5 Health Care Use

ID NUMBER:

FORM CODE: HCE VERSION: A 7/06/07

Contact Occasion

SEQ #

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 04 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

H

OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Health Care Use

ID NUMBER:

FORM CODE: HCE VERSION: A 7/06/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: Mark the appropriate box for the response. Unless instructed, mark ONLY one response.

1. In the past 12 months, where did you receive most of your health care? (Mark all that apply)

In the United States 1

In my country of origin (if not U.S.) 2

In another country 3

Did not receive any care 4

the past 12 months

Refused 5

2. Was there a time in the past 12 months when you needed health care, but could not get it?

No 0  GO TO QUESTION 5

Yes 1

Refused 2

Don’t know 9

3. What reason(s) did you not get health care in the past 12 months when you needed it?

(Mark all that apply)

a. You couldn’t get through on the telephone

b. You couldn’t get an appointment soon enough

c. Once you get there, you had to wait too long to see the doctor

d. The clinic/doctor’s office wasn’t open when you could get there

e. You didn’t have transportation

f. You had no access to an interpreter

g. You couldn’t take time off from work

h. You were concerned about any legal consequences

i. You were taking care of someone and could not leave them alone

j. You couldn’t afford it.

IF YES TO 3j  4. During the past 12 months, did you need any of the

following but, didn’t get it because you couldn’t afford it?

(Mark all that apply)

a. Prescription medications

b. To go to see a doctor  

c. Mental health care or counseling

d. Dental care

e. Eyeglasses

5. During the past 12 months, how many times did you see a physician or health care provider for your health care?

Number of times

IF RESPONSE TO QUESTION 5 IS ZERO  GO TO QUESTION 9

6. During the last 12 months, how often did office staff at a doctor’s office or clinic…

Always Usually Sometimes Never

a. treat you with courtesy and respect? 1 2 3 4

b. be as helpful as you thought they should be? 1 2 3 4

7. During the last 12 months, how often did doctors or other health providers…

Always Usually Sometimes Never

a. listen carefully to you? 1 2 3 4

b. explain things in a way you could understand? 1 2 3 4

c. show respect for what you had to say? 1 2 3 4

d. spend enough time with you? 1 2 3 4

8. During the last 12 months, how often did you have a hard time speaking with or understanding a doctor or other health providers because of language differences?

Never 1

Sometimes 2

Usually 3

Always 4

9. In the past 12 months have you used a curandero, santero, espiritista or other alternative care to treat any physical or emotional health concerns?

No 0

Yes 1

Refused 2

Don’t know 9

10. What type of health insurance coverage do you currently have? (Mark all that apply)

a. None  GO TO QUESTION 11

b. Coverage provided through a current or former

employer or credit union (excluding military coverage)

c. Coverage through an individual plan

d. Coverage through Medicaid

e. Coverage through Medicare

f. Coverage provided through the military

(e.g. CHAMPUS or Tri-Care)

g. Coverage through the Indian Health Services

h. Other

i. Refused

j. Don’t know

IF PARTICIPANTS REPORTS HAVING HEALTH INSURANCE COVERAGE  END QUESTIONNAIRE

11. About how long has it been since you last had health insurance coverage?

6 months or less 1

More than 6 months, but not more than 1 year ago 2

More than 1 year, but not more than 3 years ago 3

More than 3 years 4

Never had insurance 5  END QUESTIONNAIRE

12. Which of these are reasons you stopped being covered by health insurance? (Mark all that apply)

a. Person in family with health insurance lost job or changed employers

b. Got divorced or separated/death of spouse or parent

c. Became ineligible because of age/left school

d. Employer does not offer coverage or not eligible for coverage

e. Cost is too high; Insurance company refused coverage

f. Medicaid/medical plan stopped after pregnancy

g. Lost Medicaid/medical plan because of new job or increase in income

h. Lost Medicaid (other reason not listed above)

i. Other

If other, please specify: __________________________

j. Refused

k. Don’t Know

Health Care Use Form (HCE) Page 2 of 3