FR: ENTER THE FAMILY NUMBER OF THE FAMILY YOU WISH TO INTERVIEW.

Family number: ___________________ (Go to FID.030)
(N) No one is available to interview now. (Go to FID.035)

[If one person family]
FR: READ IF NECESSARY:

I would like to speak with {you/name}. {Are/Is} {you/he/she} available?

[If multi-person family]
FR: READ IF NECESSARY:

I would like to speak with someone in this family, preferably an adult who is knowledgeable about the family's health, to complete the interview for their family.
Is {READ NAMES FROM ROSTER} available?

(1) Yes,continue with Family section.(FID.045)
(2) No,arrange a callback (FID.035)

I need to call back to finish this family's interview.
What date and time would be best?

FR: TODAY IS {day and date in words}. ENTER CALLBACK DATE AND TIME, OR ENTER (A) FOR ANYDAY/ANYTIME, OR ENTER (N) IF CALLBACK BEFORE CLOSEOUT IS NOT POSSIBLE.

Check item: If a callback cannot be arranged at FID.035, go to FID.040; Else go to FID.020.

FR: SPECIFY WHY THIS FAMILY'S INTERVIEW CANNOT BE COMPLETED BEFORE CLOSOUT.

(Go to FIDCCI1)

FR: ENTER THE LINE NUMBER OF THE PERSON YOU ARE SPEAKING TO.
[Enter Person #] [ ]

Check item: If RELRESP1 is 14-17 years old go to RELRESP2; Else go to FID.050.

You have selected a person less than 18 years old.
Is this correct?

(1) Yes, accept this person (FID.050)
(2) No, select another person (FID.045--RELSRESP1)

FR:{RELRESP1} HAS BEEN SELECTED AS THE FAMILY REFERENCE PERSON FOR THIS FAMILY. IS THIS FAMILY MEMBER AN APPROPRIATE CHOICE? PREFERABLY A CIVILIAN ADULT?

(1) Yes, accept this person (FID.060)
(2) No, select another person (FID.050--FAMREF_B)

FAMREF_B[Enter Person #] [ ]

Check item: If the person number at FID.050--FAMREF_B is 14 to 17 years go to FID.050--FAMREF_C; Else go to FID.060.

You have selected a person less than 18 years old. Is this correct?

(1) Yes, accept this person (FID.060)
(2) No, select another person (FID.050--FAMREF_A)

FR: SHOW CARD H1. [Survey indicates H1 but, H3 card is the correct card]
What is {PX-name's/your} relationship to {FRP-name/you}?

2. Spouse (husband/wife)
3. Unmarried Partner
4. Child (biological/adoptive/in-law/step/foster)
5. Child of Partner
6. Grandchild
7. Parent (biological/adoptive/in-law/step/foster)
8. Brother/sister (biological/adoptive/in-law/step/foster)
9. Grandparent (Grandmother/Grandfather)
10. Aunt/Uncle
11. Niece/Nephew
14. Roomer/Boarder
15. Other nonrelative
16. Legal guardian
17. Ward

(2) Spouse (husband/wife) (FID.064)
(3) Unmarried partner (FID.064)
(4) Child (biological/adoptive/in-law/step/foster) (FID.070)
(5) Child of partner (Check item)
(6) Grandchild (Check item)
(7) Parent (biological/adoptive/in-law/step/foster) (FID.080)
(8) Brother/sister(biological/adoptive/ in-law/step/foster) (FID.090)
(9) Grandparent (grandmother/father) (Check item)
(10) Aunt/uncle (Check item)
(11) Niece/nephew (Check item)
(12) Other relative (Check item)
(13) Housemate/Roommate (Check item)
(14) Roomer/Boarder (Check item)
(15) Other nonrelative (Check item)
(16) Legal guardian (Check item)
(17) Ward (Check item)
(97) Refused (Check item)
(99) DK (Check item)

Check item: At FID.060 for responses of 13-15 go to FID.063; if there are no more persons go to FID.100; Else go to FID.060.

Is {name} a relative of {rpname}?

(1) Yes, they are relatives, select relationship again (FID.060)
(2) No, they are not relatives (HHC.100)

FR: READ IF NECESSARY:

Earlier I recorded {name of 1st spouse/partner} was {FRP name}'s spouse or partner. You have just reported {fill name 2nd spouse/partner} is also {FRP name}'s spouse or partner.
Which is correct?

(1) {1st spouse/partner} is the correct spouse/partner. Change relationship entry of {2nd spouse/partner}. (FID.060)
(2) {2nd spouse/partner} is the correct spouse/partner. Change relationship entry of {1st spouse/partner}. (FID.068)

FR: USING THE F1 KEY, BACKUP TO {fill name of 1st spouse/partner} AND
CHANGE RELATIONSHIP TO FAMILY REFERENCE PERSON. WHEN
FINISHED, PRESS F3 TO JUMP FORWARD.

Is {PX-name} {FRP-name}'s biological, adoptive, step, foster {son/daughter} or {son/daughter}-in-law?

(1) Biological [fill son/daughter]
(2) Adoptive [fill son/daughter]
(3) Step [fill son/daughter]
(4) Foster [fill son/daughter]
(5) [fill son/daughter]-in-law
(7) Refused
(9) Don't know

Check item: At FID.070 if there are no more persons, go to FID.100; Else go to FID.060 for the next person in the family.

You said that {you are/{name's} is} {subject nsmes}'s biological {mother/father}. There are only {1-11} years age difference between {you/them}. Is this relationship correct?

(1) Yes, continue the interview (FID.100)
(2) No, change relationship (FID.070)

Is {PX-name} {FRP-name}'s biological (natural), adoptive, step, or foster {mother/father} or {mother/father}-in-law?

(1) Biological [fill mother/father]
(2) Adoptive [fill mother/father]
(3) Step [fill mother/father]
(4) Foster [fill mother/father]
(5)[fill mother/father]-in-law
(7) Refused
(9) Don't know

Check item: At FID.080 if there are no more persons, go to FID.100; Else go to FID.060 for the next person in the family.

(1) Full [fill brother/sister]
(2) Half [fill brother/sister]
(3) Adopted [fill brother/sister]
(4) Step [fill brother/sister]
(5) Foster [fill brother/sister]
(6) [fill brother/sister]-in-law
(7) Refused
(9) Don't know

Check item: At FID.090 if there are no more persons, go to FID.100; Else go to FID.060 for the next person in the family.

Name ____ {name}
Sex ____ {SEX}
Age ____ {AGE}
DOB ____ {BMONTH/BDAY/BYEAR}
Race:{RACE}
Origin: {Non-hispanic/HISPAN}

FR: VERIFY THE ABOVE INFORMATION WITH THE RESPONDENT AND MAKE CORRECTIONS IF NECESSARY.

(1) Correction(s) needed for this person (FIDCCI3)
(2) No correction/no more corrections for this person (FID.110)

Change(s) needed for {name}
FR: ENTER EACH NUMBER THAT APPLIES. IF A WRONG CHOICE, TYPE THAT CHOICE AGAIN. ENTER (N) FOR NO MORE.

CWHAT2(M) Mistake -- No correction needed
CWHAT__1 (1) Name
CWHAT__2 (2) Age or DOB
CWHAT__3 (3) Sex
CWHAT__4 (4) National origin
CWHAT__5 (5) Race

Check item CHG_LOOP: If CWHAT__1 eq (X) [go to FID.120]; If CWHAT__2 eq (X) [go to FID.125];
If CWHAT__2 eq (X) [go to FID.180]; If CWHAT__4 eq (X) [go to FID.190]
If CWHAT__3 eq (X) [go to FID.220]; If CWHAT2 eq (X) [go to FID.110];
When all change-needed items are corrected or changed, go to FID.100 for the next
family member. When no more eligible persons in the family, go to FIDCCI3.

FR: ENTERING "D" OR "R" WILL CANCEL THIS CHANGE AND LEAVE
THE ORIGINAL INFORMATION. ENTER "D." or "R." FOR INITIAL.
IF NECESSARY ASK:

What is {name}'s correct name?

CHG_NAM1 FIRST NAME: _____________________________
CHG_NAM2 MIDDLE NAME: _____________________________
CHG_NAM3 LAST NAME: _____________________________

(Go to CHG_LOOP)

FR: ENTER THE CORRECT SEX FOR [fill name]. IF NECESSARY ASK:

I recorded {your/name's} sex as [fill SEX].
What is {your/name's} correct sex?

(1) Male
(2) Female

(Go to CHG_LOOP)

(Go to CHG_LOOP)

CHG_MLTR [equiv MLTRACE] (01-16) Race number

(Go to CHG_LOOP)

Check item FIDCCI3: If a screened household and anyone in the household with ORIGIN eq (1) (Hispanic Origin) or RACE eq (2) (Black), then If AGE ge (14) and FID.250 eq lt gt (not pre-filled) go to FID.250; Else go to FIDCCI4. If a screened household with no one with ORIGIN eq (1) or RACE eq (2), then set outcome eq (236) (screened out household)

FR: ASK OR VERIFY.
Is {your/PX-name's} spouse living in the household?

(1) Yes (FID.270)
(2) No (FIDCCI4)
(7) Refused (FIDCCI4)
(9) Don't Know (FIDCCI4)

FR: PROBE AS NECESSARY AND ENTER THE LINE NUMBER OF THE SPOUSE.

(01-30) Person number
(97) Refused
(99) Don't know

(Go to FIDCCI4)

{Have/Has} {you/PX-name} ever been married?

(1) Yes (FID.290)
(2) No (FIDCCI4)
(7) Refused (FIDCCI4)
(9) Don't Know (FIDCCI4)

What is {PX-name's/your} current legal marital status?

(1) Married
(2) Widowed
(3) Divorced
(4) Separated
(7) Refused
(9) DK

Check item: For FID.290, if FID.300 is not valid (blank), go to FID.300; Else go to FIDCCI4.

FR: PROBE AS NECESSARY AND ENTER THE LINE NUMBER OF THE COHABITING PARTNER.

(01-30) Person number
(97) Refused
(99) Don't know

Check item FIDCCI4:If AGE(PX) ge (90) [go to FIDCCI6]; Else
For Reference person's child:
If Reference person's spouse is male, go to FID.305
If Reference person's spouse is female, go to FID.315
For Reference person's partner's child:
If Reference person's partner is male, go to FID.305
If Reference person's partner is female, go to FID.315

I recorded that {father's fullname} is the father of {child's fullname}. Is child's fullname} his biological, adoptive, step, foster of {son/daughter}-in-law?

(1) Biological child
(2) Adoptive child
(3) Step child
(4) Foster child
(5){Son/daughter}-in-law
(7) Refused
(9) Don't know

Check item:If DEGREE4 eq (1)[if (father's age - child's age) less than 12 go to FID.310]; Else go to FIDCCI5.

You said that {you/name} {are/is} {PX's name} BIOLOGICAL FATHER. There is only {father's age - child's age} {years/year} agebetween {you/them}. Is this relationship correct?

(1) Yes, continue the interview (HHCCCI8)
(2) No, Change relationship (DEGREE4)

I recorded that {mother's fullname) is the mother of {child's fullname}. Is {child's fullname} herbiological, adoptive, step, foster child, or {son/daughter}-in-law? (H)

(1) Biological child
(2) Adoptive child
(3) Step child
(4) Foster child
(5) {son/daughter}-in-law
(7) Refused
(9) Don't know

Check item:If DEGREE5 eq (1)[if (mother's age - child's age) less than 12 go to FID.320]; Else go to FIDCCI5.

You said that {you/name} {are/is} {PX's name} BIOLOGICAL MOTHER. There is only {mother's age - child's age} {years/year} age between {you/them}. Is this relationship correct?

(1) Yes, continue the interview (FIDCCI5)
(2) No, Change relationship (DEGREE5)

Check item FIDCCI4A: If MOTHER(PX) ne lt ,gt [go to FIDCCI5] (mother already identified); If there are no female family members other than PX with AGE ge (12) [go to FIDCCI5]; Else [go to FID.325].

FR: ASK OR VERIFY

Is {PX-name's/your} mother a household member? (Include Mother-in-law)

ENTER THE LINE NUMBER OF THE MOTHER OR MOTHER-IN-LAW.
IF THE MOTHER OR MOTHER-IN-LAW IS NOT A HOUSEHOLD MEMBER, ENTER "00".

(00) Person not a household member (FID.340)
(01-30) Person number (FID.330)
(96) No parent in household;has legal guardian (FID.360)
(97) Refused (Go to FIDCCI5)
(99) Don't Know (Go to FIDCCI5)

Is {name(mother@)/this person} {PX-name}'s biological (natural), adoptive, step, or foster mother or mother-in-law?

(1) Biological mother
(2) Adoptive mother
(3) Step mother
(4) Foster mother
(5) Mother-in-law
(7) Refused
(9) Don't know

Check item: If the age difference between the mother and child is less than 12 years at MOTHERC1, go to MOTHERC2; Else go to (FIDCCI5).

[If MOTHERC1 eq (1); If (AGE(MOTHER) - AGE(PX)) lt (12) display:]
You said that {name(MOTHER@)} is the BIOLOGICAL MOTHER of {PX-name}.
There is only {age difference} years age difference between them, is this relationship
correct?

(1) Yes, continue the interview (FIDCCI5)
(2) No, select different person as MOTHER (FID.325)
(3) No, change relationship (FID.330--MOTHERC1)

Check item FIDCCI5: If AGE(PX) ge (90) [go to FIDCCI6]; If FATHER(PX) ne lt, gt [go to FIDCCI6] (father already identified); If there are no male family members other than PX with AGE ge (12) go to FIDCCI6; Else go to FID.340.

Is {PX-name}'s father a household member? (Include father-in-law).

ENTER THE LINE NUMBER OF THE FATHER. IF THE FATHER IS NOT A HOUSEHOLD MEMBER, ENTER "00". IF THE PERSON HAS NO PARENTS PRESENT BUT HAS A LEGAL GUARDIAN, ENTER "96".

(00) Person not a household member (FIDCCI6)
(01-30) Person number (FID.350)
(96) No Parent in Household; Has legal guardian (FID.360)
(97) Refused (FIDCCI6)
(99) Don't Known (FIDCCI6)

Is {name(father@)/this person} {PX-name}'s biological (natural), adoptive, step, or foster father or father-in-law?

(1) Biological father
(2) Adoptive father
(3) Step father
(4) Foster father
(5) Father-in-law
(7) Refused
(9) Don't know

Check item: If the age difference between the mother and child is less than 12 years at FATHERC1, go to FATHER2; Else go to (FIDCCI6).

[If FATHERC1 eq (1); If (AGE(FATHER) - AGE(PX)) lt (12) display:]
You said that {name(FATHER@)} is the BIOLOGICAL FATHER of {PX-name}, there
is only {age difference} years difference between them, is this relationship correct?

(1) Yes, continue the interview (FIDCCI6)
(2) No, select different person as FATHER (FID.340)
(3) No, change relationship (FID.350--FATHERC1)

FR: PROBE AS NECESSARY AND ENTER THE PERSON NUMBER OF {px-name's} GUARDIAN. IF THE GUARDIAN IS NOT A HOUSEHOLD MEMBER, ENTER "00".

(00) Person number (FIDCCI6)
(01-30) Person number (FIDCCI6)
(97) Refused (FIDCCI6)
(99) Don't Know (FIDCCI6)

Check item FIDCCI6:Set HHSTAT4 to (E) (Emancipated minor) in the following conditions:
(1) If a person is 14-17 years of age and married or cohabiting; or
(2) If a person is 14-17 years old and no other adults present in the family.
Go to SASEL

Check item SASEL: 1. Sort all adults (AGE gt = 18) of the same FX and NOT flagged "A" or "D" in descending age order -- from the oldest to the youngest.
If no persons in this sorted group, GO TO SCSEL.
If one person only in this sorted group, flag with "S" and GO TO SCSEL.
Else, GO TO step 2.

2. Generate a random number from 1 to N (number of persons in sort).
Set HHSTAT4 of the person whose person number corresponding to the random
number to (S) (Sample Adult); GO TO SCSEL.

Check item SCSEL: 1. Sort all children (AGE lt 18) of the same FX and NOT flagged "A" or "D" or "E" in descending age order -- from the oldest to the youngest. If no persons in this sort and more than 1 person in family, Go to SAID. If one person only in this sort, set the person's HHSTAT4 to (C), go to SAID;
Else continue with step2.

2. Generate a random number from 1 to N (number of persons in sort).
Set HHSTAT4 of the person whose person number corresponding to the random number to (C) (Sample Child); Go to SAID.

[If there is a sample adult selected]
[fill "S" flagged person name] IS SELECTED AS THE SAMPLE ADULT
FOR FAMILY [fill FX].

[endif]

[IF there is a sample child selected]
[fill "C" flagged person name] IS SELECTED AS THE SAMPLE CHILD
FOR FAMILY [fill FX]

FR: VERIFY OR ASK.
Who in the family would you say knows about the health of all the family members?

FR: ENTER THE NUMBER FOR EACH PERSON MENTIONED (UP TO 3).
[KNOW = 'x' for each person mentioned.]

Check item: If the family has a sample child, go to FID.630; Else go the next section- Family Health Status and Limitation.

We select one child in each family for additional health questions. In this family that is {sample child name}. Who in the family would you say knows about the health of {sample child name}?

FR: ENTER THE LINE NUMBER FOR EACH PERSON MENTIONED (UP TO 3 PERSONS). [KNOWSC = 'x' for each person mentioned.]
(Go to next section -- Family Health Status and Limitation)

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
[ ] FINTRO010

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 #] [ ]

HLTH_BEG I am now going to ask about {your/the} general health { /of family members} and the effects of any physical, mental, or emotional health problems.

Check item FHSCCI1: If any family member is less than 5 years old go to FHS.005; If any family member is greater than 4 and less than 18 years old go to FHS.050; If all family members are greater than 17 go to FHS.070.

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)
(2) No (FHS.050)
(7) Refused (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)
(2) No (FHS.070)
(7) Refused (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 go to FHS.290. If none with entry in
FHS.010 through FHS.260, or the family roster is exhausted go to FHS.310.

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

FR: SHOW CARD F1. 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
[ ]
[ ]
[ ]
[ ]
[ ]

(Go to 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+ times
(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 go to FHS.310.]

What conditions or health problems cause {subject's name} limitations?
FR: SHOW 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. 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
[ ]
[ ]
[ ]
[ ]
[ ]

[If item (19) mentioned, go to FSH.291; If item (20) mentioned go to FHS.292; Else go to FHS.300.]

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
(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 go to 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

(Go to 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 (FAU.120)
(9) DK (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 go to NEXT_HOSP; Else go to 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, go to 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?

[Exclude children born during interview week]

(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+ Visits
(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 about a member of this family? Include phone calls for medical advice, prescriptions or test results, but do NOT include phone calls to make appointments.

[Exclude children born during interview week]

(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+ Calls
(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.)

[Exclude children born during interview week]

(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+ Times
(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 (Go to next section - Health Insurance}
(7) Refused (Go to next section - Health Insurance)
(9) DK (Go to next section - Health Insurance}

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

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

(Go to 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.

[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.

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). (Anything else?)

FR: SHOW CARD F9.
MARK "X" ALL THAT APPLY.

1. Private health insurance plan from employer or workplace*
2. Private health insurance plan purchased directly*
3. Private health insurance plan through a state or local government program or community
4. Medicare
5. Medi-Gap
6. Medicaid
7. Military health care/VA
8.CHAMPUS/TRICARE/CHAMP-VA
9. Indian Health Service
10.State-sponsored health plan
11. 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).

[ ]HIKINDA (01) Private health insurance plan from employer or workplace
[ ]HIKINDB (02) Private health insurance plan purchased directly
[ ]HIKINDC (03) Private health insurance plan through a State or local government program or community program
[ ]HIKINDD (04) Medicare
[ ]HIKINDE (05) Medi-GAP
[ ]HIKINDF (06) Medicaid
[ ]HIKINDG (08) Military health care/VA
[ ]HIKINDH (09) CHAMPUS/TRICARE/CHAMP-VA
[ ]HIKINDI (10) Indian Health Service
[ ]HIKINDJ (11) State-sponsored health plan
[ ]HIKINDK (12) 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 5 and not 4, mark HIKINDD=X and go to FHI.080.
2. If the person in FHI.070 marked 4, go to FHI.080.
3. If the person in FHI.070 did not mark 4, 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_1Claim Number (only numbers):____________________
MCNO_2(any characters): _______________

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} under a Medicare managed care arrangement, such as 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 6 then go to FHI.120; Else go to
Check item FHICCI5.

FR: SHOW CARD F10 FOR STATE MEDICAID NAMES

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's 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?

Name:(FHI.140)

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

MACHMD_2Name:______________ (FHI.140)

State Names for MEDICAID
(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
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, Health Choice
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

{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: 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),
- Private health iinsurance plan through a State or local government program or
community program (in FHI.070 marked 3)
- Medi-gap (in FHI.070 marked 5),
Then go to Check item FHICCI6; Else go to Check item FHICCI7.

Check item FHICCI6: The next questions are about private health insurance plans obtained through work, purchased directly, or through a State or local government or community program.
[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?

NEXTPNM1 Name: _________________________

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: ____________________________

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?

NEXTPNM7 Name: ____________________________

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, go to FHI.180. If there are no such persons, go to Check item FHICCI8.

{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: FHI.200-FHI.246 are repeated for each health plan.

[If multiple plan names (i.e. from FHI.160 - FHI.179), read:]
Now I am going to ask some questions about the {plan/plans} you just told me about,{/starting with} [fill plan name].

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

[Read to everyone]
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?
FR: ENTER (0) FOR POLICYHOLDER OUTSIDE OF FAMILY.

WHONAM# [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)or community program (FHI.240)
(4) Medicare (FHI.240)
(5) Medicaid (FHI.240)
(6) State or local government
(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: SHOW CARD F12.

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), a PPO (Preferred Provider Organization), a POS (Point-of-Service), 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) POS
(4) Other
(7) Refused
(9) DK

Under this plan, can {you/the family member(s) with this plan} choose ANY doctor or MUST {you/they} choose one from a specific group or list of doctors?

(1) Any doctor (FHI.244)
(2) Select from group/list (FJI.246)
(7) Refused (FHICCI9)
(9) DK (FHICCI9)

Do {you/the family member(s) with this plan} have the option of choosing a doctor from a preferred or select list at a lower cost?

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

If {you/the family member(s) with this plan} select a doctor who is not in the plan, will {plan name} pay for any part of the cost?

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

Check item FHICCI8A: If there are more health plans, return to FHICCI8; Else go to FHICCI9.

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, go to FHI.320; Else if any member with no entry marked in FHI.060 , go to FHI.260; Else if any member marked FHI.070 with 10 or 11 go to FHI.250; Else go to FHI.300.

Earlier I recorded that {you/subject's name} {are/is} covered by a state-sponsored or other public program (other than Medicaid) that pays for health care. What is the name of the plan?

STNAME Plan: ___________________________

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 CARDS F10 AND F11.

CHAMPUS or CHAMPVA... or any private insurance?

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

State Names for MEDICAID
(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
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, Health Choice
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)
Arizona - Medically Indigent Program
California - County Medical Services Progam (CMSP), Children's Services (CCS), AIM (Access for Infants and Mothers), California's children's health
Colorado - Child Health Plan, Children's Health Plan
Connecticut - Healthy Steps, General Assistance Program (GA)
Delaware - Nemours Child Program
Florida - Healthy Kids
Hawaii - Hawaii HealthQUEST
Illinois - General Assistance Program (State Child and Family Assistance, SCFA or Transitional Assistance, TA)
Iowa - Caring Program for Children, Iowa coverage for unemployed workers
Kansas - MediKan, Caring Program for Kids, Kansas Caring Program for kids
Maine - Maine Health Program
Maryland - AIDS Insurance Assistance Program
Massachusetts - CommonHealth Program, Medical Security Plan (MSP), CenterCare Program, Children's Meidcal Security Plan, Healthy Kids
Michigan - Wayne County Plus Care Program, Medical Assistance Program, Caring Program for Children
Minnesota - MinnesotaCare, Minnesota General Assitance Medical Care Program (GAMC)
Mississippi - Mississippi subsidized insurance coverage
Missouri - General Relief Medical Assistance
Nebraska - State Disability Program
New Hampshire - Healthy Kids
New Jersey - Health Access New Jersey, New Jersey's coverage for pregnant women
New York - Home Relief, Child Health Plus (CHP), New York's subsidized insurance
North Carolina - Caring Program for Children
Ohio - Ohio Disability Assistance Medical Program, Children's Health Care Program
Oregon - Oregon Health PLan
Pennsylvania - Children's Health Insurance Program (CHIP), General Assistance Medical Program
Rhode Island - General Public Assistance (GPA) Medical Program
Tennessee - TennCare
Utah - Utah Medical Assistance Program (UMAP), Rite Care
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), Children's Health Plan
Wisconsin - General Relief Medical

Which of these are reasons {you/subject's name} stopped being covered or do not have health insurance?

FR: SHOW CARD F14.

1. Person in family with health insurance lost job or changed employers
2. Got divorced or separated/death of spouse or parent
3. Became ineligible because of age/left school
4. Employer does not offer coverage/or not eligible for coverage
5. Cost is too High
6. Insurance company refused coverage
7. Medicaid/Medical plan stopped after pregnancy
8. Lost Medicaid/Medical plan because of new job or increase in income
9. Lost Medicaid (other)
10. Other (specify)

(1) Person in family with health insurance lost job or changed employers
(2) Got divorced or separated/death of spouse or parent
(3) Became ineligible because of age/left school
(4) Employer does not offer coverage/Or not eligible for coverage
(5) Cost is too high
(6) Insurance company refused coverage
(7) Medicaid/Medical plan stopped after pregnancy
(8) Lost Medicaid/Medical plan because of new job or increase in income
(9) Lost Medicaid (other)
(10) Other (specify) ____________
(97) Refused
(99) DK

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(Go to 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: SHOW CARD F15.

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

(Go to next section--Socio-Demographic Background)

[FSD.001 to FSD.130 are asked for each person in the family.]

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

USBORNState:____________________(Go to FSDCCI1)

FR: READ IF NECESSARY:
Earlier I recorded {your/subject's name] date of birth as {fill in date of birth}.
In what year did {you/subject's name} come to the United States to stay?

Year: __________
(1900-1998) 1900-1998 years (FSD.005)
(9997) Refused (FSD.004)
(9999) DK(FSD.004)

FR: READ IF NECESSARY:
Earlier I recorded that {you/subject's name} {are/is} _____years old.
About how long {have/has} {you/subject's name} been in the United States?

FR: ENTER 95 FOR 95 OR MORE YEARS. IF LESS THAN 1 YEAR, GIVEN AS A RESPONSE, CODE THE ANSWER AS ?".

Years: _________
(1-94) years
(95) 95+ years
(97) Refused
(99) DK

FR: SHOW CARD F16.
{Are/Is} { you/subject's name} a CITIZEN of the United States?

1. Yes, born in the United States
2. Yes, born in Puerto Rico, Guam, American Virgin Islands, or U.S. territory
3. Yes, born abroad to American parents
4. Yes, U.S. citizen by naturalization
5. No, not a citizen of the United

(1) Yes, born in the United States
(2) Yes, born in Puerto Rico, Guam, American Virgin Islands, or other U.S. territory
(3) Yes, born aboard to American parent(s)
(4) Yes, U.S. citizen by naturalization
(5) No, not a citizen of the United States
(7) Refused
(9) DK

Check item FSDCCI1: If AGE is less than or equal to 6, go to FSD.006. When no more family members AGE is less than or equal 6, then go to 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: SHOW CARD F17.

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. 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)

(00) Never attended/kindergarten only
(01) 1st grade
(02) 2nd gradetechnical, or vocational program
(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,
(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

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

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

Hours: _______
(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

(Go to 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, go to FSD.130; Else, go to Check item FSDCCI2 for next person. When roster exhausted, go to next section (Income and Assets).

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

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

(Go to next section--Income and Assets)

FR: READ THE FOLLOWING:
The next questions are about {your/your combined family} income. Each income question refers to income received in {last calendar year}.

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?

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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]
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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?)

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

FR: 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 yellow/gold colored envelope.

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

Who received this? (Anyone else?)

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Check item FINCCI1: If AGE le (64) go to FIN.082; Else if AGE ge (65) go to FIN.090.

Was {your/any family member's (READ NAMES BELOW); Social Security or Railroad Retirement income received as a disability benefit?

(1) Yes (FIN.084)
(2) No (FIN.090)
(7) Refused (FIN.090)
(9) DK (FIN.090)

FR: ASK OR VERIFY.
ENTER APPLICABLE LINE NUMBER(S).
ENTER (N) FOR NO MORE AFTER THE LAST NUMBER.

Who received Social Security or Railroad Retirement as a disability benefit? (Anyone else?)

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Did {you/subject's name listed in PSSRRDB} receive this benefit because {you are/he is/she is} is disabled?

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

Did {you/any family members living here} receive income from...any disability pension {other than Social Security or Railroad Retirement}?

(1) Yes (FIN.100)
(2) No (FIN.102)
(7) Refused
(9) DK

Who received this? (Anyone else?)

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Did {you/any family members living here} receive income from...any retirement or survivor pension {fill "other than Social Security or Railroad Retirement" if FSSRR=1 and FPENS ne 1; or fill "other than disability pension if FPENS=1 and FSSRR ne 1; or fill "other than Social Security or Railroad Retirement or disability pension" if FSSRR=1 and FPENS=1; or No Fill if FSSRR ne 1 and FPENS ne 1)?

(1) Yes (FIN.104)
(2) No (FIN.110)
(7) Refused (FIN.110)
(9) DK (FIN.110)

FR: ASK OR VERIFY.
ENTER APPLICABLE LINE NUMBER(S)
ENTER (N) FOR NO MORE AFTER THE LAST NUMBER.

Who received this? (Anyone else?)

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Did {you/any family members living here} receive Supplemental Security Income (SSI)?

FR: 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.

(1) Yes (FIN.120)
(2) No (FIN.150)
(7) Refused (FIN.150)
(9) DK (FIN.150)

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

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Did {you/subject's name listed in PSSI} receive SSI because {you/he/she} {have/has} a disability?

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

At any time during {last year in 4 digit format}, even for one month, did {you/any family member living here} receive any government assistance payments because your income was low, such as welfare or temporary assistance for needy families?

(1) Yes (FIN.160)
(2) No (FIN.162)
(7) Refused (FIN.162)
(9) DK (FIN.162)

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

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At any time during {fill year}, did {you/anyone in your family} have lower rent because a government program for persons with low income was paying part of the cost?

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

At any time during {fill year}, did {you/anyone in the family} receive any OTHER kind of welfare assistance such as help with getting a job, placement in education or job training programs, or help with transportation or child care?

(1) Yes (FIN.166)
(2) No (FIN.170)
(7) Refused (FIN.170)
(9) DK (FIN.170)

Who received this? (Anyone else?)

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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?)

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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?)

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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?)

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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?)

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Now I am going to ask about the total combined income {for you/of your family} in {last year in 4 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, SHOW CARD F18.
IF ANSWER FOR FIN.260 EQUALS 2, SHOW CARD F19.
READ IF NECESSARY: INCOME IS IMPORTANT IN ANALYZING THE HEALTH INFORMATION WE COLLECT. FOR EXAMPLE, THIS INFORMATION HELPS US TO 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
OO. $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

Have {you/any of these family members living here EVER applied for Supplemental Security Income or SSI, {/This includes people who applied for benefits} even if the claim was denied?

(1) Yes (FIN.310)
(2) No (FIN.330)
(7) Refused (FIN.330)
(9) DK (FIN.330)

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

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Have {you/any of these family members living here EVER APPLIED for disability benefits from Social Security, {/This includes people who applied for benefits} even if the claim was denied?

(1) Yes (Go to FIN.340)
(2) No (FINCCI3)
(7) Refused (FINCCI3)
(9) DK (FINCCI3

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

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Check item FINCCI3: If persons not in FIN.160 go to FIN.360; Else go to FIN.350.

Earlier I recorded that {you/subject's name} received government assistance payments from programs such as welfare or temporary assistance for needy families in {last year in 4 digit format}. During {last year in 4 digit format}, about how many months did {you/subject's name} receive welfare or temporary assistance for needy families?

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 questionnaire)
(7) Refused (next questionnaire)
(9) DK (next questionnaire)

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

(Go to next questionnaire)