fam
[p.1]

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

[Questions FID.020--FID.090 asked only of multi-family households. Single family households begin at FID.100.]

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?

[Else]
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 with Family section. (FID.045)
(2) No, arrange a callback (FID.035)

FID.035

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

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

ARRANGE1

(A) Anyday/anytime
(N) Callback before closeout is not possible
(7) Refused
(9) Don't Know

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

[p.2]

FID.040

FAMNON1

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

(Go to Check Item FIDCCI1)

FID.045

RELRESP1

FR: ENTER THE LINE NUMBER OF THE PERSON YOU ARE SPEAKING TO.
[Enter Person #] [ ]
[If RELRESP1 is 14-17 years old]

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

FR:{RELRESP1=s name} 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)

[If FAMREF_A = 2]

FAMREF_B

Enter line number of family reference person: [ ]

[If FAMREF_B is 14 to 17 years old display]
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)

[p. 3]

FID.060

FR: SHOW CARD H3.

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
12. Other relative
13. Housemate/Roommate
14. Roomer/Boarder
15. Other nonrelative
16. Legal Guardian
17. Ward

FRRP

(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) House-mate / Roommate
(14) Roomer/Boarder
(15) Other nonrelative
(16) Legal guardian
(17) Ward
(97) Refused
(99) Don't know

(Go to Check Item FIDCCI2)

[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_CK

(1) Yes, they are relatives, select relationship again
(2) No, they are not relatives

[If FRPREL_CK = 2, Set those people with FRPREL = 13-15 to be 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 (natural){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 the age difference between the parent and child is less than 12, go to FID.075. If there are no more persons, go to FID.100; Else go to FID.060 for the next person in the family.]

FID.075

[If age difference gt (0)]
You said that {you/PX-name} {are/is} {Family Reference Person name}=s biological {mother/father}.
There are only {1-11} years age difference between {you/them}. Is this relationship correct?

[If age difference eq (0)]
You said that {you/PX-name} {are/is} {Family Reference Person name}=s biological {mother/father}.
However, {you and Family Reference Person-name} are the same age. Is this relationship correct?

[If age difference lt (0)]
You said that {you/PX-name} {are/is} {Family Reference Person name}=s biological {mother/father}.
However, {you/PX-name} {are/is} {1-11} years younger than {Family Reference Person name}. 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 (natural) {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 the age difference between the parent and child is less than 12, go to FID.085. If there are no more persons, go to FID.100; Else go to FID.060 for the next person in the family.]

FID.085

BIOCKF2

(1) Yes, continue the interview (FID.060)
(2) No, change the relationship (FID.080)

FID.090

Is {PX-name} {Family 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/FRRP = {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

I have recorded that
Line # Name
are the spouses or unmarried partners of {Family Reference Person Name/You}
Which one is correct?

FSPOUSCK

(01-30) 1-30
(7) Refused
(9) Don't know

[p. 6]

Check Item FIDCCI1B: Roster begin PERSONS. If the person has incorrect relationship, go to FID.092. Else, go to next person with incorrect relationship. At end, go to FID.100.

FID.092

FR: SHOW CARD H3.

What is {PX-name=s/your} relationship to {Family Reference Person Name/You}?

Card H3

FRPELCK [equiv. FRRP]

(4) Child (biological/adoptive/in-law/step/foster)
(5) Child of partner
(6) Grandchildren
(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 (FID.093)
(14) Roomer/Boarder (FID.093)
(15) Other nonrelative (FID.093)
(16) Legal guardian
(17) Ward

(Go to Check item FIDCCI1B)

FID.093

Is {PX-name} a relative of {Family Reference Person-name]?

FRPREL_2

(1) Yes, they are relatives, select relationships again (FID.092)
(2) No, they are not relatives (Check item FIDCCI1B)

FID.100

I have recorded that {your name is/{fill alias} is} {fill full name}, age is {fill age}, date-of-birth is {fill birthdate}, {his/her} national origin is {fill Hispanic origin}, and {his/her} is {fill race}.
Is this information correct?

HHCHANGE

(1) Yes, Information is correct (Check Item FIDCCI3)
(2) No, Correction(s) needed/ more corrections needed (FID.110)

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

[p. 7]

Check item CHG_LOOP: If CWHAT__1 = (X), go to FID.112; If CWHAT__2 = (X), go to FID.125; If CWHAT__3 = (X), go to FID.180; If CWHAT__4 = (X), go to FID.190; If CWHAT__5 = (X), go to FID.220; If CWHAT2 = (M), go to FID.110 for next person; 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.112

What is {your/name=s} 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.

CHG_NAM1 [equiv NAME_FNA] FIRST NAME: ____________________
CHG_NAM2 [equiv NAME_MNA] MIDDLE NAME: _________________
CHG_NAM3 [equiv NAME_LNA] LAST NAME: ____________________

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

FID.115

How shall I refer to this person for the rest of the interview?

CHG_ALIAS [equiv ALIAS] _____________________________________

(Go to CHG_LOOP)

[p. 8]

FID.125

What is {name/your} 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: ______________________

Check item CHG_AGECAL1: C_AGE1 takes information entered in CHG_AG01 and CHG_AG02 and calculates an age. If age can not be calculated, set C_AGE1 =AD@
C_AGE2 takes the date-of birth information entered in FID.125 and calculates an age. If age can not be calculated, set C_AGE2 =AD@
C_AGE3 = current year - birth year -1, C_AGE4 = C_AGE3 + 1. If not enough DOB information was given to calculate an age,AD@will be assigned to C_AGE2.

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, orAD@if an age could not be calculated.
If C_AGE1 =AD@ and C_AGE2 not =AD@, set AGE = C_AGE2, go to Check item CHG_LOOP
If C_AGE1 =AD@and C_AGE2 =AD@, and C_AGE3 = blank, go to FID.145
If C_AGE1 =AD@and C_AGE2 =AD@, and C_AGE3 not = blank, go to FID.140
If C_AGE1 not =AD@ and C_AGE2 not =AD@, and C_AGE1 = C_AGE2, go to Check item CHG_LOOP
If C_AGE1 not =AD@and C_AGE2 not =AD@, and C_AGE1 not = C_AGE2, and CHG_DOBV = (), go to FID.130
If C_AGE1 not =AD@ and C_AGE2 not =AD@, and C_AGE1 not = C_AGE2, and CHG_DOBV not = (), set AGE = C_AGE2, go to Check item CHG_LOOP
If C_AGE1 not =AD@and C_AGE2 =AD, and (C_AGE1 = C_AGE3 or C_AGE1 = C_AGE4); set AGE = C_AGE1; go to Check item CHG_LOOP
If C_AGE1 not = C_AGE3 and C_AGE1 not = C_AGE4 and birth year = blank, go to FID.140
If C_AGE1 not = C_AGE3 and C_AGE1 not = C_AGE4 and birth year not = (); set AGE = C_AGE1, go to Check item CHG_LOOP.

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}/{BDAY/BYEAR}. Is that {your/name=s} correct date-of-birth?

CHG_DOBV [equiv DOBVER]

(1) Yes (Check item CHG_LOOP)
(2) No (FID.135)
(7) Refused(Check item CHG_LOOP)
(9) Don't know(Check item CHG_LOOP)

FID.135

What is {your/name=s} correct 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_DOB1 [equiv DOB_M] MONTH: ____________
CHG_DOB2 [equiv DOB_BDAY] DAY:____________
CHG_DOB3 [equiv DOB_Y_P] YEAR: ____________

[If valid birthdate is given, update AGE accordingly. If (D) is given for the birthdate, go to FID.145. If (R) is given for the birthdate, go to FID.150]

FID.140

[If Respondent]
Are you

[Else]
Would you say {name} is

CHG_AG06 [equiv AGEPIC]

(1) [fill C_AGE3/message] year(s) old? (Check item CHG_LOOP)
(2) [fill C_AGE4] year(s) old? (Check item CHG_LOOP)
(N) Neither is correct (FID.145)
(7) Refused (FID.145)
(9) Don't Know (FID.145)

[If answer is 1 or 2 update AGE accordingly; go to CHG_LOOP.]

FID.145

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.

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

CHG_AG07 [equiv AGEGES11]

[ ] Number

CHG_AG08 [equiv AGEGES12]

[ ] Time Period

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

Check item:[If CHG_AG08 is 3 then AGE = (CHG_AG07/12);
If CHG_AG08 is 4 then AGE = (CHG_AG07). Go to Check item CHG_LOOP.
If birth year is unknown; set BYY1 = (current year-AGE-1) and BYY2 = (current year-AGE) go to FID.170;

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:___________ (Enter age 0 to 17)

(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
(0-120) 0-120

CHG_AG12 [equiv AGERNG_3]

[ ] Time Period _________________
(03-04) 3-4
(3) Month(s)
(4) Year(s)

Last/higher

CHG_AG11 [equiv AGERNG_2]

[ ] Number ____________________
(0-120) 0-120

CHG_AG13 [equiv AGERNG_4]

[ ] Time Period
(03-04) 3-4
(3) Month(s)
(4) Year(s)

(Go to CHG_LOOP)

[Convert AGERNG_1 and AGERNG_2 into year, set AGE = (AGERNG_1 + AGERNG_2)/2]

FID.170

Would you say that {name} was born in:

CHG_YEAR [equiv YEARPIC]

(1) [fill BYY1]
(2) [fill BYY2]
(7) Refused
(9) Don't Know
(N) Neither is correct

(Go to CHG_LOOP)

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)

[p. 12]

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 did {your/name=s} ancestors come from?)

Card H1
You may choose more than one.

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_NATOR [equiv ORIGIN]

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

(Go to 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 CHG_NATOR/FID.190 AND CHANGE THE ANSWER FROM "YES" TO "NO". ENTER EACH NUMBER THAT APPLIES. ENTER (N) FOR NO MORE.

Card H1
You may choose more than one.

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

(01) Puerto Rican
(02) Cuban/Cuban American
(03) Dominican
(04) Mexican
(05) Mexican American
(06) Central or South America
(07) Other Latin American
(08) Other Hispanic/Latino
(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 = (07) go to FID.210; Else if FID.200 = (08) go to FID.215; 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 THE OTHER LATIN AMERICAN

CHG_HIS6 [equiv HIS_SP2] _________________________________

(Go to FID.200)

FID.215

CHG_HIS7 [equiv HIS_SP3] _____________________________________

(Go to FID.200)

[p. 14]

FID.220

FR: SHOW CARD H2

What race or races {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
You may choose more than one.

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

(01) White
(02) Black/African American
(03) Indian (American)
(04) Alaska Native
(05) Native Hawaiian
(06) Guamanian
(07) Samoan
(08) Other Pacific Islander
(09) 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_RACE1 [ ] CHG_RACE2 [ ] CHG_RACE3 [ ] CHG_RACE4 [ ] CHG_RACE5

[Equiv RACE1 - RACE5]

[If FID.220 = (08) 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

FR: SPECIFY THE OTHER PACIFIC ISLANDER

CHG_RAC6 [equiv RACSPY1] Other Pacific Islander: ________________

(Go to FID.220)

[p. 15]

FID.232

CHG_RAC7 [equiv RACSPY2] Other Asian: ________________________

(Go to FID.220)

FID.234

CHG_RAC8 [equiv RACSPY3] 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?

[List all mentioned race in RACE1 to RACE5/FID.220.
Fill other specify descriptions if RACE1 to RACE5 = 15 or 16.]

CHG_MLTR [equiv MULTRAC]

(01-16) Race number

(Go to Check item CHG_LOOP)

Check item FIDCCI3:If a screened household and anyone in the household with ORIGIN = (1) (Hispanic Origin) or FID.220/RACE = (2) (Black), then continue the interview.
If a screened household with no one with ORIGIN = (1) or RACE = (2), then set outcome = (236) (screened out household)
For all persons in the family, if AGE ge (14) and FID.250 = ( ) (not pre-filled)go to FID.250; at end, go to Check Item FIDCCI4.

[p. 16]

FID.250

FR: ASK OR VERIFY.

(Are/Is} {you/PX-name} now married, widowed, divorced, separated, never married, or living with a partner?

MARITAL

(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)

FID.270

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

SPOUS2

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

(Go to Check Item FIDCCI4)

FID.280

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

COHAB1

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

[For FID.280, if FID.300 is not valid (blank), go to FID.300; Else go to 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)

[p. 17]

Check item FIDCCI4:If AGE(PX) ge (90) go to Check item 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 or {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 and 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?

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 and 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 are 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 is NO woman 11+ years older than PX, go to Check Item FIDCCI5;
Else go to FID.325.

[p. 18]

FID.325

FR: ASK OR VERIFY

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

FR: 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

______ Line number of Mother
(96) Legal Guardian (FID.360)
(00) Person not a household member (Check item FIDCCI5)
(01-30) Person number (FID.330)
(97) Refused (Check item FIDCCI5)
(99) Don't Know (Check item FIDCCI5)

FR: CHOOSE MOTHER OVER MOTHER-IN-LAW IF BOTH ARE PRESENT.

FID.330

{Are/Is} {you/she} {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 MOTHERCI, go to MOTHERC2; Else go to Check Item FIDCCI5.]

[If MOTHERC1 = 1 and if (AGE(MOTHER) - AGE(PX)) lt 12 display:]

You said that {name(MOTHER)} is the BIOLOGICAL MOTHER of {PX-name}. There is only less than 12 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 FATHER(PX) ne ( ) go to Check Item FIDCCI6. If there are NO man 11+ years older than PX go to Check Item FIDCCI6; Else go to FID.340.

[p. 19]

FID.340

FR: ASK OR VERIFY

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

FR: ENTER THE LINE NUMBER OF THE FATHER OR FATHER-IN-LAW. 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

______ Line number of Father
(96) Legal Guardian (FID.360)
(00) Person not a household member (Check Item FIDCCI6)
(01-30) Person number (FID.350)
(97) Refused (Check Item FIDCCI6)
(99) Don't Know (Check Item FIDCCI6)

FR: CHOOSE FATHER OVER FATHER-IN-LAW IF BOTH PRESENT

FID.350

{Are/Is} {you/he} {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 Father and child is less than 12 years at FATHERC1, go to FATHERC2; Else go to Check Item FIDCCI6.]

[If FATHERC1 = 1 and if (AGE(FATHER) - AGE(PX) lt 12, display:]

You said that {name(FATHER)} is the BIOLOGICAL FATHER of {PX-name}, there is less than 12 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)

FID.360

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

GUARD

____ Line number of Guardian
(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 adult present in the family. Go to SASEL.

Check item SASEL:
1. Sort all adults (AGE gt or equal to 18) of the same FX and NOT flagged AA@ or AD@ in descending age order C 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 AS@ 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 AA@ AD@ or AE@ in descending age order C 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.

FID.370

[If a sample adult was selected]

{Sample Adult name} IS SELECTED AS THE SAMPLE ADULT FOR FAMILY
{family number}.

[Else]
NO SAMPLE ADULT IS SELECTED FOR FAMILY {family number}

[If a sample child was selected]

{Sample Child name} IS SELECTED AS THE SAMPLE CHILD FOR THIS FAMILY.

[Else]
NO SAMPLE CHILD WAS SELECTED FOR THIS FAMILY.

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.

[Store X' in KNOW 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.]

[p. 21]

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 UP TO THREE PERSONS. 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.

[Store X= in KNOWSC for each person mentioned]

(Go to next section -- Family Health Status and Limitation)

[p. 22]

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

FHS.001

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

FINTRO

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). IF NO ENTER (N).

FR: ENTER LINE NUMBER(S) OF FAMILY MEMBERS LISTED BELOW THAT ARE CURRENTLY PRESENT. ENTER UP TO 10 NUMBERS. ENTER (N) FOR NO MORE.

[ ] FINTRO_1
[ ] FINTRO_2
[ ] FINTRO_3
[ ] FINTRO_4
[ ] FINTRO_5
[ ] FINTRO_6
[ ] FINTRO_7
[ ] FINTRO_8
[ ] FINTRO_9
[ ] FINTRO_10

FHS.002

FR: ASK IF NECESSARY:

With whom am I speaking?

ENTER THE LINE NUMBER OF THE PERSON YOU CONSIDER TO BE THE MAIN RESPONDENT FOR THIS FAMILY'S HEALTH QUESTIONS.

FAMRESP

[Enter Person #] [ ]

HLTH_BEG

FR: READ THE FOLLOWING INTRODUCTION:

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

(P) Proceed
(R) Refused

Check item FHSCCI1: If any family member is less than 5 years old, go to FHS.005; if any family member is greater than or equal to 5 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/Is (READ NAMES) 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
(2) No (FHS.050)
(7) Refused (FHS.050)
(9) Don't know (FHS.050)

FHS.010

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

Who is this? (Anyone else?)

PLAPLYLM

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

FHS.020

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

PLAPLYUN

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

FHS.050

Do any of the following family members, (READ NAMES) receive Special Educational or Early Intervention Services?

FSPEDEIS

(1) Yes
(2) No (FHS.070)
(7) Refused (FHS.070)
(9) Don't know (FHS.070)

If one person family AND FSPEDEIS eq (1); go to FHS.065

FHS.060

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

Who is this? (Anyone else?)

PSPEDEIS

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

FHS.065

{Do/Does} {you/subject's name} receive these services because of an emotional or behavioral problem?

PSPEDEM

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

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?

FR: DO NOT INCLUDE FAMILY MEMBERS UNDER 3 YEARS OLD.
IF AGE LESS THAN 3, GO TO FHS.210.

FLAADL

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

If one person family AND FLAADL eq (1); go to FHS.090

FHS.080

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

Who is this? (Anyone else?)

PLAADL

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

FHS.090

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

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

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?

FR: DO NOT INCLUDE FAMILY MEMBERS UNDER 18 YEARS OLD.
IF AGE LESS THAN 18, GO TO FHS.210.

FLAIADL

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

If one person family AND FLAIADL eq (1); go to FHS.170

FHS.160

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

Who is this? (Anyone else?)

PLAIADL

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

FHS.170

Does a physical, mental, or emotional problem NOW keep {you/anyone in the family/any of these family members} (READ NAMES) from working at a job or business?

FLAWKNOW

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

If one person family AND FLAWKNOW eq (1); go to FHS.190

[p. 25]

FHS.180

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

Who is this? (Anyone else?)

PLAWKNOW

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

FHS.190

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

FLAWKLIM

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

If one person family AND FLAWKLIM eq (1); go to FHS.210

FHS.200

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

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
(2) No (FHS.230)
(7) Refused (FHS.230)
(9) Don't know (FHS.230)

If one person family AND FLAWALK eq (1); go to FHS.230

FHS.220

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

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
(2) No (Check item FHSCCI2)
(7) Refused (Check item FHSCCI2)
(9) Don't know (Check item FHSCCI2)

If one person family AND FLAREMEM eq (1); go to FHSCCI2.

FHS.240

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

Who is this? (Anyone else?)

PLAREMEM

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

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/any family members} (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
(2) No (Check item FHSCCI3)
(7) Refused (Check item FHSCCI3
(9) Don't know (Check item FHSCCI3)

If one person family AND FLIMANY eq (1); gotoFHSCCI3

FHS.260

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

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.350. If none with entry in FHS.010 through FHS.260, or the family roster is exhausted go to FHS.500.

FHS.270

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

FR: SHOW FLASHCARD F1. DO NOT READ. MARK ALL THAT APPLY, BUT DO NOT PROBE. ENTER (N) FOR NO MORE.

Card F1
You may choose more than one.

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 or seizures
12. Learning disability
13. Attention deficit/Hyperactivity disorder (ADD/ADHD)
Other impairment/problem

LAHCC1 (1) Vision / problem seeing
LAHCC2 (2) Hearing problem
LAHCC3 (3) Speech problem
LAHCC4 (4) Asthma / breathing problem
LAHCC5 (5) Birth defect
LAHCC6 (6) Injury
LAHCC7 (7) Mental retardation
LAHCC8 (8) Other developmental problem (e.g. cerebral palsy)
LAHCC9 (9) Other mental, emotional, or behavioral problem
LAHCC10 (10) Bone, joint, or muscle problem
LAHCC11 (11) Epilepsy or seizures
LAHCC12 (12) Learning disability
LAHCC13 (13) Attention deficit/Hyperactivity disorder (ADD/ADHD)
LAHCC14 (14) Other impairment (specify one) (LAHCC@S1)
LAHCC15 (15) Other impairment (specify one) (LAHCC@S2)

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

LAHCC@S1 Condition: __________________________________________

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

LAHCC@S2 Condition: __________________________________________

FHS.280

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

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD.

LCTIME#

[ ] NUMBER(ENTER "96" IF SINCE BIRTH)

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know

LCUNIT#

[ ] 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]

[p. 28]

FHS.290

What condition or health problem causes {subject's name} limitations?

FR: SHOW FLASHCARD F2. DO NOT READ. MARK ALL THAT APPLY, BUT DO NOT PROBE. ENTER (N) FOR NO MORE.

Card F2
You may choose more than one.

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 (e.g., asthma and emphysema)
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
Other impairment/problem

LAHCA1 (1) Vision/ problem seeing
LAHCA2 (2) Hearing problem
LAHCA3 (3) Arthritis / rheumatism
LAHCA4 (4) Back or neck problem
LAHCA5 (5) Fracture, bone / joint injury
LAHCA6 (6) Other injury
LAHCA7 (7) Heart problem
LAHCA8 (8) Stroke problem
LAHCA9 (9) Hypertension / high blood pressure
LAHCA10 (10) Diabetes
LAHCA11 (11) Lung / breathing problem (e.g. asthma and emphysema)
LAHCA12 (12) Cancer
LAHCA13 (13) Birth defect
LAHCA14 (14) Mental retardation
LAHCA15 (15) Other developmental problem (e.g. cerebral palsy)
LAHCA16 (16) Senility
LAHCA17 (17) Depression / anxiety / emotional problem
LAHCA18 (18) Weight problem

(M) More conditions
(97) Refused
(99) Don't know/not sure

FHS.290

(What condition or health problem causes your limitations?)

FR: MARK ALL THAT APPLY, BUT DO NOT PROBE. ENTER (N) FOR NO MORE

(19) Missing limbs (fingers, toes or digits), amputee
(20) Kidney, bladder or renal problems
(21) Circulation problems (including blood clots)
(22) Benign tumors, cysts
(23) Fibromyalgia, lupus
(24) Osteoporosis, tendonitis
(25) Epilepsy, seizures
(26) Multiple sclerosis (MS), Muscular Dystrophy (MD)
(27) Polio (myelitis), paralysis, para/quadriplegia
(28) Parkinson's disease, other tremors
(29) Other nerve damage, including carpal tunnel syndrome
(30) Hernia
(31) Ulcer
(32) Varicose veins, hemorrhoids
(33) Thyroid problems, Graves disease, gout
(34) Knee problems (not arthritis (03), not joint injury (05)
(35) Migraine headaches (not just headaches)
(36) Other impairment/problem (Specify one) (LAHCA@S1)
(37) Other impairment/problem (Specify one) (LAHCA@S2)
(B) Back-up to previous screen

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

LAHCA@S1 Condition: __________________________________________

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

LAHCA@S2 Condition: __________________________________________

[p. 30]

FHS.300

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

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD.

LATIME#

[ ] NUMBER

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know

LAUNIT#

FHS.310

Ask this question for each member separately:
Would you say {your/subject name's} 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)

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

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

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

PDMED12M

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

FAU.030

DURING THE PAST 12 MONTHS, was there any time when {you/someone 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

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

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

PNMED12M

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

[p. 42]

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

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

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

[If HOSPNO gt 10]

FR: DO NOT READ.

{HOSPNO} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.

HOSPNO_M

(1) Make correction
(2) Proceed

[p. 43]

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 HPNITE gt 50]

FR: DO NOT READ.

{HPNITE} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.

HPNITE_M

(1) Make correction
(2) Proceed

FAU.115

FR: DO NOT READ:

[fill HPNITE_N} is less than the total number of times just reported that [fill F_DTEMPNAME] 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 [fill F_TEMPNAME] stayed in hospital (FAU.070)
(3) Proceed without correcting (Check item NEXT_HOSP)

Check item: NEXT_HOSP:Go back to HOSPNO/FAU.070 for next person listed in FAU.060. When no more people, go to FAU.120.

[p. 44]

Part C -- Health Care Contacts

FAU.120

FR: HAND CALENDER CARD

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.
During those 2 WEEKS, did {you/anyone in the family} receive care AT HOME from a nurse or other health care professional?

FHCHM2W

(1) Yes (FAU.130)
(2) No (FAU.150)
(7) Refused (FAU.150)
(9) Don't know (FAU.150)

FAU.130

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

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

[If PHCHMN2W gt 14]

FR: DO NOT READ.

{PHCHMN2W} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.

PHCHMN2W_M

(1) Make correction
(2) Proceed

FAU.150

During those 2 WEEKS, did {you/anyone in the family} get any medical advice or test results over the PHONE from a doctor, nurse, or other health care professional?
Do not include phone calls to make appointments, for billing questions or for prescription refills.

FHCPH2W

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

FAU.160

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

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

PHCPH2WR

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

FAU.170

During those 2 WEEKS, how many telephone calls
[If single person family] did you make?

[else]
were made about {subject's name}?

PHCHMN2W

(01-49) 1-49 calls
(50) 50+ calls
(97) Refused
(99) Don't know

[If PHCPHN2W gt 14]

FR: DO NOT READ.

{PHCPHN2W} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.

PHCPHN2W_M

(1) Make correction
(2) Proceed

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.)

FHCDV2W

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

FAU.190

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

Who received care? (Anyone else?)

PHCDV2W

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

[p. 46]

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

[If PHCDVN2W gt 14]

FR: DO NOT READ.

{PHCDVN2W} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.

PHCDVN2W_M

(1) Make correction
(2) Proceed

FAU.210

During the past 12 MONTHS did {you/any member of 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

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

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

P10DVYR

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

(Go to next section--Health Insurance)

[p. 47]

Section V -- HEALTH INSURANCE

FHI.050

FR: SHOW CARD F10.

The next questions are about health insurance.
{Are you/Is anyone} covered by any kind of 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 F10
You may choose more than one.

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 program
4. Medicare
5. Medi-Gap
6. Medicaid
7. Children's Health Insurance Program (CHIP/SCHIP)
8. Military health care/VA
9. TRICARE/CHAMPUS/CHAMP-VA
10. Indian Health Service
11. State-sponsored health plan
12. Other government program
13. Single service plan (e.g., dental, vision, prescriptions)
14. No coverage of any type
*EXCLUDE private plans that only provide extra cash while hospitalized.

FHICOV

(1) Yes (FHI.070)
(2) No
(7) Refused (FHI.075)
(9) Don't know (FHI.075)

If (2) mark HIKIND_N = (X) for all persons in family then go to FHI.075

FHI.070

What kind of health insurance or health care coverage {do/does} {you/subject 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: ENTER (N) FOR NO MORE ENTER EACH NUMBER THAT APPLIES. PLEASE REFER TO FLASHCARDS F10, AND F11 FOR YOUR STATE.

Card F10
You may choose more than one.

[ ] 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 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) TRICARE/CHAMPUS/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)
[ ] HIKINDN (14) No coverage of any type

(Anything else?)

[p. 48]

FHI.075

I have recorded {you/subject name} as being covered by: [refer to HIKIND/FHI.070 for appropriate fill]
Is this correct?

HICHANGE

(1) Yes (Check item FHICCI3)
(2) No (Go to FHI.070 and make corrections)
(7) Refused (Check item FHICCI3)
(9) Don't know (Check item FHICCI3)

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 Check item FHICCI35.
2. If the person in FHI.070 marked 4, go to Check item FHICCI35.
3. If the person in FHI.070 did not mark 4, go to Check item FHICCI4

Check item FHICCI35: If person with Medicare is the family respondent go to FHI.080; else go to FHI.090

FHI.080

Earlier I recorded that you are covered by Medicare. May I please see your Medicare card to determine the type of coverage and to record the Health Ins. Claim Number?

FR: ENTER THE NUMBERS AND LETTERS.

This number is needed to allow Medicare records of the centers for Medicare and Medicaid services 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: IF NECESSARY: THE PUBLIC HEALTH SERVICE ACT IS TITLE 42, UNITED STATES CODE, SECTION 242K.

MCNO_1
MCNO_2

Claim Number (only numbers):--
(any characters): -
(7) Refused
(9) Don't know

FHI.090

If person with Medicare coverage is not family respondent
Earlier I recorded that {subject name} is covered by Medicare. May I please see {subject name}'s Medicare card to determine the type of coverage?

[ELSE]

FR: FILL IN APPROPRIATE COVERAGE TYPE BELOW

MCPART

(1) Part A - Hospital Only (Check item FHICCI4)
(2) Part B - Medical Only (FHI.095)
(3) Both Part A and Part B (FHI.095)
(4) Card Not Available (FHI.095)
(7) Refused (FHI.095)
(9) Don't know (FHI.095)

FHI.095

{Are/Is} {you/subject name} enrolled in a Medicare Plus Choice plan or option?

MCCHOICE

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

FHI.100

FR: READ: DO YOU HAVE A HEALTH PLAN CARD OF SOMETHING WITH THE PLAN NAME ON IT?

{Are/Is} {you/subject 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 (FHI.110)
(2) No (FHI.114)
(7) Refused (FHI.114)
(9) Don't know (FHI.114)

FHI.110

[If MCHMO = 1]
What is the name of the HMO?

MCHMO_NA Name:

FHI.114

If {you/subject name} {need/needs} 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/his/her} Medicare insurance, {are/is} {you/subject 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

[p. 50]

Check item FHICCI4:(Medicaid Coverage) Loop through every non-deleted and non-Armed Forces family member roster. If the person in FHI.070 marked 6 then go to FHI.120; Else go to Check item FHICCI4.1.

FHI.120

FR: REFER TO FLASHCARD F11 FOR STATE MEDICAID NAMES
DO YOU HAVE A HEALTH PLAN CARD OF SOMETHING WITH THE PLAN NAME ON IT?

The next questions are about Medicaid coverage. In this State it is also called (state name). {You/subject 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 (FHI.130)
(3) Doctor is assigned (FHI.130)
(7) Refused (FHI.140)
(9) Don't know (FHI.140)

[If MACHMD eq (2)]

[flashcards assoicated with FHI.120]
Card F11-AL

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offer additionalnames for the public health insurance programsfor each State.

Alabama

Medicaid: Patient 1st; SOBRA; Maternity Care Program; Health Insurance Payment Program (HIPP)
CHIP: AL-Kids; ALL KIDS
State/Other: Children's Rehabilitation Service (CRS); Alabama Child Caring Plan, Alabama Health Insurance Plan (AHIP)

[p. 23]

Card F11-AK

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

Please find your State.

Alaska

Medicaid: Medical Assistance Program
CHIP: KidCare; AKChip
State/Other: Chronic and Acute Medical Assistance (CAMA); Health Care Program for Children with Special Health Care Needs (HCP-CSN); Alaska Comprehensive Health Insurance Association (ACHIA)

[p. 24]

Card F11-AZ

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

Please find your State.

Arizona

Medicaid: AHCCCS; Arizona Health Care Cost Containment System; Healthy Arizona
CHIP: KidsCare
State/Other: Medically Indigent-Medically Needy Program (MI/MN); Office for Children with Special Health Care Needs; Premium Sharing Program; Young Adults Transitional Insurance (YATI)

[p. 25]

Card F11-AR

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

Please find your State.

Arkansas

Medicaid: ConnectCare
CHIP: ARKids First; Child Health Insurance Program
State/Other: Arkansas Comprehensive Health Insurance Plan; Children's Medical Services

[p. 26]

Card F11-CA

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

Please find your State.

California

Medicaid: Medi-Cal
CHIP: Healthy Families Program (HFP)
State/Other: Access for Infants and Mothers(AIM); County Medical ServicesProgram (CMSP); Children'sServices (CCS); Major RiskMedical Insurance Program(MRMIP); Managed Risk MedicalInsurance Board; CARE HealthInsurance Premium PaymentProgram

[p. 27]

Card F11-CO

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

Please find your State.

Colorado

Medicaid: Primary Care Physician Program(PCPP); BabyCare/KidsCare
CHIP: Child Health Plan Plus (CHP+);Childrens Basic Health Plan
State/Other: Health Care Program forChildren with Special HealthCare Needs; CUHIP - ColoradoUninsurable Health InsurancePlan; CoverColorado; ColoradoIndigent Care Program (CICP)

[p. 28]

Card F11-CT

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

Please find your State.

Connecticut

Medicaid: Medical Assistance Program; HUSKY Part A
CHIP: The HUSKY Plan; HUSKY PLUS; HUSKY Part B
State/Other: General Assistance Medical Aid;Refugee Medical Assistance;Children with Special HealthCare Needs; Connecticut HealthReinsurance Association (HRA);Connecticut InsuranceAssistance Program for AIDSPatients (CIAPAP);State-Administered GeneralAssistance Medical Aid (SAGA)

[p. 29]

Card F11-DE

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

Please find your State.

Delaware

Medicaid: Diamond State Health Plan
CHIP: The Delaware Healthy Children Program (DHCP)
State/Other: Children with Special HealthCare Needs; Disabled Children's Program

[p. 30]

Card F11-DC

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

Please find your State.

District of Columbia

Medicaid: Medical Assistance
CHIP: DC Healthy Families
State/Other: Medical Charities Program; Health Services for Children with Special Needs

[p. 31]

Card F11-FL

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

Please find your State.

Florida

Medicaid: MediPass
CHIP: KidCare; MediKids; Florida Healthy Kids
State/Other: AIDS Insurance Continuation Program (AICP); Florida Comprehensive Health Insurance Plan; Children's Medical Services

[p. 32]

Card F11-GA

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

Please find your State.

Georgia

Medicaid: Georgia Better Health Care; Right from the Start (RSM)
CHIP: PeachCare for Kids
State/Other: Children's Medical Services; Indigent Care Trust Fund (ICTF)

[p. 33]

Card F11-HI

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

Please find your State.

Hawaii

Medicaid: Hawaii-QUEST
CHIP: Hawaii CHIP
State/Other: QUEST-Net; HCOBRA; Children with Special Health Needs

[p. 34]

Card F11-ID

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Idaho

Medicaid: Healthy Connections; Medical Assistance
CHIP: Children's Health Insurance Program
State/Other: Catastrophic Fund; Children's Special Health Program

[p. 35]

Card F11-IL

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Illinois

Medicaid: Medical Assistance; Healthy Start; Parent Assist; KidCare Assist
CHIP: KidCare Share; KidCare Premium
State/Other: Comprehensive Health Insurance Plan (ICHIP); Specialized Care for Children (DSCC); Kidcare Moms and Babies

[p. 36]

Card F11-IN

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Indiana

Medicaid: Hoosier Healthwise; Primestep; Risk Based Managed Care
CHIP: Hoosier Healthwise for Children; Children's Health Plan; Benefit Package C
State/Other: Children's Special Health Care Services; Indiana Comprehensive Health Insurance Association (ICHIA)

[p. 37]

Card F11-IA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Iowa

Medicaid: Medical Assistance; Health Insurance Premium Payment (HIPP); MediPASS; Iowa Plan
CHIP: Health and Well Kids in Iowa (HAWK-I)
State/Other: Children's Health Specialty Clinics; Iowa Comprehensive Health Association; AIDS/HIV Health Insurance Premium Payment

[p. 38]

Card F11-KS

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Kansas

Medicaid: HealthConnect; PrimeCare Kansas; KANBE Healthy
CHIP: HealthWave
State/Other: Medi-KAN; Services for Children with Special Health Care Needs (CSHSN); Kansas Uninsurable Health Insurance Plan; Kansas Health Insurance Association (KHIA)

[p. 39]

Card F11-KY

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Kentucky

Medicaid: Kentucky Patient Access and Care System (KenPAC)
CHIP: Kentucky Children's Health Insurance Program (KCHIP)
State/Other: HIV Health Insurance Assistance Program; Commission for Children with Special Health Care Needs; Kentucky Access

[p. 40]

Card F11-LA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Louisiana

Medicaid: CommunityCARE
CHIP: LACHIP
State/Other: Louisiana Health Plan; Children's Special Health Services; Louisiana Health Insurance Association

[p. 41]

Card F11-ME

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Maine

Medicaid: Medical Assistance; PrimeCare
CHIP: Cub Care
State/Other: Children with Special Health Care Needs Program (CSHNP)

[p. 42]

Card F11-MD

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Maryland

Medicaid: Medical Assistance Program; HealthChoice; REM Program
CHIP: Maryland Children's Health Program (MCHP)
State/Other: AIDS Insurance Assistance Program (MAIAP); Maryland Primary Care (MPC); Children's Medical Services (CMS)

[p. 43]

Card F11-MA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Massachusetts

Medicaid: MassHealth
CHIP: MassHealth
State/Other: Children's Medical Security Plan (CMSP); Commonhealth; Medical Security Plan (MSP); Special Kids/Special Care; Insurance Partnership; Family Assistance Plan

[p. 44]

Card F11-MI

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Michigan

Medicaid: Comprehensive Health Care Program (CHCP); Medical Assistance Program; Healthy Kids; MICHOICE
CHIP: MIChild Program
State/Other: Children's Special Health Care Services; Trust Fund for Children with Special Health Care Needs

[p. 45]

Card F11-MN

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Minnesota

Medicaid: Medical Assistance (MA); Prepaid Medical Assistance Program (PMAP) or PMAP+
CHIP: Children's Health Insurance Program
State/Other: Minnesota Care; Minnesota General Assistance Medical Care Program (GAMC); HIV/AIDS Insurance Continuation Program; Children with Special Health Care Needs (MCSHN); Minnesota Comprehensive Health Association (MCHA)

[p. 46]

Card F11-MS

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Mississippi

Medicaid: HealthMACS
CHIP: Mississippi Children's Health Insurance Program (CHIP); Title XXI
State/Other: Mississippi Comprehensive Health Insurance Risk Pool; Children with Special Health Care Needs

[p. 47]

Card F11-MO

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Missouri

Medicaid: Managed Care Plus (MC+); MCPlus; Sarah Lopez Waiver
CHIP: MC+ for Kids
State/Other: General Relief Medical Assistance; Children with Special Health Care Needs; Missouri Health Insurance Pool (MHIP)

[p. 48]

Card F11-MT

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Montana

Medicaid: Passport to Health
CHIP: Montana's CHIP
State/Other: Montana Comprehensive Health Insurance Association (MCHA); Health Insurance Continuum of Coverage Program (HICCP); Special Health Services

[p. 49]

Card F11-NE

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Nebraska

Medicaid: Medical Assistance Program; Nebraska Health Connection (NHC)
CHIP: Kids Connection
State/Other: Medically Handicapped Children's Program; Comprehensive Health Association

[p. 50]

Card F11-NV

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Nevada

Medicaid: Nevada Medicaid
CHIP: Nevada Check Up
State/Other: Family Health Services Bureau

[p. 51]

Card F11-NH

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New Hampshire

Medicaid: Medical Assistance Program; Healthy Kids Gold
CHIP: Healthy Kids Silver
State/Other: Bureau of Special Medical Services

[p. 52]

Card F11-NJ

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New Jersey

Medicaid: New Jersey Care 2000+; AIDS Community Care Alternatives (ACCAP)
CHIP: New Jersey Family Care
State/Other: Health Insurance Continuation Program (HICP); Special Child Adult and Early Intervention Services

[p. 53]

Card F11-NM

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New Mexico

Medicaid: SALUD!
CHIP: New MexiKids
State/Other: Comprehensive Health Insurance Pool; Insurance Assistance Program; Children's Medical Services

[p. 54]

Card F11-NY

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New York

Medicaid: Medical Assistance Program (MAP); The Partnership Plan
CHIP: Child Health Plus (CHPlus)
State/Other: Family Health Plus; Healthy New York; Physically Handicapped Children's Program; Children with Special Health Care Needs

[p. 55]

Card F11-NC

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

North Carolina

Medicaid: Carolina Access; Health Care Connection Access II
CHIP: NC CHIP Program; NC Health Choice for Children (NCHC)
State/Other: Children Special Health Services (CHS)

[p. 56]

Card F11-ND

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

North Dakota

Medicaid: Medical Services; North Dakota Access and Care Program (NoDAC)
CHIP: Healthy Steps Program
State/Other: Comprehensive Health Association of North Dakota; Children's Special Health Services

[p. 57]

Card F11-OH

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

Please find your State

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Ohio

Medicaid: PremierCare; Healthy Families, Healthy Start
CHIP: Healthy Start
State/Other: HIV Health Insurance Premium Payment Program; Hemophilia Insurance Pilot Program; Children with Medical Handicaps (BCMH)

[p. 58]

Card F11-OK

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Oklahoma

Medicaid: SoonerCare; Health Benefits Program
CHIP: Oklahoma CHIP, SCHIP
State/Other: Children with Special Health Care Needs; Oklahoma Health Insurance High Risk Pool

[p. 59]

Card F11-OR

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Oregon

Medicaid: Oregon Health Plan (OHP)
CHIP: Oregon CHIP
State/Other: CareAssist; Oregon Services for Children with Special Health Needs; Oregon Medical Insurance Pool; Family Health Insurance Assistance Program (FHIAP); Insurance Purchasing Cooperative

[p. 60]

Card F11-PA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Pennsylvania

Medicaid: Medical Assistance; Access Card; Family Care Network; HealthChoices
CHIP: Pa CHIP
State/Other: Division of Special Health Care Programs

[p. 61]

Card F11-RI

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Rhode Island

Medicaid: RIte Care; RI Medical Assistance; Katie Beckett
CHIP: RIte Care
State/Other: Subsidy for Health Insurance for Center-Based Child-Care Providers; Children with Special Health Care Needs; Rlte Share Premium Assistance Program

[p. 62]

Card F11-SC

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

South Carolina

Medicaid: Healthy Options Program (HOP); Physicians Enhanced Program (PEP); South Carolina Partners for Health Medicaid Insurance
CHIP: Partners for Healthy Children (PHC)
State/Other: South Carolina Health Insurance Pool; Children's Rehabilitative Services

[p. 63]

Card F11-SD

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

South Dakota

Medicaid: PRIME; Medical Assistance
CHIP: Children's Health Insurance Program (CHIP)
State/Other: Catastrophic County-Poor Relief Program (CCPR); Continuation of Health Insurance; Children's Special Health Services; Refugee Medical Assistance

[p. 64]

Card F11-TN

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Tennessee

Medicaid: TennCare; Medicaid
CHIP: TennCare for Children
State/Other: Children's Special Services (CSS); Tenncare Standard

[p. 65]

Card F11-TX

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Texas

Medicaid: State of Texas Access Reform (STAR); Star Plus
CHIP: Texas CHIP
State/Other: Texas Health Insurance Risk Pool; State Kid Insurance Program (SKIP); Children with Complex and Special Health Needs (CCSHCN)

[p. 66]

Card F11-UT

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Utah

Medicaid: Medicaid
CHIP: Children's Health Insurance Program
State/Other: Utah Medical Assistance Program (UMAP); Custody Medical Care Program; Premium Payment Program; Children with Special Health Care Needs; Comprehensive Health Insurance Pool

[p. 67]

Card F11-VT

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Vermont

Medicaid: Medicaid
CHIP: Dr. Dynasaur
State/Other: Vermont Health Access Plan (VHAP); HIV Insurance Continuation Program; Children with Special Health Care Needs

[p. 68]

Card F11-VA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Virginia

Medicaid: Virginia Medallion. Medallion II
CHIP: Children's Medical Security Insurance Plan (CMSIP); Family Access to Medical Insurance Security Plan (FAMIS)
State/Other: State and Local Hospitalization (SLH) Program; Children's Specialty Services

[p. 69]

Card F11-WA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Washington

Medicaid: Healthy Options; Basic Health Plus
CHIP: Children's Health Insurance Program
State/Other: Basic Health; State Medical; Children with Special Health Care Needs; Washington State Health Insurance Pool

[p. 70]

Card F11-WV

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

West Virginia

Medicaid: Medical Assistance; Mountain Health Trust (MHT); Physician Assured Access System (PAAS)
CHIP: Children's Health Insurance Program (CHIP)
State/Other: Children with Special Health Care Needs

[p. 71]

Card F11-WI

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Wisconsin

Medicaid: Medical Assistance MA; Wisconsin Medicaid; Healthy Start
CHIP: BadgerCare
State/Other: Health Insurance Risk Sharing Program (HIRSP); Wisconsin AIDS/HIV Health Insurance Premium Subsidy Program; Children with Special Health Care Needs

[p. 72]

Card F11-WY

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Wyoming

Medicaid: Wyoming Medicaid
CHIP: Wyoming Kid Care
State/Other: Wyoming Health Insurance Pool (WHIP); Children's Special Health Program (CSH); Caring Program for Children

FHI.130

FR: ASK or VERIFY:

What is the name of the health plan that provided the book or list?

MACHMD_1 ______________________

[If MACHMD eq (3)]

What is the name of the health plan that assigned the doctor?

MACHMD_2 ______________________

FHI.132

FR: WAS THE HEALTH PLAN NAME OBTAINED FROM A HEALTH PLAN CARD OR SOMETHING WITH THE HEALTH PLAN NAME ON IT?

[This question is only of the FR]

MANAM

(1) Yes
(2) No

FHI.140

{Are/Is} {you/subject 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} {were/was} referred to).

MAPCMD

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

FHI.150

If {you/subject 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

[p. 51]

Check item FHICCI4.1: (Single Service Coverage) Loop through every non-deleted and non-Armed Forces family member roster: If any person with Single Service plan (HIKIND_M/FHI.070 = (x)) then go to SSTYPE/FHI.156; Else go to Check item FHICCI5.

FHI.156

FR: SHOW CARD F12.

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

Card F12
You may choose more than one.

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
(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 (FHI.157)
(97) Refused
(99) Don't know

(Go to Check Item FHICCI5)

FHI.157

FR: SPECIFIED 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 program or community program.

[If more than 1 person has private insurance plan]

We have the following persons listed as being covered by such plans:

FR: READ NAMES.
FR: PRESS (P) TO PROCEED.

[p. 52]

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: READ IF NECESSARY:
DO YOU HAVE A HEALTH PLAN CARD OR SOMETHING WITH THE PLAN NAME ON IT?

HIPNAM_N Name: _____________________________

FHI.160.1

FR: DO NOT READ TO RESPONDENT:
WAS THE HEALTH PLAN NAME OBTAINED FROM A HEALTH PLAN CARD OR SOMETHING WITH THE HEALTH PLAN NAME ON IT?

PCARD1

(1) Yes
(2) No

FHI.170

Which family members are covered by that plan?

FR: MARK "X" ALL THAT APPLY.

HIPNAM_B

[Enter person #s]

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

FHI.171

FR: ASK IF NECESSARY:

Are there any more health insurance plans?
[fill HIPNAM_N]

MORPLAN

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

FHI.172

FR: READ IF NECESSARY: DO YOU HAVE A HEALTH PLAN CARD OR SOMETHING WITH THE PLAN NAME ON IT?

What is the name of the next plan?

NEXTPNM Name: _______________________

FHI.172.1

FR: DO NOT READ TO RESPONDENT:
WAS THE HEALTH PLAN NAME OBTAINED FROM A HEALTH PLAN CARD OR SOMETHING WITH THE HEALTH PLAN NAME ON IT?

PCARD2

(1) Yes
(2) No

FHI.173

Which family members are covered by that plan?

FR: MARK "X" ALL THAT APPLY.

NEXTPNM_B

[Enter person #s]

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

FHI.174

FR: ASK IF NECESSARY:

Are there any more health insurance plans in addition to those already mentioned?
[fill HIPNAM_N]
[fill NEXTPNM_N]

MORPLAN2

(1) Yes (FHI.175)
(2) No (Check Item FHCCI7)

FHI.175

FR: READ IF NECESSARY: DO YOU HAVE A HEALTH PLAN CARD OR SOMETHING WITH THE PLAN NAME ON IT?

What is the name of the next plan?

NEXTPNM2 Name: ____________________________

FHI.175.1

FR: DO NOT READ TO RESPONDENT: WAS THE HEALTH PLAN NAME OBTAINED FROM A HEALTH PLAN CARD OR SOMETHING WITH THE HEALTH PLAN NAME ON IT?

PCARD3

(1) Yes
(2) No

FHI.176

Which family members are covered by this plan?

FR: MARK "X" ALL THAT APPLY.

NEXTPNM2_B

[Enter person #s]

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

FHI.177

FR: ASK IF NECESSARY:

Are there any more health insurance plans in addition to those already mentioned?
[fill HIPNAM_N]
[fill NEXTPNM_N]
[fill NEXTPNM2_N]

MORPLAN3

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

FHI.178

FR: READ IF NECESSARY: DO YOU HAVE A HEALTH PLAN CARD OR SOMETHING WITH THE PLAN NAME ON IT?

What is the name of the next plan?

NEXTPNM3 Name: __________________________

FHI.178.1

FR: DO NOT READ TO RESPONDENT:
WAS THE HEALTH PLAN NAME OBTAINED FROM A HEALTH PLAN CARD OR SOMETHING WITH THE HEALTH PLAN NAME ON IT?

PCARD4

(1) Yes
(2) No

FHI.179

Which family members are covered by this plan?

FR: MARK "X" ALL THAT APPLY.

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 name} is listed as having private insurance but was not mentioned as being covered by any of the plans we just discussed. Is {subject 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 FHI.170: HIPNAM, NEXTPNM, NEXTPNM2.].

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

Check item FHICCI8:[If the first plan name (ie. from item HIPNAM/FHI.170)]
Now I am going to ask some questions about the {plan/plans} you just told me about, {starting with} [fill plan name].

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

FR: PRESS (P) TO PROCEED.

If anyone in the family has private health insurance, loop through all the private plans entered; [Else go to Check item FHICCI95]

[p. 55]

FHI.200

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 LINE NUMBER OF FAMILY MEMBER (FROM LIST BELOW). IN WHOSE NAME THIS PLAN IS HELD.

(0)Policyholder outside of family

FHI200

[Enter person #] [ ]

(97) Refused
(99) Don't know

FHI.210

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

FR: IF "YES" PROBE FOR 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. ENTER (N) FOR NO MORE. IF GOVERNMENT PROGRAM IS REPORTED, PROBE FOR MEDICARE OR MEDICAID OR CHIP/SCHIP 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) Children's Health Insurance Program (CHIP/SCHIP) (FHI.240)
(7) State or local government or community program (FHI.240)
(97) Refused (FHI.230)
(99) Don't know (FHI.230)

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

[p. 56]

FHI.230

How much {do you/does your family} currently spend for health insurance premiums for {plan name}? Please include payroll deductions for premiums.

HICOSTR1

[ ] NUMBER

(1-9,999) $1-$9,999
(99,997) Refused
(99,999) Don't know

HICOSTR2

[ ] TIME PERIOD

(1) Once a week
(2) Once every two weeks
(3) Once a month
(4) Twice a month
(5) Every 2 months
(6) Quarterly (Every 3 months)
(7) Once a year
(8) Twice a year
(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), fee-for-service, or indemnity or is it some other kind of plan?

PLNMGD

(1) HMO/IPA
(2) PPO
(3) POS
(4) Fee-for-service/indemnity
(5) 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/Does/Do 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

(Go to 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

[p. 57]

FHI.248

When you or a family member with this plan need to go to a different doctor or place for special care, do you or 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 FHICCI91: Loop through every non-deleted and non-Armed Forces family member roster. If HIKIND/FHI.070 = 7 go to FHI.250; Else go to Check item FHICCI92.

FHI.250

FR: SHOW CARD F11.

Earlier I recorded that {you/subject name} {are/is} covered by Children's Health Insurance Program (CHIP/SCHIP). What is the name of that plan?

FR: READ IF NECESSARY: DO YOU HAVE A HEALTH PLAN CARD OR SOMETHING WITH THE PLAN NAME ON IT?

STNAME1 Plan: _____________________________________

Check item FHICCI92: If HIKIND/FHI.070 = 11 go to FHI.251; Else go to Check item FHICCI93.

[flashcards associated with FHI.250]
Card F11-AL

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

Please find your State.

Alabama

[p. 23]

Card F11-AK

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

Please find your State.

Alaska

[p. 24]

Card F11-AZ

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

Please find your State.

Arizona

[p. 25]

Card F11-AR

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

Please find your State.

Arkansas

Medicaid: ConnectCare
CHIP: ARKids First; Child Health Insurance Program
State/Other: Arkansas Comprehensive Health Insurance Plan; Children's Medical Services

[p. 26]

Card F11-CA

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

Please find your State.

California

[p. 27]

Card F11-CO

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

Please find your State.

Colorado

[p. 28]

Card F11-CT

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

Please find your State.

Connecticut

[p. 29]

Card F11-DE

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

Please find your State.

Delaware

Medicaid: Diamond State Health Plan
CHIP: The Delaware Healthy Children Program (DHCP)
State/Other: Children with Special HealthCare Needs; Disabled Children's Program

[p. 30]

Card F11-DC

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

Please find your State.

District of Columbia

Medicaid: Medical Assistance
CHIP: DC Healthy Families
State/Other: Medical Charities Program; Health Services for Children with Special Needs

[p. 31]

Card F11-FL

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

Please find your State.

Florida

Medicaid: MediPass
CHIP: KidCare; MediKids; Florida Healthy Kids
State/Other: AIDS Insurance Continuation Program (AICP); Florida Comprehensive Health Insurance Plan; Children's Medical Services

[p. 32]

Card F11-GA

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

Please find your State.

Georgia

Medicaid: Georgia Better Health Care; Right from the Start (RSM)
CHIP: PeachCare for Kids
State/Other: Children's Medical Services; Indigent Care Trust Fund (ICTF)

[p. 33]

Card F11-HI

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

Please find your State.

Hawaii

Medicaid: Hawaii-QUEST
CHIP: Hawaii CHIP
State/Other: QUEST-Net; HCOBRA; Children with Special Health Needs

[p. 34]

Card F11-ID

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Idaho

Medicaid: Healthy Connections; Medical Assistance
CHIP: Children's Health Insurance Program
State/Other: Catastrophic Fund; Children's Special Health Program

[p. 35]

Card F11-IL

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Illinois

[p. 36]

Card F11-IN

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Indiana

[p. 37]

Card F11-IA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Iowa

[p. 38]

Card F11-KS

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Kansas

[p. 39]

Card F11-KY

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Kentucky

[p. 40]

Card F11-LA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Louisiana

Medicaid: CommunityCARE
CHIP: LACHIP
State/Other: Louisiana Health Plan; Children's Special Health Services; Louisiana Health Insurance Association

[p. 41]

Card F11-ME

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Maine

Medicaid: Medical Assistance; PrimeCare
CHIP: Cub Care
State/Other: Children with Special Health Care Needs Program (CSHNP)

[p. 42]

Card F11-MD

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Maryland

[p. 43]

Card F11-MA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Massachusetts

[p. 44]

Card F11-MI

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Michigan

[p. 45]

Card F11-MN

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Minnesota

[p. 46]

Card F11-MS

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Mississippi

Medicaid: HealthMACS
CHIP: Mississippi Children's Health Insurance Program (CHIP); Title XXI
State/Other: Mississippi Comprehensive Health Insurance Risk Pool; Children with Special Health Care Needs

[p. 47]

Card F11-MO

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Missouri

[p. 48]

Card F11-MT

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Montana

[p. 49]

Card F11-NE

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Nebraska

Medicaid: Medical Assistance Program; Nebraska Health Connection (NHC)
CHIP: Kids Connection
State/Other: Medically Handicapped Children's Program; Comprehensive Health Association

[p. 50]

Card F11-NV

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Nevada

Medicaid: Nevada Medicaid
CHIP: Nevada Check Up
State/Other: Family Health Services Bureau

[p. 51]

Card F11-NH

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New Hampshire

Medicaid: Medical Assistance Program; Healthy Kids Gold
CHIP: Healthy Kids Silver
State/Other: Bureau of Special Medical Services

[p. 52]

Card F11-NJ

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New Jersey

[p. 53]

Card F11-NM

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New Mexico

Medicaid: SALUD!
CHIP: New MexiKids
State/Other: Comprehensive Health Insurance Pool; Insurance Assistance Program; Children's Medical Services

[p. 54]

Card F11-NY

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New York

[p. 55]

Card F11-NC

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

North Carolina

Medicaid: Carolina Access; Health Care Connection Access II
CHIP: NC CHIP Program; NC Health Choice for Children (NCHC)
State/Other: Children Special Health Services (CHS)

[p. 56]

Card F11-ND

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

North Dakota

Medicaid: Medical Services; North Dakota Access and Care Program (NoDAC)
CHIP: Healthy Steps Program
State/Other: Comprehensive Health Association of North Dakota; Children's Special Health Services

[p. 57]

Card F11-OH

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

Please find your State

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Ohio

[p. 58]

Card F11-OK

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Oklahoma

Medicaid: SoonerCare; Health Benefits Program
CHIP: Oklahoma CHIP, SCHIP
State/Other: Children with Special Health Care Needs; Oklahoma Health Insurance High Risk Pool

[p. 59]

Card F11-OR

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Oregon

[p. 60]

Card F11-PA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Pennsylvania

Medicaid: Medical Assistance; Access Card; Family Care Network; HealthChoices
CHIP: Pa CHIP
State/Other: Division of Special Health Care Programs

[p. 61]

Card F11-RI

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Rhode Island

[p. 62]

Card F11-SC

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

South Carolina

[p. 63]

Card F11-SD

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

South Dakota

[p. 64]

Card F11-TN

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Tennessee

Medicaid: TennCare; Medicaid
CHIP: TennCare for Children
State/Other: Children's Special Services (CSS); Tenncare Standard

[p. 65]

Card F11-TX

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Texas

[p. 66]

Card F11-UT

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Utah

[p. 67]

Card F11-VT

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Vermont

Medicaid: Medicaid
CHIP: Dr. Dynasaur
State/Other: Vermont Health Access Plan (VHAP); HIV Insurance Continuation Program; Children with Special Health Care Needs

[p. 68]

Card F11-VA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Virginia

[p. 69]

Card F11-WA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Washington

[p. 70]

Card F11-WV

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

West Virginia

Medicaid: Medical Assistance; Mountain Health Trust (MHT); Physician Assured Access System (PAAS)
CHIP: Children's Health Insurance Program (CHIP)
State/Other: Children with Special Health Care Needs

[p. 71]

Card F11-WI

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Wisconsin

[p. 72]

Card F11-WY

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Wyoming

Medicaid: Wyoming Medicaid
CHIP: Wyoming Kid Care
State/Other: Wyoming Health Insurance Pool (WHIP); Children's Special Health Program (CSH); Caring Program for Children

FHI.251

FR: SHOW CARD F11.

Earlier I recorded that {you/subject name} {are/is} covered by a state-sponsored health plan. What is the name of that plan?

FR: READ IF NECESSARY: DO YOU HAVE A HEALTH PLAN CARD OR SOMETHING WITH THE PLAN NAME ON IT?

STNAME2 Plan: _____________________________________

Check item FHICCI93: If HIKIND/FHI.070 = 12 go to FHI.252; Else go to Check item FHICCI97.

[flashcards associated with FHI.251]
Card F11-AL

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

Please find your State.

Alabama

[p. 23]

Card F11-AK

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

Please find your State.

Alaska

[p. 24]

Card F11-AZ

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

Please find your State.

Arizona

[p. 25]

Card F11-AR

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

Please find your State.

Arkansas

Medicaid: ConnectCare
CHIP: ARKids First; Child Health Insurance Program
State/Other: Arkansas Comprehensive Health Insurance Plan; Children's Medical Services

[p. 26]

Card F11-CA

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

Please find your State.

California

[p. 27]

Card F11-CO

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

Please find your State.

Colorado

[p. 28]

Card F11-CT

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

Please find your State.

Connecticut

[p. 29]

Card F11-DE

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

Please find your State.

Delaware

Medicaid: Diamond State Health Plan
CHIP: The Delaware Healthy Children Program (DHCP)
State/Other: Children with Special HealthCare Needs; Disabled Children's Program

[p. 30]

Card F11-DC

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

Please find your State.

District of Columbia

Medicaid: Medical Assistance
CHIP: DC Healthy Families
State/Other: Medical Charities Program; Health Services for Children with Special Needs

[p. 31]

Card F11-FL

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

Please find your State.

Florida

Medicaid: MediPass
CHIP: KidCare; MediKids; Florida Healthy Kids
State/Other: AIDS Insurance Continuation Program (AICP); Florida Comprehensive Health Insurance Plan; Children's Medical Services

[p. 32]

Card F11-GA

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

Please find your State.

Georgia

Medicaid: Georgia Better Health Care; Right from the Start (RSM)
CHIP: PeachCare for Kids
State/Other: Children's Medical Services; Indigent Care Trust Fund (ICTF)

[p. 33]

Card F11-HI

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

Please find your State.

Hawaii

Medicaid: Hawaii-QUEST
CHIP: Hawaii CHIP
State/Other: QUEST-Net; HCOBRA; Children with Special Health Needs

[p. 34]

Card F11-ID

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Idaho

Medicaid: Healthy Connections; Medical Assistance
CHIP: Children's Health Insurance Program
State/Other: Catastrophic Fund; Children's Special Health Program

[p. 35]

Card F11-IL

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Illinois

[p. 36]

Card F11-IN

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Indiana

[p. 37]

Card F11-IA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Iowa

[p. 38]

Card F11-KS

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Kansas

[p. 39]

Card F11-KY

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Kentucky

[p. 40]

Card F11-LA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Louisiana

Medicaid: CommunityCARE
CHIP: LACHIP
State/Other: Louisiana Health Plan; Children's Special Health Services; Louisiana Health Insurance Association

[p. 41]

Card F11-ME

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Maine

Medicaid: Medical Assistance; PrimeCare
CHIP: Cub Care
State/Other: Children with Special Health Care Needs Program (CSHNP)

[p. 42]

Card F11-MD

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Maryland

[p. 43]

Card F11-MA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Massachusetts

[p. 44]

Card F11-MI

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Michigan

[p. 45]

Card F11-MN

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Minnesota

[p. 46]

Card F11-MS

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Mississippi

Medicaid: HealthMACS
CHIP: Mississippi Children's Health Insurance Program (CHIP); Title XXI
State/Other: Mississippi Comprehensive Health Insurance Risk Pool; Children with Special Health Care Needs

[p. 47]

Card F11-MO

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Missouri

[p. 48]

Card F11-MT

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Montana

[p. 49]

Card F11-NE

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Nebraska

Medicaid: Medical Assistance Program; Nebraska Health Connection (NHC)
CHIP: Kids Connection
State/Other: Medically Handicapped Children's Program; Comprehensive Health Association

[p. 50]

Card F11-NV

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Nevada

Medicaid: Nevada Medicaid
CHIP: Nevada Check Up
State/Other: Family Health Services Bureau

[p. 51]

Card F11-NH

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New Hampshire

Medicaid: Medical Assistance Program; Healthy Kids Gold
CHIP: Healthy Kids Silver
State/Other: Bureau of Special Medical Services

[p. 52]

Card F11-NJ

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New Jersey

[p. 53]

Card F11-NM

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New Mexico

Medicaid: SALUD!
CHIP: New MexiKids
State/Other: Comprehensive Health Insurance Pool; Insurance Assistance Program; Children's Medical Services

[p. 54]

Card F11-NY

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New York

[p. 55]

Card F11-NC

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

North Carolina

Medicaid: Carolina Access; Health Care Connection Access II
CHIP: NC CHIP Program; NC Health Choice for Children (NCHC)
State/Other: Children Special Health Services (CHS)

[p. 56]

Card F11-ND

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

North Dakota

Medicaid: Medical Services; North Dakota Access and Care Program (NoDAC)
CHIP: Healthy Steps Program
State/Other: Comprehensive Health Association of North Dakota; Children's Special Health Services

[p. 57]

Card F11-OH

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

Please find your State

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Ohio

[p. 58]

Card F11-OK

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Oklahoma

Medicaid: SoonerCare; Health Benefits Program
CHIP: Oklahoma CHIP, SCHIP
State/Other: Children with Special Health Care Needs; Oklahoma Health Insurance High Risk Pool

[p. 59]

Card F11-OR

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Oregon

[p. 60]

Card F11-PA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Pennsylvania

Medicaid: Medical Assistance; Access Card; Family Care Network; HealthChoices
CHIP: Pa CHIP
State/Other: Division of Special Health Care Programs

[p. 61]

Card F11-RI

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Rhode Island

[p. 62]

Card F11-SC

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

South Carolina

[p. 63]

Card F11-SD

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

South Dakota

[p. 64]

Card F11-TN

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Tennessee

Medicaid: TennCare; Medicaid
CHIP: TennCare for Children
State/Other: Children's Special Services (CSS); Tenncare Standard

[p. 65]

Card F11-TX

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Texas

[p. 66]

Card F11-UT

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Utah

[p. 67]

Card F11-VT

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Vermont

Medicaid: Medicaid
CHIP: Dr. Dynasaur
State/Other: Vermont Health Access Plan (VHAP); HIV Insurance Continuation Program; Children with Special Health Care Needs

[p. 68]

Card F11-VA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Virginia

[p. 69]

Card F11-WA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Washington

[p. 70]

Card F11-WV

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

West Virginia

Medicaid: Medical Assistance; Mountain Health Trust (MHT); Physician Assured Access System (PAAS)
CHIP: Children's Health Insurance Program (CHIP)
State/Other: Children with Special Health Care Needs

[p. 71]

Card F11-WI

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Wisconsin

[p. 72]

Card F11-WY

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Wyoming

Medicaid: Wyoming Medicaid
CHIP: Wyoming Kid Care
State/Other: Wyoming Health Insurance Pool (WHIP); Children's Special Health Program (CSH); Caring Program for Children

FHI.252

FR: SHOW CARD F11.

Earlier I recorded that {you/subject name} {are/is} covered by another Government program (other than Medicaid). What is the name of that plan?

FR: READ IF NECESSARY: DO YOU HAVE A HEALTH PLAN CARD OR SOMETHING WITH THE PLAN NAME ON IT?

STNAME3 Plan: _____________________________________

Check item FHICCI97: Loop through each non-deleted family member. If HIKIND/FHI.070 = 14 or only = to 13 then go to FHI.270; else go to FHI.300.

[Flashcards associated with FHI.252]
Card F11-AL

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

Please find your State.

Alabama

[p. 23]

Card F11-AK

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

Please find your State.

Alaska

[p. 24]

Card F11-AZ

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

Please find your State.

Arizona

[p. 25]

Card F11-AR

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

Please find your State.

Arkansas

Medicaid: ConnectCare
CHIP: ARKids First; Child Health Insurance Program
State/Other: Arkansas Comprehensive Health Insurance Plan; Children's Medical Services

[p. 26]

Card F11-CA

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

Please find your State.

California

[p. 27]

Card F11-CO

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

Please find your State.

Colorado

[p. 28]

Card F11-CT

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

Please find your State.

Connecticut

[p. 29]

Card F11-DE

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

Please find your State.

Delaware

Medicaid: Diamond State Health Plan
CHIP: The Delaware Healthy Children Program (DHCP)
State/Other: Children with Special HealthCare Needs; Disabled Children's Program

[p. 30]

Card F11-DC

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

Please find your State.

District of Columbia

Medicaid: Medical Assistance
CHIP: DC Healthy Families
State/Other: Medical Charities Program; Health Services for Children with Special Needs

[p. 31]

Card F11-FL

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

Please find your State.

Florida

Medicaid: MediPass
CHIP: KidCare; MediKids; Florida Healthy Kids
State/Other: AIDS Insurance Continuation Program (AICP); Florida Comprehensive Health Insurance Plan; Children's Medical Services

[p. 32]

Card F11-GA

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

Please find your State.

Georgia

Medicaid: Georgia Better Health Care; Right from the Start (RSM)
CHIP: PeachCare for Kids
State/Other: Children's Medical Services; Indigent Care Trust Fund (ICTF)

[p. 33]

Card F11-HI

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

Please find your State.

Hawaii

Medicaid: Hawaii-QUEST
CHIP: Hawaii CHIP
State/Other: QUEST-Net; HCOBRA; Children with Special Health Needs

[p. 34]

Card F11-ID

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Idaho

Medicaid: Healthy Connections; Medical Assistance
CHIP: Children's Health Insurance Program
State/Other: Catastrophic Fund; Children's Special Health Program

[p. 35]

Card F11-IL

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Illinois

[p. 36]

Card F11-IN

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Indiana

[p. 37]

Card F11-IA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Iowa

[p. 38]

Card F11-KS

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Kansas

[p. 39]

Card F11-KY

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Kentucky

[p. 40]

Card F11-LA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Louisiana

Medicaid: CommunityCARE
CHIP: LACHIP
State/Other: Louisiana Health Plan; Children's Special Health Services; Louisiana Health Insurance Association

[p. 41]

Card F11-ME

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Maine

Medicaid: Medical Assistance; PrimeCare
CHIP: Cub Care
State/Other: Children with Special Health Care Needs Program (CSHNP)

[p. 42]

Card F11-MD

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Maryland

[p. 43]

Card F11-MA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Massachusetts

[p. 44]

Card F11-MI

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Michigan

[p. 45]

Card F11-MN

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Minnesota

[p. 46]

Card F11-MS

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Mississippi

Medicaid: HealthMACS
CHIP: Mississippi Children's Health Insurance Program (CHIP); Title XXI
State/Other: Mississippi Comprehensive Health Insurance Risk Pool; Children with Special Health Care Needs

[p. 47]

Card F11-MO

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Missouri

[p. 48]

Card F11-MT

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Montana

[p. 49]

Card F11-NE

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Nebraska

Medicaid: Medical Assistance Program; Nebraska Health Connection (NHC)
CHIP: Kids Connection
State/Other: Medically Handicapped Children's Program; Comprehensive Health Association

[p. 50]

Card F11-NV

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Nevada

Medicaid: Nevada Medicaid
CHIP: Nevada Check Up
State/Other: Family Health Services Bureau

[p. 51]

Card F11-NH

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New Hampshire

Medicaid: Medical Assistance Program; Healthy Kids Gold
CHIP: Healthy Kids Silver
State/Other: Bureau of Special Medical Services

[p. 52]

Card F11-NJ

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New Jersey

[p. 53]

Card F11-NM

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New Mexico

Medicaid: SALUD!
CHIP: New MexiKids
State/Other: Comprehensive Health Insurance Pool; Insurance Assistance Program; Children's Medical Services

[p. 54]

Card F11-NY

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

New York

[p. 55]

Card F11-NC

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

North Carolina

Medicaid: Carolina Access; Health Care Connection Access II
CHIP: NC CHIP Program; NC Health Choice for Children (NCHC)
State/Other: Children Special Health Services (CHS)

[p. 56]

Card F11-ND

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

North Dakota

Medicaid: Medical Services; North Dakota Access and Care Program (NoDAC)
CHIP: Healthy Steps Program
State/Other: Comprehensive Health Association of North Dakota; Children's Special Health Services

[p. 57]

Card F11-OH

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

Please find your State

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Ohio

[p. 58]

Card F11-OK

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Oklahoma

Medicaid: SoonerCare; Health Benefits Program
CHIP: Oklahoma CHIP, SCHIP
State/Other: Children with Special Health Care Needs; Oklahoma Health Insurance High Risk Pool

[p. 59]

Card F11-OR

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Oregon

[p. 60]

Card F11-PA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Pennsylvania

Medicaid: Medical Assistance; Access Card; Family Care Network; HealthChoices
CHIP: Pa CHIP
State/Other: Division of Special Health Care Programs

[p. 61]

Card F11-RI

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Rhode Island

[p. 62]

Card F11-SC

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

South Carolina

[p. 63]

Card F11-SD

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

South Dakota

[p. 64]

Card F11-TN

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Tennessee

Medicaid: TennCare; Medicaid
CHIP: TennCare for Children
State/Other: Children's Special Services (CSS); Tenncare Standard

[p. 65]

Card F11-TX

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Texas

[p. 66]

Card F11-UT

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Utah

[p. 67]

Card F11-VT

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Vermont

Medicaid: Medicaid
CHIP: Dr. Dynasaur
State/Other: Vermont Health Access Plan (VHAP); HIV Insurance Continuation Program; Children with Special Health Care Needs

[p. 68]

Card F11-VA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Virginia

[p. 69]

Card F11-WA

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Washington

[p. 70]

Card F11-WV

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

West Virginia

Medicaid: Medical Assistance; Mountain Health Trust (MHT); Physician Assured Access System (PAAS)
CHIP: Children's Health Insurance Program (CHIP)
State/Other: Children with Special Health Care Needs

[p. 71]

Card F11-WI

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Wisconsin

[p. 72]

Card F11-WY

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

Please find your State.

Note: Some Medicaid programs are called"Medical Assistance Program" or "{State}Medicaid," such as "Alabama Medicaid." CHIP orS-CHIP programs can also be under "Title XXIProgram" or "{State} CHIP," such as "PennsylvaniaCHIP." The names provided below offerrovided below offer additional names for the public health insurance programs for each State.

Wyoming

Medicaid: Wyoming Medicaid
CHIP: Wyoming Kid Care
State/Other: Wyoming Health Insurance Pool (WHIP); Children's Special Health Program (CSH); Caring Program for Children

[p. 58]

FHI.270

FR: SHOW CARD F13.

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

Card F13

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

FR: SHOW CARD F14.

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

FR: ENTER UP TO 5 REASONS. ENTER (N) FOR NO MORE.

Card F14

You may choose more than one.
1. Person in family with health insurance lost job or changed employers
3. Became ineligible because of age/left school
2. Got divorced or separated/death of spouse or parent
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)

HISTOP

(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) @SPC
(97) Refused
(99) Don't know (other)

[ ]
[ ]
[ ]
[ ]
[ ]

(Go to FHI.320)

FHI.300

In the PAST 12 MONTHS, was there any time when {you/subject 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 name} without coverage?

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

HINOTMYR

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

[p. 59]

FHI.320

FR: SHOW CARD F15.
READ EACH CATEGORY IF TELEPHONE INTERVIEW.

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.

Card F15

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

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. 60]

Section VI -- SOCIO-DEMOGRAPHIC BACKGROUND

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

FSD.001

Where {were/was} {you/subject name} born?

PLBORN

(1) Alabama
(2) Alaska
(3) Arizona
(4) Arkansas
(5) California
(6) Colorado
(7) Connecticut
(8) Delaware
(9) Dist. of Columbia
(10) Florida
(11) Georgia
(12) Hawaii
(13) Idaho
(14) Illinois
(15) Indiana
(16) Iowa
(17) Kansas
(18) Kentucky
(19) Louisiana
(20) Maine
(21) Maryland
(22) Massachusetts
(23) Michigan
(24) Minnesota
(25) Mississippi
(26) Missouri
(27) Montana
(28) Nebraska
(29) Nevada
(30) New Hampshire
(31) New Jersey
(32) New Mexico
(33) New York
(34) North Carolina
(35) North Dakota(state unknown)
(36) Ohio
(37) Oklahoma
(38) Oregon
(39) Pennsylvania
(40) Rhode Island
(41) South Carolina
(42) South Dakota
(43) Tennessee
(44) Texas
(45) Utah
(46) Vermont
(47) Virginia
(48) Washington
(49) West Virginia
(50) Wisconsin
(51) Wyoming
(57) United States
(99) NOT IN THE U.S.

[If 99 go to POB_FOREIGN (FSD.002); if 1-51 or 57 go to Check item FSDCCI1]

FSD.002

POB_FOREIGN

ENTER THE FIRST LETTER OF THE COUNTRY OR PLACE NAME
IF THE COUNTRY IS UNKNOWN OR REFUSED, ENTER 999.

[@]
(A) [go to A_LIST]
(B) [go to B_LIST]
(C) [go to C_LIST]
(D) [go to D_LIST]
(E) [go to E_LIST]
(F) [go to F_LIST]
(G) [go to G_LIST]
(H) [go to H_LIST]
(I) [go to I_LIST]
(J) [go to J_LIST]
(K) [go to K_LIST]
(L) [go to L_LIST]
(M) [go to M_LIST]
(N) [go to N_LIST]
(O) [go to O_LIST]
(P) [go to P_LIST]
(Q) [go to Q_LIST]
(R) [go to R_LIST]
(S) [go to S_LIST]
(T) [go to T_LIST]
(U) [go to U_LIST]
(V) [go to V_LIST]
(W) [go to W_LIST]
(Y) [go to Y_LIST]
(Z) [go to Z_LIST]

(X) [clear out entry box, and display error message "FR: THERE ARE NO COUNTRIES LISTED BEGINNING WITH THIS LETTER, PLEASE ENTER ANOTHER ANSWER"]

A_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(100) ABROAD
(101) ABU DHABI
(102) ADEN
(103) AFGHANISTAN
(104) AFRICA
(105) ALBANIA
(106) ALBERTA
(107) ALGERIA
(108) ALGIERS
(109) ALSACE-LORRAINE
(060) AMERICAN SAMOA
(061) AM SAMOA
(110) AMSTERDAM
(111) ANEGADA
(112) ANGOLA
(113) ANGUILLA
(114) ANGUILLA BWI
(115) ANJOUAN
(116) ANTARCTICA
(117) ANTIGUA
(118) ANTIGUA and BARBUDA
(119) ANTIGUA WI
(120) ANTILLES
(121) ARAB PALESTINE
(122) ARABIA
(123) ARGENTINA
(124) ARMENIA
(125) ARUBA
(126) ARUBA DWI
(127) ARUBA NETHERLANDS
(128) ASCENSION ISLAND
(129) ASIA
(130) ASIA MINOR
(131) ASSAM
(132) AT SEA
(133) AUSTRALIA
(134) AUSTRIA
(135) AUSTRIA-HUNGARY
(136) AZERBAIJAN
(137) AZORES ISLANDS
(688) ANDORRA

B_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(138) BAHAMAS
(139) BAHAMAS UK
(140) BAHRAIN
(141) BAJA CAL
(142) BAJA CAL SUR
(062) BAKER ISLAND
(143) BALBOA
(144) BANGLADESH
(145) BARBADOS
(146) BARBUDA
(147) BAVARIA
(148) BELARUS
(149) BELFAST
(150) BELGIAN CONGO
(151) BELGIUM
(152) BELIZE
(153) BENIN
(154) BERLIN
(155) BERMUDA
(156) BESSARABIA
(157) BHUTAN
(158) BOHEMIA
(159) BOLIVIA
(160) BONAIRE
(161) BORNEO
(162) BOSNIA
(163) BOSNIA and HERZEGOVINA
(164) BOTSWANA
(165) BRASIL
(166) BRAZIL
(167) BRAZZAVILLE
(168) BREMEN
(169) BRITAIN
(170) BRITISH COLUMBIA
(171) BRITISH EAST AFRICA
(172) BRITISH GUIANA
(173) BRITISH GUYANA
(174) BRITISH HONDURAS
(175) BRITISH HONG KONG
(176) BRITISH ISLES
(177) BRITISH VI
(178) BRITISH VIRGIN IS
(179) BRITISH WEST INDIES
(180) BRITISH WI
(181) BRUNEI
(182) BULGARIA
(183) BURKINA FASO
(184) BURMA
(185) BURUNDI
(186) BWI
(187) BYELARUS
(188) BYELORUSSIA
(689) BRITISH INDIAN OCEAN TERRITORY

C_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(189) CAICOS ISLANDS
(190) CAM PHA
(191) CAM RANH
(192) CAMBODIA
(193) CAMEROON
(194) CAN THO
(195) CANADA
(196) CANAL ZONE
(197) CANARY ISLANDS
(198) CANTON and ENDERBURY IS
(199) CANTON ISLAND
(200) CAPE VERDE
(201) CARIBBEAN
(202) CAYMAN ISLANDS
(203) CENTRAL AFRICA
(204) CENTRAL AFRICAN REP
(205) CENTRAL AMERICA
(206) CEYLON
(207) CHAD
(208) CHANNEL ISLANDS
(209) CHIAPAS
(210) CHIHUAHUA
(211) CHILE
(212) CHINA
(213) CHINA HONG KONG
(214) CHRISTMAS ISLAND
(215) CHRISTMAS ISLAND, INDIAN OCEAN
(232) CURACAO
(216) COAHUILA
(217) COLIMA
(218) COLOMBIA
(219) COMOROS
(220) CONGO
(221) COOK ISLANDS
(222) CORAL SEA ISLANDS
(223) CORK
(224) CORSICA
(225) COSTA RICA
(226) COTE D'IVORIE
(227) CRETE
(228) CRIMEA
(229) CRISTOBAL
(230) CROATIA
(231) CUBA
(233) CYPRUS
(234) CZ
(235) CZECH REPUBLIC
(236) CZECHOSLOVAKIA

D_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(237) DA LAT
(238) DA NANG
(239) DAKAR
(240) DANZIG
(241) DELHI
(242) DEMO PEOPLE'S REP OF KOREA
(243) DEMO REP OF CONGO
(244) DENMARK
(245) DISTRITO FEDERAL
(246) DJIBOUTI
(247) DOM REP
(248) DOMINICA
(249) DOMINICA BWI
(250) DOMINICA WI
(251) DOMINICAN REPUBLIC
(252) DUBAI
(253) DUBLIN
(254) DURANGO
(255) DUTCH EAST INDIES
(256) DUTCH GUIANA
(257) DUTCH INDONESIA
(258) DUTCH NEW GUINEA
(690) DEUTSCHLAND

E_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(259) EAST PAKISTAN
(260) EAST PRUSSIA
(261) EASTER ISLAND
(262) EASTERN AFRICA
(263) ECUADOR
(264) EGYPT
(265) EIRE
(266) EL SALVADOR
(267) ENGLAND
(268) EQUATORIAL GUINEA
(269) ERITREA
(270) ESPANA
(271) ESTONIA
(272) ETHIOPIA
(273) EUROPA ISLAND
(274) EUROPE

F_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(275) FALKLAND ISLANDS
(276) FAROE ISLANDS
(277) FEDERAL DISTRICT
(278) FEDERAL REPUBLIC OF YUGOSLAVIA
(279) FEDERATED STATES OF MICRONESIA
(280) FIJI
(281) FILIPINES
(282) FINLAND
(283) FOREIGN COUNTRY
(284) FORMOSA
(285) FRANCE
(286) FRANKFURT
(287) FRENCH GUIANA
(288) FRENCH MOROCCO
(289) FRENCH POLYNESIA
(691) FRENCH SOUTHERN AND ANTARCTIC LANDS

G_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(290) GABON
(291) GALAPAGOS ISLANDS
(292) GALWAY
(293) GAMBIA
(294) GAZA STRIP
(295) GEORGIA
(296) GERMANY
(297) GHANA
(298) GIA DINH
(299) GIBRALTER
(300) GLORIOSO ISLANDS
(301) GOA
(302) GRAND BAHAMA
(303) GRAND CAYMAN
(304) GRAND TURK
(305) GREAT BRITAIN
(306) GREAT COMORE
(307) GREECE
(308) GREENLAND
(309) GRENADA
(310) GUADALAJARA
(311) GUADELOUPE
(063) GUAM
(312) GUANAJUATO
(313) GUATEMALA
(314) GUERNSEY
(315) GUERRERO
(316) GUIANA
(317) GUINEA
(318) GUINEA-BISSAU
(319) GUYANA
(692) GRENADINES, THE

H_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(320) HA DONG
(321) HAI PHONG
(322) HAITI
(323) HAMBURG
(324) HANOI
(325) HANOVER
(326) HAVANA
(327) HEARD and MCDONALD ISLANDS
(328) HERZEGOVINA
(329) HESSE
(330) HIDALGO
(331) HIGH SEAS
(332) HOLLAND
(333) HONDURAS
(334) HONG KONG
(064) HOWLAND ISLAND
(335) HUNGARY
(336) HYDERABAD

I_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(337) ICELAND
(338) INDIA
(339) INDONESIA
(340) INTERNATIONAL WATERS
(341) IRAN
(342) IRAQ
(343) IRELAND
(344) IRIAN JAYA
(345) IRISH REPUBLIC
(346) ISLE OF MAN
(347) ISRAEL
(348) ITALY
(349) IVORY COAST

J_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(350) JALISCO
(351) JAMAICA
(352) JAN MEYAN
(353) JAPAN
(065) JARVIS ISLAND
(354) JAVA
(355) JERSEY
(356) JIBUTI
(066) JOHNSTON ATOLL
(357) JORDAN
(358) JUAN DE NOVA ISLAND
(359) JUGOSLAVIA

K_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(360) KALININGRAD
(361) KAMPUCHEA
(362) KASHMIR
(363) KAZAKHSTAN
(364) KENYA
(365) KHANH HUNG
(067) KINGMAN REEF
(366) KINSHASA
(367) KIRIBATI
(368) KOREA
(369) KORO ISLAND
(370) KUWAIT
(371) KWAJALEIN
(372) KWANTUNG
(373) KYRGYZSTAN
(693) KOSOVO

L_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(374) LABRADOR
(375) LABUAN
(376) LAOS
(377) LATAKIA
(378) LATIN AMERICA
(379) LATVIA
(380) LEBANON
(381) LEEWARD ISLANDS
(382) LESOTHO
(383) LIBERIA
(384) LIBYA
(385) LIECHTENSTEIN
(386) LITHUANIA
(387) LOAS
(388) LONDONDERRY
(389) LONG XUYEN
(390) LORRAINE
(391) LUBECK
(392) LUXEMBOURG

M_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(393) MACAO
(394) MACAU
(395) MACEDONIA
(396) MADAGASCAR
(397) MADEIRA ISLANDS
(398) MAINLAND CHINA
(399) MAJORCA
(400) MALAGASY REPUBLIC
(401) MALAWI
(402) MALAYSIA
(403) MALDIVES
(404) MALI
(405) MALLORCA
(406) MALTA
(407) MACHURIA
(408) MANICA
(409) MANILA
(410) MANITOBA
(068) MANUA ISLANDS
(411) MARSHALL ISLANDS
(412) MARTINIQUE
(413) MAURITANIA
(414) MAURITIUS
(415) MAYOTTE ISLAND
(416) MELANESIA
(417) MEXICO
(418) MICHOACAN
(419) MICRONESIA
(420) MIDDLE EAST
(069) MIDWAY ISLANDS
(421) MOLDAVIA
(422) MOLDOVA
(423) MONACO
(424) MONAGAS
(425) MONGOLIA
(426) MONTENEGRO
(427) MONTSERRAT
(428) MORELOS
(429) MOROCCO
(430) MOZAMBIQUE
(431) MY THO
(694) MYANMAR

N_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(432) N. IRELAND
(433) NAM DINH
(434) NAMIBIA
(435) NAURU
(070) NAVASSA ISLAND
(436) NAYARIT
(437) NEPAL
(438) NETHERLANDS
(439) NETH. ANTILLES
(440) NETH. EAST INDIES
(441) NEVIS ISLAND
(442) NEW BRUNSWICK
(443) NEW CALEDONIA
(444) NEW GUINEA
(445) NEW HEBRIDES
(446) NEW SOUTH WALES
(447) NEW ZEALAND
(448) NEWFOUNDLAND
(449) NHA TRANG
(450) NICARAGUA
(451) NIGER
(452) NIGERIA
(453) NIUE ISLAND
(454) NORFOLK ISLAND
(455) NORTH AFRICA
(456) NORTH AMERICA
(457) NORTH KOREA
(458) NORTH VIETNAM
(459) NORTHERN IRELAND
(071) NORTHERN MARIANAS
(460) NORTHERN TERRITORY
(461) NORWAY
(462) NOVA SCOTIA
(463) NUEVO LEON
(695) NORTHWEST TERRITORY
(696) NUNAVUT TERRITORY

O_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(464) OAXACA
(465) OCEANIA
(466) OKINAWA
(467) OMAN
(468) ONTARIO
(469) OVERSEAS

P_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(470) PAKISTAN
(471) PALAU
(472) PALESTINE
(072) PALMYRA ATOLL
(473) PANAMA
(474) PANAMA CANAL ZONE
(475) PAPUA NEW GUINEA
(476) PARACEL ISLANDS
(477) PARAGUAY
(478) PELAGOSA
(479) PEOPLE'S REP. OF CHINA
(480) PEOPLE'S REP. OF CONGO
(481) PERSIA
(482) PERU
(483) PHAN THIET
(484) PHILIPPINES
(485) PITCAIRN ISLAND
(486) POLAND
(487) POLYNESIA
(488) PONAPE
(489) PORTUGAL
(490) PORTUGUESE INDIA
(491) PRINCE EDWARD ISLAND
(492) PRINCIPE ISLAND
(494) PRUSSIA
(495) PUEBLA
(073) PUERTO RICO
(496) PUNJAB
(497) PUNJAB, INDIA
(498) PUNJAB, PAKISTAN

Q_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(499) QATAR
(500) QUANG LONG
(501) QUEBEC
(502) QUEENSLAND
(503) QUERETARO
(504) QUI NHON

R_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(505) RACH GIA
(506) RAJASTHAN
(507) RED CHINA
(508) REPUBLIC OF CHINA
(509) REPUBLIC OF CYPRUS
(510) REPUBLIC OF IRELAND
(511) REPUBLIC OF KOREA
(512) REPUBLIC OF PANAMA
(513) REP. OF PHILIPPINES
(514) REP. OF SOUTH AFRICA
(515) REPUBLICA DOMINICANA
(516) REUNION ISLAND
(517) RHODESIA
(518) ROC
(519) ROK
(520) ROMANIA
(074) ROTA
(521) ROTTERDAM
(522) RUMANIA
(523) RUSSIA
(524) RUSSIAN FEDERATION
(525) RWANDA

S_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(526) SAIGON
(075) SAIPAN
(527) SALVADOR
(528) SAMOA
(529) SAN ANDRES
(530) SAN LUIS POTOSI
(531) SAN MARINO
(532) SAN SALVADOR
(076) SAND ISLAND
(533) SAO TOME ISLAND
(534) SAO TOME and PRINCIPE
(535) SARAWAK
(536) SASKATCHEWAN
(537) SAUDI ARABIA
(566) SOUTHEAST ASIA
(567) SOUTHERN AFRICA
(568) SOUTHERN RHODESIA
(569) SOVIET UNION
(570) SPAIN
(571) SPRATLEY ISLANDS
(572) SRI LANKA
(573) ST BARTHELEMY
(574) ST BARTS
(575) ST CHRISTOPHER
(576) ST CHRISTOPHER-NEVIS
(077) ST CROIX
(538) SAXONY
(539) SCOTLAND
(540) SENEGAL
(541) SEOUL
(542) SERBIA
(543) SEYCHELLES
(544) SHANGHAI
(545) SHARJAH
(546) SIBERIA
(547) SICILY
(548) SIERRA LEONE
(549) SIKKIM
(550) SINALOA
(551) SINGAPORE
(577) ST EUSTATIUS
(578) ST HELENA
(078) ST JOHN
(579) ST KITTS
(580) ST KITTS-NEVIS
(581) ST LUCIA
(582) ST MAARTEN
(583) ST MARTIN
(584) ST PIERRE and MIQUELON
(079) ST THOMAS
(585) ST VINCENT
(586) ST VINCENT and THE GRENADINES
(552) SLAVONIA
(553) SLOVAK REPUBLIC
(554) SLOVAKIA
(555) SLOVENIA
(556) SOLOMAN ISLANDS
(557) SOMALIA
(558) SONORA
(559) SOUTH AFRICA
(560) SOUTH AMERICA
(561) SOUTH AUSTRALIA
(562) SOUTH KOREA
(563) SOUTH VIETNAM
(564) SOUTH WALES
(565) SOUTH YEMEN
(587) SUDAN
(588) SUMATRA
(589) SURINAM
(590) SURINAME
(591) SVALBARD
(592) SWAZILAND
(593) SWEDEN
(594) SWITZERLAND
(595) SYRIA
(596) SYRIAN ARAB REP

T_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(597) TABASCO
(598) TADZHIK
(599) TAHITI
(600) TAIWAN
(601) TAIWAN ROC
(602) TAJIKISTAN
(603) TAMAULIPAS
(604) TANGANYIKA
(605) TANGIER
(606) TANZANIA
(607) TASMANIA
(608) THAILAND
(609) THANH HOA
(610) THE GRENADINES
(611) TIBET
(612) TIJUANA
(080) TINIAN
(613) TLAXCALA
(614) TOBAGO
(615) TOGO
(616) TOGOLAND
(617) TOKELAU
(618) TONGA
(619) TORTOISE ISLANDS
(620) TORTOLA
(621) TRANSVAAL
(622) TRANSYLVANIA
(623) TRIESTE
(624) TRINIDAD
(625) TRINIDAD and TOBAGO
(626) TRIPOLI
(627) TROMELIN ISLAND
(628) TRUK
(629) TUNIS
(630) TUNISIA
(631) TURKEY
(632) TURKMENISTAN
(633) TURKS and CAICOS IS
(634) TURK ISLANDS
(635) TUVALU
(636) TUY HOA

U_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(637) UGANDA
(638) UK
(639) UKRAINE
(640) UKRAINIA
(641) UNION ISLANDS
(642) UNION OF SOUTH AFRICA
(643) UNION OF SOVIET SOCIALIST REPUBLICS
(644) UNITED ARAB EMIRATES
(645) UNITED KINGDOM
(646) UPPER VOLTA
(647) URUGUAY
(081) US OUTLYING AREA
(082) US VIRGIN ISLANDS
(648) USSR
(083) USVI
(649) USBEKISTAN

V_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(650) VANCOUVER
(651) VANUATU
(652) VATICAN CITY
(653) VENEZUELA
(654) VERACRUZ
(655) VICTORIA
(656) VIETNAM
(657) VINH LONG
(084) VIRGIN ISLANDS
(658) VUNG TAU

W_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(085) WAKE ISLAND
(659) WALES
(660) WALLIS and FUTUNA ISLANDS
(661) WEST AFRICA
(662) WEST BANK
(663) WEST BENGAL
(664) WEST INDIES
(665) WEST PAKISTAN
(666) WESTERN AUSTRALIA
(667) WESTERN SAHARA
(668) WESTERN SAMOA
(669) WHITE RUSSIA
(670) WINDWARD ISLANDS
(671) WINNIPEG
(672) WURZBERG

Y_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(673) YAP
(674) YAR
(675) YEMEN
(676) YEMEN ARAB REPUBLIC
(677) YEREVAN
(678) YUCATAN
(679) YUGOSLAVIA
(680) YUKON TERRITORY

Z_LIST

ENTER APPROPRIATE 3-DIGIT CODE BASED UPON COUNTRY NAME. IF COUNTRY NOT LISTED, ENTER 998.

(681) ZACATECAS
(682) ZADAR
(683) ZAIRE
(684) ZAMBIA
(685) ZANZIBAR
(686) ZIMBABWE
(687) ZURICH
(997) Refused
(999) Don't know

FSD.003

FR: READ IF NECESSARY:

Earlier I recorded {your/subject name's] date of birth as {month in words, 2-digit day, 4-digit year}.
In what year did {you/subject name} come to the United States to stay?

USYR

Year: _______ (FSD.005)
(9997) Refused (FSD.004)
(9999) Don't know (FSD.004)

FSD.004

About how long {have/has} {you/subject name} been in the United States?

FR: READ IF NECESSARY:

Earlier I recorded that {you/subject name} {are/is} {AGE} years old.

FR: ENTER 95 FOR 95 OR MORE YEARS. IF LESS THAN 1 YEAR GIVEN AS A RESPONSE, CODE THE ANSWER AS "0".

USLONG

(01-94) 01-94 years
(95) 95+ years
(97) Refused
(99) Don't know

.FSD.005

FR: SHOW CARD F16.

{Are/Is} {you/subject name} a CITIZEN of the United States?

Card F16

1. Yes, born in one of the 50 United States, or the District of Columbia
2. Yes, born in Puerto Rico, Guam, American Virgin Islands, or other U.S. territory
3. Yes, born abroad to American parent(s)
4. Yes, U.S. citizen by naturalization
5. No, not a citizen of the United States

CITIZEN

(1) Yes, born in one of the 50 United States or the District of Columbia
(2) Yes, born in Puerto Rico, Guam, American Virgin Islands, or other U.S. territory
(3) Yes, born abroad to American parents
(4) Yes, U.S. citizen by naturalization
(5) No, not a citizen of the United States
(7) Refused
(9) Don't know

Check item FSDCCI1:If AGE is less than or equal to 6, go to FSD.006, else if AGE is less than or equal to 17, Goto FSD.007. When no more family members, and AGE is less than or equal to 17, then goto FSD.010.

FSD.006

Is {subject 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 name} ever attended Head Start?

HEADSTV1

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

[p. 73]

FSD.010

FR: SHOW CARD F17.

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

FR: ENTER HIGHEST LEVEL OF SCHOOL:

Card F17

0. Never attended/kindergarten only
1. 1st grade
2. 2nd grade
3. 3rd grade
4. 4th grade
5. 5th grade
6. 6th grade
7. 7th grade
8. 8th grade
9. 9th grade
10. 10thgrade
11. 11thgrade
12. 12th grade, no diploma
13. GED or equivalent
14. HIGH SCHOOL GRADUATE
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

(0) Never attended / kindergarten only
(1) 1st grade
(2) 2nd grade
(3) 3rd grade
(4) 4th grade
(5) 5th grade
(6) 6th grade
(7) 7th grade
(8) 8th grade
(9) 9th grade
(10) 10th grade
(11) 11th grade
(12) 12th grade, no diploma
(13) GED or equivalent
(14) HIGH SCHOOL GRADUATE
(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)
(97) Refused
(99) Don't know

(0 -21, 97, 99) goto FSD.041

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 Corps, or Coast Guard? (If so, who? Anyone else?)

FR: ENTER UP TO SEVEN LINE NUMBERS. ENTER "N" AFTER THE LAST ONE, OR IF NONE, 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 equal to 18 go to FSD.050; Else go to next section (Income and Assets). When the family roster is exhausted, go to next section (Income and Assets).

[p. 74]

FSD.050

Which of the following {were/was} {you/subject name} doing LAST WEEK?

DOINGLW

(1) Working for pay at a job or business (FSD.070)
(2) With a job or business but not at work (FSD.060)
(3) Looking for work (FSD.100)
(4) Working, but not for pay, at a job or business (FSD.070)
(5) Not working at a job or business AND not looking for work (FSD.060)
(7) Refused (FSD.100)
(9) Don't know (FSD.100)

FSD.060

[If FSD.050 = 2, display]
What is the main reason {you/subject name} did not work last week?

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

WHYNOWRK

(1) Taking care of house or family (FSD.100)
(2) Going to school (FSD.100)
(3) Retired (FSD.100)
(4) On a planned vacation from work (FSD.070)
(5) On family or maternity leave (FSD.070)
(6) Temporarily unable to work for health reasons (FSD.070)
(7) On layoff (FSD.100)
(8) Disabled (FSD.100)
(9) Have job/contract; off-season (FSD.100)
(10) Other (FSD.100)
(97) Refused (FSD.100)
(99) Don't know (FSD.100)

NOTE: Information from the ASD section is used to create DOINGLW1 (from DOINGLW) and WHYNOWK1 (from WHYNOWRK).

FSD.070

[If DOINGLW eq (1) or DOINGLW eq (4), display]
How many hours did {you/subject name} work LAST WEEK at ALL jobs or businesses?

[Else, display]
How many hours {do/does} {you/subject name} USUALLY work at all jobs or businesses?

FR: ENTER 95 IF THE REPORTED HOURS ARE GREATER THAN OR EQUAL TO 95 HOURS.

WRKHRS

(01-94) 1-94 hours
(95) 95 hours +
(97) Refused
(99) Don't know

[If WRKHRS lt (35) goto FSD.080; else goto FSD.100]

FSD.080

{Do/Does} {you/subject 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

FSD.100

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 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 name's} 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) $000001-$999994 dollars
(999995) $999,995+
(999997) Refused
(999999) Don't know

Check item FSDCCI3:If FSD.050 equals 1, 2, or 4, go to FSD.130; Else, go to Check item FSDCCI2 for next person. When roster exhausted, go to next section (Income and Assets).

FSD.130

Regarding {your/his/her} job or work last week, was health insurance offered to {you/subject 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. 76]

Section VII -- INCOME AND ASSETS

Part A -- Sources of Income

FIN.030

[If FINAVAIL = 2, display]
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, display]
Did you receive income in {last year in 4 digit format} from... Wages and Salaries?

[else, display]
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
(2) No
(7) Refused
(9) Don't know

[(If one person family and FSAL eq (1) or FSAL eq (2,7,9)] go to FIN.050;
[Else go to FIN.040]

FIN.040

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

Who received this? (Anyone else?)

FR: INDICATE EACH FAMILY MEMBER WITH THIS INCOME.

PSAL

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

FIN.050

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

[else, display]
Did any family member 18 and older, that is (READ NAMES) receive income in {last year in 4 digit format} 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)

[(If one person family and FSEINC eq (1)) or FSEINC eq (2,7,9)] go to FIN.070;
[Else go to FIN.060]

FIN.060

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

Who received this? (Anyone else?)

FR: INDICATE EACH FAMILY MEMBER WITH THIS INCOME.

PSEINC

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

FIN.070

Did {you/any family members living here} 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
(2) No
(7) Refused
(9) Don't know

[If one person family and FSSRR eq (1)] go to FINCCI2;
[Else if FSSRR eq (2,7,9)] go to FIN.090;
[Else go to FIN.080]

FIN.080

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

Who received this? (Anyone else?)

FR: INDICATE EACH FAMILY MEMBER WITH THIS INCOME.

PSSRR

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

Check item FINCCI2: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) Social Security or Railroad Retirement income received as a disability benefit?

FSSRRD

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

[If one person family and FSSRRD eq (1), go to FIN.086]
[If FSSRRD eq (2,7,9), go to FIN.090]
[Else go to FIN.084]

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 name listed in PSSRRDB/FIN.084} 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
(2) No
(7) Refused
(9) Don't know

[(If one person family and FPENS eq (1)) or FPENS eq (2,7,9)] go to FIN.102;
[Else go to FIN.100]

FIN.100

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

Who received this? (Anyone else?)

FR: INDICATE EACH FAMILY MEMBER WITH THIS INCOME.

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
(2) No
(7) Refused
(9) Don't know

[(If one person family and FOPENS eq (1)) or FOPENS eq (2,7,9)] go to FIN.110;
[Else go to FIN.104]

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?)

FR: INDICATE EACH FAMILY MEMBER WITH THIS INCOME.

POPENS

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

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
(2) No
(7) Refused
(9) Don't know

[If one person family and FSSI eq (1), go to FIN.122];
[Else if FSSI eq (2,7,9), go to FIN.150];
[Else go to FIN.120]

FIN.120

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

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

FR: INDICATE EACH FAMILY MEMBER WITH THIS INCOME.

PSSI

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

FIN.122

Did {you/subject name listed in PSSI/FIN.120} receive SSI because {you/he/she} {have/has} a disability?

PSSID

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

[p. 80]

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 CASH assistance from a state or county welfare program such as {specific program name}?

FR: SHOW CARD F18. PLEASE DO NOT INCLUDE FOOD STAMPS, SSI, ENERGY ASSISTANCE, OR MEDICAL ASSISTANCE PAYMENTS.

FTANF

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

[(If one person family and FTANF eq (1)) or FTANF eq (2,7,9)] go to FIN.164;
[Else go to FIN.160]

[flashcards associated with FIN.150]
Card F18-AL

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Alabama

Family Assistance (FA) Program*
JOBS

[p. 80]

Card F18-AK

Alaska

Alaska Temporary Assistance Program (ATAP)

[p. 81]

Card F18-AZ

Arizona

Employing and Moving People Off Welfare and Encouraging Responsibility (EMPOWER)

[p. 82]

Card F18-AR

Arkansas

Transitional Employment Assistance (TEA)

[p. 83]

Card F18-CA

California

California Work Opportunity and Responsibility to Kids (CalWorks)

[p. 84]

Card F18-CO

Colorado

Colorado Works

[p. 85]

Card F18-CT

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Connecticut

Temporary Family Assistance (TFA)*
JOBS FIRST

[p. 86]

Card F18-DE

Delaware

A Better Chance (ABC)

[p. 87]

Card F18-DC

District of Columbia

Temporary Assistance for Needy Families (TANF)

[p. 88]

Card F18-FL

Florida

Work and Gain Economic Self-Sufficiency (WAGES)

[p. 89]

Card F18-GA

Georgia

Temporary Assistance for Needy Families (TANF)

[p. 90]

Card F18-HI

Hawaii

Temporary Assistance for Needy Families (TANF)

[p. 91]

Card F18-ID

Idaho

Temporary Assistance for Families in Idaho (TAFI)

[p. 92]

Card F18-IL

Illinois

Temporary Assistance for Needy Families (TANF)

[p. 93]

Card F18-IN

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Indiana

Temporary Assistance for Needy Families (TANF)*
Indiana Manpower Placement and Comprehensive Training (IMPACT)

[p. 94]

Card F18-IA

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Iowa

Family Investment Program (FIP)*
PROMISE JOBS

[p. 95]

Card F18-KS

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Kansas

Temporary Assistance for Families (TAF)*
KansasWorks

[p. 96]

Card F18-KY

Kentucky

Transitional Assistance Program (K-TAP)

[p. 97]

Card F18-LA

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Louisiana

Family Independence Temporary Assistance Program (FITAP)*
Family Independence Work Program (FIND Work)

[p. 98]

Card F18-ME

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Maine

Temporary Assistance for Needy Families (TANF)*
Additional Support for People in Retraining and Employment (ASPIRE)

[p. 99]

Card F18-MD

Maryland

Family Investment Program (FIP)

[p. 100]

Card F18-MA

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Massachusetts

Transitional Aid to Families with Dependent Children (TAFDC)*
Employment Services Program (ESP)

[p. 101]

Card F18-MI

Michigan

Family Independence Program (FIP)

[p. 102]

Card F18-MN

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Minnesota

Minnesota Family Investment Program (MFIP)*
Minnesota Works 95- WorkFIRST

[p. 103]

Card F18-MS

Mississippi

Temporary Assistance for Needy Families (TANF)

[p. 104]

Card F18-MO

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Missouri

Temporary Assistance*
Beyond Welfare

[p. 105]

Card F18-MT

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Montana

Families Achieving Independence in Montana (FAIM)*
- Pathways
- Community Services Program (CSP)
Demonstration JOBS

[p. 106]

Card F18-NE

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Nebraska

Temporary Assistance for Needy Families (TANF)*
Employment First

[p. 107]

Card F18-NV

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Nevada

Temporary Assistance for Needy Families (TANF)*
New Employees of Nevada (NEON)

[p. 108]

Card F18-NH

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

New Hampshire

Family Assistance Program (FAP)*
New Hampshire Employment Program (NHEP)

[p. 109]

Card F18-NJ

New Jersey

Work First New Jersey (WFNJ)

[p. 110]

Card F18-NM

New Mexico

NM Works

[p. 111]

Card F18-NY

New York

Family Assistance (FA) Program

[p. 112]

Card F18-NC

North Carolina

Work First

[p. 113]

Card F18-ND

North Dakota

Training, Employment, Education Management(TEEM)

[p. 114]

Card F18-OH

Ohio

Ohio Works First (OWF)

[p. 115]

Card F18-OK

Oklahoma

Temporary Assistance for Needy Families (TANF)

[p. 116]

Card F18-OR

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Oregon

Temporary Assistance for Needy Families (TANF)*
Job Opportunities and Basic Skills Program (JOBS)

[p. 117]

Card F18-PA

Pennsylvania

Pennsylvania TANF

[p. 118]

Card F18-RI

Rhode Island

Family Independence Program (FIP)

[p. 119]

Card F18-SC

South Carolina

Family Independence Program

[p. 120]

Card F18-SD

South Dakota

Temporary Assistance for Needy Families (TANF)

[p. 121]

Card F18-TN

Tennessee

Families First

[p. 122]

Card F18-TX

Texas

Texas Works (Department of Human Services)

[p. 123]

Card F18-UT

Utah

Family Employment Program (FEP)

[p. 124]

Card F18-VT

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Vermont

Aid to Needy Families with Children (ANFC)*
Reach UP

[p. 125]

Card F18-VA

Note: Where there is more than one program, an asterisk* denotes which most resembles TANF.

Virginia

Virginia Independence Program (VIP)*
Virginia Initiative for Employment Not Welfare (VIEW)

[p. 126]

Card F18-WA

Washington

WorkFirst

[p. 127]

Card F18-WV

West Virginia

West Virginia Works

[p. 128]

Card F18-WI

Wisconsin

Wisconsin Works (W-2)

[p. 129]

Card F18-WY

Wyoming

Personal Opportunities with Employment Responsibility (POWER)

FIN.160

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

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

FR: INDICATE EACH FAMILY MEMBER WITH THIS INCOME.

PTANF

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

FIN.164

At any time during {last year in 4 digit format}, did {you/anyone in your 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?

FOWBEN

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

[(If one person family and FOWBEN eq (1)) or FOWBEN eq (2,7,9)] go to FIN.170;
[Else go to FIN.166]

FIN.166

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

Who received this? (Anyone else?)

FR :INDICATE EACH FAMILY MEMBER WITH THIS INCOME.

POWBEN

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

[p. 81]

FIN.170

Did {you/any family members living here} receive income from interest bearing checking accounts, saving accounts, IRA's or certificates of deposit, money market funds, treasury notes, bonds, or any other investments that earn interest?

FR: DO NOT INCLUDE DIVIDENDS.

FINTRST

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

[(If one person family and FINTRST eq (1)) or FINTRST eq (2,7,9)] go to FIN.190;
[Else go to FIN.180]

FIN.180

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

Who received this? (Anyone else?)

FR: INDICATE EACH FAMILY MEMBER WITH THIS INCOME.

PINTRSTR

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

FIN.190

Did {you/any family members living here} receive income from... dividends received from stocks or mutual funds, or net rental income from property, royalties, estates or trusts?

FDIVD

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

[(If one person family and FDIVD eq (1)) or FDIVD eq (2,7,9)] go to FIN.210;
[Else go to FIN.200]

FIN.200

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

Who received this? (Anyone else?)

FR: INDICATE EACH FAMILY MEMBER WITH THIS INCOME.

PDIVD

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

FIN.210

Did {you/any family members living here} receive income from... child support?

FCHLDSP

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

[(If one person family and FCHLDSP eq (1)) or FCHLDSP eq (2,7,9)] go to FIN.230;
[Else go to FIN.220]

FIN.220

FR: ASK OR VERIFY.

Who received this? (Anyone else?)

FR: ENTER LINE NUMBERS OF CHILDREN FOR WHOM CHILD SUPPORT WAS RECEIVED. IF THAT CHILD IS NO LONGER RESIDING WITH THIS FAMILY, ENTER LINE NUMBER OF CUSTODIAL PARENT. ENTER (N) FOR NO MORE.

PCHLDSP

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

FIN.230

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

FINCOT

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

[(If one person family and FINCOT eq (1)) or FINCOT eq (2,7,9)] go to FIN.250;
[Else go to FIN.240]

FIN.240

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

Who received this? (Anyone else?)

FR: INDICATE EACH FAMILY MEMBER WITH THIS INCOME.

PINCOT

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

[p. 83]

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.
FR: ENTER 999,996 IF THE REPORTED INCOME IS GREATER THAN $999,995

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 /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 F19.
IF ANSWER FOR FIN.260 = 2, SHOW CARD F20.

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 F19

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 F20

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}?

FR: ENTER NUMBER CORRESPONDING TO TOTAL COMBINED FAMILY INCOME.

FINCCAT

(00) A. Less than $1,000
(01) B. $1,000 - $1,999
(02) C. $2,000 - $2,999
(03) D. $3,000 - $3,999
(04) E. $4,000 - $4,999
(05) F. $5,000 - $5,999
(06) G. $6,000 - $6,999
(07) H. $7,000 - $7,999
(08) I. $8,000 - $8,999
(09) J. $9,000 - $9,999
(10) K. $10,000 - $10,999
(11) L. $11,000 - $11,999
(12) M. $12,000 - $12,999
(13) N. $13,000 - $13,999
(14) O. $14,000 - $14,999
(15) P. $15,000 - $15,999
(16) Q. $16,000 - $16,999
(17) R. $17,000 - $17,999
(18) S. $18,000 - $18,999
(19) T. $19,000 - $19,999
(20) U. $20,000 - $20,999
(21) V. $21,000 - $21,999
(22) W. $22,000 - $22,999
(23) X. $23,000 - $23,999
(24) Y. $24,000 - $24,999
(25) Z. $25,000 - $25,999
(26) AA. $26,000 - $26,999
(27) BB. $27,000 - $27,999
(28) CC. $28,000 - $28,999
(29) DD. $29,000 - $29,999
(30) EE. $30,000 - $30,999
(31) FF. $31,000 - $31,999
(32) GG. $32,000 - $32,999
(33) HH. $33,000 - $33,999
(34) II. $34,000 - $34,999
(35) JJ. $35,000 - $39,999
(36) KK. $40,000 - $44,999
(37) LL. $45,000 - $49,999
(38) MM. $50,000 - $54,999
(39) NN. $55,000 - $59,999
(40) OO. $60,000 - $64,999
(41) PP. $65,000 - $69,999
(42) QQ. $70,000 - $74,999
(43) RR. $75,000 and over
(97) Refused
(99) Don't know

FIN.280

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

HOUSEOWN

(1) Owned or being bought (FINCCI3)
(2) Rented (FIN.282)
(3) Other arrangement (FINCCI3)
(7) Refused (FINCCI3)
(9) Don't know (FINCCI3)

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. 85]

Part C -- Program Participation

Check item FINCCI3: If all family members receive SSI then they should skip over question FIN.300 and go to FIN.330.

FIN.300

[If one person family, display]
Have you EVER applied for Supplemental Security Income or SSI, even if the claim was denied?

[Else, display]
Have any 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
(2) No
(7) Refused
(9) Don't know

[(If one person family and FSSAPL eq (1)) or FSSAPL eq (2,7,9)] go to FIN.330;
[Else go to FIN.310]

FIN.310

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

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

FR: INDICATE EACH FAMILY MEMBER WHO APPLIED FOR SSI BENEFITS.

PSSAPL

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

FIN.330

[If one person family, display]
Have you EVER APPLIED for disability benefits from Social Security, even if the claim was denied?

[Else, display]
Have any 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
(2) No
(7) Refused
(9) Don't know

[(If one person family and FSDAPL eq (1)) or FSDAPL eq (2,7,9)] go to FINCCI4;
[Else go to FIN.340]

FIN.340

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

FR: INDICATE EACH FAMILY MEMBER WHO APPLIED FOR SOCIAL SECURITY DISABILITY BENEFITS. ENTER (N) FOR NO MORE AFTER THE LAST NUMBER.

PSDAPL

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

Check item FINCCI4: If persons not in FIN.160, go to FIN.360; Else go to FIN.350.

FIN.350

Earlier I recorded that {you/subject name} received cash assistance from a state or county welfare program in {last year in 4 digit format}. During {last year in 4 digit format}, about how many months did {you/subject's name} receive this assistance?

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
(2) No
(7) Refused
(9) Don't know

[If one person family and FFSTIP eq (1)] go to FIN.380;
[Else if FFSTIP eq (2,7,9)] go to FINCCI5;
[Else go to FIN.370]

FIN.370

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

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

FR: INDICATE FAMILY MEMBERS WHO WERE AUTHORIZED TO RECEIVE FOOD STAMPS.

PFSTP

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

FIN.380

During {last year in 4 digit format}, about how many months {were/was} {you/subject 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

[p. 87]

Check item FINCCI5: If any female in family between 12 and 55 OR any child in family between 0 and 5, go to FIN.384; Else go to end of section.

FIN.384

At any time during {last year in 4 digit format} did {you/anyone in your family} receive benefits from the WIC program, that is, the Women, Infants, and Children program?

FINWIC

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

[(If one person family and FINWIC eq (1)) or FINWIC eq (2,7,9)] go to end of section;
[Else go to FIN.385]

FIN.385

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

Who received this? (Anyone else?)

FR: INDICATE FAMILY MEMBERS WHO WERE AUTHORIZED TO RECEIVE WIC BENEFITS.

PWIC

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

(Go to next section)

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