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pdfBOND Implementation and Evaluation
Appendix C.
Abt Associates Inc.
Contract No. SS00-10-60011
Benefit Offset National Demonstration
Stage 2 Interim Survey Instrument
Appendix C. BOND Stage 2 Interim Survey Instrument
C-1
BOND Implementation and Evaluation
Contract No. SS00-10-60011
Table of Contents
SECTION A: CONFIRMATION OF RESPONDENT / SCREENER / INTRODUCTIONS ..... 1
SECTION B: AWARENESS OF BOND PROGRAM AND KNOWLEDGE OF
HOW EARNINGS AFFECT CALCULATION OF SSDI BENEFITS ................. 6
SECTION C: SERVICE UTILIZATION .................................................................................. 9
SECTION D: CURRENT EMPLOYMENT ........................................................................... 14
SECTION E: WORK HISTORY SINCE RANDOM ASSIGNMENT ..................................... 18
SECTION F: SECONDARY CONTACT INFORMATION ................................................... 22
SECTION G: RESPONDENT CONTACT INFORMATION ................................................. 24
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
i
BOND Implementation and Evaluation
Contract No. SS00-10-60011
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. §
3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these
questions unless we display a valid Office of Management and Budget control number. The OMB control
number for this information collection is [INSERT NUMBER], expiring [INSERT EXPIRATION DATE]. We
estimate that it will take about 30 minutes to read the instructions, gather the facts, and answer the questions.
You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 212356401. Send only comments relating to our time estimate to this address, not the completed form.
SECTION A: CONFIRMATION OF RESPONDENT / SCREENER /
INTRODUCTIONS
INITIAL CONTACT WITH RESPONDENT
NOTE TO INTERVIEWER: DO NOT READ TEXT IN ALL CAPS.
Hello, my name is _________ I work for Abt Associates Inc., a national research company based in
Cambridge, MA. Thank you for taking the time to speak with me today. You may have received a letter
in the past week or so that explained the study and the purpose of this interview.
[Use same introduction for Ts and Cs]. Abt Associates is conducting a study for the Social Security
Administration. The study is about a new program that SSA is administering called the Benefit Offset
National Demonstration Program, or BOND. You may recall applying for this new program in [YEAR OF
RANDOM ASSIGNMENT], The purpose of this interview is to find out about any types of services you
may have received and any work experiences you may have had in the past year. SSA wants to find out
about the services people get and how helpful these services are. Your opinions and experiences are
very important and valuable for the study.
You may recall answering a long survey about a year ago, for which you received $40. At this time, we
would like to ask you to complete a much shorter interview. We estimate that this interview will take
about [30] minutes to complete.
Your participation in this interview is completely voluntary. It will in no way affect your current or future
receipt of benefits. You can stop the interview at any time. If any question makes you feel
uncomfortable, you can refuse to answer that question. [IF TELEPHONE: You will receive $25 for
participating in this interview in about a month.] [IF IN-PERSON: At the end of the interview, you will
receive $25 for participating in this interview.]
All information you provide is confidential and it will be protected to the fullest extent possible by law,
including the Privacy Act. This means for example, that we may need to notify someone if keeping that
information confidential could harm you or someone else. Three groups of people will see your answers:
the interviewer, the researchers doing the study, and the Social Security Administration that funded the
study. Your name will not be attached to your survey answers in the data files used by these groups.
Your name will never appear in any report. Research reports will only present summary information. The
researchers will not use names or individual identifying information in any research report.
Do you have any questions before we begin?
IF YES: Interviewer responds to questions as they arise.
If NO:
All right then, do you mind if we start the interview now? It should take approximately 30
minutes. At the end of the interview I will [send you/give you] a [check/money order] for
$25 to thank you for your time.
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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BOND Implementation and Evaluation
Contract No. SS00-10-60011
REVIEWER NOTE: There is also a screener to verify the identity of the respondent that begins by
checking birth date and continues by checking other data (perhaps name of informant) if
interviewer cannot verify birth date. To simplify review, verification screeners have been removed
from this draft.
Screeners vary depending upon:
if a proxy is needed; or
if there is a language barrier.
Let’s begin with some general questions. We may have asked similar questions in the past. If we repeat
questions you have answered before, it is so we can update our information.
* Indicates questions not to be asked of proxies.
A1.
Are you currently working at a job or business for pay or profit? This includes work you may do
for a business that you own.
IF NEEDED READ: By ‘working at a job for pay or profit’ we mean at a job where you get paid
money for the work you do.
[INTERVIEWER: IF R IS SELF-EMPLOYED, CODE RESPONSE AS YES]
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
A2.
Are you currently enrolled in school or taking any classes?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
A3.
Do you currently do any volunteer work for an organization?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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BOND Implementation and Evaluation
A4.
Contract No. SS00-10-60011
In general, would you say your health is . . .
(SF-12)
Excellent,.............................................................................................1
Very good,...........................................................................................2
Good, ..................................................................................................3
Fair, or.................................................................................................4
Poor?...................................................................................................5
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
A5.
Compared to {THIS MONTH, LAST YEAR}, how would you rate your health in general now?
Much better now,.................................................................................1
Somewhat better now, ........................................................................2
About the same, ..................................................................................3
Somewhat worse now, or....................................................................4
Much worse now? ...............................................................................5
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
A6.
What is your current marital status? Are you now married, widowed, divorced, separated or have
you never been married?
MARRIED............................................................................................1
WIDOWED ..........................................................................................2
DIVORCED .........................................................................................3
SEPARATED ......................................................................................4
NEVER MARRIED ..............................................................................5
REFUSED ...........................................................................................7
(SKIP TO SECT B)
DON’T KNOW .....................................................................................8 (SKIP TO SECT B)
A7.
Are you currently living with a spouse or with someone who is like a spouse to you?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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BOND Implementation and Evaluation
A8.
Contract No. SS00-10-60011
CHECK FOR ABILITY TO CONTINUE WITH SELF-RESPONSE. HOW MANY ITEMS IN
QUESTIONS A1-A7 ARE ANSWERED REFUSED OR DON’T KNOW?
1 OR 2.................................................................................................1
(SKIP TO SECT B)
3 OR MORE ........................................................................................2
[INSTRUCTION: IF RESPONDENT FAILS SCREENER, CAPI WILL PROMPT FOR NAME OF A
PROXY RESPONDENT. IF PROXY IS AVAILABLE SCREENERS WILL REPEAT WITH PROXY. IF NO
PROXY AVAILABLE INTERVIEWER WILL TERMINATE]
A9.
It seems like some of these questions are difficult for you. Is there anyone who can help do this
interview you or answer questions for you?
YES .....................................................................................................1
NO .......................................................................................................2 (THANK/END)
REFUSED ...........................................................................................7 (THANK/END)
DON’T KNOW .....................................................................................8 (THANK/END)
A10.
A9a.
What is his/her first name?
A9b.
What is his/her middle name?
A9c.
What is his/her last name?
A9d.
Does his/her name have a suffix?
What is (his/her) street address?
A10a. Is there a complex/building name?
A10b. Is there an apartment number?
A10c.
In what city?
A10d. In what state?
A10e. What is the zip code?
A11.
What's the best phone number to reach (him/her) at starting with the area code?
Telephone # with area code: (_______) ________-________
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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BOND Implementation and Evaluation
A12.
Contract No. SS00-10-60011
Is she/he a friend or a relative, or what is (his/her) relationship to you?
ACCEPT ONE RESPONSE ONLY.
FRIEND...............................................................................................1
RELATIVE...........................................................................................2
LEGAL GUARDIAN.............................................................................3
CASE MANAGER ...............................................................................4
OTHER (SPECIFY):____________________________ ...................5
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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BOND Implementation and Evaluation
Contract No. SS00-10-60011
SECTION B: AWARENESS OF BOND PROGRAM AND KNOWLEDGE
OF HOW EARNINGS AFFECT CALCULATION OF SSDI
BENEFITS
B1.
Before today, had you ever heard of the Benefit Offset National Demonstration, or the BOND
program?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO B2)
REFUSED ...........................................................................................7 (SKIP TO B2)
DON’T KNOW .....................................................................................8 (SKIP TO B2)
B1a.
[IF B1=YES] If asked, how would you describe the BOND program to a friend or relative?
[RECORD VERBATIM]
___________________________________________________________________
___________________________________________________________________
INTERVIEWER READS THIS INTRODUCTION: Under the current rules of the Social Security Disability
Insurance program, disability beneficiaries are allowed to earn up to $1000 per month without a change to
your benefits. This limit is called the level of Substantial Gainful Activity or SGA and the Social Security
increases this limit each year to adjust for inflation. When disability beneficiaries go to work while
receiving disability benefits, SSA ignores the cap of $1,000 for up to 9 months, no matter how much a
beneficiary earns from work.
B2.
We’d like to know which of the following things you think would happen to your monthly
disability cash benefits if you were to work and earn more than the SGA limit of $1000 month
after those initial months have passed. Thinking about the amount of your disability cash
benefits, if you earned more than $1,000 after those initial months…
B2a.
Do you think you would lose your monthly benefits completely? That is, would the
amount of your benefits fall to $0?
YES .....................................................................................................1 (SKIP TO B2e)
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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BOND Implementation and Evaluation
B2b.
Contract No. SS00-10-60011
Do you think your benefits would be reduced but that you would be able to keep receiving
some of your monthly disability benefits?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO B2d)
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
B2c.
[IF B2b=YES] How do you think those benefits would be reduced? Do you think that they
would be reduced…
By the full amount of your benefit? ....................................................1
By half of the amount of your benefits, that is a $1 reduction in benefits for every $2 you earn
from work? ..........................................................................................2
By some other amount? .....................................................................1
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
B2d.
Do you think your disability benefits would stay the same? That is, nothing would happen
to your monthly disability benefits if you earned more than $1,000 per month after the
initial 9 months that SSA allows?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
Now, we’d like to know which of the following things you think would happen to your eligibility for
disability benefits if you were to work and earn more than the SGA limit of $1000 month after
those initial months have passed. Thinking about your eligibility for disability benefits…
B2e.
Do you think you would remain eligible for disability benefits in the future, no matter how
much you earn from work? That is, you would never have to re-apply for benefits?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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BOND Implementation and Evaluation
B2f.
Contract No. SS00-10-60011
Do you think you would remain eligible for disability benefits for awhile, but eventually you
would no longer be eligible to receive benefits? That is, do you think eventually you
would have to re-apply for benefits?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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BOND Implementation and Evaluation
Contract No. SS00-10-60011
SECTION C: SERVICE UTILIZATION
C1.
Since [RADATE] have you talked to someone about how work and earnings affect your Social
Security benefits and assistance from other programs? This is sometimes referred to as benefits
counseling, and could be done by a benefits counselor, or someone from the [PROGRAM
NAME].
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO C6)
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
C2.
I would like to ask you about how satisfied you are with your benefits counseling experience.
Think about your experience trying to contact your benefits counselor or program staff member
since [RADATE]. For each statement I read, please tell me if you were very satisfied, somewhat
satisfied, somewhat dissatisfied, or very dissatisfied with your experience in this area.
Very
Satisfied
Somewhat
Satisfied
Somewhat
Dissatisfied
Very
Dissatisfied
REF
DK
C2a. How satisfied were you with how soon
the benefits counselor or [program staff
person] was available to talk to you?
1
2
3
4
7
8
C2b. When you tried to reach the benefits
counselor, how satisfied were you with
the time it took you to reach the
counselor by phone?
1
2
3
4
7
8
1
2
3
4
7
8
C2c.
When you left a message for the
benefits counselor, how satisfied were
you with the time it took for the benefits
counselor to return a call to you?
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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BOND Implementation and Evaluation
C3.
C4.
Contract No. SS00-10-60011
Think about how the benefits counselor treated you in your most recent interaction. For each
item I read, please tell me how you would rate your experience with the benefits counselor in this
area.
Excellent
Good
Fair
Poor
Very Poor
REF
DK
C3a. Thinking about the benefits counselor who
helped you most recently, how would you
rate their courtesy? By courtesy I mean that
they treated you kindly and respectfully.
Would you say that the courtesy shown
toward you was excellent, good, fair poor,
very poor?
1
2
3
4
5
7
8
C3b. How would you rate the amount of time that
the benefits counselor or program staff
person spent with you? Would you say the
amount of time spent was excellent, very
good, good, fair, poor, or very poor?
1
2
3
4
5
7
8
Now I’d like you to think about how you felt after your received information from your benefits
counselor or program staff member over the past 6 months. For each statement I read, please
tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with the
statement.
Strongly
Agree
Somewhat
Agree
Somewhat
Disagree
Strongly
Disagree
N/A
REF
DK
1
2
3
4
5
7
8
1
2
3
4
5
7
8
Written materials about my
personal situation and benefits my
counselor gave me clearly told me
what I needed to know. Do you…
1
2
3
4
5
7
8
The pamphlets and booklets I
received from the benefits
counselor helped me to understand
how work and earnings affect my
benefits. Do you…
1
2
3
4
5
7
8
C4a. I felt that my benefits counselor
clearly explained how earning
money would affect my cash
benefits, medical insurance, and
other types of assistance. Do you
strongly agree, somewhat
agree, somewhat disagree, or
strongly disagree?
C4b. After talking with my benefits
specialist I knew what I was
supposed to do or what was
supposed to happen next. Do
you…
C4c.
C4d.
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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BOND Implementation and Evaluation
C5.
Contract No. SS00-10-60011
Considering all of the information and help given to you by the benefits counselor from
[PROGRAM NAME], how would you rate the service provided overall? Would you say the
service was excellent, very good, good, fair, poor, or very poor?
EXCELLENT ......................................................................................1 (SKIP TO C6)
VERY GOOD ......................................................................................2 (SKIP TO C6)
GOOD .................................................................................................3 (SKIP TO C6)
FAIR ...................................................................................................4
POOR .................................................................................................5
VERY POOR ......................................................................................6
REFUSED ...........................................................................................7 (SKIP TO C6)
DON’T KNOW .....................................................................................8 (SKIP TO C6)
C5a.
C6.
[IF C5=FAIR, POOR, VERY POOR] Could you please tell me more about why you rated
the overall service provided as [FAIR/POOR/VERY POOR]?
Next, I would like to ask you about different types of services or supports that you may have
received to improve your ability to work independently. For each service I read, please tell
me if it is something you have used since [RADATE], if you needed, but did not use it, or if you
did not need it.. [NBS modified]
Yes
Used
Since [RADATE] did you get…
Not
Used
Not
Needed
REF
DK
C6a. A work or job assessment?
1
2
3
7
8
C6b. Help to find a job?
1
2
3
7
8
C6c. Training to learn a new job or skill?
1
2
3
7
8
C6d. Advice about modifying your job or work
place?
1
2
3
7
8
C6e. On-the-job training, job coaching, or support
services?
1
2
3
7
8
C6f.
1
2
3
7
8
Personal care assistance?
C6g. Transportation assistance?
1
2
3
7
8
C6h. Help in keeping a job?
1
2
3
7
8
Any kind of assistive device (a piece of
equipment to make it easier for you to live
independently or work?
1
2
3
7
8
Anything else that I did not mention?
SPECIFY___________________________
1
2
3
7
8
C6i.
C6j.
IF C6c = YES, ASK C7 ELSE SKIP TO C9
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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BOND Implementation and Evaluation
C7.
Contract No. SS00-10-60011
Where did you go to receive the training to learn a new job or skill? Did you go to…
Yes
Not
Used
Not
Needed
REF
DK
C7a. A vocational rehabilitation agency?
1
2
3
7
8
C7b. A welfare agency?
1
2
3
7
8
C7c. A mental health agency?
1
2
3
7
8
C7d. A state agency?
1
2
3
7
8
C7e. A workforce center or unemployment office
1
2
3
7
8
C7f.
1
2
3
7
8
1
2
3
7
8
An employer?
C7g. OTHER(SPECIFY___________________)
C8.
Who referred you to place(s) that you went for training or to learn a new job skill?
INTERVIEWER: MARK ONLY ONE. IF R INDICATES IT WAS THEIR IDEA CODE WAS NOT
REFERRED HERE.
PARENT/GUARDIAN..........................................................................1
SPOUSE/PARTNER ...........................................................................2
FRIEND...............................................................................................3
JOB COACH .......................................................................................4
EMPLOYER/SUPERVISOR ...............................................................5
OTHER RELATIVE .............................................................................6
BENEFIT SPECIALIST .......................................................................7
MEDICAL PROVIDER ........................................................................8
WAS NOT REFERRED BY ANYONE ................................................9
OTHER (SPECIFY____________________________________) ..10
REFUSED .........................................................................................97
DON’T KNOW ...................................................................................98
[IF C6e=YES, ASK C9 ELSE SKIP TO C11]
C9.
Where did you go to receive the on the job training, job coaching, or support services?
Yes
Not
Used
Not
Needed
REF
DK
C9a. A vocational rehabilitation agency?
1
2
3
7
8
C9b. A welfare agency?
1
2
3
7
8
C9c. A mental health agency?
1
2
3
7
8
C9d. A state agency?
1
2
3
7
8
C9e. A workforce center or unemployment office
1
2
3
7
8
C9f.
1
2
3
7
8
1
2
3
7
8
An employer?
C9g. OTHER(SPECIFY___________________)
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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BOND Implementation and Evaluation
C10.
Contract No. SS00-10-60011
Who referred you to place(s) that you went for on-the-job training, job coaching, or support
services?
INTERVIEWER: MARK ONLY ONE. IF R INDICATES IT WAS THEIR IDEA CODE WAS NOT
REFERRED BY ANYONE.
PARENT/GUARDIAN..........................................................................1
SPOUSE/PARTNER ...........................................................................2
FRIEND...............................................................................................3
JOB COACH .......................................................................................4
EMPLOYER/SUPERVISOR ...............................................................5
OTHER RELATIVE .............................................................................6
BENEFIT SPECIALIST .......................................................................7
MEDICAL PROVIDER ........................................................................8
WAS NOT REFERRED BY ANYONE ................................................9
OTHER (SPECIFY____________________________________) ..10
REFUSED .........................................................................................97
DON’T KNOW ...................................................................................98
C11.
Do you use any personal assistance services related to your disability to help you work, for
example, a job coach, a sign language interpreter, a reader or interpreter for the blind, or a
personal care attendant?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO D1)
REFUSED ...........................................................................................7 (SKIP TO D1)
DON’T KNOW .....................................................................................8 (SKIP TO D1)
C12.
What kind of personal assistance services do you use? Do you use a [READ ITEM]?
YES
NO
REF
DK
C12a. JOB COACH
1
2
7
8
C12b. SIGN LANGUAGE INTERPRETER
1
2
7
8
C12c. READER/INTERPRETER FOR THE BLIND
1
2
7
8
C12d. PERSONAL CARE ATTENDANT/PERSONAL
ASSISTANT
1
2
7
8
C12e. OTHER (SPECIFY) ___________________________
1
2
7
8
Do you use a [READ ITEM]?
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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BOND Implementation and Evaluation
Contract No. SS00-10-60011
SECTION D: CURRENT EMPLOYMENT
Now I would like to ask you some questions about your work experience.
D1.
Are you currently working at a job or business for pay or profit?
[PROBE: By ‘working at a job for pay or profit’ we mean at a job where you get paid money for
the work you do. This could also include work at a business that you own.]
YES .....................................................................................................1 (SKIP TO D3)
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
D2.
Have you worked at a job or business for pay or profit since [RADATE]?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
D2a.
When did you last work for pay?
|__|__|
MO
|__|__|__|__|
YEAR
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
D2b.
During the past four weeks, about how many hours in total did you spend looking for
work?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
IF D1=2,7,8 SKIP TO E1
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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D3.
Contract No. SS00-10-60011
How many jobs do you currently have?
NUMBER OF JOBS: ______________
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
[Programming in CAPI will control for main job versus current job, depending on the response to
D3.]
D4.
How many hours per week do you typically work at [this job/your main job]?
NUMBER OF HOURS PER WEEK: ______________
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
For the purpose of this survey, it is important to obtain some information on how much you are paid on
this job. Please remember that we will keep all of your responses private.
D5.
Before taxes and other deductions how much are you paid on this job? (NBS-modified)
$___________.______
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
D5a.
Is that amount paid daily, weekly, bi-weekly, twice a month, monthly, annually, or per
unit?
HOURLY .............................................................................................1 (SKIP TO D9)
DAILY..................................................................................................2
WEEKLY .............................................................................................3 (SKIP TO D7)
EVERY TWO WEEKS.........................................................................4 (SKIP TO D10)
TWICE A MONTH ...............................................................................5 (SKIP TO D10)
MONTHLY...........................................................................................6 (SKIP TO D10)
ANNUALLY .........................................................................................7 (SKIP TO D7)
PER UNIT OR PIECE .........................................................................8 (SKIP TO D8)
REFUSED .........................................................................................97
DON’T KNOW ...................................................................................98
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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BOND Implementation and Evaluation
D6.
Contract No. SS00-10-60011
[IF RATE OF PAY IS NOT DAILY (D5a2) SKIP TO D7] How many days a week do you usually
work? (CPS; MTO Interim Evaluation)
NUMBER OF DAYS PER WEEK: ______________
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
D7.
[IF RATE OF PAY NOT ANNUAL (D5a7 SKIP TO D8] How many weeks a year do you get
paid for? (CPS; MTO Interim Evaluation)
NUMBER OF WEEK: ______________
DON’T KNOW ................................................................................... -1
REFUSED ......................................................................................... -2
D8.
[IF RATE OF PAY NOT PER UNIT (D5a8 SKIP TO D9] for how many [UNIT]s are you usually
paid per week (on this job)?
NUMBER OF UNITS: ______________
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
D9.
[IF RATE OF PAY IS NOT HOURLY (D5a1) SKIP TO D10] How many hours per week are you
paid for at this rate? (CPS; MTO Interim Evaluation)
NUMBER OF HOURS PER WEEK: ______________
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
D10.
Do you usually receive tips, or commissions (at your main job)? (CPS–modified)
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO D11)
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
D10a. (At your main job,) how much do you usually earn in tips or commissions, before taxes or
other deductions? (CPS-modified)
$___________.______
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
Abt Associates Inc.
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D11.
Contract No. SS00-10-60011
I’d like you to think about your earnings in a typical week. How much do you think you typically
earn, before taxes or other deductions, in a typical week.
$___________.______
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
Abt Associates Inc.
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BOND Implementation and Evaluation
Contract No. SS00-10-60011
SECTION E: WORK HISTORY SINCE RANDOM ASSIGNMENT
IF DATE IN C3 IS PRIOR TO THE DATE OF RANDOM ASSIGNMENT, SKIP TO SECONDARY
CONTACT INFORMATION, F1
E1.
Now, I will ask you about any other jobs you have had in the past 12 months, that is since
[RADATE]. When answering these questions, please include both part-time and full-time jobs,
but only include work you did for pay or profit at a job that lasted for one month or longer.
You should include self-employment
IF CURRENTLY EMPLOYED (A1=1) ASK: Excluding the job we just talked about, between
[INTERVIEW MONTH TWO YEAR AGO] and today, did you work for pay at any other jobs for
longer than one month?
IF NOT CURRENTLY EMPLOYED (A1 DOES NOT EQUAL 1) ASK: Between [RADATE] and
today, did you work for pay at any jobs for longer than one month?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO F1)
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
IF RESPONDENT IS CURRENTLY WORKING, CAPI WILL INCORPORATE BRACKETED TEXT IN
D2.
E2.
[Excluding your current job,] How many (other) jobs did you hold for at least one month during the
past 12 months, that is since [RADATE] years?
NUMBER OF JOBS: ______________ (1-15)
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
PROGRAMMER: E3 THROUGH E4 ASKED FOR ALL JOBS WHEN E2>01
Abt Associates Inc.
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BOND Implementation and Evaluation
E3.
Contract No. SS00-10-60011
Let us start with [the job before your current one/ your last job]. What was the name of the place
that you worked [before your current/your last job]? [REPEAT FOR 5 SPELLS]
NAME1:_____________________________________________________________
E3a.
What was the name of the place that you worked before that?
NAME2:_____________________________________________________________
NAME3:_____________________________________________________________
NAME4:_____________________________________________________________
NAME5:_____________________________________________________________
E3 LOOPS UNTIL ALL EMPLOYERS IN FOLLOW UP ARE ACCOUNTED FOR.
E4 THROUGH E8 WILL LOOP ACCORDING TO D2 RESPONSE, FOR UP TO 5 RESPONSES.
E4.
In what month and year did you start working at [E3 JOB]?
PROBE: Your best estimate is fine.
INTERVIEWER: ENTER MONTH HERE AND YEAR ON NEXT SCREEN
|__|__|
MO
|__|__|__|__|
YEAR
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
E5.
In what month and year did you stop working at [E3 JOB]?
PROBE: Your best estimate is fine.
INTERVIEWER: ENTER MONTH HERE AND YEAR ON NEXT SCEEN
|__|__|
MO
|__|__|__|__|
YEAR
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
Abt Associates Inc.
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BOND Implementation and Evaluation
E5a.
Contract No. SS00-10-60011
That means that you worked at this place [NAME OF EMPLOYER] for about [INSERT
NUMBER] months [OR YEARS]. Does that sound right?
YES .....................................................................................................1
(SKIP TO E6)
NO .......................................................................................................2
REFUSED ...........................................................................................7 (SKIP TO E6)
DON’T KNOW .....................................................................................8
E5b.
(SKIP TO E6)
About how many months [OR YEARS] did you work at that job?
_____ MONTHS
______YEARS
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
E6.
Were you self-employed at E3 JOB]?
PROBE: Self-employed means that you work for yourself or own your own business.
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
[IF E6=1 THEN CAPI WILL SUBSTITUTE ‘at this business’ FOR ‘at this job’ in E7 and E8.]
E7.
How many hours per week did you usually work [at [D3 JOB]/at this business]?
PROBE: Include overtime if you usually worked overtime.
HOURS PER WEEK: ______________ (SKIP TO F1)
IT VARIED......................................................................................... -3
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
E7a.
Did you usually work more than 35 hours per week?
YES .....................................................................................................1
NO .......................................................................................................2
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
Abt Associates Inc.
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BOND Implementation and Evaluation
E8.
Contract No. SS00-10-60011
How much did you earn per week on average when you worked at [E3 JOB]?
$___________.______
REFUSED ......................................................................................... -2
DON’T KNOW ................................................................................... -1
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
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BOND Implementation and Evaluation
Contract No. SS00-10-60011
SECTION F: SECONDARY CONTACT INFORMATION
Thank you very much for your time today. To help us be able to get back in touch with you in the future,
we would like to collect the names, telephone numbers and addresses of two people who will always
know how to reach you. Please tell me about people who live at a different address than you. This
information will be kept strictly confidential and will only be used if we are unable to contact you.
F1.
Could you tell us the name of a primary person who does not live with you and will always know
how to contact you?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO F1)
REFUSED ...........................................................................................7 (SKIP TO F1)
DON’T KNOW .....................................................................................8 (SKIP TO F1)
CONTACT #1:
F2.
F3.
F4.
What is his/her first name?
E2a.
What is his/her middle name?
E2b.
What is his/her last name?
E2c.
Does his/her name have a suffix?
What is (his/her) street address?
E3a.
Is there a complex/building name?
E3b.
Is there an apartment number?
E3c.
In what city?
E3d.
In what state?
E3e.
What is the zip code?
What's the best phone number to reach (him/her) at starting with the area code?
Telephone # with area code: (_______) ________-________
E4a.
Is she/he a friend or a relative, or what is (his/her) relationship to you?
ACCEPT ONE RESPONSE ONLY.
FRIEND...............................................................................................1
RELATIVE...........................................................................................2
OTHER (SPECIFY):____________________________ ...................3
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
Abt Associates Inc.
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Contract No. SS00-10-60011
CONTACT #2:
F5.
Could you tell us the name of a second person who does not live with you and will always know
how to contact you?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO F1)
REFUSED ...........................................................................................7 (SKIP TO F1)
DON’T KNOW .....................................................................................8 (SKIP TO F1)
E5a.
What is the name of someone else who keeps in contact with you?
E5a1. What is his/her first name?
E5a2. What is his/her middle name?
E5b3. What is his/her last name?
E5c4.
F6.
Does his/her name have a suffix?
What is (his/her) street address?
E6a1. Is there a complex/building name?
E6a2. Is there an apartment number?
E6a3. In what city?
E6a4. In what state?
E6a5. What is the zip code?
F7.
What's the best phone number to reach (him/her) at starting with the area code?
Telephone # with area code: (_______) ________-________
E7a.
Is she/he a friend or a relative, or what is (his/her) relationship to you?
ACCEPT ONE RESPONSE ONLY.
FRIEND...............................................................................................1
RELATIVE...........................................................................................2
OTHER (SPECIFY):____________________________ ...................3
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
Abt Associates Inc.
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BOND Implementation and Evaluation
Contract No. SS00-10-60011
SECTION G: RESPONDENT CONTACT INFORMATION
Thank you very much for your time today. At this time we’d like to just confirm some information about
you. The information we confirm now will allow us to help us be able to get back in touch with you in the
future. [It will also allow us to ensure that your incentive payment is sent to the correct address.]
G1.
I have your name listed as [READ AND CONFIRM SPELLING OF NAME, FIRST MIDDLE LAST
SUFFIX]. Is that correct?
YES, ALL CORRECT..........................................................................1 (SKIP TO G3)
NO, CORRECT FIRST NAME ............................................................2 (GO TO G2A)
NO, CORRECT MIDDLE NAME.........................................................3 (GO TO G2B)
NO, CORRECT LAST NAME .............................................................4 (GO TO G2C)
NO, CORRECT SUFFIX .....................................................................5 (GO TO G2D)
REFUSED ...........................................................................................7 (SKIP TO G3)
DON’T KNOW .....................................................................................8 (SKIP TO G3)
G2.
G3.
Could you please tell me how to spell your name?
G2a.
FIRST:
What is your first name?
G2b.
MIDDLE:
What is your middle name?
G2c.
LAST:
What is your last name?
G2d.
SUFFIX:
Is there anything after your last name, like Jr. or Sr.?
Our records show that your current address is (READ FROM SAMPLE SHEET). Is this correct?
YES, ALL OF THAT IS CORRECT)....................................................1 (SKIP TO G4)
NO–UPDATE STREET .......................................................................2 (GO TO G3a)
NO–UPDATE APARTMENT/UNIT .....................................................3 (GO TO G3b)
NO–UPDATE CITY ............................................................................4 (GO TO G3c)
NO–UPDATE STATE..........................................................................5 (GO TO G3d)
NO–UPDATE ZIP................................................................................6 (GO TO G3e)
REFUSED .........................................................................................97 (SKIP TO G4)
DON’T KNOW ...................................................................................98 (SKIP TO G4)
Abt Associates Inc.
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BOND Implementation and Evaluation
G4.
Contract No. SS00-10-60011
G3a.
STREET:
What is your current street address?
G3b.
APT:
Is there an apartment number?
G3c.
CITY:
In what city do you live?
G3d.
STATE:
In what state do you live?
G3e.
ZIP:
What is your zip code?
IF CAPI: Our records show your phone number as [AREA CODE/PHONE NUMBER]
IF CATI: I called you at [AREA CODE/PHONE NUMBER].
Is this the best number to reach you at?
YES .....................................................................................................1 (SKIP TO G6)
NO .......................................................................................................2
REFUSED ...........................................................................................7 (SKIP TO G6)
DON’T KNOW .....................................................................................8 (SKIP TO G6)
G5.
What is your home phone number, starting with area code?
(____) _____-________
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
G6.
Do you have a cell phone number?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO G7)
REFUSED ...........................................................................................7 (SKIP TO G7)
DON’T KNOW .....................................................................................8 (SKIP TO G7)
G6a.
What is your cell phone number, starting with area code?
(____) _____-________
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
G7.
Do you have an email address?
YES .....................................................................................................1
NO .......................................................................................................2 (SKIP TO G8)
REFUSED ...........................................................................................7 (SKIP TO G8)
DON’T KNOW .....................................................................................8 (SKIP TO G8)
Abt Associates Inc.
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G7a.
Contract No. SS00-10-60011
What is your email address?
_____________________________@____________ . _________
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
G8.
G9.
What is the best way for me to reach you in the future? Would you prefer that I call you on the
phone, send you a letter in the mail, send you an email, or should I call someone else?
PHONE ...............................................................................................1
LETTER ..............................................................................................2 (SKIP TO G9)
EMAIL .................................................................................................7 (SKIP TO G10)
CALL SOMEONE ELSE .....................................................................7 (SKIP TO G11)
G8a.
What is the best phone number to call you at, your home phone or your cell phone
number?
HOME PHONE....................................................................................1 (SKIP TO END)
CELL PHONE .....................................................................................2 (SKIP TO END)
REFUSED ...........................................................................................7 (SKIP TO END)
DON’T KNOW .....................................................................................8 (SKIP TO END)
G10.
Is [CORRECTED CURRENT ADDRESS IN G4] the best address to mail something to you?
YES .....................................................................................................1 (SKIP TO END)
NO .......................................................................................................2
REFUSED ...........................................................................................7 (SKIP TO END)
DON’T KNOW .....................................................................................8 (SKIP TO END)
G9a.
What address should we use if we mail something to you?
STREET ADDRESS:
APT NUMBER:
CITY:
STATE:
Abt Associates Inc.
ZIP:
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BOND Implementation and Evaluation
G11.
Contract No. SS00-10-60011
Is [G7aEMAIL] the best email address to contact you at?
YES .....................................................................................................1 (SKIP TO END)
NO .......................................................................................................2
REFUSED ...........................................................................................7 (SKIP TO END)
DON’T KNOW .....................................................................................8 (SKIP TO END)
G10a. What is a better email address to use to contact you?
_____________________________@____________ . _________
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
G12.
What is the name of the person I should contact first when I need to call you in the future?
G11a. What is his/her first name?
G11b. What is his/her middle name?
G11c. What is his/her last name?
G11d. Does his/her name have a suffix?
G13.
What is (his/her) street address?
G12a. Is there a complex/building name?
G12b. Is there an apartment number?
G12c. In what city?
G12d. In what state?
G12e. What is the zip code?
G14.
What's the best phone number to reach (him/her) at starting with the area code?
Telephone # with area code: (_______) ________-________
Abt Associates Inc.
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BOND Implementation and Evaluation
G15.
Contract No. SS00-10-60011
Is she/he a friend or a relative, or what is (his/her) relationship to you?
ACCEPT ONE RESPONSE ONLY.
FRIEND...............................................................................................1
RELATIVE...........................................................................................2
LEGAL GUARDIAN.............................................................................3
CASE MANAGER ...............................................................................4
OTHER (SPECIFY):____________________________ ...................5
REFUSED ...........................................................................................7
DON’T KNOW .....................................................................................8
Thank you very much.
Abt Associates Inc.
Appendix C. BOND Stage 2 Interim Survey Instrument
28
| File Type | application/pdf |
| File Title | Abt Single-Sided Body Template |
| Author | NicholsonJ |
| File Modified | 2010-08-18 |
| File Created | 2010-08-18 |