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fam
[p. 1]


FAMILY CORE
Section I--FAMILY RELATIONSHIPS and VERIFICATION OF DEMOGRAPHIC INFORMATION

FID.020

FR: ENTER THE FAMILY NUMBER OF THE FAMILY YOU WISH TO INTERVIEW.
FAMINT
Family number: ___________________ (Go to FID.030)
(N) No one is available to interview now. (Go to FID.035)

FID.030

[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?
FAMNEW
(1) Yes, continue. (FID.045)
(2) No, arrange a callback (FID.035)

FID.035

ARRANGE1
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.

[If a callback cannot be arranged at FID.035 = (N), go to FID.040; Else go to FID.020]

FID.040

FAMNON1
FR: SPECIFY WHY THIS FAMILY'S INTERVIEW CANNOT BE COMPLETED BEFORE CLOSEOUT.

(Go to Check Item FIDCCI1)

[p. 2]

FID.045

RELRESP1
FR: ENTER THE LINE NUMBER OF THE PERSON YOU ARE SPEAKING TO.

[Enter Person #] [ ]

[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?
RELRESP2
(1) Yes, accept this person (FID.050)
(2) No, select another person (FID.045/RELRESP1)

FID.050

FAMREF
FR: {RELRESP1} HAS BEEN SELECTED AS THE FAMILY REFERENCE PERSON FOR THIS FAMILY. IS THIS FAMILY MEMBER AN APPROPRIATE CHOICE?
PREFERABLY A CIVILIAN ADULT?
FAMREF_A
(1) Yes, accept this person (FID.060)
(2) No, select another person (FID.050/FAMREF_B)
FAMREF_B
[Enter line number of family reference person][ ]

[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?
FAMREF_C
(1) Yes, accept this person (FID.060)
(2) No, select another person (FID.050/FAMREF_A)

FID.060

FR: SHOW CARD H1. [Survey indicates H1 but, H3 card is the correct card]

What is {PX-name's/your} relationship to {Family Reference Person name/you}?
Card H3
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
FRPREL
(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/father)
(10) Aunt/uncle
(11) Niece/nephew
(12) Other relative
(13) Housemate/Roommate
(14) Roomer/Boarder
(15) Other nonrelative
(16) Legal guardian
(17) Ward
(97) Refused
(99) Don't know

(Check Item FIDCCI2)

[p. 3]

[If FID.060 = (4) go to FID.070, If FID.060=(7) go to FID.080, If FID.060 =(8) go to FID)090, If FID.060 =(13-15) go to FID.063; if there are no more persons go to Check Item FIDCCI2; Else go to FID.060.]
FID.063

Is {name} a relative of {Family Reference Person name}?
FRPREL_C
(1) Yes, they are relatives, select relationship again
(2) No, they are not relatives

[If FRPREL_C = (2), Set those people with FRPREL= (13-15) is deleted person]

(Go to FID.060)

FID.070

Is {PX-name} {Family Reference Person name}'s biological (natural), adoptive, step, foster {son/daughter} or {son/daughter}-in-law?
FDEGREE1
(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

[If there are no more persons, go to FID.100; Else go to FID.060 for the next person in the family. If the age difference between the parent and child is less than 12, go to FID.075.]

FID.075

You said that {you are/{name's} is} {subject names}'s biological {mother/father}. There are only {1-11} years age difference between {you/them}. Is this relationship correct?
BIOCKF1
(1) Yes, continue the interview (FID.060)
(2) No, change relationship (FID.070)

FID.080

Is {PX-name} {Family Reference Person name}'s biological (natural), adoptive, step, or foster {mother/father} or {mother/father}-in-law?
FDEGREE2
(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

[If there are no more persons, go to FID.100; Else go to FID.060 for the next person in the family. If the age difference between the parent and child is less than 12, go to FID.085.]

FID.085

You said that {you are/PX-name's} is {Family Reference Person name}'s biological {mother/father}. There are only {1-11} years age difference between {you/them}. Is this relationship correct?
BIOCKF2
(1) Yes, continue the interview (FID.060)
(2) No, change the relationship (FID.080)

[p. 4]


FID.090

Is {PX-name} { Reference Person name}'s full, half, adoptive, step, or foster {brother/sister} or {brother/sister}-in-law?
FDEGREE3
(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

[If there are no more persons, go to FID.100; Else go to FID.060 for the next person in the family.]

Check Item FIDCCI2: If more than 1 person in the family with FID.060/FRPREL = {2,3}, for each person, go to FID.091 and verify the relationship to the family reference person. Make corrections of the relationship. At end, go to FID.100.
FID.091

FR:READ IF NECESSARY:

I have recorded that
{list [L_NO] [fill name] below}
are the spouses or unmarried partners of {FRP-name}
Which one is correct?
FSPOUSCK ______________________________________(Go to FID.060)

FID.100

I have recorded that:

Name _______________ {name}
Sex _______________ {SEX}
Age _______________ {AGE}
DOB _______________ {BMONTH/BDAY/BYEAR}

Race: {RACE}
Origin: {Non-hispanic/HISPAN}

FR: READ THE INFORMATION TO THE RESPONDENT. MAKE CORRECTIONS IF NECESSARY.

Is this information correct?
HHCHANGE
(1) Yes, information is correct (Check Item FIDCCI3)
(2) No, correction(s) needed/ more corrections needed (FID.110)

[p. 5]

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
(Go to Check Item CHG_LOOP)
Check item CHG_LOOP:
If CWHAT_1 = (X) [go to FID.120]; If CWHAT_2 = (X) [go to FID.125];
If CWHAT_2 = (X) [go to FID.180]; If CWHAT_4 = (X) [go to FID.190]
If CWHAT_3 = (X) [go to FID.220]; If CWHAT2 = (M) [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 Check Item FIDCCI3.
FID.120

What is {PX-name} correct name?

FR: PROBE FOR MIDDLE NAME OR MIDDLE INITIAL IF NOT REPORTED. INITIALS MAY BE ENTERED FOR EACH FIELD BUT MUST BE FOLLOWED BY PRESS (ENTER) TO SKIP TO LAST NAME IF NO MIDDLE NAME.

[If PX gt (1)]

FR: IF LAST NAME IS THE SAME AS DISPLAYED, PRESS (ENTER), OTHERWISE, ENTER THE NEW LAST NAME.

[endif]
CHG_NAM1 [equiv NAME_FNA] FIRST NAME:____________________
CHG_NAM2 [equiv NAME_MNA] MIDDLE NAME: ________________
CHG_NAM3 [equiv NAME_LNA] LAST NAME:____________________
(Go to CHG_LOOP)

[If CHG_NAM1 and CHG_NAM3 = (D,R), go to FID.122; Else go to Check Item CHG_LOOP]

[p. 6]

FID.122

How shall I refer to this person for the rest of the interview?
CHG_ALIAS [equiv ALIAS] _____________________________________
(Go to CHG_LOOP)


FID.125

What is {your/name's} age and date of birth? Please give month, day, and year for the date of birth.

(1) January
(2) February
(3) March
(4) April
(5) May
(6) June
(7) July
(8) August
(9) September
(10) October
(11) November
(12) December
(97) Refused
(99) Don't know
CHG_AG01 [equiv AGEDOB_1]
[ ]Age/ Number
CHG_AG02 [equiv AGEDOB_2]
[ ] Time Period

(1) Day(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)

Date of Birth:
DOB_M MONTH: ______________________
DOB_BDAY DAY:______________________
DOB_Y_P YEAR:______________________
(Go to Check Item CHG_AGECAL1)
Check item CHG_AGECAL1:
C_AGE1 takes information entered in CHG_AG01 and CHG_AG02 and calculates an age.
C_AGE2 takes the date-of birth information entered in FID.125 and calculates an age.
C_AGE3 = current year - birth year -1, C_AGE4 = C_AGE3 + 1. If not enough DOB information was given to calculate an age, "D" will be assigned to C_AGE2.
(Go to Check Item CHG_AGECK)
Check item CHG_AGECK:
CHG_AGECK compares the two ages calculated in C_AGE1 and C_AGE2.
C_AGE1 and C_AGE2 will either contain an age, or "D" if an age could not be calculated.

If C_AGE1 eq (D) and C_AGE2 ne (D), set AGE = C_AGE2, go to FID.190
If C_AGE1 eq (D) and C_AGE2 eq (D), and C_AGE3 eq blank, go to FID.145
If C_AGE1 eq (D) and C_AGE2 eq (D), and C_AGE3 ne blank, go to FID.140
If C_AGE1 ne (D) and C_AGE2 ne (D), and C_AGE1 eq C_AGE2, go to FID.190
If C_AGE1 ne (D) and C_AGE2 ne (D), and C_AGE1 ne C_AGE2, and CHG_DOBV eq (), go to FID.130
If C_AGE1 ne (D) and C_AGE2 ne (D), and C_AGE1 ne C_AGE2, and CHG_DOBV ne (), set AGE=C_AGE2, go to FID.190
If C_AGE1 ne (D) and C_AGE2 = (D), and (C_AGE1 = C_AGE3 or C_AGE1 = C_AGE4); set AGE = C_AGE1; go to FID.190
If C_AGE1 ne C_AGE3 and C_AGE1 ne C_AGE4 and birth year eq blank, go to FID.140
If C_AGE1 ne C_AGE3 and C_AGE1 ne C_AGE4 and birth year ne (); set AGE = C_AGE1, go to FID.190

FID.130

There is a difference between the age the computer calculated from {your/name's} date-of-birth and the age that you gave me. I recorded {your/name's} date-of-birth as {Birth month in words}/{birthday/birthyear}. Is that {your/name's} correct date-of-birth?
CHG_DOBV [equiv DOBVER]
(1) Yes (Go to CHG_LOOP)
(2) No (Go to FID.135)

FID.135

What is {your/name's} correct date-of-birth?

FR: OLD DATE of BIRTH = {BIRTHMONTH/BIRTHDAY/BIRTHYEAR} ASK IF NECESSARY:

(1) January
(2) February
(3) March
(4) April
(5) May
(6) June
(7) July
(8) August
(9) September
(10) October
(11) November
(12) December
(97) Refused
(99) Don't know
DOB_M MONTH:____________
DOB_BDAY DAY:____________
DOB_B_P YEAR: ____________
(Go to FID.150)

FID.140

{Are you/Would you} say {name} is
CHG_AG06 [equiv AGEPIC]
(1) [fill C_AGE3/message] year(s) old? (Go to CHG_LOOP)
(2) [fill C_AGE4] year(s) old? (Go to CHG_LOOP)
(N) Neither is correct (Go to FID.145)
(7) Refused (Go to FID.145)
(9) Don't Know (Go to FID.145)

[If answer is (1,2), update AGE accordingly; go to CHG_LOOP.]

FID.145

What is your best guess of {name's} age?

FR: IF THE RESPONDENT DOES NOT KNOW THE AGE, ENTER YOUR BEST ESTIMATE OF THE PERSON'S AGE. ENTER (C) FOR COMPUTE IF THE RESPONSE IS A RANGE OF AGES.
CHG_AG07 [equiv AGEGES11]
[ ] Number
CHG_AG08 [equiv AGEGES12]
[ ] Time Period

(3) Month(s) (Check item)
(4) Year(s) (Check item)
(6) Compute from range (FID.165)
(7) Refused (FID.150)
(9) Don't know (FID.150)

[If CHG_AG08 is (3) then AGE = (CHG_AG07/12);
If CHG_AG08 is (4) then AGE = (CHG_AG07).
If DOB_Y_P = (D,R); set BYY1 eq (current year-AGE1-1) and BYY2 = (current year-AGE) go to FID.170;
If DOB_Y_P ne (D,R); set AGE = (C_AGE1), go to CHG_LOOP.
If CHG_AG08 = (D,R), go to FID.150.]

FID.150

Certain sections of this interview depend on knowing if a person is 18 years old or older. Could you please tell me if {you/name} {are/is} at least 18 years old?
CHG_AG09 [equiv AGEGES2]
(1) Less than 18 (FID.155)
(2) 18 or older (FID.160)
(7) Refused (FID.160)
(9) Don't know (FID.160)

FID.155

FR: ENTER YOUR BEST ESTIMATE OF {name's} AGE.
ENTER "0" IF LESS THAN 1 YEAR OLD.
CHG_LESS [equiv LESS18] Age:___________
(Go to CHG_LOOP)

FID.160

FR: ENTER YOUR BEST ESTIMATE OF {name's} AGE.
CHG_GREA [equiv GREAT18] Age: ___________
(Go to CHG_LOOP)

FID.165

FR: ENTER FIRST AND LAST AGES OF THE RANGE.

First/lower:
CHG_AG10 [equiv AGERNG_1]
[ ] Number
CHG_AG12 [equiv AGERNG_3]
[ ] Time Period ____________

(3) Month(s)
(4) Year(s)

Last/higher
CHG_AG11 [equiv AGERNG_2]
[ ] Number____________
CHG_AG13 [equiv AGERNG_4]
[ ] Time Period

(3) Month(s)
(4) Year(s)

[Covert CHG_AG10 and CHG_AG11 to year]
[Set AGE = (CHG_AG10 + CHG_AG11) /2]

(Go to CHG_LOOP)

FID.170

Would you say that {name} was born in:
CHG_YEAR [equiv YEARPIC]
(1) [fill with 4-digit BYEAR1]
(2) [fill with 4-digit BYEAR2]
(N) Neither is correct
(7) Refused
(9) Don't Know

(Go to CHG_LOOP)
[p. 10]


FID.180

FR: ASK IF NOT APPARENT: IF DON'T KNOW OR REFUSED, ENTER BEST GUESS

{Are/Is} {you/name} male or female?
CHG_SEX [equiv SEX]
(1) Male
(2) Female

(Go to CHG_LOOP)

FID.190

FR: SHOW CARD H1.

{Do/Does} {you/name's} consider {yourself/himself/herself} to be Hispanic or Latino?

FR: READ IF NECESSARY:

Puerto Rican
Cuban/Cuban American
Dominican (Republic)
Mexican
Mexican American
Central or South American
Other Latin American
Other Hispanic/Latino

Where do {your/name's} ancestors come from?
Card H1
1. Puerto Rican
2. Cuban/Cuban American
3. Dominican (Republic)
4. Mexican
5. Mexican American
6. Central or South American
7. Other Latin American
8. Other Hispanic/Latino
CHG_NATO [equiv ORIGIN]
(1) Yes (FID.200)
(2) No (Check Item CHG_LOOP)

FID.200

FR: SHOW CARD H1 .

Please give me the number of the group that represents {your/name}'s Hispanic origin or ancestry.

FR: IF A NONHISPANIC GROUP IS NAMED, PRESS "F1" TO RETURN TO FID.190/CHG_NATO AND CHANGE THE ANSWER FROM "YES" TO "NO".

ENTER EACH NUMBER THAT APPLIES. ENTER (N) FOR NO MORE.
Card H1
1. Puerto Rican
2. Cuban/Cuban American
3. Dominican (Republic)
4. Mexican
5. Mexican American
6. Central or South American
7. Other Latin American
8. Other Hispanic/Latino
CHG_HISPAN
(1) Puerto Rican
(2) Cuban
(3) Cuban American
(4) Mexican
(5) Mexican American
(6) Central or South American
(7) Other Latin American
(8) Other Spanish or Hispanic
(97) Refused
(99) Don't know

[ ] CHG_HIS1
[ ] CHG_HIS2
[ ] CHG_HIS3
[ ] CHG_HIS4
[ ] CHG_HIS5

[Equiv HISPAN_1 to HISPAN_5]

[If FID.200 = (7) go to FID.210; Else if FID.200 = (8) go to FID215; Else go to Check Item CHG_LOOP]

FID.210

FR: PROBE FOR THE COUNTRY
FR: IF ANY OF THE FOLLOWING ARE MENTIONED, PRESS F1 TO RETURN TO HISPAN SCREEN AND CORRECT THE ENTRY.

Puerto Rican
Cuban/Cuban American
Dominican (Republic)
Mexican
Mexican American
Central or South American (REFER TO HELP SCREEN)

[(H) FOR A LIST OF CENTRAL OR SOUTH AMERICAN COUNTRIES]

FR: SPECIFY OTHER LATIN AMERICAN
CHG_HIS_SP2 [equiv HIS_SP2] Other Latin American: _______________
(Go to FID.200)

FID.215

FR: PROBE FOR THE COUNTRY
FR: IF ANY OF THE FOLLOWING ARE MENTIONED, PRESS F1 TO RETURN TO HISPAN SCREEN AND CORRECT THE ENTRY.

Puerto Rican
Cuban/Cuban American
Dominican (Republic)
Mexican
Mexican American
Central or South American (REFER TO HELP SCREEN)

[(H) FOR A LIST OF CENTRAL OR SOUTH AMERICAN COUNTRIES]

FR: SPECIFY OTHER SPANISH OR HISPANIC
CHG_HIS_SP3 [equiv HIS_SP3] Other Spanish or Hispanic: ____________

(Go to FID.200)

FID.220

FR: SHOW CARD H2

What race {does/do} {name/you} consider {himself/herself/yourself} to be? Please select 1 or more of these categories.

FR: ENTER (N) FOR NO MORE
Card H2
1. White
2. Black/African American
3. Indian (American)
4. Alaska Native
5. Native Hawaiian
6. Guamanian
7. Samoan
8. Other Pacific Islander
9. Asian Indian
10. Chinese
11. Filipino
12. Japanese
13. Korean
14. Vietnamese
15. Other Asian
16. Some Other Race
(1) White
(2) Black/African American
(3) Indian (American)
(4) Alaska Native
(5) Native Hawaiian
(6) Guamanian
(7) Samoan
(8) Other Pacific Islander
(9) Asian Indian
(10) Chinese
(11) Filipino
(12) Japanese
(13) Korean
(14) Vietnamese
(15) Other Asian
(16) Some other race
(97) Refused
(99) Don't know

[ ] CHG_RAC1
[ ] CHG_RAC2
[ ] CHG_RAC3
[ ] CHG_RAC4
[ ] CHG_RAC5

[Equiv RACE1 - RACE5]

[If FID.220 = (8) go to FID.230; If FID.220 = (15) go to FID.232; If FID.220 = (16) go to FID.234; If multiple entries in FID.220 go to FID.240; Else go to Check Item CHG_LOOP]

FID.230

FR: IF ANY OF THE FOLLOWING ARE MENTIONED, PRESS F1 TO RETURN TO RACE AND CORRECT THE ENTRY.

White
Black/African American
Indian (American)
Alaska Native
Native Hawaiian
Guamanian
Samoan
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
(97) Refused
(99) Don't know

FR: SPECIFY THE OTHER PACIFIC ISLANDER
CHG_RAC_SP1 [equiv RACSP1] Other Pacific Islander: _______________
(Go to FID.220)

FID.232

FR: IF ANY OF THE FOLLOWING ARE MENTIONED, PRESS F1 TO RETURN TO RACE AND CORRECT THE ENTRY.

White
Black/African American
Indian (American)
Alaska Native
Native Hawaiian
Guamanian
Samoan
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
(97) Refused
(99) Don't know

FR: SPECIFY THE OTHER ASIAN
CHG_RAC_SP2 [equiv RACSP2] Other Asian: ______________________
(Go to FID.220)

FID.234

FR: IF ANY OF THE FOLLOWING ARE MENTIONED, PRESS F1 TO RETURN TO RACE AND CORRECT THE ENTRY.

White
Black/African American
Indian (American)
Alaska Native
Native Hawaiian
Guamanian
Samoan
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
(97) Refused
(99) Don't know

FR: SPECIFY THE OTHER RACE
CHG_RAC_SP3 [equiv RACSP3] Other Race: _______________________
(Go to FID.220)

FID.240

Which one of these groups, that is (FR: READ GROUPS) would you say BEST represents {your/name's} race?
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 = (1) (Hispanic Origin) or RACE = (2) (Black), then If AGE ge (14) and FID.250 = ( ) (not pre-filled) go to FID.250; Else go to Check Item FIDCCI4. If a screened household with no one with ORIGIN = (1) or RACE = (2), then set outcome = (236) (screened out household)

FID.250

FR: ASK OR VERIFY.

(Are/Is} {you/PX-name} now married, widowed, divorced, separated, never married, or living with a partner?
MARITL
(1) Married (FID.260)
(2) Widowed (Check Item FIDCCI4)
(3) Divorced (Check Item FIDCCI4)
(4) Separated (Check Item FIDCCI4)
(5) Never married (Check Item FIDCCI4)
(6) Living with a partner (FID.280)
(7) Refused (Check Item FIDCCI4)
(9) Don't Know (Check Item FIDCCI4)

FID.260

FR: ASK OR VERIFY.

Is {your/PX-name's} spouse living in the household?
SPOUS
(1) Yes (FID.270)
(2) No (Check Item FIDCCI4)
(7) Refused (Check Item FIDCCI4)
(9) Don't Know (Check Item FIDCCI4)

[p. 15]

FID.270

FR: PROBE AS NECESSARY AND ENTER THE LINE NUMBER OF THE SPOUSE.
SPOUS2
(01-30) Person number
(97) Refused
(99) Don't know

(Go to Check Item FIDCCI4)


FID.280

{Have/Has} {you/PX-name} ever been married?
COHAB1
(1) Yes (FID.290)
(2) No (Check Item FIDCCI4)
(7) Refused (Check Item FIDCCI4)
(9) Don't Know (Check Item FIDCCI4)


FID.290

What is {PX-name's/your} current legal marital status?
COHAB2
(1) Married
(2) Widowed
(3) Divorced
(4) Separated
(7) Refused
(9) Don't know

[For FID.290, if FID.300 is not valid (blank), go to FID.300; Else go to Check Item FIDCCI4.]
FID.300

FR: PROBE AS NECESSARY AND ENTER THE LINE NUMBER OF THE COHABITING PARTNER.
COHAB3
(01-30) Person number
(97) Refused
(99) Don't know

(Go to Check Item FIDCCI4)
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
Else go to Check Item FIDCCI4A

FID.305

I noted 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?
DEGREE4
(1) Biological child
(2) Adoptive child
(3) Step child
(4) Foster child
(5){Son/daughter}-in-law
(7) Refused
(9) Don't know

[If DEGREE4 = (1)[if (father's age - child's age) less than 12 go to FID.310];
Else go to Check Item FIDCCI6.]

FID.310

You said that {you/name} {are/is} {PX's name} BIOLOGICAL FATHER. There is only {father's age - child's age} {years/year} age difference between {you/them}. Is this relationship correct?
BIOCK4
(1) Yes, continue the interview (HHCCCI6)
(2) No, Change relationship (FID.305)


FID.315

I noted that {mother's fullname) is the mother of {child's fullname}. Is {child's fullname} her biological, adoptive, step, foster child, or {son/daughter}-in-law? (H)
DEGREE5
(1) Biological child
(2) Adoptive child
(3) Step child
(4) Foster child
(5) {son/daughter}-in-law
(7) Refused
(9) Don't know

[If DEGREE5 = (1)[if (mother's age - child's age) less than 12 go to FID.320];
Else go to Check Item FIDCCI6.]

FID.320

You said that {you/name} {are/is} {PX's name} BIOLOGICAL MOTHER. There is only {mother's age - child's age} {years/year} age difference between {you/them}. Is this relationship correct?
BIOCK5
(1) Yes, continue the interview (Check Item FIDCCI6)
(2) No, Change relationship (FID.315)
Check item FIDCCI4A: If MOTHER(PX) ne ( ) go to Check Item FIDCCI5 (mother already identified); If there are no female family members other than PX with AGE ge (12) go to Check Item FIDCCI5; Else go to FID.325.

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". IF THE PERSON HAS NO PARENTS PRESENT BUT HAS A LEGAL GUARDIAN, ENTER "96."
MOTHER
(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 (Check Item FIDCCI5)
(99) Don't Know (Check Item FIDCCI5)

FID.330

Is {name(mother@)/this person} {PX-name}'s biological (natural), adoptive, step, or foster mother or mother-in-law?
MOTHERC1
(1) Biological mother
(2) Adoptive mother
(3) Step mother
(4) Foster mother
(5) Mother-in-law
(7) Refused
(9) Don't know

[If the age difference between the mother and child is less than 12 years at MOTHERC1, go to MOTHERC2; Else go to Check Item FIDCCI5.]

[If MOTHERC1 = (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?
MOTHERC2
(1) Yes, continue the interview (Check Item 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 Check Item FIDCCI6; If FATHER(PX) ne ( ) go to Check Item FIDCCI6 (father already identified); If there are no male family members other than PX with AGE ge (12) go to Check Item FIDCCI6; Else go to FID.340.
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".
FATHER
(00) Person not a household member (Check Item FIDCCI6)
(01-30) Person number (FID.350)
(96) No Parent in Household; Has legal guardian (FID.360)
(97) Refused (Check Item FIDCCI6)
(99) Don't Know (Check Item FIDCCI6)

[p. 18]

FID.350

Is {name(father@)/this person} {PX-name}'s biological (natural), adoptive, step, or foster father or father-in-law?
FATHERC1
(1) Biological father
(2) Adoptive father
(3) Step father
(4) Foster father
(5) Father-in-law
(7) Refused
(9) Don't know

[If the age difference between the mother and child is less than 12 years at FATHERC1, go to FATHERC2; Else go to Check Item FIDCCI6.]

[If FATHERC1 = (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?
FATHERC2
(1) Yes, continue the interview (Check Item FIDCCI6)
(2) No, select different person as FATHER (FID.340)
(3) No, change relationship (FID.350--FATHERC1)

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

FID.360

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

(Go to Check Item 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 or = 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]

FID.370

[fill "S" flagged person name] IS SELECTED AS THE SAMPLE ADULT]
SAID
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].

FID.380

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

FR: SELECT ALL THAT APPLY. TO SELECT A PERSON, ENTER THE NUMBER NEXT TO THE PERSON'S NAME. TO UNSELECT A PERSON, RE-ENTER THE NUMBER ENTER (N) FOR NO MORE.

[KNOW = 'x' for each person mentioned.]
[If the family has a sample child, go to FID.630; Else go the next section- Family Health Status and Limitation.]

FID.630

KNOWSC
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: SELECT ALL THAT APPLY. TO SELECT A PERSON, ENTER THE NUMBER NEXT TO THE PERSON'S NAME. TO UNSELECT A PERSON, RE-ENTER THE NUMBER
ENTER (N) FOR NO MORE

[KNOWSC = 'x' for each person mentioned.]
(Go to next section -- Family Health Status and Limitation)
[p. 20]


FAMILY CORE
Section II-- HEALTH STATUS AND LIMITATION OF ACTIVITIES

FINTRO
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.


FHS.005

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?
FLAPLYLM
(1) Yes (FHS.010)
(2) No (FHS.050)
(7) Refused (FHS.050)
(9) Don't know (FHS.050)

FHS.010

Who is this? (Anyone else?)
PLAPLYLM
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

[p. 21]


FHS.020

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?
PLAPLYUN
(1) Yes (FHS.050)
(2) No (FHS.050)
(7) Refused (FHS.050)
(9) Don't know (FHS.050)


FHS.050

Do any of the following family members, {fill names of children under age 18} receive Special Educational or Early Intervention Services?
FSPEDEIS
(1) Yes (FHS.060)
(2) No (FHS.070)
(7) Refused (FHS.070)
(9) Don't know (FHS.070)

FHS.060

Who is this? (Anyone else?)
PSPEDEIS
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FHS.070

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?
FLAADL
(1) Yes (FHS.080)
(2) No (FHS.150)
(7) Refused (FHS.150)
(9) Don't know (FHS.150)

FHS.080

Who is this? (Anyone else?)
PLAADL
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FHS.090

{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) Don't know (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?


FHS.150

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?
FLAIADL
(1) Yes (FHS.160)
(2) No (FHS.170)
(7) Refused (FHS.170)
(9) Don't know (FHS.170)

FHS.160

Who is this? (Anyone else?)
PLAIADL
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FHS.170

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?
FLAWKNOW
(1) Yes (FHS.180)
(2) No (FHS.190)
(7) Refused (FHS.190)
(9) Don't know (FHS.190)

FHS.180

Who is this? (Anyone else?)
PLAWKNOW
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FHS.190

{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?
FLAWKLIM
(1) Yes (FHS.200)
(2) No (FHS.210)
(7) Refused (FHS.210)
(9) Don't know (FHS.210)

FHS.200

Who is this? (Anyone else?)
PLAWKLIM
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FHS.210

Because of a health problem, {do/does} {you/anyone in the family} have difficulty walking without using any special equipment?
FLAWALK
(1) Yes (FHS.220)
(2) No (FHS.230)
(7) Refused (FHS.230)
(9) Don't know (FHS.230)

FHS.220

Who is this? (Anyone else?)
PLAWALK
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FHS.230

{Are/is} {you/anyone in the family} LIMITED IN ANY WAY because of difficulty remembering or because {you/they} experience periods of confusion?
FLAREMEM
(1) Yes (FHS.240)
(2) No ( Check item FHSCCI2)
(7) Refused (Check item FHSCCI2)
(9) Don't know (Check item FHSCCI2)

FHS.240

Who is this? (Anyone else?)
PLAREMEM
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

[p. 23]


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.

FHS.250

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?
FLIMANY
(1) Yes (FHS.260)
(2) No (Check item FHSCCI3))
(7) Refused (Check item FHSCCI3
(9) Don't know (Check item FHSCCI3)

FHS.260

Who is this? (Anyone else?)
PLIMANY
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


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.

FHS.270

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.
Card F1
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
LAHCC
(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) Don't know/not sure

[ ]
[ ]
[ ]
[ ]
[ ]

(Go to FHS.280)

FHS.271

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

FHS.272

FR: SPECIFY CONDITION CAUSING LIMITATION. THIS SHOULD BE THE NAME OF A SPECIFIC CONDITION THAT IS NOT ON THE CONDITION LIST.
LACCSPEC_1 CONDITION: _______________

[p. 24]


FHS.280

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

(01-94) 1-94 times
(95)95+ times
(96)Since birth
(97) Refused
(99) Don't know
LHCCLT
[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) Don't know

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


FHS.290

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.
Card F2
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
LAHCA
(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) Don't know/not sure

[ ]
[ ]
[ ]
[ ]
[ ]

(Go to FHS.300)

FHS.291

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

FHS.292

FR: SPECIFY CONDITION CAUSING LIMITATION. THIS SHOULD BE THE NAME OF A SPECIFIC CONDITION THAT IS NOT ON THE CONDITION LIST.
LACASPEC_1 CONDITION: _______________


FHS.300

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

(01-94) 1-94
(95)95+
(96)Since birth
(97) Refused
(99) Don't know
LHCALT
[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) Don't know

[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:

FHS.310

Would you say {subject's name} health in general is excellent, Very good, good, fair, or poor?
PHSTAT
(1) Excellent
(2) Very good
(3) Good
(4) Fair
(5) Poor
(7) Refused
(9) Don't know

(Go to next section--Injuries)
[p. 35]


Section IV -- HEALTH CARE ACCESS AND UTILIZATION

Part A -- Access To Care


FAU.010

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?
FDMED12M
(1) Yes (FAU.020)
(2) No (FAU.030)
(7) Refused (FAU.030)
(9) Don't know (FAU.030)

FAU.020

For which family member was medical care delayed? (Anyone else?)
PDMED12M
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FAU.030

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?
FNMED12M
(1) Yes (FAU.040)
(2) No (FAU.050)
(7) Refused (FAU.050)
(9) Don't know (FAU.050)

FAU.040

Who didn't get needed care? (Anyone else?)
PNMED12M
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

[p. 36]

Part B -- Hospital Utilization


FAU.050

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.
FHOSPYR
(1) Yes (FAU.060)
(2) No (FAU.120)
(7) Refused (FAU.120)
(9) Don't know (FAU.120)

FAU.060

Who was in a hospital overnight? (Anyone else?)
PHOSPYR
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FAU.070

How many different times did {you/subject's name} stay in any hospital overnight or longer DURING THE PAST 12 MONTHS?
HOSPNO
(001-365) 1-365 Times
(997)Refused
(999) Don't know


FAU.110

Altogether how many nights {were/was} {you/subject's name} in the hospital DURING THE PAST 12 MONTHS?
HPNITE
(001-365) 1-365 Nights
(997)Refused
(999) Don't know
[If FAU.070 lt FAU.110 go to NEXT_HOSP; Else go to FAU.115]

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.
HPVER
(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.
[p. 37]

Part C -- Health Care Contacts

These next questions are about health care received during the 2 WEEKS outlined on that calendar. Include care from ALL types of medical doctors, such as dermatologists, psychiatrists, ophthalmologists, and general practitioners. Also include care from OTHER health professionals such as nurses, physical therapists, and chiropractors. DO NOT INCLUDE DENTAL CARE.


FAU.120

[If FAU.050 = 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]
FHCHM2W
(1) Yes (FAU.130)
(2) No (FAU.150)
(7) Refused (FAU.150)
(9) Don't know (FAU.150)

FAU.130

Who received care at home? (Anyone else?)
PHCHM2W
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FAU.140

How many home visits did {you/subject's name} receive during those 2 WEEKS?
PHCHMN2W
(01-49) 1-49 Visits
(50)50+ Visits
(97) Refused
(99) Don't know


FAU.150

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]
FHCPH2W
(1) Yes (FAU.160)
(2) No (FAU.180)
(7) Refused (FAU.180)
(9) Don't know (FAU.180)

FAU.160

Who was the phone call about? (Anyone else?)
PHCPH2W
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FAU.170

During those 2 WEEKS, how many telephone calls were made about {you/subject's name}?
PHCPHN2W
(01-49) 1-49 Calls
(50)50+ Calls
(97) Refused
(99) Don't know

[p. 38]


FAU.180

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]
FHCDV2W
(1) Yes (FAU.190)
(2) No (FAU.210)
(7) Refused (FAU.210)
(9) Don't know (FAU.210)

FAU.190

Who received care? (Anyone else?)
PHCDV2W
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FAU.200

How many times did {you/subject's name} visit a doctor or other health care professional during those 2 WEEKS?
PHCDVN2W
(01-49) 1-49 Times
(50)50+ Times
(97) Refused
(99) Don't know


FAU.210

During the past 12 MONTHS did {you/anyone in the family} receive care from doctors or other health care professionals 10 or more times?
F10DVYR
(1) Yes (FAU.220)
(2) No (FHI.010)
(7) Refused (FHI.010)
(9) Don't know (FHI.010)

FAU.220

Who received care 10 or more times (exclude telephone calls)? (Anyone else?)
P10DVYR
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

(Go to next section--Health Insurance)
[p. 39]

Section V -- HEALTH INSURANCE

FHI.010

The next questions are about health insurance.

Are you familiar with the family's health care coverage?
HRFHI
(1) Yes (FHI.050)
(2) No (FHI.020)
(7) Refused (FHI.020)
(9) Don't know (FHI.020)

FHI.020

Who else in the family could answer questions about the family's health insurance?
PHIWHO
[Enter person #s]

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

FHI.030

Is {the person/anyone that} you just mentioned available now to answer questions about health insurance?
FAVAIL
(1) Yes (FHI.040)
(2) No (FHI.050)
(7) Refused (FHI.050)
(9) Don't know (FHI.050)

FHI.040

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.


FHI.050

FR: SHOW CARD F9.

[If FAVAIL = (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 PAY MEDICAL BILLS.
Card F9
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. CHIP (Children's Health Insurance Program)
8. Military health care/VA
9. CHAMPUS/TRICARE/CHAMP-VA
10. Indian Health Service
11. State-sponsored health plan
12. Other government program
13. Single service plan (e.g., dental, vision, prescriptions)
*EXCLUDE private plans that only provide extra cash while hospitalized.
FHICOV
(1) Yes (FHI.060)
(2) No (Check Item FHICCI9)
(7) Refused (Check Item FHICCI9)
(9) Don't know (Check Item FHICCI9)

[p. 40]


FHI.060

Who has coverage? (Anyone else?)
PHICOV
[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.]


FHI.070

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

FR: SHOW CARD F9 AND CARD F10.
MARK "X" ALL THAT APPLY.
Card F9
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. CHIP (Children's Health Insurance Program)
8. Military health care/VA
9. CHAMPUS/TRICARE/CHAMP-VA
10. Indian Health Service
11. State-sponsored health plan
12. Other government program
13. Single service plan (e.g., dental, vision, prescriptions)
*EXCLUDE private plans that only provide extra cash while hospitalized.
[ ] 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 (07) CHIP (Children's Health Insurance Program)
[ ] HIKINDH (08) Military health care/VA
[ ] HIKINDI (09) CHAMPUS/TRICARE/CHAMP-VA
[ ] HIKINDJ (10) Indian Health Service
[ ] HIKINDK (11) State-sponsored health plan
[ ] HIKINDL (12) Other government program
[ ] HIKINDM (13) Single Service Plan (e.g. dental, vision, prescriptions)

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


FHI.080

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): -_____

FHI.090

FR: FILL IN APPROPRIATE COVERAGE TYPE BELOW
MCPART
(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) Don't know (FHI.100)


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).
MCHMO
(1) Yes
(2) No
(7) Refused
(9) Don't know

[If answer = 1, ask: ]

FHI.110

What is the name of the HMO?
MCHMO_NA Name: _______________


FHI.114

If {you/subject's name} {need/s} to go to a different doctor or place for special care, {do/does} {you/she/he} need approval or a referral? (Do not include emergency care.)
MCREF
(1) Yes
(2) No
(7) Refused
(9) Don't know


FHI.116

Besides {your/subject's name} Medicare insurance, {are/is} {you/subject's name} paying an additional monthly or yearly premium to receive a more comprehensive health benefit plan?
MCPAYPRE
(1) Yes
(2) No
(7) Refused
(9) Don't know

Check item FHICCI4: (Medicaid Coverage) If the person in FHI.070 marked 6 then go to FHI.120; Else go to Check item FHICCI4.5.

FHI.120

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?
MACHMD
(1) Any doctor (FHI.140)
(2) Select from book/list (MACHMD_1)
(3) Doctor is assigned (MACHMD_2)
(7) Refused (FHI.140)
(9) Don't know (FHI.140)

[Flashcards associated with FHI.120]
Card F10-AL
State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Alabama

Medicaid: Patients 1st; BAY Health Plan or BAY Program
CHIP: AL-Kids or Medicaid Expansion
State/Other: Hypertension Program

[p. 22]

Card F10-AK

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Alaska

Medicaid: Medical Assistance Program
CHIP: Smart Start for Alaska's Children
State/Other: General Relief Medical (GRM); Chronic and Acute Medical Assistance (CAMA)

[p. 23]

Card F10-AZ

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Arizona

Medicaid: AHCCCS
CHIP: KidsCare
State/Other: ALTCS; ComCare; Medically Indigent Program

[p. 24]

Card F10-AR

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Arkansas

Medicaid: ConnectCare
CHIP: ARKids First or Child Health Insurance Program
State/Other: Arkansas Comprehensive Health Insurance Plan; Kidney Disease Commission

[p. 25]

Card F10-CA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

California

Medicaid: Medi-Cal or Medi-Cal Managed Care or The Two-Plan Model
CHIP: Healthy Families Program
State/Other: Access for Infants and Mothers (AIM); County Medical Services Program (CMSP); Children's Services (CCS); California's children's health

[p. 26]

Card F10-CO

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Colorado

Medicaid: Primary Care Physician Program (PCPP); PACE
CHIP: Colorado Child Health Plan or Child Health Plan Plus (CHP+)
State/Other: Assistance for AIDS Specific Drugs (AASD)

[p. 27]

Card F10-CT

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Connecticut

Medicaid: Connecticut Access
CHIP: HUSKY or HUSKY PLUS
State/Other: Connecticut Insurance Assistance Program for AIDS Patients (CIAP/AP); ConnTRANS; Healthy Steps; General Assistance Program (GA)

[p. 28]

Card F10-DE

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Delaware

Medicaid: Diamond State Health Plan
CHIP: The Delaware Healthy Children Program (DHCP) or Diamond State Health Plan for Children
State/Other: Nemours Child Plan

[p. 29]

Card F10-DC

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

District of Columbia

Medicaid: Medical Assistance; HSCSN
CHIP: Healthy DC Kids
State/Other: Medical Charities Program

[p. 30]

Card F10-FL

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Florida

Medicaid: Medipass or Medcaid HMO Program
CHIP: Florida Healthy Kids Program
State/Other: Florida Health Security (FHS): Statewide Kidney Disease Program

[p. 31]

Card F10-GA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Georgia

Medicaid: Better Health Care; Georgia Behavioral Health Plan
CHIP: PeachCare or Georgia CHIP or Medicaid look-alike
State/Other: AIDS Drug Assistance Program

[p. 32]

Card F10-HI

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Hawaii

Medicaid: Hawaii-QUEST
CHIP:
State/Other: QUEST-Net; HIV Drug Assistance Program

[p. 33]

Card F10-ID

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Idaho

Medicaid: Healthy Connections; Medical Assistance
CHIP: State Child Health Plan
State/Other: Catastrophic Fund

[p. 34]

Card F10-IL

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Illinois

Medicaid: MediPlan Plus
CHIP: KidCare or Medicaid Expansion
State/Other: General Assistance Program; State Child and Family Assistance (SCFA); Transitional Assistance (TA)

[p. 35]

Card F10-IN

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Indiana

Medicaid: Hoosier Healthwise
CHIP:
State/Other: ICHIA; Renal Program

[p. 36]

Card F10-IA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Iowa

Medicaid: Medical Assistance; Health Insurance Premium Payment (HIPP); MediPASS
CHIP: Health and Well Kids in Iowa (HAWK-I)
State/Other: Home and Community Based Services (HCBS/MR); Caring Program for Children; Iowa coverage for unemployed workers

[p. 37]

Card F10-KS

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Kansas

Medicaid: Community Care of Kansas (CCK); HealthConnect; PrimeCare Kansas
CHIP: State Children's Health Insurance Program (SCHIP)
State/Other: Independent Living Program; Medi-KAN

[p. 38]

Card F10-KY

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Kentucky

Medicaid: Kentucky Patient Access and Care System (KenPAC); Health Care Partnership Plan or The Partnership Program
CHIP: KCHIP or Kentucky Children's Health Insurance Program
State/Other: Kentucky AIDS Drug Assistance Program (KADAP)

[p. 39]

Card F10-LA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Louisiana

Medicaid: Louisiana Health Access (LHA); CommunityCARE
CHIP: LaCHIP
State/Other: Louisiana Health Insurance Association; HIV Formulary

[p. 40]

Card F10-ME

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Maine

Medicaid: Medical Assistance; PrimeCare
CHIP: Cub Care
State/Other: Health Program; Elderly Low Cost Drug Program

[p. 41]

Card F10-MD

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Maryland

Medicaid: Maryland Access to Care or MAC
CHIP: HealthChoice Program
State/Other: AIDS Insurance Assistance Program; Kidney Disease Program

[p. 42]

Card F10-MA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Massachusetts

Medicaid: MassHealth; Elder Service Plans; PACE
CHIP: Premium Assistance Plan; CommonHealth Program
State/Other: Children's Medical Security Plan; Medical Security Plan (MSP); CenterCare; Uncompensated Free Care Pool

[p. 43]

Card F10-MI

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Michigan

Medicaid: Comprehensive Health Care Plan (CHCP); Physician Sponsor Plan; The Clinic Plan
CHIP: MIChild Program
State/Other: Wayne County Plus Care Program; Children's Hourly In-Home Locally Delivered Services (CHILD); Habilitation/Support (HCBS)

[p. 44]

Card F10-MN

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Minnesota

Medicaid: Prepaid Medical Assistance Program (PMAP) or PMAP+
CHIP:
State/Other: MinnesotaCare; Minnesota General Assistance Medical Care Program (GAMC); MCHA; HIV/AIDS Insurance Program

[p. 45]

Card F10-MS

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Mississippi

Medicaid: HealthMACS
CHIP: Mississippi Children's Health Insurance Program (CHIP)
State/Other: Mississippi Comprehensive Health Insurance Risk Pool

[p. 46]

Card F10-MO

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Missouri

Medicaid: Missouri Managed Care Plus (MC+); MCPlus
CHIP:
State/Other: General Relief Medical Assistance; MHIP; Kidney Program

[p. 48]

Card F10-MT

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Montana

Medicaid: Montana Mental Health Access Plan; Passport to Health
CHIP: Montana's CHIP
State/Other: Montana Comprehensive Health Association (MCHA)

[p. 48]

Card F10-NE

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Nebraska

Medicaid: Medical Assistance Program; Nebraska Health Connection (NHC); Primary Care+
CHIP: Kids Connection
State/Other: State Disability Program; Nevada Comprehensive Health Insurance Pool

[p. 49]

Card F10-NV

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Nevada

Medicaid:
CHIP: Nevada Check Up
State/Other:

[p. 50]

Card F10-NH

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

New Hampshire

Medicaid: Medical Assistance Program; Community Care Systems; Capitated Medicaid Managed Care
CHIP: New Hampshire Healthy Kids Corporation
State/Other:

[p. 51]

Card F10-NJ

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

New Jersey

Medicaid: New Jersey Care 2000; Managed Charity Care Demonstration (MCCD)
CHIP: New Jersey KidCare or NJ KidCare-Plan A, B, C
State/Other: HealthStart; AIDS Community Care Alternatives (ACCAP); Home and Community-based Service for Develop-mentally disabled; Medically fragile Children; Persons With Traumatic Brain Injuries; Statewide Respite Care Program; PAAD; ADDP; HAAAD; HCEP; Health Access

[p. 52]

Card F10-NM

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

New Mexico

Medicaid: The SALUD! Program; Primary Care Network (PCN) Program
CHIP: New Mexico Title XXI Program
State/Other: Comprehensive Health Insurance Pool: Home Delivery Drug Program

[p. 53]

Card F10-NY

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

New York

Medicaid: Medical Assistance (MA); The Partnership Plan; MAX; PACE; Elderplan
CHIP: Child Health Plus (CHP) or CHPlus
State/Other: Home Relief; New York's subsidized insurance

[p. 54]

Card F10-NC

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

North Carolina

Medicaid: Carolina Access; Carolina Alternatives; Baby Love; Community Alternatives; Health Check; Nursing Home Reform; Drug Use Review (DUR)
CHIP: Health Choice or Title XXI Program
State/Other: Cancer Program; Sickle Cell Syndrome Program; State Kidney Program; HIV Medications Program

[p. 55]

Card F10-ND

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

North Dakota

Medicaid: Medical Services or North Dakota Access and Care Program (NoDAC)
CHIP: North Dakota Healthy Steps or Healthy Steps Program
State/Other: Comprehensive Health Association of North Dakota

[p. 56]

Card F10-OH

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Ohio

Medicaid: OhioCare; Ohio Medicaid-Managed Care Program; ABC Program
CHIP: The Healthy Start Program (HS or HST)
State/Other: PACE; Core; Core Plus; Waiver Program; Facility Based Long-term Care; HCAP

[p. 57]

Card F10-OK

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Oklahoma

Medicaid: SoonerCare
CHIP:
State/Other:

[p. 58]

Card F10-OR

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Oregon

Medicaid: Oregon Health Plan (OHP)
CHIP: Medicaid look-alike CHIP Program
State/Other: Family Health Insurance Assistance Program (FHIAP)

[p. 59]

Card F10-PA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Pennsylvania

Medicaid: Medical Assistance; Family Care Network; HealthChoices; HealthPass
CHIP: Pa CHIP-Free and Subsidized Program
State/Other: General Assistance Medical Program; PACE, SPBP

[p. 60]

Card F10-RI

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Rhode Island

Medicaid: Rite Care
CHIP: Medicaid Rite Care Program Expansion
State/Other: General Public Assistance (GPA) Medical Program; RIPAE

[p. 61]

Card F10-SC

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

South Carolina

Medicaid: South Carolina Palmetto Health Initiative (PHI); SCHAP; PACE
CHIP: Partners for Healthy Children or State Child Health Plan or Title XXI
State/Other: South Carolina Health Insurance Pool

[p. 62]

Card F10-SD

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

South Dakota

Medicaid: Medicaid Managed Care Program; Prime; Title 19; Primary Care Provider Program
CHIP: Children's Health Insurance Program (CHIP)
State/Other: Catastrophic County-Poor Relief Program

[p. 63]

Card F10-TN

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Tennessee

Medicaid: TennCare
CHIP:
State/Other: Tennessee Renal Disease Program

[p. 64]

Card F10-TX

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Texas

Medicaid: State of Texas Access Reform (STAR); Star Plus; Lonestar Select
CHIP: Texas CHIP
State/Other: Chronically Ill and Disabled Children Program (CIDC); Division of Kidney Health Care Program; AIDS/STD Medication Program

[p. 65]

Card F10-UT

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Utah

Medicaid: Family; Pregnant Womens' Program; Newborn; Newborn Plus; Child; Nursing Home Program; Emergency Medicaid; Refugee Medicaid
CHIP: Children's Health Insurance Program
State/Other: Utah Medical Assistance Program (UMAP); Custody Medical Care Program; Subsidized Adoption Assistance; Aged, Blind, or Disabled; Home and Community Based Waiver Program; HIV/AIDS Drug Therapy; UHIP

[p. 66]

Card F10-VT

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Vermont

Medicaid: Vermont Health Access Plan (VHAP)
CHIP: Dr. Dynasaur
State/Other: General Assistance Medical Program; Vscript

[p. 67]

Card F10-VA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Virginia

Medicaid: Virginia Medallion
CHIP: Virginia's Children's Medical Security Insurance Plan or Children's Health Insurance Law in the Dominion (CHILD)
State/Other: State and Local Hospitalization (SLH) Program; Caring Program for Children

[p. 68]

Card F10-WA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Washington

Medicaid: Healthy Options
CHIP: Basic Health Plus
State/Other: General Assistance Unemployable Program (GA-U); State Health Insurance Pool: Medically Indigent Program

[p. 69]

Card F10-WV

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

West Virginia

Medicaid: Medical Assistance
CHIP: Children's Health Insurance Program (CHIP)
State/Other: General Assistance for Disabled Adults; Special Pharmacy Program

[p. 70]

Card F10-WI

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Wisconsin

Medicaid: Medical Assistance Program; Wisconsin Medicaid/HMO Program; PACE
CHIP: BadgerCare
State/Other: General Relief Medical

[p. 71]

Card F10-WY

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Wyoming

Medicaid:
CHIP:
State/Other: Wyoming Health Insurance Pool; Basic Foster Care Program; Minimum Medical Program (MMP)

[p. 42]


FHI.130

[If answer = 2, ask:]
What is the name of the health plan that provided the book or list?
MACHMD_1 Name: __________ (FHI.140)
[If answer = 3, ask:]
What is the name of the health plan that assigned the doctor?
MACHMD_2 Name: __________ (FHI.140)


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).
MAPCMD
(1) Yes
(2) No
(7) Refused
(9) Don't know


FHI.150

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.)
MAREF
(1) Yes
(2) No
(7) Refused
(9) Don't know

[When roster exhausted go to Check item FHICCI4.5.]
Check item FHICCI4.5: If any person in FHI.070 marked 13, then go to FHI.156; else go to Check item FHICCI5.


FHI.156

What type of service or care do {your/subject name's} single service plan or plans pay for? (Mark all that apply)

FR: SHOW CARD F11.
Card F11
1. Accidents
2. AIDS care
3. Cancer treatment
4. Catastrophic care
5. Dental care
6. Disability insurance (cash payments when unable to work for health reasons)
7. Hospice care
8. Hospitalization only
9. Long-term care (nursing home care)
10. Prescriptions
11. Vision care
12. Other
SSTYPE
(1) Accidents (Check Item FHICCI5)
(2) AIDS care (Check Item FHICCI5)
(3) Cancer treatment (Check Item FHICCI5)
(4) Catastrophic care (Check Item FHICCI5)
(5) Dental care (Check Item FHICCI5)
(6) Disability Insurance (cash payments when unable to work for health reasons) (Check Item FHICCI5)
(7) Hospice care (Check Item FHICCI5)
(8) Hospitalization only (Check Item FHICCI5)
(9) Long-term care (nursing home care) (Check Item FHICCI5)
(10) Prescriptions (Check Item FHICCI5)
(11) Vision care (Check Item FHICCI5)
(12) Other - specify (FHI.157)
(97) Refused (Check Item FHICCI5)
(99) Don't know (Check Item FHICCI5)

FHI.157

FR: SPECIFY OTHER TYPE OF SERVICE
SSOTHER Service: ___________________________

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 insurance 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}.

FHI.160

It is important that we record the complete and accurate name of each health insurance plan. What is the COMPLETE name of the first plan?

FR: REMIND RESPONDENT IF NECESSARY:

Do NOT include plans that only provide extra cash while in the hospital or plans that pay for only one type of service, such as nursing home care, accidents, or dental care.

FR: IF NECESSARY:

Do you have something with the plan name on it?
HIPNAM_N Name: _______________

FHI.170

Which family members are covered by that plan?
HIPNAM_B
[Enter person #s]

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


FHI.171

Are there any more health insurance plans?
MORPLAN
(1) Yes (FHI.172)
(2) No (Check Item FHICCI7)

FHI.172

What is the name of the next plan?
NEXTPNM Name: _______________

FHI.173

Which family members are covered by that plan?
NEXTPNM_B
[Enter person #s]

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


FHI.174

Are there any more health insurance plans in addition to those already mentioned?
MORPLAN2
(1) Yes (FHI.175)
(2) No (Check Item FHICCI7)

FHI.175

What is the name of the next plan?
NEXTPNM2 Name: _______________

FHI.176

Which family members are covered by that plan?
NEXTPNM2_B
[Enter person #s]

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


FHI.177

Are there any more health insurance plans in addition to those already mentioned?
MORPLAN3
(1) Yes (FHI.178)
(2) No (Check Item FHICCI7)

FHI.178

What is the name of the next plan?
NEXTPNM3 Name: _______________

FHI.179

Which family members are covered by that plan?
NEXTPNM3_B
[Enter person #s]

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
Check item FHICCI7: If any private insurance covered person wasn't listed on any of the above plans, go to FHI.180. If there are no such persons, go to Check item FHICCI8.

FHI.180

{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?
HIVER1
(1) Yes (FHI.190)
(2) No (FHI.070)
(7) Refused (FHI.070)
(9) Don't know (FHI.070)

FHI.190

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
[If anyone in the family has private health insurance, loop through all the private plans; Else go to Check item FHICCI9]
Check item FHICCI8: FHI.200-FHI.248 are repeated for each health plan.
[p. 45]


FHI.200

[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 #]

[ ]


FHI.210

Was this plan originally obtained through the workplace, such as through a present or former employer or union?
PLNWRK
(1) Employer
(2) Union
(3) Through workplace, but Don't know if employer or union
(4) Through workplace, self-employed or professional association
(5) No
(7) Refused
(9) Don't know


FHI.220

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 7.
IF GOVERNMENT IS THE EMPLOYER, ENTER CODE 2.
PLNPAY
(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) CHIP (Children's Health Insurance Plan) (FHI.240)
(7) State or local government or community program (FHI.240)
(97) Refused (FHI.240)
(99) Don't know (FHI.240)

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

[p. 46]


FHI.230

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.
HICOSTNO
[ ] NUMBER

(1-9,999) Less than $500
(99,997) Refused
(99,999) Don't know
HICOSTTP
[ ] TIME PERIOD

(1) Week
(2) Bi-weekly
(3) Month
(4) Quarter
(5) Bi-yearly
(6) Yearly
(97) Refused
(99) Don't know


FHI.240

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?
PLNMGD
(1) HMO/IPA
(2) PPO
(3) POS
(4) Other
(7) Refused
(9) Don't know


FHI.242

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?
MGCHMD
(1) Any doctor (FHI.244)
(2) Select from group/list (FHI.246)
(7) Refused (FHI.248)
(9) Don't know (FHI.248)


FHI.244

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?
MGPRMD
(1) Yes
(2) No
(7) Refused
(9) Don't know

(FHI.248)


FHI.246

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?
MGPYMD
(1) Yes
(2) No
(7) Refused
(9) Don't know


FHI.248

When a family member with this plan needs to go to a different doctor or place for special care, does the family member need approval or a referral? (Do not include emergency care.)
MGPREF
(1) Yes
(2) No
(7) Refused
(9) Don't know

Check item FHICCI8A: If there are more health plans, return to Check Item FHICCI8; Else go to Check Item FHICCI9.
[p. 47]
Check item FHICCI9: Loop through each non-deleted family member: If any family member is 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 7, 11, or 12 go to FHI.250; Else if any member FHI.070 only 13 marked, go to FHI.260. Else go to FHI.300.

FHI.250

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: ____________________


FHI.260

Just to verify, other than single service plans, {do/does} {you/he/she} have Medicare, Medicaid, CHIP (Children's Health Insurance Program), CHAMPUS, or CHAMPVA ... or any private insurance?

FR: READ STATE NAME FOR MEDICAID AND STATE SPONSORED HEALTH INSURANCE PROGRAM FROM CARDS F9 AND F10.
HICHECK
(1) Yes (FHI.060)
(2) No (FHI.270)
(7) Refused (FHI.270)
(9) Don't know (FHI.270)
Card F9
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. CHIP (Children's Health Insurance Program)
8. Military health care/VA
9. CHAMPUS/TRICARE/CHAMP-VA
10. Indian Health Service
11. State-sponsored health plan
12. Other government program
13. Single service plan (e.g., dental, vision, prescriptions)
*EXCLUDE private plans that only provide extra cash while hospitalized.

[p. 21]

Card F10-AL
State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Alabama

Medicaid: Patients 1st; BAY Health Plan or BAY Program
CHIP: AL-Kids or Medicaid Expansion
State/Other: Hypertension Program

[p. 22]

Card F10-AK

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Alaska

Medicaid: Medical Assistance Program
CHIP: Smart Start for Alaska's Children
State/Other: General Relief Medical (GRM); Chronic and Acute Medical Assistance (CAMA)

[p. 23]

Card F10-AZ

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Arizona

Medicaid: AHCCCS
CHIP: KidsCare
State/Other: ALTCS; ComCare; Medically Indigent Program

[p. 24]

Card F10-AR

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Arkansas

Medicaid: ConnectCare
CHIP: ARKids First or Child Health Insurance Program
State/Other: Arkansas Comprehensive Health Insurance Plan; Kidney Disease Commission

[p. 25]

Card F10-CA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

California

Medicaid: Medi-Cal or Medi-Cal Managed Care or The Two-Plan Model
CHIP: Healthy Families Program
State/Other: Access for Infants and Mothers (AIM); County Medical Services Program (CMSP); Children's Services (CCS); California's children's health

[p. 26]

Card F10-CO

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Colorado

Medicaid: Primary Care Physician Program (PCPP); PACE
CHIP: Colorado Child Health Plan or Child Health Plan Plus (CHP+)
State/Other: Assistance for AIDS Specific Drugs (AASD)

[p. 27]

Card F10-CT

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Connecticut

Medicaid: Connecticut Access
CHIP: HUSKY or HUSKY PLUS
State/Other: Connecticut Insurance Assistance Program for AIDS Patients (CIAP/AP); ConnTRANS; Healthy Steps; General Assistance Program (GA)

[p. 28]

Card F10-DE

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Delaware

Medicaid: Diamond State Health Plan
CHIP: The Delaware Healthy Children Program (DHCP) or Diamond State Health Plan for Children
State/Other: Nemours Child Plan

[p. 29]

Card F10-DC

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

District of Columbia

Medicaid: Medical Assistance; HSCSN
CHIP: Healthy DC Kids
State/Other: Medical Charities Program

[p. 30]

Card F10-FL

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Florida

Medicaid: Medipass or Medcaid HMO Program
CHIP: Florida Healthy Kids Program
State/Other: Florida Health Security (FHS): Statewide Kidney Disease Program

[p. 31]

Card F10-GA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Georgia

Medicaid: Better Health Care; Georgia Behavioral Health Plan
CHIP: PeachCare or Georgia CHIP or Medicaid look-alike
State/Other: AIDS Drug Assistance Program

[p. 32]

Card F10-HI

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Hawaii

Medicaid: Hawaii-QUEST
CHIP:
State/Other: QUEST-Net; HIV Drug Assistance Program

[p. 33]

Card F10-ID

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Idaho

Medicaid: Healthy Connections; Medical Assistance
CHIP: State Child Health Plan
State/Other: Catastrophic Fund

[p. 34]

Card F10-IL

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Illinois

Medicaid: MediPlan Plus
CHIP: KidCare or Medicaid Expansion
State/Other: General Assistance Program; State Child and Family Assistance (SCFA); Transitional Assistance (TA)

[p. 35]

Card F10-IN

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Indiana

Medicaid: Hoosier Healthwise
CHIP:
State/Other: ICHIA; Renal Program

[p. 36]

Card F10-IA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Iowa

Medicaid: Medical Assistance; Health Insurance Premium Payment (HIPP); MediPASS
CHIP: Health and Well Kids in Iowa (HAWK-I)
State/Other: Home and Community Based Services (HCBS/MR); Caring Program for Children; Iowa coverage for unemployed workers

[p. 37]

Card F10-KS

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Kansas

Medicaid: Community Care of Kansas (CCK); HealthConnect; PrimeCare Kansas
CHIP: State Children's Health Insurance Program (SCHIP)
State/Other: Independent Living Program; Medi-KAN

[p. 38]

Card F10-KY

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Kentucky

Medicaid: Kentucky Patient Access and Care System (KenPAC); Health Care Partnership Plan or The Partnership Program
CHIP: KCHIP or Kentucky Children's Health Insurance Program
State/Other: Kentucky AIDS Drug Assistance Program (KADAP)

[p. 39]

Card F10-LA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Louisiana

Medicaid: Louisiana Health Access (LHA); CommunityCARE
CHIP: LaCHIP
State/Other: Louisiana Health Insurance Association; HIV Formulary

[p. 40]

Card F10-ME

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Maine

Medicaid: Medical Assistance; PrimeCare
CHIP: Cub Care
State/Other: Health Program; Elderly Low Cost Drug Program

[p. 41]

Card F10-MD

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Maryland

Medicaid: Maryland Access to Care or MAC
CHIP: HealthChoice Program
State/Other: AIDS Insurance Assistance Program; Kidney Disease Program

[p. 42]

Card F10-MA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Massachusetts

Medicaid: MassHealth; Elder Service Plans; PACE
CHIP: Premium Assistance Plan; CommonHealth Program
State/Other: Children's Medical Security Plan; Medical Security Plan (MSP); CenterCare; Uncompensated Free Care Pool

[p. 43]

Card F10-MI

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Michigan

Medicaid: Comprehensive Health Care Plan (CHCP); Physician Sponsor Plan; The Clinic Plan
CHIP: MIChild Program
State/Other: Wayne County Plus Care Program; Children's Hourly In-Home Locally Delivered Services (CHILD); Habilitation/Support (HCBS)

[p. 44]

Card F10-MN

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Minnesota

Medicaid: Prepaid Medical Assistance Program (PMAP) or PMAP+
CHIP:
State/Other: MinnesotaCare; Minnesota General Assistance Medical Care Program (GAMC); MCHA; HIV/AIDS Insurance Program

[p. 45]

Card F10-MS

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Mississippi

Medicaid: HealthMACS
CHIP: Mississippi Children's Health Insurance Program (CHIP)
State/Other: Mississippi Comprehensive Health Insurance Risk Pool

[p. 46]

Card F10-MO

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Missouri

Medicaid: Missouri Managed Care Plus (MC+); MCPlus
CHIP:
State/Other: General Relief Medical Assistance; MHIP; Kidney Program

[p. 48]

Card F10-MT

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Montana

Medicaid: Montana Mental Health Access Plan; Passport to Health
CHIP: Montana's CHIP
State/Other: Montana Comprehensive Health Association (MCHA)

[p. 48]

Card F10-NE

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Nebraska

Medicaid: Medical Assistance Program; Nebraska Health Connection (NHC); Primary Care+
CHIP: Kids Connection
State/Other: State Disability Program; Nevada Comprehensive Health Insurance Pool

[p. 49]

Card F10-NV

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Nevada

Medicaid:
CHIP: Nevada Check Up
State/Other:

[p. 50]

Card F10-NH

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

New Hampshire

Medicaid: Medical Assistance Program; Community Care Systems; Capitated Medicaid Managed Care
CHIP: New Hampshire Healthy Kids Corporation
State/Other:

[p. 51]

Card F10-NJ

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

New Jersey

Medicaid: New Jersey Care 2000; Managed Charity Care Demonstration (MCCD)
CHIP: New Jersey KidCare or NJ KidCare-Plan A, B, C
State/Other: HealthStart; AIDS Community Care Alternatives (ACCAP); Home and Community-based Service for Develop-mentally disabled; Medically fragile Children; Persons With Traumatic Brain Injuries; Statewide Respite Care Program; PAAD; ADDP; HAAAD; HCEP; Health Access

[p. 52]

Card F10-NM

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

New Mexico

Medicaid: The SALUD! Program; Primary Care Network (PCN) Program
CHIP: New Mexico Title XXI Program
State/Other: Comprehensive Health Insurance Pool: Home Delivery Drug Program

[p. 53]

Card F10-NY

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

New York

Medicaid: Medical Assistance (MA); The Partnership Plan; MAX; PACE; Elderplan
CHIP: Child Health Plus (CHP) or CHPlus
State/Other: Home Relief; New York's subsidized insurance

[p. 54]

Card F10-NC

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

North Carolina

Medicaid: Carolina Access; Carolina Alternatives; Baby Love; Community Alternatives; Health Check; Nursing Home Reform; Drug Use Review (DUR)
CHIP: Health Choice or Title XXI Program
State/Other: Cancer Program; Sickle Cell Syndrome Program; State Kidney Program; HIV Medications Program

[p. 55]

Card F10-ND

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

North Dakota

Medicaid: Medical Services or North Dakota Access and Care Program (NoDAC)
CHIP: North Dakota Healthy Steps or Healthy Steps Program
State/Other: Comprehensive Health Association of North Dakota

[p. 56]

Card F10-OH

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Ohio

Medicaid: OhioCare; Ohio Medicaid-Managed Care Program; ABC Program
CHIP: The Healthy Start Program (HS or HST)
State/Other: PACE; Core; Core Plus; Waiver Program; Facility Based Long-term Care; HCAP

[p. 57]

Card F10-OK

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Oklahoma

Medicaid: SoonerCare
CHIP:
State/Other:

[p. 58]

Card F10-OR

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Oregon

Medicaid: Oregon Health Plan (OHP)
CHIP: Medicaid look-alike CHIP Program
State/Other: Family Health Insurance Assistance Program (FHIAP)

[p. 59]

Card F10-PA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Pennsylvania

Medicaid: Medical Assistance; Family Care Network; HealthChoices; HealthPass
CHIP: Pa CHIP-Free and Subsidized Program
State/Other: General Assistance Medical Program; PACE, SPBP

[p. 60]

Card F10-RI

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Rhode Island

Medicaid: Rite Care
CHIP: Medicaid Rite Care Program Expansion
State/Other: General Public Assistance (GPA) Medical Program; RIPAE

[p. 61]

Card F10-SC

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

South Carolina

Medicaid: South Carolina Palmetto Health Initiative (PHI); SCHAP; PACE
CHIP: Partners for Healthy Children or State Child Health Plan or Title XXI
State/Other: South Carolina Health Insurance Pool

[p. 62]

Card F10-SD

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

South Dakota

Medicaid: Medicaid Managed Care Program; Prime; Title 19; Primary Care Provider Program
CHIP: Children's Health Insurance Program (CHIP)
State/Other: Catastrophic County-Poor Relief Program

[p. 63]

Card F10-TN

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Tennessee

Medicaid: TennCare
CHIP:
State/Other: Tennessee Renal Disease Program

[p. 64]

Card F10-TX

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Texas

Medicaid: State of Texas Access Reform (STAR); Star Plus; Lonestar Select
CHIP: Texas CHIP
State/Other: Chronically Ill and Disabled Children Program (CIDC); Division of Kidney Health Care Program; AIDS/STD Medication Program

[p. 65]

Card F10-UT

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Utah

Medicaid: Family; Pregnant Womens' Program; Newborn; Newborn Plus; Child; Nursing Home Program; Emergency Medicaid; Refugee Medicaid
CHIP: Children's Health Insurance Program
State/Other: Utah Medical Assistance Program (UMAP); Custody Medical Care Program; Subsidized Adoption Assistance; Aged, Blind, or Disabled; Home and Community Based Waiver Program; HIV/AIDS Drug Therapy; UHIP

[p. 66]

Card F10-VT

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Vermont

Medicaid: Vermont Health Access Plan (VHAP)
CHIP: Dr. Dynasaur
State/Other: General Assistance Medical Program; Vscript

[p. 67]

Card F10-VA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Virginia

Medicaid: Virginia Medallion
CHIP: Virginia's Children's Medical Security Insurance Plan or Children's Health Insurance Law in the Dominion (CHILD)
State/Other: State and Local Hospitalization (SLH) Program; Caring Program for Children

[p. 68]

Card F10-WA

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Washington

Medicaid: Healthy Options
CHIP: Basic Health Plus
State/Other: General Assistance Unemployable Program (GA-U); State Health Insurance Pool: Medically Indigent Program

[p. 69]

Card F10-WV

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

West Virginia

Medicaid: Medical Assistance
CHIP: Children's Health Insurance Program (CHIP)
State/Other: General Assistance for Disabled Adults; Special Pharmacy Program

[p. 70]

Card F10-WI

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Wisconsin

Medicaid: Medical Assistance Program; Wisconsin Medicaid/HMO Program; PACE
CHIP: BadgerCare
State/Other: General Relief Medical

[p. 71]

Card F10-WY

State names for Medicaid, CHIP, State-/Local-sponsored, and other health insurance programs

Note: If no name exists, some Medicaid programs are called "Medical Assistance Program" or "{State}Medicaid", such as "Alabama Medicaid". CHIP or S-CHIP programs can also be under "Title XXI Program" or "{State} CHIP", such as "Pennsylvania CHIP".

Wyoming

Medicaid:
CHIP:
State/Other: Wyoming Health Insurance Pool; Basic Foster Care Program; Minimum Medical Program (MMP)


FHI.270

Not including Single Service Plans, about how long has it been since {subject's name} last had health care coverage?

FR: SHOW CARD F12.
Card F12
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
HILAST
(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
(7) Refused
(9) Don't know


FHI.280

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

FR: SHOW CARD F13.
Card F13
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) Don't know
HISTOP
[ ]
[ ]
[ ]
[ ]
[ ]

(Go to FHI.320)

[p. 48]


FHI.300

In the PAST 12 MONTHS, was there any time when {subject's name} did NOT have ANY health insurance or coverage?
HINOTYR
(1) Yes (FHI.310)
(2) No (FHI.320)
(7) Refused (FHI.320)
(9) Don't know (FHI.320)


FHI.310

In the PAST 12 MONTHS, about how many months {were/was} {you/subject's name} without coverage?
HINOTMYR
(01-12) 1-12 months
(97)Refused
(99) Don't know


FHI.320

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 F14.
Card F14
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
HCSPFYR
(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) Don't know

(Go to next section--Socio-Demographic Background)
[p. 49]

Section VI -- SOCIO-DEMOGRAPHIC BACKGROUND

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

FSD.001

In what country {were/was} {you/subject's name} born?
PLBORN
(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) Don't know

OTHER COUNTRIES FOR NATIVITY
PLBORN2
(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
PLBORN3
(108) Finland
(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
(224) Malaysia
(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.
(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
PLBORN4
(389) South America
(304) North America
(148) Europe
(252) Middle East
(468) North Africa
(527) Other Africa
(555) Asia
(462) Pacific Islands
(245) Elsewhere

If PLBORN=1 go to FSD.002; all others go to FSD.003.
FSD.002

In what state {were/was} {you/subject's name} born?
USBORN State: _______________ (Go to FSDCCI1)


FSD.003

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?
USYR
Year: __________
(1900-1999) 1900-1999 years (FSD.005)
(9997) Refused (FSD.004)
(9999) Don't know (FSD.004)

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 "1".
USLONG
Years: _________
(0-95) 0-95 years
(97) Refused
(99) Don't know

[p. 51]


FSD.005

FR: SHOW CARD F15.

{Are/Is} { you/subject's name} a CITIZEN of the United States?
Card F15
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, US. citizen by naturalization
5. No, not a citizen of the United States
CITIZEN
(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) Don't know


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

FSD.006

Is {subject's name} now attending Head Start?
HEADST
(1) Yes (FSD.010)
(2) No (FSD.007)
(7) Refused (FSD.007)
(9) Don't know (FSD.007)

FSD.007

Has {subject's name} ever attended Head Start?
HEADSTEV
(1) Yes
(2) No
(7) Refused
(9) Don't know


FSD.010

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 F16.
Card F16
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. 10thgrade
11. 11thgrade
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)
EDUC
(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

[p. 52]


FSD.041

{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
MILTRYDS
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


Check item FSDCCI2 : Go through all non-deleted family members, If AGE greater than or = 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).

FSD.050

Which of the following {were/was} {you/subject's name} doing LAST WEEK?
DOINGLW
(1) Working at a job or business (FSD.070)
(2) With a job or business but not at work (FSD.060)
(3) Looking for work (FSD.060)
(4) Not working at a job or business (FSD.090)
(7) Refused (FSD.060)
(9) Don't know (FSD.060)

FSD.060

Did {you/subject's name} do any work at a job or business at all LAST WEEK (includes unpaid work in family farm or business)?
WRKLW
(1) Yes (FSD.070)
(2) No (If FSD.050=3 Go to FSD.100; Else FSD.090)
(7) Refused (FSD.100)
(9) Don't know (FSD.100)


FSD.070

How many hours did {you/subject's name} work LAST WEEK at ALL jobs or businesses?
WRKHRS
Hours: _______
(01-34) 1-34 hours (FSD.080)
(35-95) 35-95 hours (FSD.110)
(97) Refused (FSD.080)
(99) Don't know (FSD.080)


FSD.080

{Do/Does} {you/subject's name} USUALLY work 35 hours or more per week in total at ALL jobs or businesses?
WRKFTALL
(1) Yes
(2) No
(7) Refused
(9) Don't know

(Go to FSD.110)
[p. 53]

FSD.090

[If FSD.050 = 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?
WHYNOWRK
(1) Taking care of house or family
(2) Going to school
(3) Retired
(4) Unable to work for health reasons
(5) On layoff
(6) Disabled
(7) Refused
(9) Don't know

FSD.100

[If FSD.060 = 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}?
WRKLYR
(1) Yes (FSD.110)
(2) No (Check item FSDCCI3)
(7) Refused (Check item FSDCCI3)
(9) Don't know (Check item FSDCCI3)

FSD.110

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).
WRKMYR
(01-12) 1-12 months
(97)Refused
(99) Don't know


FSD.120

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.
ERNYR
(000001-999994) 1-999994 dollars
(999995) $999,995+
(999997) Refused
(999999) Don't know

Check item FSDCCI3: If FSD.050 = 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).
[p. 54]


FSD.130

Was health insurance offered to {you/subject's name} through {your/his/her} workplace?
HIEMPOF
(1) Yes
(2) No
(7) Refused
(9) Don't know

(Go to next section--Income and Assets)
[p. 55]


Section VII -- INCOME AND ASSETS

Part A -- Sources of Income

INTROINC
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}.
FIN.010

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?
FCINC
(1) Yes (FIN.030)
(2) No (FIN.011)
(7) Refused (FIN.011)
(9) Don't know (FIN.011)

FIN.011

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

FIN.012

Is anyone that you just mentioned available now to answer questions about finances?
FINAVAIL
(1) Yes (FIN.013)
(2) No (Check item FINCCI1)
(7) Refused (Check item FINCCI1)
(9) Don't know (Check item FINCCI1)

FIN.013

Person number of respondent for detailed income questions.
PNINDT
[Enter person #s]

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

FIN.030

[If FINAVAIL = (2), ask:]
Since no one else is available to answer these questions, we can just continue. Just give the best answers you can.

[If one person family, ask:]
Did you receive income in {last year in 4 digit format} from... Wages and Salaries?

[else, ask:]
Did any family members 18 and older, that is (READ NAMES), receive income in {last year in 4 digit format} from... Wages and Salaries?
FSAL
(1) Yes (FIN.040)
(2) No (FIN.050)
(7) Refused (FIN.050)
(9) Don't know (FIN.050)

FIN.040

Who received this? (Anyone else?)
PSAL
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FIN.050

[If one person family, ask:]
Did you receive income in {last year in 4 digit format} from... self-employment including business and farm income?

[else, ask:]
Did any family member 18 and older, that is (FR: READ NAMES AGAIN IF NECESSARY) receive income in {last year} from ... self-employment including business and farm income?
FSEINC
(1) Yes (FIN.060)
(2) No (FIN.070)
(7) Refused (FIN.070)
(9) Don't know (FIN.070)

FIN.060

Who received this? (Anyone else?)
PSEINC
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FIN.070

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.
FSSRR
(1) Yes (FIN.080)
(2) No (FIN.090)
(7) Refused (FIN.090)
(9) Don't know (FIN.090)

FIN.080

Who received this? (Anyone else?)
PSSRR
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

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

FIN.082

Was {your/any family member's} (READ NAMES BELOW); Social Security or Railroad Retirement income received as a disability benefit?
FSSRRD
(1) Yes (FIN.084)
(2) No (FIN.090)
(7) Refused (FIN.090)
(9) Don't know (FIN.090)

FIN.084

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?)
PSSRRDB
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FIN.086

Did {you/subject's name listed in FIN.084/PSSRRDB} receive this benefit because {you are/he is/she is}is disabled?
PSSRRD
(1) Yes
(2) No
(7) Refused
(9) Don't know


FIN.090

Did {you/any family members living here} receive income from...any disability pension {other than Social Security or Railroad Retirement}?
FPENS
(1) Yes (FIN.100)
(2) No (FIN.102)
(7) Refused (FIN.102)
(9) Don't know (FIN.102)

FIN.100

Who received this? (Anyone else?)
PPENS
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FIN.102

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)?
FOPENS
(1) Yes (FIN.104)
(2) No (FIN.110)
(7) Refused (FIN.110)
(9) Don't know (FIN.110)

FIN.104

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

Who received this? (Anyone else?)
POPENS
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

[p. 58]


FIN.110

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.
FSSI
(1) Yes (FIN.120)
(2) No (FIN.150)
(7) Refused (FIN.150)
(9) Don't know (FIN.150)

FIN.120

Who in the family received this? (Anyone else?)
PSSI
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FIN.122

Did {you/subject's name listed in FIN.120/PSSI} receive SSI because {you/he/she} {have/has} a disability?
PSSID
(1) Yes
(2) No
(7) Refused
(9) Don't know


FIN.150

At any time during {last year in 4 digit format}, even for one month, did {you/any family member living here} receive any government payments because your income was low, such as welfare, public assistance, AFDC, or some other program?
FTANF
(1) Yes (FIN.160)
(2) No (FIN.170)
(7) Refused (FIN.170)
(9) Don't know (FIN.170)

FIN.160

Who in the family received this? (Anyone else?)
PTANF
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FIN.164

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?
FOWEN
(1) Yes (FIN.166)
(2) No (FIN.170)
(7) Refused (FIN.170)
(9) Don't know (FIN.170)

FIN.166

Who received this? (Anyone else?)
POWEN
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

[p. 59]


FIN.170

Did {you/anyone in the family} receive interest from savings or other bank accounts?
FINTRST
(1) Yes (FIN.180)
(2) No (FIN.190)
(7) Refused (FIN.190)
(9) Don't know (FIN.190)

FIN.180

Who received this? (Anyone else?)
PINTRST
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FIN.190

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?
FDIVD
(1) Yes (FIN.200)
(2) No (FIN.210)
(7) Refused (FIN.210)
(9) Don't know (FIN.210)

FIN.200

Who received this? (Anyone else?)
PDIVD
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FIN.210

Did {you/anyone in the family} receive income from... child support?
FCHLDSP
(1) Yes (FIN.200)
(2) No (FIN.230)
(7) Refused (FIN.230)
(9) Don't know (FIN.230)

FIN.220

Who received this? (Anyone else?)
PCHLDSP
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]


FIN.230

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?
FINCOT
(1) Yes (FIN.240)
(2) No (FIN.250)
(7) Refused (FIN.250)
(9) Don't know (FIN.250)

FIN.240

Who received this? (Anyone else?)
PINCOT
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

[p. 60]

Part B -- Amounts and Home Ownership


FIN.250

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.
FAMINC
(0-999995) 0-999,995 dollars (FIN.280)
(999996) 999,995+ dollars (FIN.280)
(999997) Refused (FIN.260)
(999999) Don't know (FIN.260)

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
FINC20
(1) $20,000 or more (FIN.270)
(2) Less than $20,000 (FIN.270)
(7) Refused (FIN.280)
(9) Don't know (FIN.280)

FR: IF ANSWER FOR FIN.260 = 1, SHOW CARD F18.
IF ANSWER FOR FIN.260 = 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.
Card F18
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
Card F19
A. Less than $1,000
B. $1,000 - $1,999
C. $2,000 - $2,999
D. $3,000 - $3,999
E. $4,000 - $4,999
F. $5,000 - $5,999
G. $6,000 - $6,999
H. $7,000 - $7,999
I. $8,000 - $8,999
J. $9,000 - $9,999
K. $10,000 - $10,999
L. $11,000 - $11,999
M. $12,000 - $12,999
N. $13,000 - $13,999
O. $14,000 - $14,999
P. $15,000 - $15,999
Q. $16,000 - $16,999
R. $17,000 - $17,999
S. $18,000 - $18,999
T. $19,000 - $19,999

FIN.270

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}?
FINCCAT
(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) Don't know


FIN.280

Is this house/apartment owned, being bought, rented or occupied by some other arrangement by {you/someone in the family}?
HOUSEOWN
(1) Owned or being bought (FIN.300)
(2) Rented (FIN.282)
(3) Other arrangement (FIN.300)
(7) Refused (FIN.300)
(9) Don't know (FIN.300)

[p. 61]


FIN.282

{Are/Is} {you/anyone in your family} paying lower rent because the Federal, State, or local government is paying part of the cost?
FGAH
(1) Yes
(2) No
(7) Refused
(9) Don't know

[p. 62]

Part C -- Program Participation


FIN.300

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.
FSSAPL
(1) Yes (FIN.310)
(2) No (FIN.330)
(7) Refused (FIN.330)
(9) Don't know (FIN.330)

FIN.310

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


FIN.330

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.
FSDAPL
(1) Yes (FIN.340)
(2) No (Check Item FINCCI3)
(7) Refused (Check Item FINCCI3)
(9) Don't know (Check Item FINCCI3)

FIN.340

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

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

FIN.350

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

FR: IF LESS THAN 1 MONTH, ENTER (1).
TANFMYR
(01-11) 1-11 months
(12) 12 months or all
(97) Refused
(99) Don't know


FIN.360

{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
FFSTIP
(1) Yes (single person family FIN.380; else FIN.370)
(2) No (next questionnaire)
(7) Refused (next questionnaire)
(9) Don't know (next questionnaire)

FIN.370

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

[p. 63]


FIN.380

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).
FSTPMYR
(01-11) 1-11 months
(12)12 months or all
(97) Refused
(99) Don't know


FIN.384

At any time during {last year in 4 digit format} did {you/anyone in the family} receive benefits from the WIC program, that is, the Women, Infants, and Children program?
FINWIC
(1) Yes (single person family go to next question; Else FIN.385)
(2) No (Go to next questionnaire)
(7) Refused (Go to next questionnaire)
(9) Don't know (Go to next questionnaire)

FIN.385

Who in your family received this? (Anyone else?)
PWIC
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

(Go to next questionnaire)