Screener Survey

SCREENER

A. COMPETENCY SCREENER

A-1. First, I need to briefly explain again a few things about the study. I will then ask you some questions to be sure you understand it. The interview includes questions about your previous work history; your health now; and any health care services you might use. Can you repeat the topics to me so that I can confirm you know what this interview is about?

LISTS ALL 1

LISTS ANY 2 2

LISTS ONLY 1 3

INCORRECT ANSWER(S) 4

DK 8

IF A-1 = 3, 4, OR 8 THEN REPEAT A-1.

IF A-1 = 3, 4, OR 8 A SECOND TIME, THEN END SCREENER.

OTHERWISE, CONTINUE WITH A-2.

A-2. Now, I need to remind you that your participation in this study is fully voluntary. You can decide to participate or not. Also, you can refuse to answer any questions during the interview or stop at any time if the questions make you uncomfortable.

When I say your participation is fully voluntary, what does that mean to you?

[INTERVIEWER: IF RESPONDENT SAYS “It is voluntary,” THEN PROBE FOR AN EXPLANATION. AN ACCURATE ANSWER IS “It is my choice whether or not to participate; I don’t have to do this (participate); I can do this (interview) if I want”; etc.]

ACCURATE ANSWER 1

INACCURATE ANSWER 2

A-3. All information you provide today will be kept confidential and used only for research purposes. Nobody other than members of the research team will have access to the information we get from you.

When I say that all information will be kept confidential, what does that mean to you?

[INTERVIEWER: IF RESPONDENT SAYS “It is confidential,” THEN PROBE FOR AN EXPLANATION. AN ACCURATE ANSWER IS “It will be secret; Only authorized (some) people will see what I said; What I say will be (kept) private; It will only be used for research”; etc.]

ACCURATE ANSWER 1

INACCURATE ANSWER 2

IF RESPONDENT CORRECTLY DEFINES VOLUNTARY AND

CONFIDENTIAL (A-2 = 1 AND A-3 = 1), THEN CONTINUE WITH NEXT SECTION.

OTHERWISE, END SCREENER.

B. COMORBID CONDITIONS SCREENER

The next few questions ask about any physical health conditions you may have that may prevent you from working at a job or business.

B-1. Do you have any diseases, disorders, or physical impairments that would prevent you from working, receiving supported employment services, or participating in any other study activities?

YES 1

NO 2 (C-1)

MAYBE 3

B-2. Tell me what that disease, disorder, or physical impairment is. Anything else?

TERMINAL CANCER 1 (END SCREENER)

HIV/AIDS 2 (END SCREENER)

END STAGE RENAL DISEASE 3 (END SCREENER)

OTHER (SPECIFY) 4

C. BENEFICIARY CONTACT INFORMATION

C-1. Are you still at {INSERT CURRENT ADDRESS ON FILE}?

YES 1 (C-3)

NO 2

C-2. What is your current address?

STREET ADDRESS

CITY

STATE

ZIP CODE

C-3. Is there another telephone number where we can reach you?

YES 1

NO 2 (C-5)

C-4. What is that number?

|__|__|__| - |__|__|__| - |__|__|__|__|

TELEPHONE NUMBER

C-5. Are you planning to move in the next 3 months?

YES 1

NO 2 (C-10)

C-6. What will your new address be?

STREET ADDRESS

CITY

STATE

ZIP CODE

C-7. When will you move to this new address?

|__|__| / |__|__| / |__|__|__|__|

MONTH DAY YEAR

C-8. Will you keep the same telephone number?

YES 1 (C-10)

NO 2

C-9. What will your new telephone number be?

|__|__|__| - |__|__|__| - |__|__|__|__|

TELEPHONE NUMBER

C-10. We’d like the names, addresses and phone numbers of two people who will know where you are if we have trouble contacting you during this study. We will not contact these people except to have them help us locate you to speak with you again, should that be necessary. If we do contact them, we will not discuss any of your personal information with them.

CONTACT 1 NAME

STREET ADDRESS

CITY

STATE

ZIP CODE

|__|__|__| - |__|__|__| - |__|__|__|__|

TELEPHONE NUMBER

CONTACT 2 NAME

STREET ADDRESS

CITY

STATE

ZIP CODE

|__|__|__| - |__|__|__| - |__|__|__|__|

TELEPHONE NUMBER

END SCREENER. Unfortunately you are not eligible to participate in our study at this time. Thank you for your interest.

4