FR: ENTER THE FAMILY NUMBER OF THE FAMILY YOU WISH TO CONTINUE. IF ALL FAMILIES IN THE HOUSEHOLD HAVE BEEN COMPLETED, ENTER (A) FOR ALL.

Family number: ____________________

(A) All families are totally complete
(N) No one is available to interview now

FR: THE REMAINDER OF THE INTERVIEW IS NOT REQUIRED FOR THIS FAMILY SINCE ALL ARE CURRENT ARMED FORCES MEMBERS.

FR: ASK IF NECESSARY: With whom am I speaking?
ENTER PERSON NUMBER OF THE RESPONDENT FOR THE FAMILY QUESTIONS FOR THIS FAMILY. IF MORE THAN ONE, ENTER THE NUMBER OF THE ONE YOU CONSIDER TO BE THE MAIN RESPONDENT.

FAMRESP [Enter Person #] [ ]

FR: CAN YOU CONTINUE WITH THE FAMILY SECTION, OR DO YOU NEED TO ARRANGE A CALLBACK?

(1) Continue with Family Section (FINTRO)
(2) Arrange Callback (CP_BEG)
(3) Noninterview (PRE_ARRAN)

FR: IF ANY PERSONS LISTED BELOW ARE NOT PRESENT, SAY:

We would like to have all adult family members who are at home take part in the interview. Are (READ NAMES BELOW) at home now? IF YES, ASK: Could they join us? (ALLOW TIME)

FR: ENTER LINE NUMBER(S) OF FAMILY MEMBERS LISTED BELOW THAT ARE CURRENTLY PRESENT. ENTER UP TO 10 NUMBERS.

[ ] FINTRO01
[ ] FINTRO02
[ ] FINTRO03
[ ] FINTRO04
[ ] FINTRO05
[ ] FINTRO06
[ ] FINTRO07
[ ] FINTRO08
[ ] FINTRO09
[ ] FINTRO10

Are {fill names of children under 5}/Is {fill in name of child under 5} limited in the kind or amount of play activities he/she/they can do because of a physical, mental, or emotional problem?

(1) Yes (FHS.010)
(2) No (FHS.050)
(7) Refused (FHS.050)
(9) DK (FHS.050)

Who is this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Is {subject's name listed in PLAYPLYLM} able to take part AT ALL in the usual kinds of play activities done by most children {subject's name}'s age?

(1) Yes (FHS.050)
(7) Refused (FHS.050)
(2) No (FHS.050)
(9) DK (FHS.050)

Do any of the children under 18 in this family, {fill names of children under age 18} receive Special Educational or Early Intervention Services?

(1) Yes (FHS.060)
(7) Refused (FHS.070)
(2) No (FHS.070)
(9) DK (FHS.070)

Who is this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Because of a physical, mental, or emotional problem, {do/does} {you/anyone in the family} need the help of other persons with PERSONAL CARE NEEDS, such as eating, bathing, dressing, or getting around inside this home?

(1) Yes (FHS.080)
(2) No (FHS.150)
(7) Refused (FHS.150)
(9) DK (FHS.150)

Who is this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

{Do/Does} {you/subject's name} need the help of other persons with ....?

(1) Yes (FHS.150)
(2) No (FHS.150)
(7) Refused (FHS.150)
(9) DK (FHS.150)

LABATH Bathing or showering?
LADRESS Dressing?
LAEAT Eating?
LABED Getting in or out of bed or chairs?
LATOILT Using the toilet, including getting to the toilet?
LAHOME Getting around inside the home?

Because of a physical, mental, or emotional problem, {do/does} {you/anyone in the family} need the help of other persons in handling ROUTINE NEEDS, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

(1) Yes (FHS.160)
(2) No (FHS.170)
(7) Refused (FHS.170)
(9) DK (FHS.170)

Who is this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Does a physical, mental, or emotional problem NOW keep {you/anyone in the family (fill in names of family members aged 18 and older)} from working at a job or business?

(1) Yes (FHS.180)
(2) No (FHS.190)
(7) Refused (FHS.190)
(9) DK (FHS.190)

Who is this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

{Are/(Other than the persons mentioned), are any of these family members} {you/repeat adult names if needed} limited in the kind OR amount of work {you/they} can do because of a physical, mental or emotional problem?

(1) Yes (FHS.200)
(2) No (FHS.210)
(7) Refused (FHS.210)
(9) DK (FHS.210)

Who is this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Because of a health problem, {do/does} {you/anyone in the family} have difficulty walking without using any special equipment?

(1) Yes (FHS.220)
(2) No (FHS.230)
(7) Refused (FHS.230)
(9) DK (FHS.230)

Who is this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

{Are/is} {you/anyone in the family} LIMITED IN ANY WAY because of difficulty remembering or because {you/they} experience periods of confusion?

(1) Yes (FHS.240)
(2) No (Check item FHSCCI2)
(7) Refused (Check item FHSCCI2)
(9) DK (Check item FHSCCI2)

Who is this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Check item FHSCCI2: For family members NOT in the entry in FHS.010, FHS.060, FHS.080, FHS.160, FHS.180, FHS.200, FHS.220, or FHS.240 go to FHS.250; Otherwise, go to Check item FHSCCI3.

Are {you/anyone in the family (list names of persons without limitation if needed)} LIMITED IN ANY WAY in any activities because of physical, mental or emotional problems?

(1) Yes (FHS.260)
(2) No (Check item FHSCCI3))
(7) Refused (Check item FHSCCI3
(9) DK (Check item FHSCCI3)

Who is this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Check item FHSCCI3: For family members with an entry in FHS.010 through FHS.260: If AGE is less than 18 go to FHS.270; Else goto FHS.290. If none with entry in FHS.010 through FHS.260, or the family roster is exhausted goto FHS.310.

What conditions or health problems cause {subject's name} limitations?

FR: HAND CARD F2. DO NOT READ. CODE ALL THAT APPLY, UP TO 5, BUT DO NOT PROBE. ENTER (N) FOR NO MORE.

1. Vision/problem seeing
2. Hearing problem
3. Speech problem
4. Asthma/breathing problem
5. Birth defect
6. Injury
7. Mental retardation
8. Other developmental problem (e.g. cerebral palsy)
9. Other mental, emotional or behavioral problem
10. Bone, joint, or muscle problem
11. Epilepsy
12. Other impairment/problem

(1) Vision/ problem seeing
(2) Hearing problem
(3) Speech problem
(4) Asthma/breathing problem
(5) Birth defect
(6) Injury
(7) Mental retardation
(8) Other developmental problem (e.g. cerebral palsy)
(9) Other mental, emotional, or behavioral problem
(10) Bone, joint, or muscle problem
(11) Epilepsy
(12) Other impairment/problem (specify one) (FHS.271)
(13) Other impairment/problem (specify one) (FHS.272)
(97) Refused
(99) DK/not sure

(Goto FHS.280)

FR: SPECIFY CONDITION CAUSING LIMITATION. THIS SHOULD BE THE NAME OF A SPECIFIC CONDITION THAT IS NOT ON THE CONDITION LIST.

LACCSPEC CONDITION:_________________________

FR: SPECIFY CONDITION CAUSING LIMITATION. THIS SHOULD BE THE NAME OF A SPECIFIC CONDITION THAT IS NOT ON THE CONDITION LIST.

LACCSPEC_1 CONDITION:_________________________

How long {have/has}{you/subject's name} had [fill condition entered in FHS.270]?

[ ] NUMBER

(01-94) 1-94 times
(95) 95+
(96) Since birth
(97) Refused
(99) DK

[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) DK

[Go back to Check item FHSCCI3 for next family member. If no more family members goto FHS.310.]

What conditions or health problems cause {subject's name} limitations?

FR: HAND CARD F3. DO NOT READ. CODE ALL THAT APPLY, UP TO 5, BUT DO NOT PROBE. ENTER (N) FOR NO MORE.

1. Vision/problem seeing
2. Hearing problem
3. Arthritis/rheumatism
4. Back or neck problem
5. Fracture, bone/joint injury
6. Other injury
7. Heart problem
8. Stroke problem
9. Hypertension/high blood pressure
10. Diabetes
11. Lung/breathing problem
12. Cancer
13. Birth defect
14. Mental retardation
15. Other developmental problem (e.g. cerebral palsy)
16. Senility
17. Depression/anxiety/emotional problem
18. Weight problem
19. Other impairment/problem

(1) Vision/ problem seeing
(2) Hearing problem
(3) Arthritis/rheumatism
(4) Back or neck problem
(5) Fractures, bone/joint injury
(6) Other injury
(7) Heart problem
(8) Stroke problem
(9) Hypertension/high blood pressure
(10) Diabetes
(11) Lung/breathing problem
(12) Cancer
(13) Birth defect
(14) Mental retardation
(15) Other developmental problem (e.g. cerebral palsy)
(16) Senility
(17) Depression/anxiety/emotional problem
(18) Weight problem
(19) Other impairment/problem (specify one)(FHS.291)
(20) Other impairment/problem (specify one)(FHS.292)
(97) Refused
(99) DK/not sure

[ ]
[ ]
[ ]
[ ]
[ ]

FR: SPECIFY CONDITION CAUSING LIMITATION. THIS SHOULD BE THE NAME OF A SPECIFIC CONDITION THAT IS NOT ON THE CONDITION LIST.

LACASPEC CONDITION:_____________________________

FR: SPECIFY CONDITION CAUSING LIMITATION. THIS SHOULD BE THE NAME OF A SPECIFIC CONDITION THAT IS NOT ON THE CONDITION LIST.

LACASPEC_1 CONDITION:_____________________________

How long {have/has}{you/subject's name} had [fill condition entered in FHS.290]?

[ ] NUMBER

(01-94) 1-94
(99) DK
(95) 95+
(97) Refused
(96) Since birth

[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) DK

[Go back to Check item FHSCCI3 for next family member. If no more family members goto FHS.310.]

Ask this question for each member separately:

Would you say {subject's name} health in general is excellent, Very good, good, fair, or poor?

(1) Excellent
(2) Very good
(3) Good
(4) Fair
(5) Poor
(7) Refused
(9) DK

(Goto next section--Injuries)

The following questions are about the use of health care. Do not include dental care. DURING THE PAST 12 MONTHS, has medical care been delayed for {you/anyone in the family} because of worry about the cost?

(1) Yes (FAU.020)
(2) No (FAU.030)
(7) Refused (FAU.030)
(9) DK (FAU.030)

For which family member was medical care delayed? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

DURING THE PAST 12 MONTHS, was there any time when {you/anyone in the family} needed medical care, but did not get it because {you/the family} couldn't afford it?

(1) Yes (FAU.040)
(2) No (FAU.050)
(7) Refused (FAU.050)
(9) DK (FAU.050)

Who didn't get needed care? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

DURING THE PAST 12 MONTHS {were/was} {you/anyone in the family} a patient in a hospital OVERNIGHT? (Do not include an overnight stay in the emergency room.)

[If there is a child lt 1 year old in the family add] Remember to include any new mothers and/or babies who were hospitalized for the baby's birth.

(1) Yes (FAU.060)
(2) No (FAU.120)
(7) Refused (Check item FAU.120)
(9) DK (Check item FAU.120)

Who was in a hospital overnight? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

How many different times did {you/subject's name} stay in any hospital overnight or longer DURING THE PAST 12 MONTHS?

(001-365) 1-365 Times
(997) Refused
(999) DK

Altogether how many nights {were/was} {you/subject's name} in the hospital DURING THE PAST 12 MONTHS?

(001-365) 1-365 Nights
(997) Refused
(999) DK

[If FAU.070 lt FAU.110 goto NEXT_HOSP; Else goto FAU.115]

FR: DO NOT READ ALOUD:

[fill HPNITE_N] is less than the total number of times just reported that {you/subject's name} was in the hospital overnight. PROBE TO CORRECT.

(1) Increase total number of nights in hospital (FAU.110)
(2) Decrease total number of times [you/subject's name] stayed in hospital (FAU.070)
(3) Proceed without correcting (NEXT_HOSP)

Check item: NEXT_HOSP: Go back for next person listed in FAU.060. When no more people, goto FAU.120.

[If FAU.050 equals 1, add:]
Do not include care while an overnight patient in a hospital.

[Else, continue to read:]
During those 2 WEEKS, did {you/anyone in the family} receive care AT HOME from a nurse or other health care professional?

(1) Yes (FAU.130)
(2) No (FAU.150)
(7) Refused (FAU.150)
(9) DK (FAU.150)

Who received care at home? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

How many home visits did {you/subject's name} receive during those 2 WEEKS?

(01-49) 1-49 Visits
(50) 50+
(97) Refused
(99) DK

During those 2 WEEKS, did {you/anyone in the family} talk over the PHONE with a doctor, nurse, or other health care professional? Include phone calls for medical advice, prescriptions or test results, but do NOT include phone calls to make appointments.

(1) Yes (FAU.160)
(2) No (FAU.180)
(7) Refused (FAU.180)
(9) DK (FAU.180)

Who was the phone call about? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

During those 2 WEEKS, how many telephone calls were made about {you/subject's name}?

(01-49) 1-49 Calls
(50) 50+
(97) Refused
(99) DK

During those 2 WEEKS, did {you/anyone in the family} see a doctor or other health care professional at a doctor's OFFICE, a clinic, an emergency room, or some other place? (Do not include times during an overnight hospital stay.)

(1) Yes (FAU.190)
(2) No (FAU.210)
(7) Refused (FAU.210)
(9) DK (FAU.210)

Who received care? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

How many times did {you/subject's name} visit a doctor or other health care professional during those 2 WEEKS?

(01-49) 1-49 Times
(50) 50+
(97) Refused
(99) DK

During the past 12 MONTHS did {you/anyone in the family} receive care from doctors or other health care professionals 10 or more times?

(1) Yes (FAU.220)
(2) No (Goto next section -Health Insurance}
(7) Refused (Goto next section - Health Insurance)
(9) DK (Goto next section - Health Insurance}

Who received care 10 or more times? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

(Goto next section--Health Insurance)

The next questions are about health insurance. Are you familiar with the family's health care coverage?

(1) Yes (FHI.050)
(2) No (FHI.020)
(7) Refused (FHI.020)
(9) DK (FHI.020)

Who else in the family could answer questions about the family's health insurance?

[Enter person #s]

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Is {the person/anyone that} you just mentioned available now to answer questions about health insurance?

(1) Yes (FHI.040)
(2) No (FHI.050)
(7) Refused (FHI.050)
(9) DK (FHI.050)

FR: SELECT APPROPRIATE PERSON TO ANSWER DETAILED HEALTH INSURANCE QUESTIONS.

FAVAIL31 [Enter person #] [ ]

Check item FHICCI1: If FHI.040 has more than 1 input: show message "FR: PLEASE MARK ONLY ONE RESPONDENT. (1) Back up and make a correction", go back to FHI.040 for correction.

FR: HAND CARD F9.

1. Private health insurance plan from employer or workplace*
2. Private health insurance plan purchased directly*
3. Medicare
4. Medi-Gap
5. Medicaid
6. Military health care/VA
7. CHAMPUS/TRICARE/CHAMP-VA
8. Indian Health Service
9. State-sponsored health plan
10. Other government program

*EXCLUDE private plans that only provide extra cash while hospitalized or pay for only one type of service (nursing home care, accidents, or dental care).

[If FAVAIL eq (1)]
The next questions are about health insurance.

[If FAVAIL ne (1)]
Since no one else is available to answer these questions, we can just continue. Just give the best answers you can.
{Are you/Is anyone} covered by health insurance or some other kind of health care plan?

FR: READ IF NECESSARY: INCLUDE HEALTH INSURANCE OBTAINED THROUGH EMPLOYMENT OR PURCHASED DIRECTLY AS WELL AS GOVERNMENT PROGRAMS LIKE MEDICARE AND MEDICAID THAT PROVIDE MEDICAL CARE OR HELP PAYMEDICAL BILLS.

(1) Yes (FHI.060)
(2) No (FHICCI9)
(7) Refused (FHICCI9)
(9) DK (FHICCI9)

Who has coverage? (Anyone else?)

[Enter person #s]

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

[For members who were not marked in FHI.060, go to FHICCI9; Those family members who were marked in FHI.060, go to FHI.070.]

What kind of health insurance or health care coverage {do/does} {you/subject's name} have? EXCLUDE private plans that only provide extra cash while hospitalized or pay for only one type of service (nursing home care, accidents, or dental care).

FR: ENTER EACH NUMBER THAT APPLIES. (Anything else?)

[ ] HIKINDA (01) Private health insurance plan from employer or workplace
[ ] HIKINDB (02) Private health insurance plan purchased directly
[ ] HIKINDC (03) Medicare
[ ] HIKINDD (04) Medi-Gap
[ ] HIKINDE (05) Medicaid
[ ] HIKINDF (06) Military health care/VA
[ ] HIKINDG (07) CHAMPUS/TRICARE/CHAMP-VA
[ ] HIKINDH (08) Indian Health Service
[ ] HIKINDI (09) State-sponsored health plan
[ ] HIKINDJ (10) Other government program

Check item FHICCI3: (Medicare Coverage) Loop through every non-deleted and non Armed Forces family member roster:
1. If the person in FHI.070 marked 4 and not 3, go to FHI.080.
2. If the person in FHI.070 marked 3, go to FHI.080.
3. If the person in FHI.070 did not mark 3, go to Check item FHICCI4

Earlier I recorded that {you/subject name} {are/is} covered by Medicare. May I please see {your/subject's name} Medicare card to determine the type of coverage and to record the Health Ins. Claim Number? This number is needed to allow Medicare records of the Health Care Financing Administration to be easily and accurately located and identified for statistical or research purposes. We may also need to link it with other records in order to re-contact you. Except for these purposes, NCHS will not release your Health Insurance Claim Number to anyone, including any other government agency. Providing the Health Insurance Claim Number is voluntary and collected under the authority of the Public Health Service Act. Whether the number is given or not, there will be no effect on your benefits. This number will be held in strict confidence.

FR: READ IF NECESSARY: THE PUBLIC HEALTH SERVICE ACT IS TITLE 42, UNITED STATES CODE, SECTION 242K.

MCNO_1 Claim Number (only numbers): ______-________-_______
MCNO_2 (any characters): -____________

(Goto FHI.090)

FR: FILL IN APPROPRIATE COVERAGE TYPE BELOW

(1) Part A - Hospital Only (Check item FHICCI4)
(2) Part B - Medical Only (FHI.100)
(3) Both Part A and Part B (FHI.100)
(4) Card Not Available (FHI.100)
(7) Refused (FHI.100)
(9) DK (FHI.100)

{Are/Is} {You/subject's name} signed up with an HMO, that is, a Health Maintenance Organization? (With an HMO, you must generally receive care from HMO doctors, otherwise the expense is not covered unless you were referred by the HMO or there was a medical emergency).

(1) Yes
(2) No (FHICCI4)
(7) Refused (FHICCI4)
(9) DK (FHICCI4)

[If answer equals 1, ask: ]

What is the name of the HMO?

MCHMO_NA Name: _______________

Check item FHICCI4: (Medicaid Coverage) If the person in FHI.070 marked 5 then goto FHI.120; Else goto Check item FHICCI5.

The next questions are about Medicaid coverage. In this State it is also called (state name) {You/Subject's name} {are/is} listed as having Medicaid coverage. Can {you/subject name} go to ANY doctor who will accept Medicaid or MUST {you/he/she} choose from a book or list of doctors or is a doctor assigned?

(1) Any doctor (FHI.140)
(2) Select from book/list (MACHMD_1)
(3) Doctor is assigned (MACHMD_2)
(7) Refused (FHI.140)
(9) DK (FHI.140)

[If answer equals 2, ask:]
What is the name of the health plan that provided the book or list?

MACHMD_1 Name: _________________________ (FHI.140)

[If answer equals 3, ask:]
What is the name of the health plan that assigned the doctor?

MACHMD_2 Name: _________________________ (FHI.140)

{Are/Is} {you/subject's name} required to sign up with a certain primary care doctor, group of doctors, or certain clinic which {you/he/she} must go to for all of {your/his/her} routine care? (Do not include emergency care or care from a specialist {you/he/she} was referred to).

(1) Yes
(2) No
(7) Refused
(9) DK

If {you/subject's name} {need/needs} to go to a different doctor or place for special care, (do/does} {you/he/she} need approval or a referral? (Do not include emergency care.)

(1) Yes
(2) No
(7) Refused
(9) DK

Check item FHICCI5: (Private Coverage) Loop through the family member roster: If any person with
- Private health insurance plan from employer or workplace (in FHI.070 marked 1 ),
- Private health insurance plan purchased directly (in FHI.070 marked 2),
- Medi-gap (in FHI.070 marked 4),
Then go to Check item FHICCI6; Else go to Check item FHICCI7.

Check item FHICCI6: The next questions are about health insurance plans obtained through work or purchased directly.

[If more than 1 person has private insurance plan say:]
We have the following persons listed as being covered by such plans {read names}.

Are there any more health insurance plans?

(1) Yes (FHI.172)
(2) No (FHICCI7)

What is the name of the next plan?

NEXTPNM Name: _________________________ (FHI.173)

Which family members are covered by that plan?

[Enter person #s]

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Are there any more health insurance plans in addition to those already mentioned?

(1) Yes (FHI.175)
(2) No (FHICCI7)

What is the name of the next plan?

NEXTPNM5 Name: _________________________ (FHI.176)

Which family members are covered by that plan?

[Enter person #s]

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Are there any more health insurance plans in addition to those already mentioned?

(1) Yes (FHI.178)
(2) No (FHICCI7)

What is the name of the next plan?

NEXTPNM5 Name: _________________________ (FHI.179)

Which family members are covered by that plan?

[Enter person #s]

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Check item FHICCI7: If any private insurance covered person wasn't list on any of the above plans, goto

{Subject's name} is listed as having private insurance but was not mentioned as being covered by any of the plans we just discussed. Is {subject's name} covered by private insurance?

(1) Yes (FHI.190)
(2) No (FHI.070)
(7) Refused (FHI.070)
(9) DK (FHI.070)

Is the health insurance plan of {subject's name} the same as one of those already mentioned?

FR: MARK "X" ANY THAT APPLY fill in from FHI.170: HIPNAM, NEXTPNM, NEXTPNM2.

HIVER2_1 [ ]1 [fill HIPNAM]
HIVER2_2 [ ]2 [fill NEXTPNM] (if available)
HIVER2_3 [ ]3 [fill NEXTPNM2] (if available)
HIVER2_4 [ ]4 [fill NEXTPNM3] (if available)
HIVER2_5 [ ]5 Some other plan not already mentioned

Check item FHICCI8: [If more plan name (ie. from item HIPNAM), ask:]

Now I am going to ask some questions about the {plan/plans} you just told me about,{/starting with} [fill plan name].

[else]
Next I would like to ask you about [fill plan name].

Health insurance plans are usually obtained in one person's name even if other family members are covered. That person is called the policyholder. In whose name is this plan?

Enter (0) for policyholder outside of family.
Enter person #] [ ]

Was this plan originally obtained through the workplace, such as through a present or former employer or union?

(1) Employer
(2) Union
(3) Through workplace, but DK if employer or union
(4) Through workplace, self-employed or professional association
(5) No
(7) Refused
(9) DK

Who pays for this health insurance plan?

FR: ENTER ALL THAT APPLY. IF GOVERNMENT PROGRAM IS REPORTED, PROBE FOR MEDICARE OR MEDICAID BEFORE ENTERING CODE 6. IF GOVERNMENT IS THE EMPLOYER, ENTER CODE 2.

(1) Self or Family (FHI.230)
(2) Employer or Union (FHI.240)
(3) Someone outside the household (FHI.240)
(4) Medicare (FHI.240)
(5) Medicaid (FHI.240)
(6) Government Program (FHI.240)
(7) Refused (FHI.240)
(9) DK (FHI.240)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

During the PAST 12 MONTHS, how much did {you/your family} spend for health insurance premiums for {plan name}? Please include payroll deductions for premiums.

FR: HAND CARD F10.

1. Less than $500
2. $500-$999
3. $1,000 - $1,999
4. $2,000 - $2,999
5. $3,000 or more

(1) Less than $500
(2) $500-$999
(3) $1,000-$1,999
(4) $2,000-$2,999
(5) $3,000 or more
(7) Refused
(9) DK

Is {plan name} an HMO (Health Maintenance Organization), an IPA (Individual Practice Association), or is it some other kind of plan?

FR: ACCEPT PPO AS A VALID RESPONSE IF THE RESPONDENT OFFERS IT. ENTER CODE 2 FOR PPO. READ IF NECESSARY: Health Maintenance Organizations, or HMOs, and Individual Practice Associations, or IPAs, are plans whose members are required to use only those doctors who work for or in association with the plan. Sometimes members may choose to go to doctors not associated with the plan, but usually at greater cost to the member. Generally, members do not have to submit claims for costs of medical care services.

(1) HMO/IPA
(2) PPO
(3) Other
(7) Refused
(9) DK

Check item FHICCI9: Loop through each non-deleted family member: If any member is in a family with a family member in the armed forces, goto FHI.320; Else if any member with no entry marked in FHI.060 , goto FHI.260; Else if any member marked FHI.070 with 9 or 10 goto FHI.250; Else go to FHI.300.

Earlier I recorded that {you/subject's name} {do/does} not have health care coverage of any kind. {Do/Does} {you/he/she} have Medicare, Medicaid,

FR: READ STATE NAME FOR MEDICAID AND STATE SPONSORED HEALTH INSURANCE PROGRAM FROM FLASHCARD PG.19 AND 20.

CHAMPUS or CHAMPVA... or any private insurance?

(Note: OR indicates that the state also has the name "state name medicaid" such as "Iowa Medicaid")

Alaska . . . Medical Assistance Program
Arizona . . . AHCCCS (Pronounced "Access") OR Acute Care Program OR Long Term Care System (ALTCS)
California . . . Medi-Cal
Connecticut . . . OR ConnecticutAccess (CONNECT CARD)
D.C. . . . OR Medical Assistance
Florida . . . OR MediPass
Georgia . . . OR Better Health Care Program OR Medical Assistance
Hawaii . . . OR Med-QUEST OR Maluhia OR Medical Assistance
Idaho . . . OR Healthy Connections OR Medical Assistance
Illinois . . . OR MediPlan
Indiana . . . OR Hoosier Healthwise
Iowa . . . OR MediPASS (Medical Assistance)
Kansas . . . OR PrimeCare OR Community Care Kansas (CCK) OR HealthConnect
Kentucky . . . OR Kentucky Patient Access and Care System (KenPAC) OR Medical Assistance
Louisiana . . . OR CommunityCARE Progam
Maine . . . OR PrimeCare
Maryland . . . OR Maryland Access to Care (MAC) OR Medical Assistance
Massachusetts . . . MassHealth
Minnesota . . . OR Prepaid Medical Assistance Program (PMAP), Health Care Programs
Mississippi . . . OR HealthMACS
Missouri . . . OR MC Plus
Montana . . . OR Passport to Health
Nebraska . . . OR Primary Care Plus (+) OR Health Connection
Nevada . . . OR MAPnet
New Jersey . . . OR New Jersey Care 2000
New Mexico . . . OR Primary Care Network
New York . . . OR MAX
North Carolina . . . OR Carolina Access
North Dakota . . . OR North Dakota Access to Care (NoDAC)
Ohio . . . OR Accessing Better Care (ABC) Program
Oklahoma . . . OR SoonerCare
Oregon . . . OR Oregon Health Plan (OHP), Kaiser-S/HMO, Medical Assistance
Pennsylvania . . . OR HealthPASS, Family Care Network (FCN), Lancaster Community Health Plan, Blue Card or Green Card, ACCESS
Rhode Island . . . OR Rlte care OR Medical Assistance
South Carolina . . . Or South Carolina Health Access Plan (SCHAP)
South Dakota . . . OR Primary Care Provider Program
Tennessee . . . TennCare
Texas . . . OR LoneSTAR (State of Texas Access Reform)
Vermont . . . OR Dr. Dynosaur, Vermont Health Access Program (VHAP), AIM
Virginia . . . OR Medallion, Options, Medical Assistance
Washington . . . OR Health Access Spokane, Kaiser-S/HMO, Healthy Options
West Virginia . . . OR West Virginia Physician Assured Access System (PAAS)
Wisconsin . . . Medical Assistance Program

Alaska . . . General Relief Medical (GRM)
California . . . County Medical Services Progam (CMSP), Children's Services (CCS)
Colorado . . . Child Health Plan
Connecticut . . . Healthy Steps, General Assistance Program (GA)
Florida . . . Healthy Kids
Illinois . . . General Assistance Program (State Child and Family Assistance, SCFA or Transitional Assistance, TA)
Iowa . . . Caring Program for Children
Kansas . . . MediKan, Caring Program for Kids
Massachusetts . . . CommonHealth Program, Medical Security Plan (MSP), CenterCare Program, Children's Medical Security Plan
Michigan . . . Wayne County Plus Care Program, Medical Assistance Program, Caring Program for Children
Minnesota . . . MinnesotaCare, Minnesota General Assistance Medical Care Program (GAMC)
Missouri . . . General Relief Medical Assistance
Nebraska, . . . State Disability Program
New Jersey . . . Health Access New Jersey
New York . . . Home Relief, Child Health Plus (CHP)
North Carolina . . . Caring Program for Children
Ohio . . . Ohio Disability Assistance Medical Program
Pennsylvania . . . Children's Health Insurance Program (CHIP), General Assistance Medical Program
Rhode Island . . . General Public Assistance (GPA) Medical Program
Utah . . . Utah Medical Assistance Program (UMAP)
Virginia . . . State and Local Hospitalization (SLH) Program, Caring Program for Children
Washington . . . Basic Health Plan, Children's Health Program, General Assistance Unemployable Program (GA-U)
Wisconsin . . . General Relief Medical

(1) Yes (FHI.060)
(2) No (FHI.270)
(7) Refused (FHI.270)
(9) DK (FHI.270)

About how long has it been since {subject's name} last had health care coverage?

FR: HAND CARD T.

1. 6 months or less
2. More than 6 months, but not more than 1 year ago
3. More than 1 year, but not more than 3 years ago
4. More than 3 years
5. Never

(1) 6 months or less (FHI.280)
(2) More than 6 months, but not more than 1 year ago (FHI.280)
(3) More than 1 year, but not more than 3 years ago (FHI.280)
(4) More than 3 years (FHI.320)
(5) Never (FHI.320)
(7) Refused (FHI.320)
(9) DK (FHI.320)

Which of these are reasons {you/subject's name} stopped being covered by health insurance?

FR: HAND CARD F11. ENTER UP TO 5 REASONS. ENTER 'N' FOR NO MORE.

1. Lost job or changed employers
2. Spouse/parent lost job or changed employers
3. Got divorced or separated/death of spouse or parent
4. Became ineligible because of age/left school
5. Employer stopped offering coverage
6. Cut back to part-time/became temporary employee
7. Benefits from employer/former employer ran out
8. Couldn't afford to pay premiums
9. Insurance plan raised cost of premiums
10. Insurance company refused coverage
11. Other

(1) Lost job or changed employers
(2) Spouse/parent lost job or changed employers
(3) Got divorced or separated/death of spouse or parent
(4) Became ineligible because of age/left school
(5) Employer stopped offering coverage
(6) Cut back to part-time/became temporary employee
(7) Benefits from employer/former employer ran out
(8) Couldn't afford to pay premiums
(9) Insurance plan raised cost of premiums
(10) Insurance company refused coverage
(11) Other (specify) @SPC
(97) Refused
(99) DK

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

(Goto FHI.320)

In the PAST 12 MONTHS, was there any time when {subject's name} did NOT have ANY health insurance or coverage?

(1) Yes (FHI.310)
(2) No (FHI.320)
(7) Refused (FHI.320)
(9) DK (FHI.320)

In the PAST 12 MONTHS, about how many months {were/was} {you/subject's name} without coverage?

(01-12) 1-12 months
(97) Refused
(99) DK

During the PAST 12 MONTHS, about how much did {you/your family} spend for medical care, including dental care? Do NOT include the cost of health insurance premiums, over the counter remedies, or any costs for which you expect to be reimbursed.

FR: HAND CARD F12.

0. Zero
1. Less than $500
2. $500 - $1,999
3. $2,000 - $2,999
4. $3,000 - $4,999
5. $5,000 or more

(0) Zero
(1) Less than $500
(2) $500-$1,999
(3) $2,000-$2,999
(4) $3,000-$4,999
(5) $5,000 or more
(7) Refused
(9) DK

(Goto next section--Socio-Demographic Background)

In what country {were/was} {you/subject's name} born?

(001) United States
(002) Puerto Rico
(003) Outlying Area of the U.S.(American Samoa, Guam, U.S.Virgin Islands, Northern Marianas, Other U.S. Territory)
(004) Canada
(005) Cambodia
(006) China
(007) Colombia
(008) Cuba
(009) Dominican Republic
(010) Ecuador
(011) El Salvador
(012) England
(013) France
(014) Germany
(015) Greece
(016) Guatemala
(017) Guyana
(018) Haiti
(019) Honduras
(020) Hong Kong
(021) Hungary
(022) India
(023) Iran
(024) Ireland/Eire
(025) Italy
(026) Jamaica
(027) Japan
(997) Refused
(999) DK

OTHER COUNTRIES FOR NATIVITY

(028) Laos
(029) Mexico
(030) Nicaragua
(031) Peru
(032) Philippines
(033) Poland
(034) Portugal
(035) Russia
(036) Scotland
(037) Korea/South Korea
(038) Taiwan
(039) Thailand
(040) Trinidad and Tobago
(041) Vietnam
(042) Yugoslavia
(200) Afghanistan
(375) Argentina
(185) Armenia
(102) Austria
(501) Australia
(130) Azores
(333) Bahamas
(202) Bangladesh
(334) Barbados
(310) Belize
(103) Belgium
(300) Bermuda
(376) Bolivia
(377) Brazil
(205) Burma
(378) Chile
(311) Costa Rica
(155) Czech Republic
(105) Czechoslovakia
(106) Denmark
(338) Dominica
(415) Egypt
(417) Ethiopia
(507) Fiji

OTHER COUNTRIES FOR NATIVITY

(421) Ghana
(138) Great Britain
(340) Grenada
(126) Holland
(211) Indonesia
(213) Iraq
(214) Israel
(216) Jordan
(427) Kenya
(183) Latvia
(222) Lebanon
(184) Lithuania
(108) Finland
(436) Morocco
(128) Netherlands
(514) New Zealand
(440) Nigeria
(142) Northern Ireland
(127) Norway
(229) Pakistan
(253) Palestine
(317) Panama
(132) Romania
(233) Saudi Arabia
(234) Singapore
(156) Slovakia/Slovak Rep.
(224) Malaysia
(449) South Africa
(134) Spain
(136) Sweden
(137) Switzerland
(237) Syria
(240) Turkey
(195) Ukraine
(387) Uruguay
(180) USSR
(388) Venezuela
(353) Caribbean
(318) Central America

OTHER REGIONS/CONTINENTS FOR NATIVITY

(389) South America
(304) North America
(148) Europe
(252) Middle East
(468) North Africa
(527) Pacific Islands
(555) Elsewhere
(462) Other Africa
(245) Asia

If PLBORN=1 goto FSD.005; all others goto FSDCCI1.

In what state {were/was} {you/subject's name} born?

USBORNState: _________________________ (Goto FSDCCI1)

Check item FSDCCI1: If AGE is less than or equal to 6, goto FSD.006. When no more family members AGE is less than or equal 6, then goto FSD.010.

Is {subject's name} now attending Head Start?

(1) Yes (FSD.010)
(2) No (FSD.007)
(7) Refused (FSD.007)
(9) DK (FSD.007)

Has {subject's name} ever attended Head Start?

(1) Yes
(2) No
(7) Refused
(9) DK

What is the HIGHEST level of school {you/subject's name} {have/has} completed or the highest degree {you/subject's name} {have/has} received? Please tell me the number from the card.
Enter highest level of school:

FR: HAND CARD F13.

0. Never attended/kindergarten only
1. 1st grade
2. 2nd grade
3. 3rd grade
4. 4th grade
5. 5th grade
6. 6th grade
7. 7th grade
8. 8th grade
9. 9th grade
10. 10th grade
11. I lth grade
12. 12th grade, no diploma
13. HIGH SCHOOL GRADUATE
14. GED or equivalent
15. Some college, no degree
16. Associate degree: occupational, technical, or vocational program
17. Associate degree: academic program
18. Bachelor's degree (Example: BA, AB, BS, BBA)
19. Master's degree (Example: MA, MS, MEng, MEd, MBA)
20. Professional School degree (Example: MD, DDS, DVM, JD)
21. Doctoral degree (Example: PhD, EdD)

(00) Never attended/ kindergarten only
(01) 1st grade
(02) 2nd grade
(03) 3rd grade
(04) 4th grade
(05) 5th grade
(06) 6th grade
(07) 7th grade
(08) 8th grade
(09) 9th grade
(10) 10th grade
(11) 11th grade
(12) 12th grade, no diploma
(13) HIGH SCHOOL GRADUATE
(14) GED or equivalent
(15) Some college, no degree
(16) Associate degree: occupational, technical, or vocational program
(17) Associate degree: academic program
(18) Bachelor's degree (Example: BA, AB, BS, BBA)
(19) Master's degree (Example: MA, MS, Meng, Med, MBA)
(20) Professional School degree (Example: MD, DDS, DVM, JD)
(21) Doctoral degree (Example: PhD, EdD)
(22) Child under 5 years old
(97) Refused
(99) Don't know

{Have you/Has anyone in the family} ever been honorably discharged from active duty in the U.S. Army, Navy, Air Force, Marine Corp, or Coast Guard? (If so, who? Anyone else?)

FR: SERVICE IN NATIONAL GUARD OR RESERVES IS NOT CONSIDERED ACTIVE DUTY

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Check item FSDCCI2: Go through all non-deleted family members, If AGE greater than or equal to 18 goto FSD.050; Else goto next section. When the family roster is exhausted, goto next section.

How many hours did {you/subject's name} work LAST WEEK at ALL jobs or businesses?

(01-94) 1-94 hours (FSD.080)
(95) 95+ (FSD.110)
(97) Refused (FSD.080)
(99) DK (FSD.080)

{Do/Does} {you/subject's name} USUALLY work 35 hours or more per week in total at ALL jobs or businesses?

(1) Yes
(2) No
(7) Refused
(9) DK

(Goto FSD.110)

[If FSD.050 equals 2, ask:]
What is the main reason {you/subject's name} did not work last week?

[Else, ask:]
What is the main reason {you/subject's name} did not have a job or business last week?

(1) Keeping house
(2) Going to school
(3) Retired
(4) Unable to work for health reasons
(5) On layoff
(6) Other
(7) Refused
(9) DK

[If FSD.060 equals 7 or 9, ask:]
Did {you/he/she} work for pay at any time in {last year in 4 digit format}?

[Else, ask:]
Although you reported that {you/subject's name} did not work at any time in the LAST week, did {you/he/she} work for pay at any time in {last year in 4 digit format}?

(1) Yes (FSD.110)
(2) No (Check item FSDCCI3)
(7) Refused (Check item FSDCCI3)
(9) DK (Check item FSDCCI3)

How many months in {last year in 4 digit format} did {you/subject's name} have at least one job or business?

FR: IF LESS THAN ONE MONTH, ENTER (1).

(01-12) 1-12 months
(97) Refused
(99) DK

What is your best estimate of {your/subject's name} earnings (include hourly wages, salaries, tips and commissions) before taxes and deductions from ALL jobs and businesses in {last year in 4 digit format}?

FR: ENTER 999,995 IF THE REPORTED INCOME IS GREATER THAN $999,995.

(000001-999994) 1-999994 dollars
(999995) $999,995+
(999997) Refused
(999999) DK

Check item FSDCCI3: If FSD.050 equals 1 or 2, goto FSD.130; Else, goto Check item FSDCCI2 for next person. When roster exhausted, goto next section.

Was health insurance offered to {you/subject's name} through {your/his/her} workplace?

(1) Yes
(2) No
(7) Refused
(9) DK

(Goto next section--Income and Assets)

FR: READ THE FOLLOWING:

The next questions are about {your/your combined family} income.

When answering these questions, please remember that by "combined family income", I mean your income PLUS the income of all family members living in this household (including cohabiting partners, and armed forces members living at home) BEFORE TAXES.
Are you knowledgeable about your family's finances?

(1) Yes (FIN.030)
(2) No (FIN.011)
(7) Refused (FIN.011)
(9) DK (FIN.011)

Who else in the family could answer questions about the family's finances?

[ ] PINWHO_1
[ ] PINWHO_2
[ ] PINWHO_3
[ ] PINWHO_4
[ ] PINWHO_5

Is anyone that you just mentioned available now to answer questions about finances?

(1) Yes (FIN.013)
(2) No (Check item FINCCI1)
(7) Refused (Check item FINCCI1)
(9) DK (Check item FINCCI1)

Person number of respondent for detailed income questions.

[Enter person #s]

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Check item FINCCI1: If an entry in FIN.011 equals respondent, set SAINFLG = 1 (SAINFLG = Sample Adult Income Flag), go to FIN.030.

[If one person family, ask:]
Did you receive income from... self-employment including business and farm income?

[else, ask:]
Did they (FR: READ NAMES AGAIN IF NECESSARY) receive income from...self-employment including business and farm income?

(1) Yes (FIN.060)
(2) No (FIN.070)
(7) Refused (FIN.070)
(9) DK (FIN.070)

Who received this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Did {you/anyone in the family} receive income in {last year in 4 digit format} from Social Security or Railroad Retirement?

(1) Yes (FIN.080)
(2) No (FIN.090)
(7) Refused (FIN.090)
(9) DK (FIN.090)

Who received this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Did {you/anyone in the family} receive income from... pensions from other sources?

(1) Yes (FIN.100)
(2) No (FIN.110)
(7) Refused (FIN.110)
(9) DK (FIN.110)

Who received this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Did {you/anyone in the family} receive Supplemental Security Income (SSI)?

(1) Yes - the entire family (FIN.130)
(2) Yes - some people but not everybody (FIN.120)
(3) No (FIN.130)
(7) Refused (FIN.130)
(9) DK (FIN.130)

Who in the family received this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Did {you/anyone in the family} receive income from... Social Security Disability Insurance?

(1) Yes - the entire family (FIN.150)
(2) Yes - some people but not everybody (FIN.140)
(3) No (FIN.150)
(7) Refused (FIN.150)
(9) DK (FIN.150)

Who in the family received this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Did {you/anyone in the family} receive income from... Welfare, Aid for Families with Dependent Children, or General Assistance?

(1) Yes - the entire family (FIN.170)
(2) Yes - some people but not everybody (FIN.160)
(3) No (FIN.170)
(7) Refused (FIN.170)
(9) DK (FIN.170)

Who in the family received this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Did {you/anyone in the family} receive interest from savings or other bank accounts?

(1) Yes (FIN.180)
(2) No (FIN.190)
(7) Refused (FIN.190)
(9) DK (FIN.190)

Who received this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Did {you/anyone in the family} receive income from... dividends received from stocks
or mutual funds, or net rental income from property, royalties, estates or trusts?

(1) Yes (FIN.200)
(2) No (FIN.210)
(7) Refused (FIN.210)
(9) DK (FIN.210)

Who received this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Did {you/anyone in the family} receive income from... child support?

(1) Yes (FIN.200)
(2) No (FIN.230)
(7) Refused (FIN.230)
(9) DK (FIN.230)

Who received this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Did {you/anyone in the family} receive income from any other source such as alimony, contributions from family/others, VA payments, Worker's Compensation, or unemployment compensation?

(1) Yes (FIN.240)
(2) No (FIN.250)
(7) Refused (FIN.250)
(9) DK (FIN.250)

Who received this? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Now I am going to ask about the total combined income {for you/of your family} in {last year in4 digit format}, including income from all sources we have just talked about such as wages, salaries, Social Security or retirement benefits, help from relatives and so forth. Can you tell me
that amount before taxes?

FR: IF NECESSARY REMIND RESPONDENT THAT TOTAL COMBINED FAMILY INCOME IS THEIR INCOME PLUS THE INCOME OF ALL FAMILY MEMBERS INCLUDING COHABITING PARTNERS AND ARMED FORCES MEMBERS LIVING AT HOME BEFORE TAXES.

(0-999995) 0-999995 dollars (FIN.280)
(999996) 999,995+ dollars (FIN.280)
(999997) Refused (FIN.260)
(999999) DK (FIN.260)

You may not be able to give us an exact figure for your { /total combined family} income, but can you tell me, if your income in {last year in 4 digit format} was

(1) $20,000 or more (FIN.270)
(2) Less than $20,000 (FIN.270)
(7) Refused (FIN.280)
(9) DK (FIN.280)

FR: IF ANSWER FOR FIN.260 EQUALS 1, HAND CARD F14.IF ANSWER FOR FIN.260 EQUALS 2, HAND CARD F15.READ IF NECESSARY: INCOME IS IMPORTANT IN ANALYZING THE HEALTH INFORMATION WE COLLECT. FOR EXAMPLE, THIS INFORMATION HELPS USTO LEARN WHETHER PERSONS IN ONE INCOME GROUP USE CERTAIN TYPES OF MEDICAL SERVICES OR HAVE CERTAIN CONDITIONS MORE OR LESS OFTEN THAN THOSE IN ANOTHER GROUP.

u. $20,000 - $20,999
v. $21,000 - $21,999
w. $22,000 - $22,999
x. $23,000 - $23,999
y. $24,000 - $24,999
z. $25,000 - $25,999
AA. $26,000 - $26,999
BB. $27,000 - $27,999
CC. $28,000 - $28,999
DD: $29,000 - $29,999
EE. $30,000 - $30,999
FF. $31,000 - $31,999
GG. $32,000 - $32,999
HH. $33,000 - $33,999
II. $34,000 - $34,999
JJ. $35,000 - $39,999
KK. $40,000 - $44,999
LL. $45,000 - $49,999
MM. $50,000 - $54,999
NN. $55,000 - $59,999
00. $60,000 - $64,999
PP. $65,000 - $69,999
QQ. $70,000 - $74,999
RR. $75,000 and over

Of those income groups, can you tell me which letter best represents {your/the total combined FAMILY} income during {last year in 4 digit format}?

(00) A
(01) B
(02) C
(03) D
(04) E
(05) F
(06) G
(07) H
(08) I
(09) J
(10) K
(11) L
(12) M
(13) N
(14) O
(15) P
(16) Q
(17) R
(18) S
(19) T
(20) U
(21) V
(22) W
(23) X
(24) Y
(25) Z
(26) AA
(27) BB
(28) CC
(29) DD
(30) EE
(31) FF
(32) GG
(33) HH
(34) II
(35) JJ
(36) KK
(37) LL
(38) MM
(39) NN
(40) OO
(41) PP
(42) QQ
(43) RR
(97) Refused
(99) DK

Is this house/apartment owned, being bought, rented or occupied by some other arrangement by {you or anyone in the family/you}?

(1) Owned
(2) Being bought
(3) Rented
(4) Other arrangement
(7) Refused
(9) DK

[If FIN.110=1,2, goto FIN.290; Else goto FIN.300]

Earlier I recorded that {you/subject's name} received income from Supplemental Security Income. Did {you/subject's name} receive SSI because {you/he/she} {have/has} a disability?

(1) Yes
(2) No
(7) Refused
(9) DK

[If FIN.130=1,2, goto FIN.320; Else goto FIN.330]

Have {you/anyone in the family (READ NAMES)} ever applied for Supplemental Security Income, { /This includes people who applied for benefits} even if the claim was denied?

(1) Yes (FIN.310)
(2) No (FIN.320)
(7) Refused (FIN.320)
(9) DK (FIN.320)

Who in the family applied for it? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Earlier I recorded that {you/subject's name} received income from Social Security Disability Income. Did {you/subject's name} receive SSDI because {you/he/she} {have/has} a disability?

(1) Yes
(2) No
(7) Refused
(9) DK

[If FIN.150=1,2, goto FIN.350; Else goto FIN.360]

Have {you/anyone in the family (READ NAMES)}ever applied for Social Security Disability Income, { /This includes people who applied for benefits} even if the claim was denied?

(1) Yes
(2) No
(7) Refused
(9) DK

Who in the family applied for it? (Anyone else?)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

Earlier I recorded that {you/subject's name} received AFDC or General Assistance in {last year in 4 digit format}. During {last year in 4 digit format}, about how many months did {you/subject's name} receive AFDC or general assistance?

FR: IF LESS THAN 1 MONTH, ENTER (1).

(01-11) 1-11 months
(12) 12 months or all
(97) Refused
(99) DK

{Were/Was} {you/anyone in the family} authorized to receive food stamps (which includes a food stamp card or voucher, or cash grants from the state for food) at anytime during {last year in 4 digit format}?

FR: AN AUTHORIZED PERSON IS ONE WHOSE NAME APPEARS ON A CERTIFICATION CARD

(1) Yes ( single person family FIN.380; else FIN.370)
(2) No (next section)
(7) Refused (next section)
(9) DK (next section)

Who was authorized to receive Food Stamps? (Anyone else?)

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During {last year in 4 digit format}, about how many months {were/was} {you/subject's name} authorized to receive Food Stamps?

FR: IF LESS THAN 1 MONTH, ENTER (1).

(01-11) 1-11 months
(12)12 months or all
(97) Refused
(99) DK

(Goto next section)