this?
Mark (x) "Applied for SSA" in person's column.

1[] Applied for SSA

c. Anyone else?

[] Yes (Reask 7b and c)
[] No (7d)
[] DK (7d)


Ask 7d for each person with box marked in 7b.
d. How many times has -- applied for disability benefits from Social Security?

________ Times applied for SSA
(Number)

99[] DK
(7d for NP with 7b, or 8 on page 40)

[p.192]

Part D - Income and Assets - Continued


8a. In (month), did anyone in the family receive Supplemental Security Income or SSI?
Read if necessary: Federal SSI are either automatically deposited in the bank or mailed to arrive on the first of every month. If mailed, they are sent in blue colored envelope.

1[] Yes (8b)
2[] No (9)
9[] DK (9)

b. Who was this?
Mark (x) "SSI" in person's column

1[] SSI

c. Anyone else?

[] Yes (Reask 8b and c)
[] No (8d)
[] DK (8d)


Ask 8d-e for each person with "SSI" marked in 8b.
d. How much income did -- receive in (month) for Supplemental Security Income or SSI?

$______
(Dollars)

9999[] DK


e. How long has -- received Supplement Security Income?

________
(Number)
1[] Months
2[] Years


99[] DK


9a. (Besides --) Has anyone in the family EVER applied for Supplemental Security Income or SSI? This includes people who applied for benefits even if the claim was denied.

1[] Yes (9b)
2[] No (10)
9[] DK (10)

b. Who was this?
Mark (x) "Applied for SSI" in person's column.

1[] Applied for SSI

c. Anyone else?

[] Yes (Reask 9b and c)
[] No (9d)
[] DK (9d)


Ask 9d for each person with box marked in 9b.
d. How many times has -- applied for Supplemental Security Income (SSI)

________ Times applied for SSI
(Number)

99[] DK
(9d for NP with 9b, or 10)


10a. In (month), did anyone in the family receive any disability pension (other than Social Security or Railroad Retirement)?

1[] Yes (10b)
2[] No (11 on page 42)
9[] DK (11 on page 42)

b. Who was this?
Mark (x) "Disability" in person's column.

1[] Disability

c. Anyone else?

[] Yes (Reask 10b and c)
[] No (10d)
[] DK (10d)


Ask 10d for each person with "Disability" marked in 10b.
d. How much did -- receive in (month) BEFORE deductions from a disability pension?
1[] Already included

$_______
(Dollars)

9999[] DK
(10d for NP with 10b, or 11 on page 42)

[p.193]

Part D - Income and Assets - Continued


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

1[] Yes (11b)
2[] No (D2)
9[] DK (D2)

b. Who was this?
Mark (x) "Pension" in person's column

1[] Pension

c. Anyone else?

[] Yes (Reask 11b and c)
[] No (11d)
[] DK (11d)


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)?

1[] Already included

$______
(Dollars)

999999[] DK
(11d for NP with 11b, or D2)


ITEM D2
Refer to family composition and income in 8a on page 48 of HIS-1

1[] Single person family and income = $20,000 or more (14 on page 44)
2[] Married couple only and family income = $20,000 or more (14 on page 44)
8[] Other (12)

12a. In (month), did anyone in the family receive public assistance or welfare payments from the state or local welfare office? Do not include SSI.

1[] Yes (12b)
2[] No (13 on page 44)
9[] DK (13 on page 44)

b. Who was this?
Mark (x) "welfare" in person's column

1[] Welfare

c. Anyone else?

[] Yes (Reask 12b and c)
[] No (12d)
[] DK (12d)


Ask 12d-f for each person with "welfare" marked in 12d.

d. Did -- receive Aid to Families with Dependent Children, sometimes called AFDC or ADC, or some other type of assistance payments in (month)?
Mark (x) only one

1[] AFDC
2[] Other
3[] Both
9[] DK


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

12 [] All

________ Months
(Number)

99[] DK


f. How much income did -- receive from public assistance or welfare in (month)?
1[] Already included

$______
(Dollars)

9999[] DK
(12d for NP with 12 b, or 13 on page 44)

[p.194]

Part D - Income and Assets - Continued


13a. In (month), did anyone in the family receive food stamps? This includes receipt of a food stamp card or vouchers, or cash grants from the state for food.

1[] Yes (13b)
2[] No (14)
9[] DK (14)


b. What was the total value of the food stamp allotment received in (month)? (This includes receipt of a food stamp card or vouchers, or cash grants from the state for food.)

$ ______
(Dollars)

9999[] DK


14a. In (month), did anyone in the family have money in any kind of savings or other bank account that EARNED interest? Do not include dividends.
Read if necessary: Include saving accounts, money market funds, treasury notes, IRA's or certificates of deposit, interest earning checking accounts, bond or any other investments that earn interest.

1[] Yes (14b)
2[] No (15 on page 46)
9[] DK (15 on page 46)

b. Who was this?
Mark (x) "interest" in person's column

1[] Interest

c. Anyone else?

[] Yes (Reask 14b and c)
[] No (14d)
[] DK (14d)


Ask 14d-f as appropriate for each person with "Interest" marked in 14b.
d. What is your best estimate of the total amount of interest -- earned in (months)?

1[] Already included (14d for NP with 14b, or 15 on page 46)

$ _____ (14d for NP with 14b, or 15 on page 46)
(Dollars)

9999[] DK (14e)

e. Was it more than $25 or less than $25?

1[] More than $25 (14f)
2[] Less than $25 (14d for NP with 14b, or 15 on page 46)
3[] $25 exactly (14d for NP with 14b, or 15 on page 46)
9[] DK (14d for NP with 14b, or 15 on page 46)

Hand Card FD2.
CARD FD2

1[] $25 - $99
2[] $100 - $499
3[] $500 - $999
4[] $1000 - $4999,
5[] $5000 or more

f. Was it - Read answer categories.

1[] $25 - $99 (14d for NP with 14b, or 15 on page 46)
2[] $100 - $499 (14d for NP with 14b, or 15 on page 46)
3[] $500 - $999 (14d for NP with 14b, or 15 on page 46)
4[] $1000 - $4999, or (14d for NP with 14b, or 15 on page 46)
5[] $5000 or more (14d for NP with 14b, or 15 on page 46)
9[] DK (14d for NP with 14b, or 15 on page 46)

[p.195]

Part D - Income and Assets - Continued


15a. In (month), did anyone in the family receive dividend income from stocks or mutual funds of income from rental property, royalties, estates, or trusts?

1[] Yes (15b)
2[] No (16)
9[] DK (16)

b. Who was this?
Mark (x) "Dividends" in person's column

1[] Dividends

c. Anyone else?

[] Yes (Reask 15b and c)
[] No (15d)
[] DK (15d)


Ask 15d-f as appropriate for each person with "Dividends" marked in 15b.
d. What is your best estimate of the total amount that -- received from dividends, NET rental property income, royalties, estates, or trusts in (month)?

1[] Already included (15d for NP with 15b, or 16)
0[] Loss (15d for NP with 15b, or 16)

$______ (15d for NP with 15b, or 16)
(Dollars)

9999[] DK (15e)

e. Was it more than $25 or less than $25?

1[] More that $25 (15f)
2[] Less than $25 (15d for NP with 15b, or 16)
3[] $25 exactly (15d for NP with 15b, or 16)
9[] DK (15d for NP with 15b, or 16)

Hand card FD2.
CARD FD2

1[] $25 - $99
2[] $100 - $499
3[] $500 - $999
4[] $1000 - $4999,
5[] $5000 or more

f. Was it -- Read answer categories.

1[] $25 - $99 (15d for NP with 15b, or 16)
2[] $100 - $499 (15d for NP with 15b, or 16)
3[] $500 - $999 (15d for NP with 15b, or 16)
4[] $1000 - $4999, or (15d for NP with 15b, or 16)
5[] $5000 or more? (15d for NP with 15b, or 16)
9[] DK (15d for NP with 15b, or 16)


16a. 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 sale of a home.

1[] Yes (16b)
2[] No (17 on page 48)
9[] DK (17 on page 48)

b. Who was this?
Mark (x) "Other income" in person's column

1[] Other income

c. Anyone else?

[] Yes (Reask 16b and c)
[] No (16d)
[] DK (16d)


Ask 16d-f as appropriate for each person with "other income" marked in 16b.
d. How much income did -- receive in (month) from ALL OTHER sources?

1[] Already included (16d for NP with 16b, or 17 on page 48)
$______ (16d for NP with 16b, or 17 on page 48)
(Dollars)

9999[] DK (15e)

e. Was it more than $25 or less than $25?

1[] More than $25 (16f)
2[] Less than $25 (16d for NP with 16b, or 17 on page 48)
3[] $25 exactly (16d for NP with 16b, or 17 on page 48)
9[] DK (16d for NP with 16b, or 17 on page 48)

Hand card FD2.
CARD FD2

1[] $25 - $99
2[] $100 - $499
3[] $500 - $999
4[] $1000 - $4999,
5[] $5000 or more

f. Was it -Read answer categories

1[] $25 - $99 (16d for NP with 16b, or 17 on page 48)
2[] $100 - $499 (16d for NP with 16b, or 17 on page 48)
3[] $500 - $999 (16d for NP with 16b, or 17 on page 48)
4[] $1000 - $4999, or (16d for NP with 16b, or 17 on page 48)
5[] $5000 or more? (16d for NP with 16b, or 17 on page 48)
9[] DK (16d for NP with 16b, or 17 on page 48)

[p.196]

Part D - Income and Assets - Continued


17a. Does anyone in the family own a car, truck, recreational vehicle, motorcycle, or boat?

1[] Yes (17b)
2[] No (18)
9[] DK (18)


Hand card FD3. Read categories if telephone interview.
CARD FD3

1[] Less than $2,000
2[] $2,000 - $4,999
3[] $5,000 - $9,999
4[] $10,000 - $19,999
5[] $20,000 - $49,999
6[] $50,000 - $99,999
7[] $100,000 or more

b. Altogether, how much are they worth?
Mark (x) only one

1[] Less than $2,000
2[] $2,000 - $4,999
3[] $5,000 - $9,999
4[] $10,000 - $19,999
5[] $20,000 - $49,999
6[] $50,000 - $99,999
7[] $100,000 or more
9[] DK


18a. Is this [house/apartment] now-


(1) Owned or being bought by you (or someone in the household)?
1[] Yes (18b)
2[] No (Ask (2))


(2) Rented for money?
1[] Yes (18e)
2[] No (Ask (3))


(3) Occupied without payment of money rent?
1[] Yes (19)
2[] No (19)


Hand card FD4. Read categories if telephone interview.
CARD FD4

1[] Less than $25,000
2[] $25,000 - $49,999
3[] $50,000 - $99,999
4[] $100,000 - $199,999
5[] $200,000 - $299,999
6[] $300,000 - $499,999
7[] $500,000 or more

b. About how much is this place worth on today's market?
Mark (x) only one.

1[] Less than $25,000
2[] $25,000 - $49,999
3[] $50,000 - $99,999
4[] $100,000 - $199,999
5[] $200,000 - $299,999
6[] $300,000 - $499,999
7[] $500,000 or more
9[] DK


c. Is it fully paid for or do you still owe something?

1[] Fully paid for, nothing is owed (19)
2[] Still owe something (18d)
9[] DK (19)


Hand card FD5. Read categories if telephone interview.

(Note: No CARD FD5 in survey.)
d. What is the monthly mortgage payment?
Mark (x) only one.

1[] Less than $500 (19)
2[] $500 -$999 (19)
3[] $1,000 - $1,999 (19)
4[] $2,000 or more (19)
9[] DK (19)


Hand card FD5. Read categories if telephone interview.

(Note: No CARD FD5 in survey.)
e. What is the monthly rent?
Mark (x) only one

1[] Less than $500
2[] $500 - $999
3[] $1,000 - $1,999
4[] $2,000 or more
9[] DK


f. Does the monthly rent include meals and/or utilities?

1[] Yes
2[] No
9[] DK


19. [Do you/Does your family] own any other assets, such as another house, a business, or stocks and bonds?

1[] Yes (20)
2[] No (Item D3)
9[] DK (Item D3)


20a. [Do you/Does your family] own other property, such, as another home, rental property, or land?

1[] Yes (20b)
2[] No (21)
9[] DK (21)


Hand card FD4. Read categories if telephone interview.
CARD FD4

1[] Less than $25,000
2[] $25,000 - $49,999
3[] $50,000 - $99,999
4[] $100,000 - $199,999
5[] $200,000 - $299,999
6[] $300,000 - $499,999
7[] $500,000 or more

b. If [you/your family] sold this other property now and paid off any debts on it, about how much would [you/your family] get?
Mark (x) only one.

1[] Less than $25,000
2[] $25,000 - $49,999
3[] $50,000 - $99,999
4[] $100,000 - $199,999
5[] $200,000 - $299,999
6[] $300,000 - $499,999
7[] $500,000 or more
9[] DK

[p.197]

Part D - Income and Assets - Continued


21a. (Besides this property)[Do you/Does your family] own part or all of a business, farm, or professional practice?

1[] Yes (21b)
2[] No (22)
9[] DK (22)


Hand card FD4. Read categories if telephone interview.
CARD FD4

1[] Less than $25,000
2[] $25,000 - $49,999
3[] $50,000 - $99,999
4[] $100,000 - $199,999
5[] $200,000 - $299,999
6[] $300,000 - $499,999
7[] $500,000 or more

b. If [you/your family] sold this business, farm, or professional practice now and paid off any debts on it, about how much would [you/your family] get?
Mark (x) only one

1[] Less than $25,000
2[] $25,000 - $49,999
3[] $50,000 - $99,999
4[] $100,000 - $199,999
5[] $200,000 - $299,999
6[] $300,000 - $499,999
7[] $500,000 or more
9[] DK


22a. [Do you/Does your family] have any other savings, assets, or property? Include stocks and bonds and certificates of deposit (CDs)

1[] Yes (22b)
2[] No (Item D3)
9[] DK (Item D3)


Hand card FD4. Read categories if telephone interview.
CARD FD4

1[] Less than $25,000
2[] $25,000 - $49,999
3[] $50,000 - $99,999
4[] $100,000 - $199,999
5[] $200,000 - $299,999
6[] $300,000 - $499,999
7[] $500,000 or more

b. Altogether, what is the present value of these other savings, assets, or property?
Mark (x) only one

1[] Less than $25,000
2[] $25,000 - $49,999
3[] $50,000 - $99,999
4[] $100,000 - $199,999
5[] $200,000 - $299,999
6[] $300,000 - $499,999
7[] $500,000 or more
9[] DK

ITEM D3
About how often did the Respondent appear to answer the questions in Part D, Income and Assets accurately?

1[] All the time
2[] Most of the time
3[] Some of the time
4[] Rarely or never
9[] DK
ITEM D4
About how often did the Respondent appear to answer the questions in Part D, Income and Assets honestly?

1[] All the time
2[] Most of the time
3[] Some of the time
4[] Rarely or never
9[] DK
ITEM D5
Enter the person number of the respondent. If more than one, enter the person number of the one who answered the most questions in Part D.

Person number _____

[p.198]

10. Response status

a. Section II A (Access to care)
Interview:
1[] Complete (Mark mode) Explain Partial in notes
2[] Partial (Mark mode) Explain Partial in notes


Noninterview:
3[] Refused (Explain in notes)
4[] Other (Explain in notes)


Mode of interview:
All or most of the supplement was conducted-
1[] In Person
2[] By telephone


b. Sections II B-D (Health Care, Income and Assests)
Interview:
1[] Complete (Mark mode) Explain Partial in notes
2[] Partial (Mark mode) Explain Partial in notes


Noninterview:
3[] Refused (Explain in notes)
4[] Other (Explain in notes)


Mode of interview:
All or most of the supplement was conducted-
1[] In Person
2[] By telephone