Addendum to the Supporting Statement for the Mental Health Treatment Study (MHTS)
OMB No. 0960-0726
Revisions to the Collection Instrument:
SSA is making the following revisions to the Follow-Up Questionnaire:
On pages 1 and 2, we are adding new questions at the beginning of the Questionnaire and renumbering them DM-1 through DM-9a:
DM-1. Are you still at (the current address as indicated on RIS)?
YES…………………………………………..1 (DM-3)
NO……………………………………………2
DM-2. What is your current address?
____________________________________
STREET ADDRESS
____________________________________
CITY
____________________________________
STATE
____________________________________
ZIP CODE
DM-3. Is there a telephone number other than (the one indicated on the RIS) where we can reach you?
YES………………………………….………..1
NO……………………………………………2 (DM-5)
DM-4. What is that number?
|__|__|__| - |__|__|__| - |__|__|__|__|
TELEPHONE NUMBER
DM-5. Are you planning to move in the next 3 months?
YES………………………………….………..1
NO……………………………………………2 (DM-9a)
DM-6. What will your new address be?
____________________________________
STREET ADDRESS
____________________________________
CITY
____________________________________
STATE
____________________________________
ZIP CODE
DM-7. When will you move to this new address?
|__|__|/|__|__|/|__|__|__|__|
MONTH DAY YEAR
DM-8. Will you keep the same telephone number?
YES…………………………………………..1 (DM-9a)
NO……………………………………………2
DM-9. What will your new telephone number be?
|__|__|__| - |__|__|__| - |__|__|__|__|
TELEPHONE NUMBER
[PROGRAMMER: ADD IN ITEM CO-10 FROM BASELINE INTERVIEW].
DM-9a. We’d like the names, addresses and phone numbers of two people who will know where you are if we need to contact you in the future and have trouble locating you. 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 not 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
On page 12, under AS-14 we are adding the following language:
[PROGRAMMER: PLEASE ADD A SOFT EDIT IF AS-1a > 0 AND RESPONSE TO AS-14 BELOW is 0 (ZERO).]
On page 13, under AS-15 we are adding the following language:
[PROGRAMMER: PLEASE ADD A SOFT EDIT IF (ANY AS-1c THROUGH AS-1m) = 1 (YES) AND RESPONSE TO AS-15 BELOW is 0 (ZERO).]
We are moving the Health Care Service Utilization (HC) questions from before to after the Employment Outcomes (EO) section.
On page 16, under EO-3 we are adding the following language:
[PROGRAMMER: PLEASE ADD A HARD EDIT IF EO-1 = 1 (YES) AND RESPONSE TO EO-3 BELOW is 0 (ZERO).]
On page 17:
We are removing the original question #6 “What {do/did} you do on the job?” and renumbering the question accordingly.
Under EO-7 we are adding the following language as well as EO-7a, EO‑7b and EO-7c:
[PROGRAMMER: PLEASE ADD THE THREE NEW ITEMS BELOW. WE BASICALLY MOVED ITEMS EO-20 THROUGH EO-22 HERE TO BE INCLUDED IN THE SUBROUTINE THAT IS REPEATED FOR EACH JOB THAT IS ENUMERATED. WE ALSO REMOVED THE FILL FROM THE ITEMS.]
EO-7a. How many hours per day {do/did} you usually work at that job?
|__|__|
HOURS
EO-7b. How many days per week {do/did} you usually work at that job?
|__|
DAYS
EO-7c. How many weeks per month {do/did} you usually work at that job?
|__|
WEEKS
We have added in new questions for EO-8, EO-8a, EO-8b:
EO-8. What {are/were} your main activities or duties on this job?
____________________________________
JOB DUTIES
EO-8a. What {is/was} the name of the organization or company you {work/worked} for?
____________________________________
NAME OF ORGANIZATION/COMPANY
EO-8b. What type of business {is/was} it, that is what type of product {is/was} made or what type of service {is/was} provided?
____________________________________
TYPE OF BUSINESS
On page 18, we are making the following changes:
We have changed the order of EO-9 and EO-10 so that we ask about hourly wage prior to asking if the respondent received a piece rate.
For EO-11 through EO-15, we added “CASUAL LABOR/SELF-EMPLOYED” as an optional answer.
On page 19, we are making the following changes:
Under EO-18, the parenthetical remark next to “NO………….2” will be changed to “(EO-19a)”
Under EO-19, we are revising the following:
We are adding EO-19a:
[PROGRAMMER: ADD IN NEW ITEM].
EO-19a. {Are you working/Did you work} full-time or part-time as (a/an) {INSERT JOB TITLE FROM EO-17}?
FULL-TIME……………………………………..1
PART-TIME……………………………………..2
We are removing EO-20, EO-21 and EO-22 (as we have moved them to EO-7 and renamed them EO-7a, EO-7b, and EO-7c).
We are removing EO-27.
On page 21, under EO-30, we are adding EO-30a:
[PROGRAMMER: ADD IN NEW ITEM}
ONLY ASK EO-30a IF WORKING PART-TIME AT MAIN JOB (EO-19a = 2)
EO-30a. People have many reasons for not working full-time. Why {are you not working/did you not work} full-time?
COULDN’T FIND FULL-TIME JOB…………………..1
TOO SICK TO WORK FULL-TIME…………………....2
DON’T WANT TO WORK MORE…………...................3
OTHER DEMANDS ON TIME (i.e., PETS, CHILD)…...4
MAKE ENOUGH MONEY WORKING PART-TIME….5
OTHER (SPECIFY)……………………………………..91
On page 22:
Under EO-31, a., we are adding the following instructions:
[PROGRAMMER: PLEASE ADD A HARD EDIT IF EO-4 = 1 (YES) AND RESPONSE TO EO-31a ABOVE IS 0 (ZERO). PLEASE ADD A SOFT EDIT IF EO-1 =1 (YES) AND RESPONSE TO EO-31a ABOVE IS 0 (ZERO)]
In the box under EO-33, we are changing “GO TO NEXT SECTION” to “GO TO INTRO TO EO-35”
On page 23, we are adding the following:
Instructions before EO-35:
[PROGRAMMER: ADD IN ITEM AT-6 FROM BASELINE INTERVIEW. PLEASE NOTE ITEM (i) HAS BEEN ADDED AS A NEW ITEM.]
I’d like to ask you a few questions about your basic understanding of Social Security benefits.
A new EO-35:
EO-35. Fear of losing benefits is common among most beneficiaries. Please tell me whether you agree or disagree with these statements about Social Security benefits.
DISAGREE NOT SURE AGREE
a. As soon as people start working they stop getting their benefit checks. 1 2 3
b. I can make more money just collecting my benefit checks than I can if
I go to work while on benefits. 1 2 3
c. I can make money at a job and still collect my benefit checks. 1 2 3
d. As soon as people start working they lose their medical coverage. 1 2 3
e. Unless a job offers coverage of mental health and prescriptions, I can’t
afford to take it. 1 2 3
f. If I go to work, get off of benefits and get sick right away, I’ll have a hard
time getting back on benefits. 1 2 3
g. I can’t afford to get training to help me get a better job. 1 2 3
h. If I knew that I wouldn’t lose all of my benefits, I would try to get a job
or get a better job. 1 2 3
i. If I go to work, the Social Security Administration might think I’m really
not sick and that I can work. 1 2 3
Instructions before CQ-38 and CQ-39:
ONLY ASK CQ-38 AND CQ-39 FOR BENEFICIARIES IN THE CONTROL GROUP.
The new CQ-38 and CQ-39:
CQ-38. Did you receive any employment, vocational, job skills, or job finding services since {INSERT DATE FROM LAST INTERVIEW}?
YES…………………………………………..1
NO……………………………………………2 (NEXT SECTION)
CQ-39. Tell me about those services.
[INTERVIEWER: CODE ALL THAT APPLY.]
SUPPORTED EMPLOYMENT 1
JOB FINDING SERVICES 2
JOB SKILLS TRAINING 3
VOCATIONAL REHABILITATION 4
PREVOCATIONAL WORK CREW 5
OTHER EMPLOYMENT OR VOCATIONAL
SERVICES 6
We are revamping the entire Health Care Coverage and Utilization sections by creating a separate set of questions for Coverage. The Coverage section, section A, will be asked prior to the Utilization questions (which we already ask in the current version of the questionnaire).
On page 24, we are making the following changes:
We are adding the following instructions at the top of the page:
[PROGRAMMER: ADD IN ITEMS HC-1 THROUGH HC-18 ON HEALTH INSURANCE COVERAGE FROM BASELINE INTERVIEW].
ONLY ASK HC-1 THROUGH HC-18 FOR BENEFICIARIES IN THE CONTROL GROUP.
A. HEALTH CARE COVERAGE
Now I’d like to ask you some questions about health insurance.
We are creating new questions for HC-1, HC-2, HC-3, HC-4 and HC-5:
HC-1. Do you have health insurance coverage now?
[INTERVIEWER: PROBE IF NECESSARY: “For instance, are you covered by a plan that someone else in your family has, or through a health plan your employer provides, or Medicare, Medicaid, or a plan you bought on your own?”]
YES…………………………………………..1 (HC-3)
NO……………………………………………2
HC-2. So, you are uninsured, is that correct?
[INTERVIEWER: PROBE IF NECESSARY: “This means no Medicaid coverage or any other government sponsored health insurance coverage.”]
YES…………………………………………..1 (HC-15)
NO……………………………………………2
HC-3. Are you covered by Medicare?
[INTERVIEWER: PROBE IF NECESSARY: “Medicare is the health insurance plan for people 65 and older or for people with certain disabilities.”]
YES…………………………………………..1
NO……………………………………………2 (HC-7)
HC-4. Are you enrolled in Part B of Medicare which provides coverage for doctor and clinic visits, laboratories, and other nonhospital services?
YES…………………………………………..1
NO……………………………………………2
HC-5. Are you enrolled in Part D of Medicare which provides coverage for prescription medications?
YES…………………………………………..1
NO……………………………………………2
On page 25, we are adding HC-6, HC-7, HC-8, HC-9, HC-10, HC-11 and HC-12:
HC-6. Are you covered by Medicare supplemental insurance or Medigap?
[INTERVIEWER: PROBE IF NECESSARY: “These policies are designed to cover the costs of health care that are not covered by Medicare.”]
YES…………………………………………..1
NO……………………………………………2
HC-7. Are you covered by any private health insurance plan (excluding Medigap plans), such as health insurance that you obtain through an employer, through COBRA, through a family member, or buy personally?
YES,EMPLOYER 1
YES, COBRA OR BOUGHT PERSONALLY 2
YES, THROUGH A FAMILY MEMBER 3
NO 4 (HC-9)
YES, SOME OTHER PRIVATE
SOURCE (SPECIFY) 91
HC-8. Does this plan pay for some part of your prescription medications?
YES…………………………………………..1
NO……………………………………………2
HC-9. Are you covered by Medicaid?
[INTERVIEWER: PROBE IF NECESSARY: “Medicaid is the government assistance program that helps pay for health care.”]
YES…………………………………………..1
NO……………………………………………2
HC-10. {INSERT STATE SCHIP PROGRAM } is a government assistance program that helps pay for health care for children in this state. Sometimes this program helps pay for health care for parents too. Are you covered by {INSERT STATE SCHIP PROGRAM}?
YES…………………………………………..1
NO……………………………………………2
HC-11. Are you covered by a military health insurance plan such as CHAMPUS, CHAMP-VA, or TRICARE?
YES…………………………………………..1
NO……………………………………………2
HC-12. Do you have state, county or any other government health insurance coverage through some other source that I have not mentioned?
YES (SPECIFY)……………………………...1
NO……………………………………………2 (HC-14)
On page 26, we are adding HC-13, HC-14, HC-15, HC-16, HC-17 and HC-18:
HC-13. Does this plan pay for some part of your prescription medications?
YES…………………………………………..1
NO……………………………………………2
HC-14. Do you receive medications or get help in paying for medications from any other programs?
[INTERVIEWER: PROBE IF NECESSARY: “Programs such as State Pharmacy Assistance Program, Pharmaceutical Companies.”]
YES (SPECIFY)……………………………...1
NO……………………………………………2
HC-15. Do you get free or subsidized health care services directly from any other program?
YES (SPECIFY)……………………………...1
NO……………………………………………2 (BOX HC-1)
HC-16. Does this program also provide prescription medications?
YES…………………………………………..1
NO……………………………………………2
BOX HC-1
IF RESPONDENT IS UNINSURED (HC-2 = 1), THEN CONTINUE WITH HC-17 OTHERWISE, GO TO SECTION B.
HC-17. In the past have you ever had health insurance?
YES…………………………………………..1
NO……………………………………………2 (HC-19)
HC-18. When did you become uninsured? Would you say…
Within the past six months, …………………...1
Within the past year, ………………………….2
Within the past 2 years, ……………………….3
With in the past 5 years, or ……………………4
More than 5 years ago? ………………………..5
On p. 27-p.29, we are adding the following:
The title “B. HEALTH CARE SERVICE UTILIZATION”
The questions in this section appear in the Health Care Utilization section of the current version of the questionnaire.
We are deleting HC-2.
We are adding instructions to the interviewer and programmer for HC-3 through HC-8:
HC-3:
[INTERVIEWER: ASK RESPONDENT ABOUT PREVIOUS EMERGENCY ROOM VISITS BY READING THE DATE AND NAME OF THE LAST EMERGENCY ROOM VISIT ENTERED. VISITS MUST BE WITHIN THE LAST SIX MONTHS.]
HC-4:
[INTERVIEWER: ENTER NAME OF EMERGENCY ROOM. IF RESPONDENT DOES NOT KNOW THE NAME OR REFUSES TO GIVE IT, PLEASE ENTER A DESCRIPTION. ENTER THE WORD “DELETE” TO INDICATE THIS ENTRY IS AN ERROR.]
HC-5:
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-3) AND NAME OF PLACE (RESPONSE TO HC-4) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
HC-6:
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-3) AND NAME OF PLACE (RESPONSE TO HC-4) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
HC-7:
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-3) AND NAME OF PLACE (RESPONSE TO HC-4) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
HC-8:
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-3) AND NAME OF PLACE (RESPONSE TO HC-4) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
We are deleting HC-10.
We are adding instructions to the interviewer and programmer for HC-12 through HC-14, HC-16, HC-19 through HC-20, and HC-23 through HC-28:
HC-12:
[INTERVIEWER: ENTER NAME OF HOSPITAL. IF RESPONDENT DOES NOT KNOW THE NAME OR REFUSES TO GIVE IT, PLEASE ENTER A DESCRIPTION. ENTER THE WORD “DELETE” TO INDICATE THIS ENTRY IS AN ERROR.]
HC-13:
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-11) AND NAME OF PLACE (RESPONSE TO HC-12) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
HC-14:
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-11) AND NAME OF PLACE (RESPONSE TO HC-12) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.
HC-16:
[INTERVIEWER: ENTER NAME OF PSYCHIATRIC EMERGENCY CENTER. IF RESPONDENT DOES NOT KNOW THE NAME OR REFUSES TO GIVE IT, PLEASE ENTER A DESCRIPTION THAT WILL UNIQUELY IDENTIFY THIS VISIT FROM ANY OTHER VISIT. ENTER THE WORD “DELETE” TO INDICATE THIS ENTRY IS AN ERROR.]
HC-19:
[PROGRAMMER: DISPLAY NAME OF CENTER (RESPONSE TO HC-16) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
HC-20:
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY NAME OF CENTER (RESPONSE TO HC-16) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
HC-23:
[INTERVIEWER: ENTER NAME OF CLINIC OR MENTAL HEALTH PROVIDER. IF RESPONDENT DOES NOT KNOW THE NAME OR REFUSES TO GIVE IT, PLEASE ENTER A DESCRIPTION THAT WILL UNIQUELY IDENTIFY THIS CLINIC FROM ANY OTHER CLINIC. ENTER THE WORD “DELETE” TO INDICATE THIS ENTRY IS AN ERROR.]
HC-24:
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY NAME OF CLINIC (RESPONSE TO HC-23) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
HC-25:
[PROGRAMMER: DISPLAY NAME OF CLINIC (RESPONSE TO HC-23) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
HC-26:
[INTERVIEWER: IF RESPONDENT DOES NOT KNOW THE NAME OR REFUSES TO GIVE IT, PLEASE ENTER A DESCRIPTION THAT WILL UNIQUELY IDENTIFY THIS PROVIDER FROM ANY OTHER PROVIDER.]
HC-27:
[PROGRAMMER: DISPLAY NAME OF CLINIC (RESPONSE TO HC-23) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
HC-28:
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY NAME OF CLINIC (RESPONSE TO HC-23) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
On p. 33, we are removing the current HC-30 and adding a new HC-30, HC-31, and HC-32:
HC-30. How often do you use your psychiatric medications as prescribed by the doctor or as directed on the label? Would you say…
Most of the time, and by that I mean at least 80% of the time, ………… 1
Some of the time, and by that I mean 50% to 80% of the time, or ……... 2
Less than half the time, which means less than 50% of the time? ……… 3
HC-31. Do you have all of the information you need about your psychiatric medications? Would you say…
Yes, I have all of the information I need, or …...1
No, I do not have enough information? ………..2
HC-32. In general, how do you feel about taking psychiatric medications? Would you say…
Positive, ……………………………..………...1
Negative, …………………………………..….2
Neither one? …………………………………...3
On p. 34, we are making the following revisions:
Under QL-1:
We are adding interviewer instructions:
[INTERVIEWER: SHOW QL CARD.]
We are adding the following box:
ONLY ASK QL-2 THROUGH QL-6 FOR BENEFICIARIES IN THE TREATMENT GROUP.
We are revising the language in the sentence below the box to state as follows: “Now I want to ask about the vocational services you were getting.”
In QL-2 we are making the following changes:
We are revising the question to read as follows: “How do you feel about the vocational services you received at {INSERT NAME OF MHTS SITE}?”
We are adding the following interviewer instructions:
[INTERVIEWER: SHOW QL CARD.]
On p. 35, we are adding QL-3, QL-4, and QL-5:
QL-3. How do you feel about the assistance you received from the Nurse Care Coordinator at {INSERT NAME OF MHTS SITE}?
[INTERVIEWER: PROBE IF NECESSARY: “By Nurse Care Coordinator, I mean (INSERT NAME OF NURSE CARE COORDINATOR AT YOUR SITE).
[INTERVIEWER: SHOW QL CARD.]
TERRIBLE …………………...……..………... 1
UNHAPPY …………………………………... 2
MOSTLY DISSATISFIED …………………... 3
MIXED ……………………………………….. 4
MOSTLY SATISFIED ……………………….. 5
PLEASED …………………………………….. 6
DELIGHTED …………………………………. 7
QL-4. How do you feel about the systematic medication management services you received at {INSERT NAME OF MHTS SITE}?
[INTERVIEWER: PROBE IF NECESSARY: “By systematic medication management, I mean the help you received from your prescriber and the Nurse Care Coordinator to help you manage your medications.
[INTERVIEWER: SHOW QL CARD.]
TERRIBLE …………………...……..………... 1
UNHAPPY …………………………………... 2
MOSTLY DISSATISFIED …………………... 3
MIXED ……………………………………….. 4
MOSTLY SATISFIED ……………………….. 5
PLEASED …………………………………….. 6
DELIGHTED …………………………………. 7
QL-5. How do you feel about any other behavioral services that you received at {INSERT NAME OF MHTS SITE}?
[INTERVIEWER: PROBE IF NECESSARY: “By other behavioral health services, I mean any help you may have received with case management, substance use, housing, family or social intervention, or help with financial or legal problems.
[INTERVIEWER: SHOW QL CARD.]
TERRIBLE …………………...……..………... 1
UNHAPPY …………………………………... 2
MOSTLY DISSATISFIED …………………... 3
MIXED ……………………………………….. 4
MOSTLY SATISFIED ……………………….. 5
PLEASED …………………………………….. 6
DELIGHTED …………………………………. 7
On p. 33, we are adding QL-6:
QL-6. Now I’d like to ask you a few additional questions about the services you received at {INSERT NAME OF MHTS SITE}. I am going to read you a series of statements about your experience with {INSERT NAME OF MHTS SITE}. Please tell me if you strongly agree, somewhat disagree, or strongly disagree.
[INTERVIEWER: SHOW EO CARD.]
STRONGLY SOMEWHAT SOMEWHAT STRONGLY
AGREE AGREE DISAGREE DISAGREE
a. No child care services were offered. 1 2 3 4
b. {INSERT NAME OF MHTS SITE} did not help me with
transportation. 1 2 3 4
c. {INSERT NAME OF MHTS SITE} had limited job opportunities. 1 2 3 4
d. The enrollment process at {INSERT NAME OF MHTS SITE}
was complicated . 1 2 3 4
e. It felt like there wasn’t anybody else like me at
{INSERT NAME OF MHTS SITE}. 1 2 3 4
f. The options offered by {INSERT NAME OF MHTS SITE} to
help me with my mental illness were limited. 1 2 3 4
g. I need more help to get ready to go back to work. 1 2 3 4
h. I did not want to tell any employers about my mental illness
so I did not have a job coach with me at my job. 1 2 3 4
I did not want any help from {INSERT NAME OF MHTS SITE}
with my mental illness. I just wanted help finding a job. 1 2 3 4
| File Type | application/msword |
| File Title | Addendum to the Supporting Statement for the Mental Health Treatment Study (MHTS) |
| Author | 177717 |
| Last Modified By | 177717 |
| File Modified | 2009-05-06 |
| File Created | 2009-03-19 |