Fidelity Assessment Family Member Interview

6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
QUARTERLY INTERVIEW

Thank you for agreeing to participate in this interview for the Supported Employment Demonstration, a
research study by the Social Security Administration (SSA). I work for Westat, the research company that
SSA has contracted to carry out this study.
The Supported Employment Demonstration seeks to find out if providing high quality employment
services and behavioral health services helps people who were recently denied Social Security disability
benefits find good jobs they want and function better overall in their daily lives. SSA also wants to know
which services and treatments work best and what they cost.
We will do this quarterly interview with you every three months until the end of the study. The interview
will last approximately [20/30] minutes and will ask questions about your health, work history and health
care. Afterwards you will receive [$25/$40] as a thank you for your time.
Your participation is voluntary. You can decide not to participate in this interview or stop participating
without penalty. If you are appealing your denial or reapplying for SSA benefits, you can still participate in
this interview and your participation will not affect your appeal or reapplication.
During this interview, you may experience anxiety, fatigue or frustration. If this happens, you can take a
break, skip any section, or stop the interview. If you become particularly upset, I may offer to refer you to
crisis management services that you can use if you wish.
Do you have any questions? [ANSWER ALL QUESTIONS]
OK let’s begin.

EMPLOYMENT OUTCOMES (EO)

A. WORK HISTORY
Now I’d like to ask you some questions about your work experience since the last time we talked. That would be the
time period from {INSERT DATE FROM LAST INTERVIEW} to today.
EO-1.

Have you worked at a job or business for since {INSERT DATE FROM LAST INTERVIEW}?
YES .............................................................................
NO ..............................................................................

EO-2.

1
2

Are you currently working at a job or business for pay?
YES .............................................................................
NO ..............................................................................

1
2

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
Now, I am going to ask some questions about your work history since {date of last interview} starting with your
{current/ most recent} job. If you {have/had} more than one job in the same time period, tell me about the main job
first. Also, if you have held more than one position within the same company, you should tell me about those
positions as separate jobs. You should include part-time and full-time jobs, but only include jobs or positions you
have held for pay.

ASK EO-3 TO EO-17 FOR EACH JOB HELD SINCE LAST INTERVIEW

EO-3.

What {is/was} your job title?/ What job did you do before that?
[INTERVIEWER: PLEASE MAKE SURE EACH JOB TITLE IS UNIQUE.]
__________________________________________
NAME OF JOB/JOB TITLE

EO-4.

On what date did you begin that job?
|__|__| / |__|__| / |__|__|__|__|
DAY MONTH YEAR
(If R KNOWS DAY, EO-5, IF R UNSURE, CONTINUE WITH PROBES)

EO-4A Was it closer to the beginning of the month, or the end of the month?
If you have a calendar, that might help.

EO-5.

One what date did that job end?
|__|__| / |__|__| / |__|__|__|__|
DAY MONTH YEAR
CURRENTLY WORKING MAIN JOB ........................... 95
CURRENTLY WORKING SECOND JOB ................... 96
(If R KNOWS DAY, EO-6, IF R UNSURE, CONTINUE WITH PROBES)

EO-5A Was it closer to the beginning of the month, or the end of the month?
If you have a calendar, that might help.

EO-6.

How many hours per day {do/did} you usually work at that job?
|__|__|
HOURS

EO-7.

How many days per week {do/did} you usually work at that job?
|__|
DAYS

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

EO-8.

How many weeks per month {do/did} you usually work at that job?
|__|
WEEKS

EO-9.

What {are/were} your main activities or duties on this job?
__________________________________________
JOB DUTIES

EO-10. What {is/was} the name of the organization or company you {work/worked} for?
__________________________________________
NAME OF ORGANIZATION/COMPANY
CASUAL LABOR/SELF-EMPLOYED .......................... 95

EO-11. 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

EO-12. What {is/was} your hourly wage?
$|___|___|___|.|__|__| HOURLY WAGE

EO-13. Is it possible that you {are/were} paid a piece rate? That is, your pay {is/was} not based on an hourly rate
but on the number of items that you {produce/produced}?
YES .............................................................................
NO ..............................................................................
CASUAL LABOR/SELF-EMPLOYED .........................

E0-14.

Is/was this a temporary position?
YES .............................................................................
NO ..............................................................................

1
2
3

1
2 (WI-16)

EO-14b If yes, when will/did you end the job?
|__|__| / |__|__| / |__|__|__|__|

EO-14c. Is/was this a seasonal job or a transitional job?
SEASONAL JOB ......................................................... 1
TRANSITIONAL JOB .................................................. 2
OTHER JOB (SPECIFY) ______________________ 91

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

EO-15. From whom do/did you receive your paycheck or cash payment?
Employer .....................................................................
Temporary agency .......................................................
Mental health or rehabilitation agency .........................
Self employment ..........................................................
Other ............................................................................

11
12
13
14
15

EO-16
EO-16
EO-16
EO-16

EO-15a. Are/were you part of a work crew consisting of clients at the agency? Examples of a work crew would be a
cleaning service or a group operating a snack bar. Or are/were you part of an agency-run business?
Work crew ................................................................... 11
Agency-run business ................................................... 12

EO-16. About how much {do/did} you earn at this job?

$|___|___|___|___|___|___|___| |__|__|

UNIT1

EO-16a. Is that before taxes and other deductions {are/were} taken out or after taxes and other deductions {are/were}
taken out?
BEFORE TAXES ........................................................
AFTER TAXES ...........................................................
UNIT
EVERY HOUR ......................................................................................................
EVERY DAY .........................................................................................................
EVERY WEEK ......................................................................................................
EVERY TWO WEEKS ...........................................................................................
TWICE A MONTH .................................................................................................
EVERY MONTH....................................................................................................
EVERY QUARTER ...............................................................................................
EVERY YEAR .......................................................................................................
OTHER (SPECIFY) ________________________________________________
CWSSpecifyUnitPayEarnedOther
“CWSSpecified Other Unit of Pay Earned”

1
2

10
11
12
13
14
15
16
17
91

EO-17. {Are/Were} the following benefits available to you at your job as (a/an) {INSERT JOB TITLE FROM EO-3}?

a.
b.
c.

Medical insurance? ......................................................
Vacation leave? ...........................................................
Sick leave? ..................................................................

YES
1
1
1

NO
2
2
2

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
d.

Any other benefits? (SPECIFY) ________________

1

2

ASK EO-18 FOR CURRENT OR MOST RECENT JOB ONLY
EO-18. Taking everything into consideration, how do you feel about your {current/most recent} job as a whole?
Extremely dissatisfied .................................................
Slightly dissatisfied.......................................................
Neither dissatisfied nor satisfied .................................
Slightly satisfied ..........................................................
Extremely satisfied ......................................................

1
2
3
4
5

EO-19. Have you worked at a volunteer job in the past month?
YES .............................................................................
NO ..............................................................................

1
2

IF RESPONDENT IS CURRENTLY WORKING (EO-2 = 1) THEN GO TO EO-21.

EO-20. Which of the following best describes your current work status? Would you say…
Have a job but currently not at work (for instance on
a leave of absence or suspended), .......................... 1
Looking for work, ......................................................... 2
Keeping house or caregiving, ...................................... 3
Going to school, .......................................................... 4
Doing volunteer work, ................................................. 5
In vocational training, .................................................. 6
Retired, ....................................................................... 7
Unable to work, or ....................................................... 8
Something else? (SPECIFY) ___________________ 91

B. CURRENT INCOME SOURCES
EO-21. Please tell me how much money you received from the following sources during the past month.
Remember, everything you tell me is strictly confidential.
a.

b.
c.
d.
e.

Any earned income or money from all paid employment,
including tips or commissions. Please tell me the take
home amount ...............................................................
$|__|__|,|__|__|__|.|__|__|
Social Security Disability Income .................................
$|__|__|,|__|__|__|.|__|__|
Social Security Retirement or Survivors Benefits .........
$|__|__|,|__|__|__|.|__|__|
Supplemental Security Income (SSI) ...........................
$|__|__|,|__|__|__|.|__|__|
VA or other armed services disability benefits .............
$|__|__|,|__|__|__|.|__|__|

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
f.

Other state or county social welfare benefits such as
general assistance or public aid ..................................
$|__|__|,|__|__|__|.|__|__|
g. Food Stamp Program or SNAP (the Supplemental
Nutritional Assistance Program)...................................
$|__|__|,|__|__|__|.|__|__|
h. Temporary Assistance for Needy Families (TANF),
also known as cash welfare .........................................
$|__|__|,|__|__|__|.|__|__|
i. Vocational program such as Vocational Rehabilitation,
the Job Training Partnership Act, or Easter Seal .........
$|__|__|,|__|__|__|.|__|__|
j. Unemployment compensation......................................
$|__|__|,|__|__|__|.|__|__|
k. Retirement, pension (including military), investing, or
savings income that you receive regular payments
from ..............................................................................
$|__|__|,|__|__|__|.|__|__|
l. Alimony and child support ............................................
$|__|__|,|__|__|__|.|__|__|
m. Money from family members including gifts, loans,
or bill payments ............................................................
$|__|__|,|__|__|__|.|__|__|

EO-22. Sometimes people’s income is increased through other sources that are not reported to the government.
The kinds of things I’m referring to include money received by doing odd jobs such as babysitting or yard
work, helping in a business, or doing work “under the table.” Did you receive any income this way last
month that you have not already told me about? Remember, what you tell me is strictly confidential. I
cannot share this information with anyone, no matter what the reason.
YES .............................................................................
NO ..............................................................................

1
2 (BOX EO-2)

EO-23. How much did you receive that you have not already told me about?
$|__|__|,|__|__|__|.|__|__|

EO-24. About how much was your total household income last month? Household income means the total amount
of money that everyone in your household, including yourself, received during the past month.
$|__|__|,|__|__|__|.|__|__|

IF DON’T KNOW:
EO24a. Ok, let’s try to estimate your total household income last month. Was it…
[INTERVIEWER begin with category including sum of EO-21 and EO-23.]
[PROGAMMER – DISPLAY SUM]
Less than $500 ...........................................................
$500 to $999 ...............................................................

1
2

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
$1,000 to $1,499 .........................................................
$1,500 to $1,999 ..........................................................
$2,000 to $2,499 ..........................................................
$2,500 to $2,999 ..........................................................
$3,000 to $3,499 ..........................................................
$3,500 to $3,999 ..........................................................
$4,000 to $4,499 ..........................................................
$5,500 to $5,999 ..........................................................
$6,000 to $6,499 ..........................................................
$6,500 to $6,999 ..........................................................
$7,000 or more.............................................................

3
4
5
6
7
8
9
10
11
12
13

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

HEALTH STATUS (HS)
SF-12
[ONLY ASK EVERY FOUR QUARTERS]

The next few questions ask about your health and how well you are able to do your usual activities. First I will ask
about your health now. Please try to answer the question as accurately as you can.
HS-1.

In general, would you say your health is…
Excellent, .....................................................................
Very good,....................................................................
Good, ...........................................................................
Fair, or .........................................................................
Poor? ...........................................................................

1
2
3
4
5

Now, I’m going to ask about activities that you might do during a typical day. As I read each item, please tell me if
your health now limits you a lot, limits you a little, or does not limit you at all in these activities.
HS-2.

Does your health now limit you in moderate activities such as moving a table, pushing a vacuum cleaner,
bowling, or playing golf? Does it limit you…
A lot, ............................................................................
A little, or .....................................................................
Not at all? .....................................................................

HS-3.

1
2
3

Does your health now limit you in climbing several flights of stairs? Does it limit you…
A lot, ............................................................................
A little, or .....................................................................
Not at all? .....................................................................

1
2
3

The next two questions ask about your physical health and your daily activities.
HS-4.

During the past 4 weeks, how much of the time have you accomplished less than you would have liked to as
a result of your physical health? Would you say…

All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

1
2
3
4
5

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
HS-5.

During the past 4 weeks, how much of the time were you limited in the kind of work or other regular daily
activities you do as a result of your physical health? Would you say…

All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

1
2
3
4
5

Now I will ask about any emotional problems and your daily activities.
HS-6.

During the past 4 weeks, how much of the time have you accomplished less than you would have liked to as
a result of any emotional problems, such as feeling depressed or anxious? Would you say…
All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

HS-7.

During the past 4 weeks, how much of the time did you not do work or other activities as carefully as usual
as a result of any emotional problems, such as feeling depressed or anxious? Would you say…
All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

HS-8.

1
2
3
4
5

1
2
3
4
5

During the past 4 weeks, how much did pain interfere with your normal work, including both work outside the
home and housework? Did it interfere.
Not at all, ......................................................................
A little bit, .....................................................................
Moderately, ..................................................................
Quite a bit, or ...............................................................
Extremely? ...................................................................

1
2
3
4
5

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

These next questions are about how you feel and how things have been with you during the past 4 weeks. For each
question, please give me the one answer that comes closest to the way you have been feeling.

HS-9.

During the past 4 weeks, how much of the time have you felt calm and peaceful? Would you say…

All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

1
2
3
4
5

HS-10. During the past 4 weeks, how much of the time did you have a lot of energy? Would you say…
[INTERVIEWER: SHOW HS CARD.]
All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

1
2
3
4
5

HS-11. During the past 4 weeks, how much of the time have you felt downhearted and depressed? Would you
say…

All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

1
2
3
4
5

HS-12. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered
with your social activities, like visiting with friends or relatives? Would you say…

All of the time, ..............................................................
Most of the time, ..........................................................
Some of the time, .........................................................
A little of the time, or ....................................................
None of the time?.........................................................

1
2
3
4
5

PAIN
[ONLY ASK EVERY FOUR QUARTERS]

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

This next question is about pain.
Please rate your current pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine.
You can use these faces to help. How would you rate your pain?
|__|__| ENTER NUMBER BETWEEN 0 AND 10

COLORADO SYMPTOM INDEX (CSI)
[ONLY ASK EVERY FOUR QUARTERS]
Now I am going to ask you some questions about any psychological or emotional difficulties that you may have had. I
am going to ask you how often you experienced certain problems during the past month. For each problem I mention,
please let me know how often you have had the problem in the past month. The responses are “At least every day,”
“Several times a week,” “Several times during the month,” “Once during the month,” and “Not at all.” If you have
experienced the problem at least once in the past month you would choose “Once during the month.” If you have
experienced the problem more often, you would choose “Several times during the month.” Do you have any
questions about what the choices mean?
CSI-1

In the past month, how often have you felt nervous, tense, worried, frustrated, or afraid?
Not at all .......................................................................
Once during the month ...............................................
Several times during the month ...................................
Several times a week ...................................................
At least every day .......................................................

CSI-2

In the past month, how often have you felt depressed?
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

CSI-3

1
2
3
4
5

In the past month, how often have others told you that you acted “paranoid” or “suspicious”?
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

CSI-5
there?

1
2
3
4
5

In the past month, how often have you felt lonely?
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

CSI-4

1
2
3
4
5

1
2
3
4
5

In the past month, how often did you hear voices, or hear or see things that other people didn’t think were
Not at all .......................................................................

1

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
Once during the month ...............................................
Several times during the month ...................................
Several times a week ...................................................
At least every day .......................................................

2
3
4
5

CSI-6
(Read slowly) In the past month, how often did you have trouble making up your mind about something, like
deciding where you wanted to go or what you wanted to do, or how to solve a problem?
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

1
2
3
4
5

CSI-7
(Read slowly) In the past month, how often did you have trouble thinking straight, or concentrating on
something you needed to do like worrying so much, or thinking about problems so much that you can’t remember or
focus on other things?
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

1
2
3
4
5

CSI-8
In the past month, how often did you feel that your behavior or actions were strange or different from that of
other people?
NOT AT ALL ................................................................ 1
ONCE DURING THE MONTH .................................... 2
SEVERAL TIMES DURING THE MONTH ................... 3
SEVERAL TIMES A WEEK.......................................... 4
AT LEAST EVERY DAY .............................................. 5
CSI-9

In the past month, how often did you feel out of place or like you did not fit in?
Not at all .......................................................................
Once during the month ...............................................
Several times during the month ...................................
Several times a week ...................................................
At least every day .......................................................

CSI-10

In the past month, how often did you forget important things?
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

CSI-11

1
2
3
4
5

1
2
3
4
5

In the past month, how often did you have problems with thinking too fast (thoughts racing)?
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

1
2
3
4
5

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
CSI-12 In the past month, how often did you feel suspicious or paranoid?
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................
CSI-13

In the past month, how often did you feel like hurting or killing yourself?
NOT AT ALL ................................................................
ONCE DURING THE MONTH ....................................
SEVERAL TIMES DURING THE MONTH ...................
SEVERAL TIMES A WEEK..........................................
AT LEAST EVERY DAY ..............................................

CSI-14

1
2
3
4
5

1
2
3
4
5

In the past month, how often have you felt like seriously hurting someone else?
Not at all .......................................................................
Once during the month ...............................................
Several times during the month ...................................
Several times a week ...................................................
At least every day .......................................................

1
2
3
4
5

BRIEF RESILIENCE SCALE (BR)
[ONLY ASK EVERY FOUR QUARTERS]
Next, I am going to read you a series of statements. Let me know how much you agree or disagree with each of the
statements.
BR-1.

I tend to bounce back quickly after hard times. Would you say you…

Strongly disagree .........................................................
Disagree ......................................................................
Neutral .........................................................................
Agree, or ......................................................................
Strongly agree? ...........................................................

BR-2.

I have a hard time making it through stressful events. Would you say you…

Strongly disagree .........................................................
Disagree ......................................................................
Neutral .........................................................................
Agree, or ......................................................................
Strongly agree? ...........................................................
BR-3.

1
2
3
4
5

1
2
3
4
5

It does not take me long to recover from a stressful event. Would you say you…

Strongly disagree .........................................................

1

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
Disagree ......................................................................
Neutral .........................................................................
Agree, or ......................................................................
Strongly agree? ...........................................................
BR-4.

It is hard for me to snap back when something bad happens. Would you say you…

Strongly disagree .........................................................
Disagree ......................................................................
Neutral .........................................................................
Agree, or ......................................................................
Strongly agree? ...........................................................

BR-5.

1
2
3
4
5

I usually come through difficult times with little trouble. Would you say you…

Strongly disagree .........................................................
Disagree ......................................................................
Neutral .........................................................................
Agree, or ......................................................................
Strongly agree? ...........................................................
BR-6.

2
3
4
5

1
2
3
4
5

I tend to take a long time to get over set-backs in my life. Would you say you…

Strongly disagree .........................................................
Disagree ......................................................................
Neutral .........................................................................
Agree, or ......................................................................
Strongly agree? ...........................................................

1
2
3
4
5

SATISFACTION WITH LIFE (SL)
[ONLY ASK EVERY FOUR QUARTERS]
The next questions are about how you like your present life. For each question, please let me know which option best
reflects your feelings about your life at this time.
SL-1

How much do you like the place where you live?

SL-2

Not at all ....................................................................... 1
Very little ..................................................................... 2
Average or ok............................................................... 3
A lot, or......................................................................... 4
A great deal? ............................................................... 5
How satisfied are you with the amount of privacy you have in your current living situation?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................

1
2
3

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
A lot, or.........................................................................
A great deal? ...............................................................
SL-3

How satisfied are you with the amount of space you have in your current living situation?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-4

1
2
3
4
5

Do you feel as close to your friends as you would like to be?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-8

1
2
3
4
5

How satisfied are you with the number of friends you have?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-7

1
2
3
4
5

How satisfied are you with the way you spend your evenings and weekends?
Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

SL-6

1
2
3
4
5

How much do you like the food you usually eat?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-5

4
5

1
2
3
4
5

How satisfied are you with the kind and amount of contact you have with the opposite sex?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................

1
2
3
4

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
A great deal? ...............................................................
SL-9

How satisfied are you with your current social life?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

SL-10

1
2
3
4
5

Do you feel that you are working as much as you would like?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

SL-14

1
2
3
4
5

How satisfied are you with the kind of work that you do?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-13

1
2
3
4
5

How satisfied are you with the way you spend your days?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

SL-12

1
2
3
4
5

How satisfied are you with the kinds of relationships you have with members of your family?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-11

5

1
2
3
4
5

How satisfied are you with your current psychological condition?
Not at all .......................................................................
Very little .....................................................................

1
2

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

SL-15

How satisfied are you with your present life?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

SL-16

1
2
3
4
5

Do you feel you get as much enjoyment from life as most people do?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................
SL-18

1
2
3
4
5

How satisfied are you with yourself on the whole?

Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

SL-17

3
4
5

1
2
3
4
5

Do you feel that you have as much freedom as you want?
Not at all .......................................................................
Very little .....................................................................
Average or ok...............................................................
A lot, or.........................................................................
A great deal? ...............................................................

1
2
3
4
5

ALCOHOL, DRUGS, AND TOBACCO USE (SA)
[ONLY ASK EVERY FOUR QUARTERS]

SA-1.

These next questions are about smoking and tobacco use. In the last week, how many days did you smoke
cigarettes or use tobacco in other forms such as cigars, pipes, hookahs, vaporizers, or chewing tobacco?”
|__|__|
DAYS
(IF >0, CONTINUE TO SA-2, OTHERWISE SKIP TO SA-7)

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

What form or forms of tobacco did you use in the last week? Was it…
SA-2a.

Cigarettes?
YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

Pipes, hookahs, or vaporizers?
YES ..............................................................................
NO ..............................................................................

1
2

SA-2d. Chewing tobacco?
YES ..............................................................................
NO ..............................................................................

1
2

SA-2b. Cigars?

SA-2c.

IF SA-2A = YES, ASK SA-3; IF SA-2B = YES, ASK SA-4; IF SA-2C = YES, ASK SA-5; IF SA-2D = YES, ASK SA-6

SA-3.

How many cigarettes did you smoke in a typical day in the past week?
|__|__|
CIGARETTES

SA-4.

How many cigars did you smoke in a typical day in the past week?
|__|__|
CIGARS

SA-5.

How many pipes full of tobacco did you smoke in a typical day in the past week?
|__|__|
PIPES

SA-6.

How many times did you use chewing tobacco in a typical day in the past week?
|__|__|
TIMES

SA-7.

You just told me that in the past week you [SUMMARIZE SMOKING HABITS]. Now think about the past
three months. Was this past week typical of all the other weeks in the past three months, or were there
weeks you used more or used less than this?
TYPICAL ......................................................................
SOME WEEKS MORE ................................................
SOME WEEKS LESS ..................................................

1
2
3

18

6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
Now I am going to ask you about your use of alcohol and drugs in the past week. This includes any use of alcohol,
not just getting high or drunk, and this includes different types of alcohol such as beer, malt liquor, wine, wine coolers,
and hard liquor such as whisky, vodka, rum, and so forth). For drug use, this includes the use of any illegal drugs
such as marijuana and cocaine, and it includes abuse of prescription or over-the-counter medicines.
SA-8.

In the last week, how many days did you drink and amount of alcohol?
|__|__|
DAYS
(IF >0, CONTINUE TO SA-9, OTHERWISE SKIP TO SA-10)

SA-9.

How many drinks did you have in a typical day in the past week?
|__|__|
DRINKS

SA-10. Now think about the past three months. Was this past week typical of all the other weeks in the past three
months, or were there weeks you drank more or drank less than this?
TYPICAL ......................................................................
SOME WEEKS MORE ................................................
SOME WEEKS LESS ..................................................

1
2
3

SA-11. In the last week, did you use any of these drugs? This includes marijuana, sedatives, cocaine, stimulants,
hallucinogens, heroin, methadone, other opiates, and inhalants.
YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

(SA-16)

Which drug or drugs did you use?
SA-12a. Marijuana?

SA-12b. Sedatives?

SA-12c. Cocaine?

SA-12d. Stimulants?

SA-12e. Hallucinogens?

SA-12f. Heroin?

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
SA-12g. Methadone?
YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

YES ..............................................................................
NO ..............................................................................

1
2

SA-12h. Other opiates?

SA-12g. Inhalants?

SA-12h. Other?

[REPEAT SA-13 AND SA-14 FOR EACH DRUG]
SA-13. How many days in the last week did you use [DRUG]?
|__|__|
DAYS
SA-14. Now think about the past three months. Was this past week typical of all the other weeks in the past three
months, or were there weeks you used more or used less than this?
TYPICAL ......................................................................
SOME WEEKS MORE ................................................
SOME WEEKS LESS ..................................................

1
2
3

SA-15. Now think about your prescribed medications. How many days in last week did you take more of your
medication than the doctor prescribed?
|__|__|
DAYS
SA-16. Now think about the past three months. Was this past week typical of all the other weeks in the past three
months, or were there weeks you took more medication that prescribed more or less often?
TYPICAL ......................................................................
SOME WEEKS MORE ................................................
SOME WEEKS LESS ..................................................

1
2
3

SA-17. How many days in last week did you take medication that was prescribed to someone else?
|__|__|
DAYS
SA-18. Now think about the past three months. Was this past week typical of all the other weeks in the past three
months, or were there weeks you took medication that was not prescribed to you more or less often?
TYPICAL ......................................................................
SOME WEEKS MORE ................................................
SOME WEEKS LESS ..................................................

1
2
3

20

6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

BMI
[ONLY ASK EVERY FOUR QUARTERS]
BMI-1 How tall are you without shoes?
|__| |__|__|
FEET INCHES
BMI-1 How much do you weigh without shoes?
|__|__|__|
POUNDS

HEALTH CARE COVERAGE AND SERVICE UTILIZATION (HC)

A. HEALTH CARE COVERAGE
Now I’d like to ask you some questions about health insurance. In the previous interview, you reported that you
{receive health care coverage through LIST OF INSURANCES FROM PREVIOUS INTERVIEW/were uninsured}.
HC-1.

Are you still {receiving health care coverage through {LIST INSURANCES}/uninsured}?
YES .............................................................................
NO ..............................................................................

1 (HC-3)
2 (BOX HC-1)

BOX HC-1
IF RESPONDENT WAS PREVIOUSLY UNINSURED, HC-4
IF RESPONDENT PREVIOUSLY HAD INSURANCE, HC-2

HC-2.

What insurance are you no longer covered through?
[DISPLAY LIST OF INSURANCES FROM PREVIOUS INTERVIEW]

HC-3.

And, since {DATE OF LAST INTERVIEW} did you gain any new health insurance coverage?

YES .............................................................................
NO ..............................................................................

HC-4.

1
2

(HC-6)

What is/are the new health insurance or health coverage plans?
INSURANCE THROUGH A CURRENT OR FORMER EMPLOYER OR UNION (OF YOURS OR ANOTHER
FAMILY MEMBER)
INSURANCE PURCHASED DIRECTLY FROM AN INSURANCE COMPANY (BY YOU OR ANOTHER
FAMILY MEMBER)

21

6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
INSURANCE THROUGH HEALTHCARE.GOV OR A STATE EXCHANGE
MEDICARE, FOR PEOPLE 65 AND OLDER, OR PEOPLE WITH CERTAIN DISABILITIES
MEDICAID, MEDICAL ASSISTANCE, OR ANY KIND OF GOVERNMENT-ASSISTANCE PLAN FOR
THOSE WITH LOW INCOMES OR A DISABILITY
VA (INCLUDING THOSE WHO HAVE EVER USED OR ENROLLED FOR VA HEALTH CARE)
TRICARE, TRICARE FOR LIFE OR OTHER MILITARY HEALTH CARE
INDIAN HEALTH SERVICE
OTHER SPECIFY

B. HEALTH CARE SERVICE UTILIZATION
HC-6.

Since {DATE OF LAST INTERVIEW}, did you receive any care in an emergency room?
YES .............................................................................
NO ..............................................................................

1
2 (HC-13)

I would like to get more information about your emergency room visits. Let’s begin with the most recent time you
visited an emergency room and work backwards since {DATE OF LAST INTERVIEW}.

ASK HC-7 TO HC-12 ABOUT EACH EMERGENCY ROOM SINCE LAST INTERVIEW.

HC-7.

When did you go on your most recent visit?/When did you go before that?
[INTERVIEWER: ASK RESPONDENT ABOUT PREVIOUS EMERGENCY ROOM VISITS BY READING
THE DATE AND NAME OF THE LAST EMERGENCY ROOM VISIT ENTERED. VISITS MUST BE SINCE
DATE OF LAST INTERVIEW.]
|__|__| - |__|__|__|__|
MONTH
YEAR

HC-8.

Where did you go?
[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.]
__________________________________________
NAME OF EMERGENCY ROOM

HC-9.

There may be more than one reason for this visit. Please tell us all the reasons for this visit. Was it for…
[INTERVIEWER: SELECT ALL THAT APPLY.]

22

6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-7) AND NAME OF PLACE (RESPONSE TO HC8) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
A physical problem, ..................................................... 1
A mental health problem, ........................................... 2
An alcohol problem, .................................................... 3
A drug problem, or ...................................................... 4
Some other problem? (SPECIFY) ______________ 91

HC-10. Were you admitted to the hospital following this emergency room visit?
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-7) AND NAME OF PLACE (RESPONSE TO HC8) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
YES .............................................................................
NO ..............................................................................
HC-13)

1
2 (NEXT VISIT OR

HC-11. There may be more than one reason why you were admitted to the hospital following this emergency room
visit. Please tell us all the reasons for this admission into the hospital. Was it for…
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-7) AND NAME OF PLACE (RESPONSE TO HC8) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
A physical problem, ..................................................... 1
A mental health problem, ........................................... 2
An alcohol problem, .................................................... 3
A drug problem, or ...................................................... 4
Some other problem? (SPECIFY) ______________ 91

HC-12. How many nights did you stay in the hospital?
[[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-7) AND NAME OF PLACE (RESPONSE TO HC8) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
|__|__| NIGHTS

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

HC-13. Since {DATE OF LAST INTERVIEW}, have you stayed overnight in a hospital other than the ones you
mentioned in the previous questions?
YES .............................................................................
NO ..............................................................................

1
2 (HC-18)

I’d like to get more information about your hospital since {DATE OF LAST INTERVIEW} other than the ones you
mentioned earlier. Let’s begin with the most recent time you were in the hospital and work backwards over the past
year.

ASK HC-14 TO HC-17 ABOUT EACH HOSPITAL VISIT SINCE {DATE OF LAST INTERVIEW}

HC-14. When did you stay in the hospital?/When did you stay before that?
|__|__| - |__|__|__|__|
MONTH
YEAR

HC-15. Where did you stay?
[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.]
__________________________________________
NAME OF HOSPITAL

HC-16. There may be more than one reason for this hospital stay. Please tell us all the reasons for your admission.
Was it for…
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-14) AND NAME OF PLACE (RESPONSE TO HC15) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
A physical problem, ..................................................... 1
A mental health problem, ........................................... 2
An alcohol problem, .................................................... 3
A drug problem, or ...................................................... 4
Some other problem? (SPECIFY) ______________ 91

24

6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

HC-17. How many nights did you stay in the hospital?
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-14) AND NAME OF PLACE (RESPONSE TO HC15) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
|__|__| NIGHTS
HC-18. Since {DATE OF LAST INTERVIEW}, have you had any outpatient visits for day surgeries or other serious
non-routine medical services?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-22)

I would like to get more information about those outpatient visits. Let’s begin with the most recent visit and work
backwards since {DATE OF LAST INTERVIEW}.

ASK HC-19 – HC-22 ABOUT EACH NON-ROUTINE OUTPATIENT VISIT SINCE {DATE OF LAST
INTERVIEW},

HC-19. When did you receive care?/When did you stay before that?
|__|__| - |__|__|__|__|
MONTH
YEAR

HC-20. Where did you receive care?
[INTERVIEWER: ENTER NAME OF OUTPATIENT CENTER/CLINIC. 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.]
__________________________________________
NAME OF CENTER/CLINIC

HC-21. There may be more than one reason for this visit. Please tell us all the reasons for your visit. Was it for…
[INTERVIEWER: SELECT ALL THAT APPLY.]
[PROGRAMMER: DISPLAY DATE (RESPONSE TO HC-19) AND NAME OF PLACE (RESPONSE TO HC20) IN BRACKETS AND ALL CAPS TO ORIENT INTERVIEWER AND RESPONDENT.]
A physical problem, ..................................................... 1
A mental health problem, ........................................... 2
An alcohol problem, .................................................... 3
A drug problem, or ...................................................... 4
Some other problem? (SPECIFY) ______________ 91

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

Next, I want to ask you about outpatient visits for help with drug or alcohol abuse, emotional or psychiatric problems.
BE SURE NOT TO COUNT THE SAME SERVICE IN TWO CAETGROIES (for example alcohol counseling and
community mental health center)—CHOSE THE ONE THAT FITS BEST IN YOUR OPINION.
Do not include visits exclusively for research data collection.
Now, I’m going to read a list of some places from which you may have received services for an emotional or
psychiatric problem including visits for problems related to alcohol or drug use.
In the past month, how many visits did you attend at these programs for an emotional or psychiatric problem, or for
an alcohol or drug problem?
On average how long did each type of visit last?
HC-22

In the past month, did you attend an outpatient visit to a psychiatrist for an emotional or psychiatric problem,
or for an alcohol or drug problem?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-23)

HC-22a How many outpatient visits did you attend?
|__|__| VISITIS
HC-22b On average, how long did each visit last?
|__|__| MINUTES

HC-23

In the past month, did you attend an outpatient visit to some other mental health professional (e.g., social
worker, psychologist, nurse, etc.) for an emotional or psychiatric problem, or for an alcohol or drug problem?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-24)

HC-23a How many outpatient visits did you attend?
|__|__| VISITIS
HC-23b On average, how long did each visit last?
|__|__| MINUTES
HC-24

In the past month, did you attend an outpatient visit to a Community Health Center for an emotional or
psychiatric problem, or for an alcohol or drug problem?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-25)

HC-24a How many outpatient visits did you attend?
|__|__| VISITIS
HC-24b On average, how long did each visit last?
|__|__| MINUTES

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

HC-25

In the past month, did you attend an outpatient visit to a Family Service or Child Guidance Agency?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-26)

HC-25a How many outpatient visits did you attend?
|__|__| VISITIS
HC-25b On average, how long did each visit last?
|__|__| MINUTES
HC-26

In the past month, did you attend an outpatient for alcohol or drug counseling?
YES .............................................................................
NO ..............................................................................

1
2 (HC-27)

HC-26a How many outpatient visits did you attend?
|__|__| VISITIS
HC-26b On average, how long did each visit last?
|__|__| MINUTES
HC-27

In the past month, did you attend an outpatient visit to a self-help group for an emotional or psychiatric
problem, or for an alcohol or drug problem?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-28)

HC-27a How many outpatient visits did you attend?
|__|__| VISITIS
HC-27b On average, how long did each visit last?
|__|__| MINUTES
HC-28

In the past month, did you attend an outpatient visit to a day hospital or day treatment center for an
emotional or psychiatric problem, or for an alcohol or drug problem?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-29)

HC-28a How many outpatient visits did you attend?
|__|__| VISITIS
HC-28b On average, how long did each visit last?
|__|__| MINUTES
HC-29

In the past month, did you attend an outpatient visit to a VA clinic for an emotional or psychiatric problem, or
for an alcohol or drug problem?
YES ............................................................................. 1

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
NO ..............................................................................

2 (HC-30)

HC-29a How many outpatient visits did you attend?
|__|__| VISITIS
HC-29b On average, how long did each visit last?
|__|__| MINUTES
HC-30

In the past month, did you attend an outpatient visit to a Psychosocial Rehabilitation Program?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-31)

HC-30a How many outpatient visits did you attend?
|__|__| VISITIS
HC-30b On average, how long did each visit last?
|__|__| MINUTES
HC-31

In the past month, did you attend an outpatient visit for intensive case management/ACT for an emotional or
psychiatric problem, or for an alcohol or drug problem? (If case management services were included in
previous categories, do not count here.)
YES ............................................................................. 1
NO .............................................................................. 2 (HC-32)

HC-31a How many outpatient visits did you attend?
|__|__| VISITIS
HC-31b On average, how long did each visit last?
|__|__| MINUTES
HC-32

In the past month, did you attend an outpatient visit to any other professional for an emotional or psychiatric
problem, or for an alcohol or drug problem?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-33)

HC-32a How many outpatient visits did you attend?
|__|__| VISITIS
HC-32b On average, how long did each visit last?
|__|__| MINUTES
HC-33

In the past month, did you attend an outpatient visit for peer support/counseling (other than AA/CA/NA) for
an emotional or psychiatric problem, or for an alcohol or drug problem? (e.g., formal support/assistance
from other people who have personally experienced mental illness)
YES ............................................................................. 1
NO .............................................................................. 2 (HC-34)

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

HC-33a How many outpatient visits did you attend?
|__|__| VISITIS
HC-33b On average, how long did each visit last?
|__|__| MINUTES
Now, I’m going to read a list of some places from which you may have received medical services.
In the past month, how many visits did you attend at these clinics for medical problems?
HC-34

In the past month, have you visited a private medical doctor for outpatient medical services?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-35)

HC-35a How many outpatient visits did you attend?
|__|__| VISITIS
HC-35

In the past month, have you visited a private health care practitioner (Non-M.D.) for outpatient medical
services?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-36)

HC-35a How many outpatient visits did you attend?
|__|__| VISITIS
HC-36

In the past month, have you visited an outpatient clinic for outpatient medical services?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-37)

HC-36a How many outpatient visits did you attend?
|__|__| VISITIS
HC-37

In the past month, have you visited a community health center for outpatient medical services?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-38)

HC-37a How many outpatient visits did you attend?
|__|__| VISITIS
HC-38

In the past month, have you visited anywhere else for outpatient medical services?
YES ............................................................................. 1
NO .............................................................................. 2 (HC-39)

HC-48a How many outpatient visits did you attend?
|__|__| VISITIS

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6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

HC-39. In the past month, have you received any employment, vocational, job skills, or job finding services?
YES ............................................................................. 1
NO .............................................................................. 2 (NEXT SECTION)
HC-39a How many times did you receive these services?
|__|__| TIMES
HC-39b Where did you receive these services?
|______|
HC-39a What kinds of services did you receive?
SUPPORTED EMPLOYMENT ....................................
JOB FINDING SERVICES ..........................................
JOB SKILLS TRAINING ..............................................
VOCATIONAL REHABILITATION ..............................
PREVOCATIONAL WORK CREW .............................
OTHER EMPLOYMENT OR
VOCATIONAL SERVICES ..........................................

1
2
3
4
5
6

30

6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
HEALTH CONDITIONS/COMORBIDITIES (CM)
[ONLY ASK EVERY FOUR QUARTERS]
The next questions are about different medical conditions you may have.
CM-1.

Have you ever been told by a doctor or other health professions that you had hypertension, also called high
blood pressure?
YES .............................................................................
NO ..............................................................................

CM-2.

1
2 (CM-3)

Were you told on 2 or more different visits that you had hypertension, also called high blood pressure?
YES .............................................................................
NO ..............................................................................

1
2

CM-2a. Do you receive treatment for hypertension?
YES .............................................................................
NO ..............................................................................

1
2

CM-2b. Does your hypertension limit any of your activities?
YES .............................................................................
NO ..............................................................................

CM-3.

1
2

Have you ever been told by a doctor or other health professional that you had diabetes or sugar diabetes?
YES .............................................................................
NO ..............................................................................
BORDERLINE OR PREDIABETES ............................

CM-3a. Do you receive treatment for diabetes?
YES .............................................................................
NO ..............................................................................

1
2 (CM-4)
3

1
2

CM-3b. Does your diabetes limit any of your activities?
YES .............................................................................
NO ..............................................................................
CM-4.

1
2

Have you ever been told by a doctor or other health professional that you had congestive heart failure?
YES .............................................................................
NO ..............................................................................

CM-4a. Do you receive treatment for congestive heart failure?
YES .............................................................................
NO ..............................................................................

1
2 (CM-5)

1
2

CM-4b. Does your congestive heart failure limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

31

6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

CM-5.

Have you ever been told by a doctor or other health professional that you had coronary heart disease?
YES .............................................................................
NO ..............................................................................

CM-5a. Do you receive treatment for your heart disease?
YES .............................................................................
NO ..............................................................................

1
2 (CM-6)

1
2

CM-5b. Does your heart disease limit any of your activities?
YES .............................................................................
NO ..............................................................................
CM-6.

1
2

Have you ever been told by a doctor or other health professional that you had a lung disease?
YES .............................................................................
NO ..............................................................................

CM-6a. Do you receive treatment for your lung disease?
YES .............................................................................
NO ..............................................................................

1
2 (CM-7)

1
2

CM-6b. Does your lung disease limit any of your activities?
YES .............................................................................
NO ..............................................................................
CM-7.

1
2

Have you ever been told by a doctor or other health professional that you had an ulcer or stomach disease?
YES .............................................................................
NO ..............................................................................

CM-7a. Do you receive treatment for your ulcer or stomach disease?
YES .............................................................................
NO ..............................................................................

1
2 (CM-8)

1
2

CM-7b. Does your ulcer or stomach disease limit any of your activities?
YES .............................................................................
NO ..............................................................................
CM-8.

1
2

Have you ever been told by a doctor or other health professional that you had anemia or other blood
disease?
YES .............................................................................
NO ..............................................................................

CM-8a. Do you receive treatment for your blood disease?
YES .............................................................................
NO ..............................................................................

1
2 (CM-9)

1
2

32

6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
CM-8b. Does your blood disease limit any of your activities?
YES .............................................................................
NO ..............................................................................

CM-9.

1
2

Have you ever been told by a doctor or other health professional that you had a stroke?
YES .............................................................................
NO ..............................................................................

CM-9a. Do you receive treatment for strokes?
YES .............................................................................
NO ..............................................................................

1
2 (CM-10)

1
2

CM-9b. Does your stroke history limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-10. Have you ever been told by a doctor or other health professional that you had asthma?
YES .............................................................................
NO ..............................................................................
CM-10a. Do you receive treatment for your asthma?
YES .............................................................................
NO ..............................................................................

1
2 (CM-11)

1
2

CM-10b. Does your asthma limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-11. Have you ever been told by a doctor or other health professional that you had emphysema?
YES .............................................................................
NO ..............................................................................
CM-11a. Do you receive treatment for your emphysema?
YES .............................................................................
NO ..............................................................................

1
2 (CM-12)

1
2

CM-11b. Does your emphysema limit any of your activities?
YES .............................................................................
NO ..............................................................................

CM-12

1
2

Have you ever been told by a doctor or other health professional that you had chronic bronchitis?
YES .............................................................................
NO ..............................................................................

1
2 (CM-13)

33

6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

CM-12a. Do you receive treatment for your chronic bronchitis?
YES .............................................................................
NO ..............................................................................

1
2

CM-12b. Does your chronic bronchitis limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-13 Have you ever been told by a doctor or other health professional that you had COPD?
YES .............................................................................
NO ..............................................................................
CM-13a. Do you receive treatment for your COPD?
YES .............................................................................
NO ..............................................................................

1
2 (CM-14)

1
2

CM-13b. Does your COPD limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-14. Have you ever been told by a doctor or other health professional that you had a thyroid problem?
YES .............................................................................
NO ..............................................................................
CM-14a. Do you receive treatment for your thyroid problem?
YES .............................................................................
NO ..............................................................................

1
2 (CM-15)

1
2

CM-14b. Does your thyroid problem limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-15. Have you ever been told by a doctor or other health professional that you had a liver disease or any other
kind of liver problem?
YES .............................................................................
NO ..............................................................................
CM-15a. Do you receive treatment for your liver problem?
YES .............................................................................
NO ..............................................................................

1
2 (CM-16)

1
2

CM-15b. Does your liver problem limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

34

6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

CM-16. Have you ever been told by a doctor or other health professional that you had a kidney disease or weak or
failing kidneys? Do not include kidney stones, bladder infections, or incontinence.
YES .............................................................................
NO ..............................................................................
CM-17a. Do you receive treatment for your kidney problem?
YES .............................................................................
NO ..............................................................................

1
2 (CM-17)

1
2

CM-17b. Does your kidney problem limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-18. Have you ever been told by a doctor or other health professional that you had osteoarthritis or degenerative
arthritis?
YES .............................................................................
NO ..............................................................................
CM-18a. Do you receive treatment for your arthritis?
YES .............................................................................
NO ..............................................................................

1
2 (CM-19)

1
2

CM-18b. Does your arthritis limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-19. Have you ever been told by a doctor or other health professional that you had rheumatoid arthritis?
YES .............................................................................
NO ..............................................................................
CM-19a. Do you receive treatment for your arthritis?
YES .............................................................................
NO ..............................................................................

1
2 (CM-20)

1
2

CM-19b. Does your arthritis limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-20. Have you ever been told by a doctor or other health professional that you had cancer?
YES .............................................................................
NO ..............................................................................
CM-20a. Do you receive treatment for your cancer?
YES .............................................................................
NO ..............................................................................

1
2 (CM-21)

1
2

35

6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17

CM-20b. Does your cancer limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-21. Have you ever been told by a doctor or other health professional that you had depression?
YES .............................................................................
NO ..............................................................................
CM-21a. Do you receive treatment for depression?
YES .............................................................................
NO ..............................................................................

1
2 (CM-22)

1
2

CM-21b. Does your depression limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-22. Have you ever been told by a doctor or other health professional that you had back pain?
YES .............................................................................
NO ..............................................................................
CM-22a. Do you receive treatment for your back pain?
YES .............................................................................
NO ..............................................................................

1
2 (CM-23)

1
2

CM-22b. Does your back pain limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-23. Have you ever been told by a doctor or other health professional that you had HIV?
YES .............................................................................
NO ..............................................................................
CM-23a. Do you receive treatment for your HIV?
YES .............................................................................
NO ..............................................................................

1
2 (CM-24)

1
2

CM-23b. Does your HIV limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

CM-24. Do you have any other health conditions?
YES .............................................................................
NO ..............................................................................

1
2

(NEXT SECTION)

CM-24a. Please tell me about the other health conditions that you have.

36

6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
[OPEN TEXT BOX]
CM-24b. Do you receive treatment for your [OTHER TEXT]?
YES .............................................................................
NO ..............................................................................

1
2

CM-24c. Does your [OTHER TEXT] limit any of your activities?
YES .............................................................................
NO ..............................................................................

1
2

PRESCRIPTION MEDICATION (PM)
[ONLY ASK EVERY FOUR QUARTERS]
PM-1

Have you obtained any prescription medicines in the last three months? For example, have you had any
new prescriptions or a refill of a prescription? Please include any on-line prescriptions
YES .............................................................................
NO ..............................................................................

PM-2

1
2 (PM-3)

What health problem are these medicines prescribed for?

PROBE: Any other health problems? IF CONDITION IS ALREADY LISTED, SELECT ENTRY ON ROSTER.
[1. Medical Condition]
[2. Medical Condition]
[3. Medical Condition]

JUSTICE INVOLVEMENT (JI)
[ONLY ASK EVERY FOUR QUARTERS]

These final questions are about your possible involvement with the justice system.

JI-1

Not counting minor traffic violations, how many times during the past 12 months have you been arrested and
booked for breaking the law? Being "booked" means that you were taken into custody and processed by the
police or by someone connected with the courts, even if you were then released.
|______|

JI-2

Have you been convicted of any misdemeanors in the past 12 months?
YES .............................................................................
NO ..............................................................................

JI-3

1
2 (JI-5)

Have you been convicted of any felonies in the past 12 months?
YES .............................................................................
NO ..............................................................................

1
2 (JI-5)

37

6464 Supported Employment Demonstration Attachment L. Quarterly Interview 05-03-17
JI-4

In the past 12 months, how many nights did you spend in jail, prison, or a correctional facility?
|______|

JI-5

Were you on probation at any time in the past 12 months?
YES .............................................................................
NO ..............................................................................

1
2

WORK DISABILITY FUNCTIONAL ASSESSMENT BATTERY (FAB)
[ONLY ASK EVERY FOUR QUARTERS]

[INTERVIEWER: ADMINISTER THE WORK DISABILITY FUNCTIONAL ASSESSMENT BATTERY2 USING THE
ONLINE COMPUTERIZED ADAPTIVE TESTING SOFTWARE.]

2

The WD-FAB is administered using computerized adaptive testing (CAT) methodology, where an item is initially presented from the mid-range of a
defined list of items and then selects subsequent items at an appropriate level based on the respondent’s previous answers. Typically, if the test-taker
is answering the first questions correctly or in accordance with preset or expected response algorithms, the next questions will be more difficult until
the level appropriate for the examinee performance is best reached or the test is completed. If one does not answer the first questions correctly or as
typically expected, then easier questions would generally be presented to the test-taker. CAT estimates scores of the test-taker after each response to
a question and adjusts the administration of the next question accordingly. CAT software tailors an assessment by asking only the most informative
questions, based on a person’s response to previous questions, thus, fewer questions, in total, are needed to achieve an accurate and precise
assessment. Attachment X includes the full item pool for the WD-FAB.

38

6464 Supported Employment Demonstration Attachment M1. IPS Fidelity Assessment Participant
Invitation Letter 05-03-17

[Study Letterhead]
[Date]
Dear [Participant Name]:
You have been selected to share your opinions about your experiences with the
supported employment services that you have received as part of the Supported
Employment Demonstration. I work for Westat, a research organization that is
carrying out the study on behalf of the Social Security Administration.
We would like for you to meet with an interviewer on [date] at [time] at [location]
to share your opinions about the services. The interview will last about 60 minutes.
Afterwards, you will receive $40 to thank you for your participation.
The purpose of the interview is to learn from you whether the supported
employment services offered through the study have been helpful. The interviewer
will ask you what you think about these services, and you are free to share as little
or as much as you would like. By sharing your experience, you will help people
who share your circumstances because this study will likely affect national policy
on work and disability for many years.
I will call you in the coming week to discuss your participation. We very much
look forward to seeing you.
You can wait for my call or if you want, you can call me at (xxx) xxx-xxxx.
Sincerely,

[RA’s name]

6464 Supported Employment Demonstration Attachment M2. IPS Fidelity Assessment Participant Phone Call
Sample Script 05-03-17

Sample Script for IPS Fidelity Assessment Participant Phone Call
Hello, may I speak with [participant’s name]?
If respondent asks who’s calling:
My name is [RA’s name] and I am calling about an important research study by
the Social Security Administration.
If respondent insists on more information:
I am calling to invite [participant’s name] to give [his/her] feedback.
If participant is not available (depending on respondent’s response):
When is a good time to reach [participant’s name]?
May I leave a message for [participant’s name]?
I will try to reach [participant’s name] again another time.
Thank you for your time and have a good day.
If leaving a message for participant:
My name is [site visitor’s name]. I am calling about the Supported Employment
Demonstration. I would like to invite you to share your feedback. Please call me
at [RA’s contact number] or email me at xxxx@westat.com.
Once participant is on the phone:
My name is [RA’s name]. I am calling about the Supported Employment
Demonstration. I work for Westat, the research organization that is carrying out
this study on behalf of the Social Security Administration. I’d like to invite you to
participate in an interview about the employment services you are receiving. The
interview will last about 60 minutes. Afterwards, you will receive $40 to thank
1

6464 Supported Employment Demonstration Attachment M2. IPS Fidelity Assessment Participant Phone Call
Sample Script 05-03-17

you for your participation. Did you receive a letter about this interview in the
mail?
If the participant cannot recall the letter, provide prompts as follows:
The letter invited you to share your opinions about the employment services you
are receiving. It also said that someone would call you to set up the interview.
If participant did not receive the letter:
I sent the letter to [address on file] on [insert date or approximate date]. Is this
your current address?
If yes: I will resend the letter to you today.
If no: Please provide me with your current address so I can mail the letter
to you today.
If participant received the letter:
Would you be able to participate in an interview on [date] at [time]?
If no: Would [second date] at [second time] be better for you?
When would be a good time for you during the week of [range of
dates]?
If yes: Great! I will see you [confirm date and time] at [confirm location].
If you have questions or need to cancel, please call me at [RA’s
contact number].
Thank you and have a good day. Goodbye.

2

6464 Supported Employment Demonstration Attachment M3. IPS Fidelity Assessment Participant Consent Script 0503-17

Supported Employment Demonstration
IPS Fidelity Assessment Consent Script for Participants
Thank you for agreeing to participate in this interview. My name is [NAME] and this is my colleague [NAME].
We work for Westat, a research organization based in Rockville, MD. The Social Security Administration, or
SSA, has contracted with Westat to carry out the Supported Employment Demonstration on its behalf.
As a reminder, the purpose of this study is to find out if providing high quality employment services and
behavioral health services helps people who were recently denied Social Security disability benefits to find good
jobs they want and to function better overall in their daily lives. SSA also wants to know which services and
treatments work best and what they cost.
Today we’d like to hear about your experiences with the services you have received. These services include
supported employment and behavioral health care. SSA wants to know if these services are useful to study
participants and why they are helpful or not helpful.
Before we get started, there are a few things I should mention. This is a research project. Your participation in
this interview is voluntary. There is no penalty if you decide not to participate. You can still participate in the
study. If any questions make you feel uncomfortable, you can take a break, skip any questions or stop the
interview. If you get upset, we may offer you a referral to crisis management services that you can use if you
wish. However, if you tell us that you are planning to hurt yourself or someone else, this will be reported to the
appropriate authorities.
We will present a report to SSA about how well the study is being implemented. We may use quotes from you or
other interviewees in our reports but no names will be linked to any responses.
We have planned for this interview to last about 60 minutes. You will receive $40 to thank you for your
participation.
Do you have any questions? [ANSWER ALL QUESTIONS.]
Finally, with your permission, we would like to record this interview to help us recall what was said.
Are you okay with us recording? [PAUSE FOR RESPONSE.]
I’d like to start the audio recording now. [TURN ON THE RECORDER.]
For purposes of the recording, I am going to ask you:
Are you willing to participate in the interview? Are you willing to have the interview audio-recorded?
[PAUSE FOR RESPONSE.]
OK let’s begin.
1

6464 Supported Employment Demonstration Att M4. IPS Fidelity Assessment Family Member Invitation
Letter 05-03-17

[Study Letterhead]
[Date]
Dear [family member name]:
You have been selected to share your opinions about the services offered to
[participant’s name] as part of the Supported Employment Demonstration.
[Participant’s name] mentioned you as someone [he or she] is close to and knows
about [his or her] involvement in this study. I work for Westat, a research
organization in Rockville, MD that is carrying out the study on behalf of the Social
Security Administration.
We would like for you to meet with an interviewer on [date] at [time] at [location]
to share your opinions about the services. The interview will last about 60 minutes.
Afterwards, you will receive $40 to thank you for your participation.
The purpose of the interview is to learn whether the supported employment
services offered through the study have been helpful to [participant’s name]. The
interviewer will ask you what you think about these services, and you are free to
share as little or as much as you would like. By sharing your opinions, you will
help people who share [participant’s name]’s circumstances because this study
will likely affect national policy on work and disability for many years.
I will call you in the coming week to discuss your participation. We very much
look forward to seeing you.
You can wait for my call or if you want, you can call me at (xxx) xxx-xxxx.
Sincerely,

[RA’s name]

6464 Supported Employment Demonstration Att M5. IPS Fidelity Assessment Family Member Phone Call Sample
Script 05-03-17

Sample Script for IPS Fidelity Assessment Family Member Phone Call
Hello, may I speak with [family member’s name]?
If respondent asks who’s calling:
My name is [RA’s name] and I am calling about an important research study by the
Social Security Administration.
If respondent insists on more information:
I am calling to invite [family member’s name] to give [his/her] feedback.
If participant is not available (depending on respondent’s response):
When is a good time to reach [family member’s name]?
May I leave a message for [family member’s name]?
I will try to reach [family member’s name] again.
Thank you for your time and have a good day.
If leaving a message for family member:
My name is [RA’s name]. I am calling about a research study by the Social Security
Administration. I would like to invite you to share your feedback. Please call me at
[RA’s contact number] or email me at xxxx@westat.com.
Once family member is on the phone:
My name is [RA’s name]. I am calling about the Supported Employment
Demonstration. I work for Westat, a research organization that is carrying out this
study on behalf of the Social Security Administration. I’d like to invite you to
participate in an interview about the employment services that [participant’s name]
is receiving. The interview will last about 60 minutes. Afterwards, you will receive
1

6464 Supported Employment Demonstration Att M5. IPS Fidelity Assessment Family Member Phone Call Sample
Script 05-03-17

$40 to thank you for your participation. Did you receive a letter about this interview
in the mail?
If the participant cannot recall the letter, provide prompts as follows:
The letter invited you to share your opinions about the employment services
received by [participant’s name]. It also said that someone would call you to set up
the interview.
If family member did not receive the letter:
I sent the letter to [address on file] on [insert date or approximate date]. Is this your
current address?
If yes: I will resend the letter to you today.
If no: Please provide me with your current address so I can mail the letter to
you today.
If family member received the letter:
Would you be able to participate in an interview on [date] at [time]?
If no: Would [second date] at [second time] be better for you?
When would be a good time for you during the week of [range of
dates]?
If yes: Great! I will see you [confirm date and time] at [confirm
location]. If you have questions or need to cancel, please call
me at [RA’s contact number].
Thank you and have a good day. Goodbye.

2

6464 Supported Employment Demonstration Attachment M6. IPS Fidelity Assessment Family Member Consent Script
05-03-17

Supported Employment Demonstration
IPS Fidelity Assessment Consent Script for Family Members
Thank you for agreeing to participate in this interview. My name is [NAME] and this is my colleague [NAME].
We work for Westat, a research organization based in Rockville, MD. The Social Security Administration, or
SSA, has contracted with Westat to carry out the Supported Employment Demonstration on its behalf.
The purpose of this study is to find out if providing high quality employment services and behavioral health
services helps people who were recently denied Social Security disability benefits to find good jobs they want and
to function better overall in their daily lives. SSA also wants to know which services and treatments work best
and what they cost.
Today we’d like to hear your opinions about [NAME OF FAMILY MEMBER]’s experiences with the services
provided through the study. These services include supported employment and behavioral health care. SSA
wants to know if these services are useful and why they are helpful or not helpful.
Before we get started, there are a few things I should mention. This is a research project. Your participation in
this interview is voluntary. There is no penalty if you decide not to participate. It will not have any effect on your
[NAME OF FAMILY MEMBER]’s participation in this study. If any questions make you feel uncomfortable,
you can take a break, skip any questions or stop the interview.
We will present a report to SSA about how well the study is being implemented. We may use quotes from you or
other interviewees in our reports, but no names will be linked to any responses.
We have planned for this interview to last about 60 minutes. You will receive $40 to thank you for your
participation.
Do you have any questions? [ANSWER ALL QUESTIONS.]
Finally, with your permission, we would like to record this interview to help us recall what was said.
Are you okay with us recording? [PAUSE FOR RESPONSE.]
I’d like to start the audio recording now. [TURN ON THE RECORDER.]
For the purpose of recording I am going to ask you:
Are you willing to participate in the interview? Are you willing to have the interview audio-recorded?
[PAUSE FOR RESPONSE.]
OK let’s begin.

1

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

IPS Interview Guide
The Supported Employment Fidelity Review Manual (2015) provides information about how to
successfully conduct a supported employment fidelity review using the 25-item Supported
Employment Fidelity Scale (2008). The 25-item scale defines the critical components of
evidence-based supported employment, also known as IPS, Individual Placement and Support.
Fidelity reviewers conduct in-person interviews and observations, and review chart and agency
documentation to make the ratings.

Sources of information
Fidelity reviewers rely on multiple sources of information to make valid ratings. For example,
reviewers may find information about community-based services by reviewing an IPS
specialist’s daily calendar, asking clients where they meet with the IPS specialist, and noting
service location codes on progress notes when reading client records. Sources of information
include interviews with staff, clients, families, teachers, state Vocational Rehabilitation
counselors, and benefits counselors; observations of mental health treatment team meetings and
vocational unit meetings; observation of IPS specialists while they meet with employers to
develop relationships; documentation reviews (e.g., job lists, outcome data, etc.); and client
record reviews.

Fidelity Interview Questions by Stakeholder Group
The following questions are organized by stakeholder (e.g., IPS employment specialist, IPS
supervisor, family member, etc.) to address the fidelity items. The listed questions are examples
to help structure the interviews. In order to obtain the information needed to score all the fidelity
items, we recommend that all reviewers (i.e., experienced reviewers as well less experienced
reviewers) use these questions to guide the fidelity review.
Reviewers should select questions for IPS peer specialists based on their responsibilities (job
descriptions may vary by location).
Tailor the terms used in the questions to the terminology used by agency staff. For example, if
the IPS team is integrated with a housing team instead of a mental health team, use housing
team.

Sample questions for IPS specialists
Questions:

Relates to fidelity
item:

How many people are on your caseload?

Caseload Size

Can you please share your caseload list with me?

Caseload Size

Are there some people on your caseload who are inactive? How do
you define inactive? Are those people included in the total number on

Caseload Size

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

your caseload?
Are you responsible for writing employment plans for inactive clients? Caseload Size
How do you decide when someone’s IPS case should be closed?
Are you responsible for any duties at the agency other than
employment and education? Do you help with groups, day treatment
services, or transportation for medical appointments? How often? Did
you perform any of those activities last week?
Are you ever asked to carryout case management services? For
example, have you been asked to drive someone to a food bank for
donated food, help someone find housing, drive someone to doctor
appointments, manage a mental health crisis, help someone apply for
disability benefits? When was the last time? How often does this
occur?
Is there anyone on your caseload who does not have a case
manager/service coordinator? What happens when this person needs
case management services?
I am interested in learning more about your job and understanding
what a typical day is like for you. Can you show me in your datebook
what you did last Tuesday? What time did you start work that day?
What did you do first? Where was that meeting? And what did you do
next? What time was that?
Do you ever find that case manager/service coordinator caseloads are
so high that you help them out? What is an example? When was the
last time that happened?
If a person is referred to you, are you the first person from the IPS
team to meet that person?
For the people on your caseload, who conducts the career profile? The
job search activities? On-the-job training, if that is needed? Job or
educational supports?
Do you ever refer people to other vocational programs? Which ones?
How many times in the past three months? How would you decide to
make a referral to another program?
Who refers people to you? Anyone else?

Within the mental health agency, who makes referrals to your
caseload?
How many people on your caseload do not have a mental health
worker from the agency?

Caseload Size
Employment
Services Staff

Employment
Services Staff

Employment
Services Staff

Employment
Services Staff

Employment
Services Staff
Vocational
Generalists
Vocational
Generalists
Vocational
Generalists
Integration of
Rehabilitation with
Mental Health thru
Team Assignment
Integration of
Rehabilitation with
Mental Health thru
Team Assignment
Integration of
Rehabilitation with
Mental Health thru

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

Team Assignment
Let’s review your caseload. Which people do not receive mental
health services from Teams A or B (your assigned teams)?

Do you attend mental health treatment team meetings? How often?

Do you usually stay for the entire meeting?

Do you represent any of your fellow IPS specialists when you attend
mental health team meetings?

What is the purpose of attending the meetings? Are the meetings
helpful to you? Why or why not?

What are some examples of how mental health practitioners have
helped people with education and employment goals?

How do you communicate with medication prescribers (psychiatrists,
nurse practitioners)? Has that been effective?

How many Vocational Rehabilitation counselors work with people
who are on your caseload? How often do you meet with each of these
counselors? Where do you meet?

How do the Vocational Rehabilitation counselors help people on your
caseload?

Integration of
Rehabilitation with
Mental Health thru
Team Assignment
Integration of
Rehabilitation with
Mental Health thru
Frequent Team
Member Contact
Integration of
Rehabilitation with
Mental Health thru
Frequent Team
Member Contact
Integration of
Rehabilitation with
Mental Health thru
Frequent Team
Member Contact
Integration of
Rehabilitation with
Mental Health thru
Frequent Team
Member Contact
Integration of
Rehabilitation with
Mental Health thru
Frequent Team
Member Contact
Integration of
Rehabilitation with
Mental Health thru
Frequent Team
Member Contact
Collaboration
Between
Employment
Specialists and
Vocational
Rehabilitation
Counselors
Collaboration
Between
Employment

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

How does everyone work together with clients to develop the
employment plan?

To whom do you report?

Specialists and
Vocational
Rehabilitation
Counselors
Collaboration
Between
Employment
Specialists and
Vocational
Rehabilitation
Counselors
Vocational Unit

Can you share an example of a time that you helped another specialist
Vocational Unit
or that someone helped you?
How often do you meet with the other IPS specialists? What do you do
Vocational Unit
during these meetings? How are the meetings helpful?
Please give an example of the last time that you shared a job lead with
Vocational Unit
someone else on the team.
Was the meeting that we observed today a typical meeting?

Vocational Unit

Do you meet with your supervisor for individual supervision (or for
group supervision)? How often? What happens during those meetings?
How did you learn how to build relationships with employers? Did
your supervisor ever go with you to meet employers? When was the
last time?
Do you receive information about the outcomes for the IPS program?
How do you receive that information? Does your team have goals to
improve outcomes? What are the goals and how will you achieve
them?
Does your supervisor ever help you set performance goals for
yourself? What is an example?
Who should be referred to IPS? Who should not be referred to IPS?
How about people with substance abuse problems? People with
histories of violence? Someone who misses appointments with his
counselor?
If someone leaves a job without notice because he does not like the
job, what do you do?
If someone lost a job because of symptoms, would you help that
person find another job? What next steps would you recommend?
Can you serve people who are not open with state Vocational
Rehabilitation? (If the answer is no, “Are there any people whom
Vocational Rehabilitation counselors cannot serve?”)
Do some case managers or therapists refer people more frequently
than others? Does your caseload list include the name of the

Role of Employment
Supervisor
Role of Employment
Supervisor
Role of Employment
Supervisor
Role of Employment
Supervisor
Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
Criteria

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

practitioner who referred each person to you?
Does the executive director think that employment is a critical
component of services at this agency? What gives you that
impression?
What is the difference between “competitive employment” and other
types of employment?
What type of benefits counseling is available for people in this
program? Who provides benefits planning?

Executive Team
Support for SE
Executive Team
Support for SE
Work Incentives
Planning

How do you keep track of which people receive benefits planning and
which people do not meet with a benefits planner?

Work Incentives
Planning

What do you do if someone does not attend a benefits appointment?

Work Incentives
Planning

How many of the people on your caseload have participated in
benefits planning?

Work Incentives
Planning

Do you know if people receive examples of what would happen to
their total income if they worked part or full time? Do they receive
written examples to refer to later?

Work Incentives
Planning

Do you ever help clients report their earnings? Can you give an
example?

Work Incentives
Planning

Have you ever helped someone receive benefits planning a second or
third time because of a change in income?

Work Incentives
Planning

If you were going to help me with a job search, how would you
explain disclosure? What if I said that I wasn’t sure whether or not I
should disclose? What if I said that I didn’t want to share information
about my mental illness?
Do you ever bring up disclosure on more than one occasion? If so,
when would you have another discussion about disclosure? Can you
give me an example?
I am guessing that some people on your caseload are okay with
disclosure and some are not. About what percentage of people on your
caseload choose to disclose?
How long does it take to complete the career profile? What happens
after you fill it out—do you refer to it again for ideas that will help a
job search, job support? Do you add information to it?
What are sources of information for the profile?
Do you have clients who would benefit from a vocational evaluation
or situational assessment? Please explain.
In the past six months, how many people on your caseload have
completed a vocational evaluation or situational assessment?

Disclosure

Disclosure

Disclosure
Ongoing Work-based
Vocational
Assessment
Ongoing Work-based
Vocational
Assessment
Ongoing Work-based
Vocational
Assessment
Ongoing Work-based
Vocational

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

Assessment
Do you ever suggest volunteer work in order to learn about a person’s
work behaviors and work skills?
What happens after you first meet someone? Please describe your first
few meetings.
About how long does it take to start the job search? Are there ever any
exceptions? Why would those exceptions occur?
How did you decide which employers to contact for (name of client)?
How did you decide which type of jobs?
What jobs do you recommend for people who have not worked in
many years?
What jobs do you recommend for people who have legal histories?
Please tell me about someone who needed a very specific type of job.
How did you help that person find the right job?
Do you ever suggest jobs to clients? How do you decide what type of
jobs to suggest?
Does the case manager/service coordinator or psychiatrist help you
and your clients think of good job matches? What is an example?
If the IPS specialist says she helped a person look for a certain type of
work because that is the kind of work he had done in the past: Did you
help him explore other options for employment? How did you do that?
Why does the person want to do a ________ job?
Do you include phone contacts on your job development (employer
contact) logs?
If a client makes an employer contact without you, is that contact
included in the logs?
Does your supervisor review your logs with you?
If you meet with a person who has no hiring authority, but shares
excellent information about how people are hired, and what positions
are available, is that contact included in your employer contact logs?
Have you been away from work for a week or longer during the past
two months?
How do you approach an employer for the first time? What do you
say? What do you try to accomplish during that first contact? What
would happen next?

Ongoing Work-based
Vocational
Assessment
Rapid Job Search for
Competitive Jobs
Rapid Job Search for
Competitive Jobs
Individualized Job
Search
Individualized Job
Search
Individualized Job
Search
Individualized Job
Search
Individualized Job
Search
Individualized Job
Search
Individualized Job
Search
Individualized Job
Search
Job Development—
Frequent Employer
Contact
Job Development—
Frequent Employer
Contact
Job Development—
Frequent Employer
Contact
Job Development—
Frequent Employer
Contact
Job Development—
Frequent Employer
Contact
Job Development—
Quality of Employer
Contact

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

Tell me about an employer whom you contacted recently? What was
your approach? What happened? Do you have plans to follow up with
that employer?
I noticed that a few people are working at temporary agencies. Can
you tell me about the person at Ready Labor? Why did he choose that
job? How about the person working at …?
I noticed that someone is cleaning at a company called Abilities. Is
that a job that anyone can apply for?

Job Development—
Quality of Employer
Contact

Sue is volunteering. Please tell me about that.

Competitive Jobs

What is a competitive job?

Competitive Jobs

Has anyone on your caseload started a job within the past month?
How often do you meet him? What other types of supports have you
offered? Did you talk to the mental health treatment team for their
suggestions about job supports? What supports has the mental health
treatment team provided?

Individualized
Follow-along
Supports

What percent of working people uses job supports?

How do you decide what type of job supports to offer?
Do you ask for help from the medication prescriber when someone is
having problems with symptoms or side effects on the job?
Is anyone on your caseload going to school? How are you helping?
Have you ever helped someone quit a job to find a better job? What is
an example?
Have you ever helped someone ask for a promotion or transfer to a
more desirable position within his or her company?
Please tell me about the last couple of people who obtained jobs. How
long after they started the job did you have a face-to-face meeting?
How did you support that person over the first month of work? Did
anyone else provide supports?
Tell me about the last few working people who were transferred off
the IPS team. How long had they been working? Why was it the right
time for a transfer? Was each person included in the decision?
How do you know when it is the right time for someone to transfer off
the IPS team?

Competitive Jobs
Competitive Jobs

Individualized
Follow-along
Supports
Individualized
Follow-along
Supports
Individualized
Follow-along
Supports
Individualized
Follow-along
Supports
Individualized
Follow-along
Supports
Individualized
Follow-along
Supports
Time-unlimited
Follow-along
Supports
Time-unlimited
Follow-along
Supports
Time-unlimited
Follow-along
Supports

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

Thanks for bringing your appointment book. I was hoping to get a
better understanding of your job. Please show me what you did last
week. What time did you start work on Monday? Where did you meet
the person to start the career profile? What did you do next? What did
you do on Tuesday?
Do some people prefer to meet with you at the office? Is that
common? How do you spend the time in the office?
What do you do when someone begins missing appointments (or
misses the first appointment)? Can you give me an example of
someone who has not been consistent in keeping appointments with
you?

At what point do you close the person’s case?

Do you document your efforts to reach people who miss
appointments?

Have you ever contacted a family member to learn why someone was
missing appointments or to ask how to re-connect with the person?

Community-based
Services
Community-based
Services
Assertive
Engagement and
Outreach by
Integrated
Treatment Team
Assertive
Engagement and
Outreach by
Integrated
Treatment Team
Assertive
Engagement and
Outreach by
Integrated
Treatment Team
Assertive
Engagement and
Outreach by
Integrated
Treatment Team

Sample questions for the IPS supervisor
Questions:

Relates to fidelity
item:

Do you keep an updated caseload list for each IPS specialist? If so,
would you share that with me?

Caseload Size

Is there a waiting list for the IPS program?

Caseload Size

Why are caseload sizes low? Have you talked to mental health
practitioners about the reasons they do not refer more people?
What are the guidelines for when a person’s case should be closed
from the IPS program?
What types of work do the IPS peer specialists do? (Reviewers ask to
understand how peers fit in the vocational unit, but they do not lower
the score if the peers provide non-employment duties.)

Caseload Size
Caseload Size
Employment
Services Staff

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

When was the last time that an IPS specialist helped a client with
something that was not directly related to school, getting a job or
keeping a job?
Are there any specialized positions on the IPS team? Is any one IPS
specialist responsible for a particular activity, such as job
development?
Does your team ever refer people to other employment programs?
Would you share an example of when this happened?
Are the IPS specialists assigned to mental health treatment teams? If
so, which specialists work with which teams?

Does the vocational unit receive referrals from other sources than the
mental health treatment teams? How many?

How many Vocational Rehabilitation counselors work with people
who are on your caseload? How often do you meet with each of these
counselors? Where do you meet?

How do the Vocational Rehabilitation counselors help people on your
caseload?

How does everyone work together with clients to develop the
employment plan?

Employment
Services Staff
Vocational
Generalists
Vocational
Generalists
Integration of
Rehabilitation with
Mental Health
Treatment Thru
Team Assignment
Integration of
Rehabilitation with
Mental Health
Treatment Thru
Team Assignment
Collaboration
Between
Employment
Specialists and
Vocational
Rehabilitation
Counselors
Collaboration
Between
Employment
Specialists and
Vocational
Rehabilitation
Counselors
Collaboration
Between
Employment
Specialists and
Vocational
Rehabilitation
Counselors

How do IPS specialists work together?

Vocational Unit

How often do you schedule team meetings?

Vocational Unit

What is a typical agenda for a team meeting?

Vocational Unit

What are your responsibilities at the agency? What positions do you
supervise? Are you on agency committees? Do you have any other

Role of Employment
Supervisor

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

jobs at the agency? Do you carry a caseload? Is it an employment
caseload?
How do you use your program outcome data? Are you currently trying
to improve any specific outcome? Can you tell me how you are
working on that? Do individual IPS specialists have goals for
improvement and can you share some examples?
How do new IPS specialists learn about job development? (If the IPS
team leader says that she models meeting with employers, ask what
happens when they go out together. Also ask if she is using field
mentoring logs.) What do you do when a specialist has a low number
of job starts?
How do you provide supervision? How often? If it varies by specialist,
how does the supervisor decide how much supervision to provide to
each specialist?
How do you coordinate IPS with mental health treatment or housing
programs? What is your relationship with the other supervisors at the
agency? How do you get feedback about the IPS program from other
supervisors and staff? How do you hear about changes in services at
the agency?
How are clients referred to the IPS program? How long does it take?
Can anyone make a referral to the program?
How would any person served by the agency know that he could refer
himself to IPS?
Who should be referred to IPS? Who should not be referred to IPS?
Have you received any inappropriate referrals over the past few
months? If so, please describe.
Do you have access to the executive leadership at this agency (for
example, the executive director, quality assurance director, and
medical director) to ask for help with the IPS program? How have
they helped? Do they understand the challenges to implementation and
sustainability, as well as recent successes?
Do you have a steering committee or leadership meeting for IPS? Who
participates in the meetings? What has been the focus of the meetings?
Are they helpful? How often does the group meet?

Role of Employment
Supervisor

Role of Employment
Supervisor

Role of Employment
Supervisor

Role of Employment
Supervisor
Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
Criteria
Executive Team
Support for SE
Executive Team
Support for SE

Does the executive director prioritize competitive employment for
agency clients?

Executive Team
Support for SE
Executive Team
Support for SE

How do you train new specialists to talk about disclosure?

Disclosure

What are some important guidelines for IPS specialists to consider
when they discuss disclosure with clients?

Disclosure

Is there a fidelity action plan? May we see a copy?

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

Do you track the number of people who participate in vocational
evaluation or situational assessments?
Do you track the number of people who volunteer? Why do people
volunteer?
How do IPS specialists gather information to determine ideas for job
types and job supports?
Is anyone in the program working as an intern? What criteria do you
use to distinguish internships from volunteer positions?

Ongoing Work-based
Vocational
Assessment
Ongoing Work-based
Vocational
Assessment
Ongoing Work-based
Vocational
Assessment
Ongoing Work-based
Vocational
Assessment

Please tell us about the last time that you helped an IPS specialist think
about possible good job matches for a job seeker. What suggestions
Individualized Job
did you make? Why did you think that your suggestions would be
Search
appealing to the job seeker?
Individualized Job
Have you met most of the people served by the IPS specialists?
Search
Do you know about most of the educational and career training
Individualized Job
programs in this area? How did you learn about what is available?
Search
Job Development Do you review the employer contact logs? How often? How do you
Frequent Employer
know whether the contacts were with someone with hiring authority?
Contact
Job Development What is your approach if someone is consistently having difficulty
Frequent Employer
making employer contacts?
Contact
Job Development What is the average number of employer contacts that specialists make
Frequent Employer
each week?
Contact
Job Development Have any IPS specialists been absent for a week or longer during the
Frequent Employer
past two months?
Contact
Job Development How do you know if specialists follow up with employers on multiple
Quality of Employer
occasions?
Contact
Job Development Do you help specialists plan which employers they will visit and the
Quality of Employer
purpose of those visits? Please tell us about that.
Contact
Community-based
What strategies has the team used to increase time in the community?
Services
What do you do to help specialists if you are concerned they are in the Community-based
office too much?
Services
Assertive
Does the program have a policy about missed appointments?
Engagement and

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

At what point should specialists close a person’s case if he has been
missing appointments?

Outreach by
Integrated
Treatment Team
Assertive
Engagement and
Outreach by
Integrated
Treatment Team

Sample questions for mental health practitioners (case managers, service
coordinators, counselors, therapists)
Questions:

Relates to fidelity
item:

Do IPS specialists ever help you out, for example, taking someone to a
doctor’s appointment, helping someone with housing, or taking
someone to the grocery store? When was the last time? Do they help
on a regular basis?

Employment
Services Staff

What happens if an IPS specialist and case manager/service
coordinator disagree about whether or not a person should quit a job,
stop looking for jobs, etc.?

Can you remember a time when you (or another case manager/service
coordinator) helped the IPS specialist think of a good job match or
good job support?

Can you think of an example of a time when an IPS specialist or peer
specialist suggested work for a person who had not yet been referred
to the IPS program?
Does the IPS supervisor ever come to your mental health team
meeting? How is that helpful? When was the last time?
When is the right time to talk to someone about work?
When would you not recommend a competitive job to someone?
Are there times when a person needs to develop prevocational skills
before engaging with the IPS program? Are there programs that help

Integration of
Rehabilitation with
Mental Health
Treatment Thru
Frequent Team
Member Contact
Integration of
Rehabilitation with
Mental Health
Treatment Thru
Frequent Team
Member Contact
Integration of
Rehabilitation with
Mental Health
Treatment Thru
Frequent Team
Member Contact
Role Of Employment
Supervisor
Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
Criteria

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

people develop those skills? How often have you referred to those
programs in the past six months?
Do you ever worry that a job could worsen a person’s substance abuse
problem by providing more income? How do you approach this issue?
What do you do if you are working with a person who has poor
hygiene, but says that he wants a job?
What is your strategy for working with someone who says he is
interested in a job but does not take medicine on a regular basis?
Do you ever suggest work for people who are in their fifties, sixties, or
older?

Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
What leads you to have discussions about employment with people?
Criteria
Have you ever worked with someone who was homeless but wanted to Zero Exclusion
get a job?
Criteria
Has there ever been a time when you suggested that someone stop
Zero Exclusion
focusing on employment so that he or she could work on treatment
Criteria
issues? Please describe.
Zero Exclusion
How many people on your caseload are in the IPS program?
Criteria
If the program has a waiting list: Have you continued to make
Zero Exclusion
referrals?
Criteria
Who on your caseload is interested in work? Have you referred those
Zero Exclusion
people?
Criteria
Agency Focus on
How do you define competitive employment?
Competitive
Employment
Agency Focus on
How many people with serious mental illness served by this agency
Competitive
have competitive jobs?
Employment
Agency Focus on
Have working people had opportunities to share their stories
Competitive
(newsletters, speaking at events or treatment groups, etc.)?
Employment
When you are working on the annual assessment (or treatment plan)
Agency Focus on
what do you do if someone says he wants to work? What do you do if Competitive
he says he isn’t sure he wants to work?
Employment
Agency Focus on
What is the current rate of competitive employment for persons with
Competitive
serious mental illness at your agency?
Employment
Does the executive director think that employment is a critical
Executive Team
component of services at this agency? What gives you that
Support for SE
impression?
What is the difference between “competitive employment” and other
Executive Team
types of employment?
Support for SE

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

When a working person transitions from the IPS program, what do you
do when her income changes? Can you refer the person to benefits
counseling? Have you ever done so?

Work Incentives
Planning

Do most people in the IPS program get good information about how
their benefits would be affected by earned income?

Work Incentives
Planning

Where do you usually find the IPS specialist when you need him?

If a person misses appointments with the IPS specialist, what do you
do?

How do you help people connect to the IPS specialist for the first
time?

Community-based
Services
Assertive
Engagement and
Outreach by
Integrated
Treatment Team
Assertive
Engagement and
Outreach by
Integrated
Treatment Team

Sample questions for medication prescribers or medical directors
Questions:
When is the right time to talk to someone about work?
When would you not recommend a competitive job to someone?
Are there times when a person needs to develop prevocational skills
before engaging with the IPS program? Are there programs that help
people develop those skills? How often have you referred to those
programs in the past six months?
Do you ever worry that a job could worsen a person’s substance abuse
problem by providing more income? How do you approach this issue?
What do you do if you are working with a person who has poor
hygiene, but says that he wants a job?
What is your strategy for working with someone who says he is
interested in a job but does not take medicine on a regular basis?
Do you ever suggest work for people who are in their fifties, sixties, or
older?

Relates to fidelity
item:
Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
Criteria

Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
What leads you to have discussions about employment with people?
Criteria
Have you ever worked with someone who was homeless but wanted to Zero Exclusion
get a job?
Criteria

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

Has there ever been a time when you suggested that someone stop
focusing on employment so that he or she could work on treatment
issues? Please describe.
How many people on your caseload are in the IPS program?
If the program has a waiting list: Have you continued to make
referrals?
Who on your caseload is interested in work? Have you referred those
people?

Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
Criteria
Zero Exclusion
Criteria

Sample questions for a mental health supervisor or clinical director
Questions:
Are the mental health practitioners organized into teams? If so, please
describe the teams.

What happens if an IPS specialist and case manager disagree about
whether or not a person should quit a job, stop looking for jobs, etc.?

Can you remember a time when you (or another case manager/service
coordinator) helped the IPS specialist think of a good job match or
good job support?
Can you think of an example of a time when an IPS specialist or peer
specialist suggested work for a person who had not yet been referred
to the IPS program?
Do you know how many people are working on each practitioner’s
caseload?
How do you supervise mental health practitioners who do not have
many clients who work?

Relates to fidelity
item:
Integration of
Rehabilitation and
Mental Health thru
Team Assignment
Integration of
Rehabilitation and
Mental Health thru
Frequent Team
Member Contact
Integration of
Rehabilitation and
Mental Health thru
Frequent Team
Member Contact
Integration of
Rehabilitation and
Mental Health thru
Frequent Team
Member Contact
Zero Exclusion
Criteria
Zero Exclusion
Criteria

Sample questions for IPS peer specialists
(peer specialists who are part of the IPS team)

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

Questions:
Please describe your duties. How are your duties different from the
IPS specialist’s?
What IPS services do you provide? Does anyone else provide those
services?
When would a person work with you alone, and not with an IPS
specialist at the same time?
Do you attend mental health treatment team meetings? Which ones?
How often? Do you stay for the entire meeting? (The score is not
affected by peers attending or not attending mental health treatment
team meetings but reviewers may recommend that they attend weekly
for better integration of services.

Do mental health practitioners share ideas for what may help a person
with her career goals?

What is your role in the mental health treatment team meetings?

How do you help practitioners remember to talk about work with their
clients? Do you ever suggest work for people who are unemployed?
(If peers recommend work for people who are unemployed, reviewers
give credit for that component.)

Do you participate in meetings with Vocational Rehabilitation
counselors?

How do the Vocational Rehabilitation counselors help people on the
IPS team?

Relates to fidelity
item:
Employment
Services Staff
Vocational
Generalists
Vocational
Generalists
Integration of
Rehabilitation with
Mental Health
Treatment thru
Frequent Team
Member Contact
Integration of
Rehabilitation with
Mental Health
Treatment thru
Frequent Team
Member Contact
Integration of
Rehabilitation with
Mental Health
Treatment thru
Frequent Team
Member Contact
Integration of
Rehabilitation with
Mental Health
Treatment thru
Frequent Team
Member Contact
Collaboration
Between
Employment
Specialists and
Vocational
Rehabilitation
Counselors
Collaboration
Between
Employment
Specialists and
Vocational
Rehabilitation

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

Counselors

How does everyone work together with clients to develop the
employment plan?

Collaboration
Between
Employment
Specialists and
Vocational
Rehabilitation
Counselors

Was the meeting that we observed today a typical meeting?

Vocational Unit

Do you provide coverage when an IPS specialist is away or has a
scheduling conflict? (This may improve the score, for example, if
there is only one IPS specialist but the peer specialist is able to provide
back up.)
Are the meetings strengths-based? Why or why not? (This information
may also pertain to items Individualized Job Search, Individualized
Follow-along Supports, Zero Exclusion Criteria, or Ongoing
Work-based Assessment.)
Do you receive information about outcomes for the IPS program?
How do you receive that information? Does the program have goals to
improve any outcomes?
What goals have you and your supervisor set for your own
performance? (If the peer specialist does not have goals for
performance improvement, reviewers may still give credit for that
component, but they may also recommend that the supervisor helps
the peer set and achieve goals, just like his team members.)

Vocational Unit

Vocational Unit

Role of Employment
Supervisor

Role of Employment
Supervisor

Are there any restrictions for who can be referred to the IPS program?

Zero Exclusion
Criteria

Who can refer a person to IPS? Can people refer themselves? Does
any person who receives treatment for serious mental illness know
how to refer himself?

Zero Exclusion
Criteria

Who should be referred to IPS? Who should not be referred to IPS?
What could be done to improve adherence to zero exclusion criteria at
this agency?
What can be done to raise awareness about the importance of
employment among practitioners? (The purpose of asking is that peers
may have good suggestions to share in the report. Reviewers do not
ask in order to alter the final score.)

Zero Exclusion
Criteria
Zero Exclusion
Criteria
Agency Focus on
Competitive
Employment

How do clients learn about IPS services? What would be better
strategies to advertise IPS?

Agency Focus on
Competitive
Employment

Do you ever accompany people to appointments with benefits
planners? Is the information clear and comprehensive?

Work Incentives
Planning

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

Do most people in the IPS program receive benefits planning?
What would improve benefits planning?
Does the benefits planner give people written information to refer to
later? Is it helpful information?
Do you ever help people consider whether to disclose a disability or
not? What do you say in those discussions? What would you say to
someone who is unsure whether or not to disclose to potential
employers?
Do you ever suggest assessments to help people prepare for the right
job, or to determine if someone is ready for work? Does anyone at the
agency ever make those suggestions?
Do you help people consider what jobs are good matches?
Does anyone ever have unrealistic job preferences? What do you do in
those situations?
Do you ever help people explore new options for employment other
than the types of jobs they have had in the past? Please tell me about
that.
What is a competitive job? What other types of jobs are people
working? Do you ever suggest jobs that are not competitive?
I noticed that someone is cleaning at a company called Abilities. Is
that a job that anyone can apply for?
Do you provide job supports? What type of supports? Are you
providing job supports for anyone now? What supports do you
provide?
Do you provide educational supports? What type of supports?

Do you encourage people to consider career support plans?
Do mental health practitioners suggest job or educational supports for
individuals?
Please tell me about someone who was offered a job within the past
couple of months. What types of supports has that person received?
Please tell me about a working person who was recently transferred
off the IPS team. Why was he transferred? How long had he been
working? Was it the right time for him to discontinue IPS services?
What do you do when someone misses appointments with you?

Work Incentives
Planning
Work Incentives
Planning
Work Incentives
Planning
Disclosure
Ongoing Work-based
Vocational
Assessment
Individualized Job
Search
Individualized Job
Search
Individualized Job
Search
Competitive Jobs
Competitive Jobs
Individualized
Follow-along
Supports
Individualized
Follow-along
Supports
Individualized
Follow-along
Supports
Individualized
Follow-along
Supports
Time-unlimited
Follow-along
Supports
Time-unlimited
Follow-along
Supports
Assertive
Engagement and

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

When would someone’s IPS case be closed due to missed
appointments?

Outreach by
Integrated
Treatment Team
Assertive
Engagement and
Outreach by
Integrated
Treatment Team

Sample questions for people using IPS services (clients)
Questions:
Who was the first person you met from the IPS program? Who helped
you find a job?
Who provided job supports? Who helped you select a career? Who
helped with education or training?
Do you remember when someone at this agency asked if you were
interested in employment? Was that the right time? Would you have
been interested in hearing about work at an earlier time?

Relates to fidelity
item:
Vocational
Generalists
Vocational
Generalists
Zero Exclusion
Criteria

How did you learn about the IPS program?

Zero Exclusion
Criteria

Did you go to a different employment program before meeting with
(name of employment specialist)? How did you learn about that
program? How did you decide to start that program?

Zero Exclusion
Criteria

Has anyone ever suggested that you should hold off on work?

Zero Exclusion
Criteria

Did anyone ask if you would be interested in learning how your
benefits would be affected by a return to work? What happened next?

Work Incentives
Planning

Did the person who gave information about benefits talk to you about
all the sources of income that you have? For example, Social Security,
food stamps, or housing assistance? Did she ask about the amount of
money that you receive from each source?

Work Incentives
Planning

Did the person who gave you information provide any examples? For
instance, did he tell you what would happen if you worked part time or Work Incentives
Planning
full time?
Did the information help you? Was it understandable?

Work Incentives
Planning

After the appointment, did you receive a report to help you remember
the details? Was the report specific to you and the benefits that you
receive, or was it a list of rules that apply to everyone who gets

Work Incentives
Planning

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

benefits?
Did anyone tell you how to report your earnings after you went back
to work? Did she tell you how to do that for each source of income?

Work Incentives
Planning

Did anyone help you report your earnings to Social Security
Administration or other entitlement systems? Would you have wanted
help?

Work Incentives
Planning

Does your IPS specialist talk to employers on your behalf—to
advocate for them to hire you? Were you asked if you wanted the
specialist to do that?
Do you remember talking to your employment specialist about
disclosure—letting employers know that you get services from ABC
mental health agency? What do you remember about that
conversation?
Does your IPS specialist have contact with your employer now? How
did you decide that you did (or didn’t) want your specialist to talk to
your employer?
When you first met the IPS specialist, what did you talk about? What
happened after that first meeting?
Were you asked to do any vocational testing or participate in a job
tryout?
After you first met with the IPS specialist, about how long was it
before you started contacting employers about a job? If it was more
than a month, what slowed things down? Was that the right pace for
you?
How did you decide to apply for (the job you just applied for OR the
job you have)?
What types of jobs are you and your IPS specialist looking for? Why
do you think that type of job is right for you?
What type of job would you enjoy?
What are your strengths and skills? How do those pertain to the jobs
you are seeking (or the job you have)?
How does the employment specialist help with finding jobs?
Why did you choose a volunteer job? Would you have preferred to
work at a paying job? Did anyone offer you help with a paying job?
How do you like your job at the temporary agency? Is that the type of
work that you were hoping for?
For those of you who have a job now, is it a time-limited position or
can you keep it as long as your employer is satisfied with your work?

Disclosure

Disclosure

Disclosure
Ongoing Work-based
Vocational
Assessment
Ongoing Work-based
Vocational
Assessment
Rapid Job Search for
Competitive Jobs
Individualized Job
Search
Individualized Job
Search
Individualized Job
Search
Individualized Job
Search
Job Development Quality of Employer
Contact
Competitive Jobs
Competitive Jobs
Competitive Jobs

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

Has anyone asked you about your long-term career goals?
How does your employment specialist help you with your job? Is that
the kind of help that you need or want?
How does your case manager/service coordinator or therapist help you
with your job?
Has anyone offered to help you with your long-term career goals?
How did your IPS specialist help you select your education/technical
training program? What supports did he provide while you were in
school or training?
Have you ever had a problem with your job? How did your
employment specialist help?
When did you start your job?

How often do you meet with the employment specialist?

Do you meet in person or by phone?
Where do you usually meet with your employment specialist?
Where do you prefer to meet with your employment specialist?

Competitive Jobs
Individualized
Follow-along
Supports
Individualized
Follow-along
Supports
Individualized
Follow-along
Supports
Individualized
Follow-along
Supports
Individualized
Follow-along
Supports
Time-unlimited
Follow-along
Supports
Time-unlimited
Follow-along
Supports
Time-unlimited
Follow-along
Supports
Community-based
Services
Community-based
Services

Sample question for family members
Questions:
How quickly did the employment specialist help your family member
connect with employers?
Do you know what determined the timing for starting the job search?

Relates to fidelity
item:
Rapid Job Search for
Competitive Jobs
Rapid Job Search for
Competitive Jobs

Please tell me about the job your family member has (or is seeking). Is
that the right position for him? Why or why not? What position would
be a better match?

Individualized Job
Search

What type of job or educational supports has the IPS specialist

Individualized

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

provided to your family member? Are those the right supports? Why
or why not?
Where does the specialist usually meet with your family member?

Follow-along
Supports
Community-based
Services

Sample questions for state Vocational Rehabilitation counselors
Questions:

How often do you meet with the IPS specialists? In what context?

How does everyone work together with clients to develop the
employment plan?

How can collaboration be improved?

Relates to fidelity
item:
Collaboration
Between
Employment
Specialists and
Vocational
Rehabilitation
Counselors
Collaboration
Between
Employment
Specialists and
Vocational
Rehabilitation
Counselors
Collaboration
Between
Employment
Specialists and
Vocational
Rehabilitation
Counselors

How do people receive information about working and benefits? Is
this service available for all of the people who need it? Do clients
receive helpful information that is specific to their individual
situations?

Work Incentives
Planning

Do you ever suggest a vocational evaluation or situational assessment
for someone? Under what circumstances would you do that? How
often?
Do the IPS specialists help your clients search for positions that are
related to their preferences, skills, and needs?
Please tell me about someone who needed a very specific type of job.
How did you and the specialist help the person find the right position?
Do the IPS specialists know about a wide range of job types available
in this community? Do they know about most of the educational and

Ongoing Work-based
Vocational
Assessment
Individualized Job
Search
Individualized Job
Search
Individualized Job
Search

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

career training programs in the area?
Are you able to help with educational and career training goals?
What types of job supports do IPS specialists provide to working
people? Can you provide a recent example of supports provided to
someone who is working?
Do you believe that the supports are individualized to each person’s
preferences and needs?
Do you help develop job support plans?

Individualized Job
Search
Individualized
Follow-along
Supports
Individualized
Follow-along
Supports
Individualized
Follow-along
Supports

Sample questions for agency leaders/executive team members
Questions:
Is the IPS program able to serve most of the people who want to work
at your agency?
When you measure the rate of competitive employment for clients,
which people are included?
How do you define competitive employment?
How is information about competitive employment collected? How
often?
How is information about the rate of competitive employment shared
with staff?
Since the last fidelity review, have there been opportunities for people
to share their back-to-work stories with other clients and staff? Please
describe.
Do you collect information about other types of employment (e.g.,
sheltered jobs, jobs set aside for people with disabilities)? Are those
types of jobs separated from competitive employment?
How many people with serious mental illness have competitive jobs?
Are there goals to increase this number?
Executive director and clinical director: Please describe the IPS
program. How is IPS different than other employment programs? (If
either of those people defers to the IPS supervisor or another person to

Relates to fidelity
item:
Zero Exclusion
Criteria
Agency Focus on
Competitive
Employment
Agency Focus on
Competitive
Employment
Agency Focus on
Competitive
Employment
Agency Focus on
Competitive
Employment
Agency Focus on
Competitive
Employment
Agency Focus on
Competitive
Employment
Agency Focus on
Competitive
Employment
Executive Team
Support for SE

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

answer, reviewers should redirect their questions to the executive
director and clinical director.)
What changes have you made in order to improve fidelity to supported
employment? What changes will you make in the future?
(To the executive director): Have there been opportunities for you to
talk to agency staff about IPS supported employment? How do you
share your goals for competitive employment? (Reviewers: if others
attempt to answer for the executive director about what he or she has
done, address your question to the executive director again).
(To the executive director): Do you ever talk directly with the IPS
supervisor?
Is fidelity part of the quality assurance process? For example, does the
quality assurance process monitor fidelity scores? Does the quality
assurance process include client outcomes for IPS supported
employment? May we review a recent quality assurance report (or to
see the section of the report related to IPS)?
Do you have an IPS steering committee or leadership committee?
Who participates in the meetings? What has been the focus of the
meetings? How often does the group meet? Does anyone from the
executive team participate in the steering committee?
How does the IPS supervisor share information about the program
with the executive team? How has the executive team helped with
program implementation or sustainability?
Describe the relationship between state Vocational Rehabilitation
counselors and IPS practitioners? Has the executive team been able to
help build a stronger partnership?

Executive Team
Support for SE
Executive Team
Support for SE
Executive Team
Support for SE
Executive Team
Support for SE

Executive Team
Support for SE
Executive Team
Support for SE
Executive Team
Support for SE

Sample questions for the work incentives planner
Questions:

Relates to fidelity
item:

Do you provide information regarding benefits other than Social
Security? For instance, if someone receives veteran’s benefits, can you
help that person? If a person has a spouse or dependent who also
Work Incentives
receives benefits, can you provide good information about how her
Planning
earnings would affect other people in the family? Can you provide
information about housing subsidies? Food stamps?
How did you receive training in work incentives? Have you
participated in training (or have you received updates) during the past
year? Please describe.

Work Incentives
Planning

Do you provide people with written information about their personal
situations? Would it be possible to see a sample report?

Work Incentives
Planning

6464 Supported Employment Demonstration Attachment M7. IPS Fidelity Assessment Guide 05-03-17

Do you meet with people in person or by phone?

Work Incentives
Planning

Are you able to tell people how their total income will be affected by
part or full-time work? Can you provide individualized information or
do you provide information about work incentive rules?

Work Incentives
Planning

When someone is referred to you, how long is it before the person
meets with you?

Work Incentives
Planning

6464 Supported Employment Demonstration Attachment N1. Key Informant Interview Administrator Initial 05-03-17

Supported Employment Demonstration Year 1
Initial Interview for Administrators
Thank you for agreeing to participate in this interview. My name is [NAME] and this is my colleague [NAME].
We work for Westat, a research organization based in Rockville, MD. The Social Security Administration, or
SSA, has contracted with Westat to carry out the Supported Employment Demonstration on its behalf. The
study aims to find out if providing high quality employment services and behavioral health services helps people
who were recently denied Social Security disability benefits to find good jobs they want and to function better
overall in their daily lives. SSA also wants to know which services and treatments work best and what they cost.
Today we’d like to hear your opinions about the successes and challenges involved in implementing the services
offered through this study. We are also interested in your views on the progress participants are making towards
employment and health goals.
Before we get started, there are a few things I should mention. This is a research project. Your participation in
this interview is voluntary. There is no penalty if you decide not to participate. It will not affect your work on
behalf of the Supported Employment Demonstration. If any questions make you uncomfortable, you can take a
break, skip questions or stop the interview.
We are speaking with administrators of sites sponsoring the Supported Employment Demonstration across the
country. After each site visit, we submit a report to the Social Security Administration that summarizes the major
findings. At the end of the study, we will also submit a final report that evaluates the implementation and
outcomes of the Supported Employment Demonstration across all sites. We may use quotes from you or other
interviewees in our reports but no names will be linked to any responses.
We have planned for this interview to last about 60 minutes.
Do you have any questions? [ANSWER ALL QUESTIONS.]
Finally, with your permission, we would like to record this interview to help us recall what was said. Are you
okay with us recording? [PAUSE FOR RESPONSE.]
I’d like to start the audio recording now. [TURN ON THE RECORDER.]
For the purpose of recording I am going to ask you: Are you willing to participate in the interview?
Are you willing to have the interview audio-recorded? [PAUSE FOR RESPONSE.]
OK let’s begin.

1

6464 Supported Employment Demonstration Attachment N1. Key Informant Interview Administrator Initial 05-03-17

I.

INTRODUCTION
I’d like to start by asking you to describe your background and role in this clinic. Please tell me how long
you have been working at this site, and what you do here, and your area of training (psychiatry, clinical
psychology, social work, etc., etc.).

II.

FOLLOW UP QUESTIONS FROM SUPPORTED EMPLOYMENT FIDELITY ASSESSMENT
[The interviewers will have attended interviews for the Supported Employment Fidelity Review
conducted earlier in the site visit. Interviewers will have noted follow-up questions about the services
offered as part of Supported Employment Demonstration and will use the first portion of the interview
to ask those questions. Potential questions may focus on: staffing, integration of services, staff and
clinician roles, services delivered to participants, job development, and community services. This portion
of the interview will not exceed 15 minutes.]

III.

OVERVIEW OF SUPPORTED EMPLOYMENT DEMONSTRATION IMPLEMENTATION
I’d like to start by having you describe your experiences with the Supported Employment Demonstration
project thus far.
A. What were your objectives for the Supported Employment Demonstration at the beginning of the
Study? In what ways, if at all, have your objectives changed since then? Please explain.
B. Please describe how you have provided education and training for Supported Employment
Demonstration staff and providers.
C. What changes, if any, have been made to your original implementation plan and why?
D. What are the challenges of recruiting Supported Employment Demonstration participants?
E. How do you provide effective leadership for the Supported Employment Demonstration program?
What seems to work?

IV.

AGENCY FUNDING SOURCES
We’d like to ask you some information about the past calendar or fiscal year. These questions pertain to
financing for services offered across the agency, not the Supported Employment Demonstration.
A. Does your organization follow a calendar year or a fiscal year?
B. I’m going to read a list of typical sources of funding for agencies. Please tell me which were sources
contributed to your agency during the past [CALENDAR OR FISCAL] year?


Federal grant of contract



Private foundation grant
2

6464 Supported Employment Demonstration Attachment N1. Key Informant Interview Administrator Initial 05-03-17

V.



State or county grant or contract



Special program or study (similar to Supported Employment Demonstration)



Medicare



Medicaid



Private insurance



Other insurance (state or county)



Client payment for services



Client payment, sliding scale



Ticket to work, subcontract work



School contracts, donations



Agency fundraising, donations, or endowments

SUPPORTED EMPLOYMENT DEMONSTRATION COMPONENTS AND ACTIVITIES
Now we’d like to focus on the primary activities and how services are delivered to Supported
Employment Demonstration participants. We’d like to capture all the components of the program that
are being offered.
A. Intake, engagement, and service coordination
1. Please walk us through the intake process for participants and highlight any barriers to initial
delivery of services, such as transportation issues, privacy and information-sharing issues,
paperwork, etc.
2. Are there any difficulties with the process you have in place to get new participants connected
with the services they need? If so, please describe.
3. What is your experience working with the new staff (i.e., Nurse Care Coordinator, Research
Assistant, additional IPS specialists) to implement the Supported Employment Demonstration?
4. What is your experience working with existing staff of your clinic to implement the Supported
Employment Demonstration?
5. Has the approach of using existing staff to accomplish some tasks and new staff for others,
balanced, or has it overburdened staff, or do staffing demands vary?
B. Employment and job-related services
1. How do IPS services fit into this center?
2. How do you know when IPS services are successful?
3

6464 Supported Employment Demonstration Attachment N1. Key Informant Interview Administrator Initial 05-03-17

3. Does the state department of vocational rehabilitation have any role in your center? [IF YES]:
What are their roles?
4. Was funding for any mental health or case management services to participants a problem for
your site? Do you anticipate that funding for these services will be problematic for your site after
the contract ends? Please describe the situation and your thoughts about problem resolution, if
applicable.
5. What services, besides IPS, are the greatest priority for participants you are seeing? Please
describe.
C. Professional development: information and training for staff on the Supported Employment
Demonstration
Now we’d like to discuss training issues for staff involved with the Supported Employment
Demonstration.
1. Did you encounter any problems with the training provided to existing and new staff on
Supported Employment Demonstration components? If so, please describe.
2. Did you personally participate in any training activities? Do you think they were helpful in
working with participants? Has any topic or training been particularly useful? If yes, why?
3. Are there other training areas of which you are aware that you think would better prepare staff to
work with participants?
D. Policy
Now we’d like your perspectives on policy changes that might address barriers you have identified in
launching the Supported Employment Demonstration, and how supporting individuals with mental
illnesses who are denied disability benefits might be strengthened here.
1. Have you encountered problems funding some of the services used by participants that are
associated with existing policies (e.g., clients do not meet income threshold for Medicaid available
in your state)? Please describe.
2. Do you or others at your site have any policy recommendations for funding or implementing
services for individuals who want to work and have a mental illness? Recommendations may be
made for the local, state, or federal, level.

4

6464 Supported Employment Demonstration Attachment N1. Key Informant Interview Administrator Initial 05-03-17

VI.

RECOMMENDATIONS AND CLOSING
A. Participants are persons at risk of dropping out of the work force due to a psychiatric problem. What
suggestions do you have for how they, and others who are at risk, may be better served?
B. Is there anything we didn’t ask about that you think is important for us to know about the Supported
Employment Demonstration services and participants?

Thank you for your time.

5

6464 Supported Employment Demonstration Attachment N2. Key Informant Interview Administrator Follow Up 05-03-17

Supported Employment Demonstration
Demonstration Years 2, 3, and 4
Follow Up Interview for Administrators
Thank you for agreeing to participate in this interview. My name is [NAME] and this is my colleague [NAME].
We work for Westat, a research organization based in Rockville, MD. The Social Security Administration, or
SSA, has contracted with Westat to carry out the Supported Employment Demonstration on its behalf. The
study aims to find out if providing high quality employment services and behavioral health services helps people
who were recently denied Social Security disability benefits to find good jobs they want and to function better
overall in their daily lives. SSA also wants to know which services and treatments work best and what they cost.
Today we’d like to hear your opinions about the successes and challenges involved in implementing the services
offered through this study. We are also interested in your views on the progress participants are making towards
employment and health goals.
Before we get started, there are a few things I should mention. This is a research project. Your participation in
this interview is voluntary. There is no penalty if you decide not to participate. It will not affect your work on
behalf of the Supported Employment Demonstration. If any questions make you uncomfortable, you can take a
break, skip questions or stop the interview.
We are speaking with administrators of sites sponsoring the Supported Employment Demonstration across the
country. After each site visit, we submit a report to the Social Security Administration that summarizes the major
findings. At the end of the study, we will also submit a final report that evaluates the implementation and
outcomes of the Supported Employment Demonstration across all sites. We may use quotes from you or other
interviewees in our reports but no names will be linked to any responses.
We have planned for this interview to last about 60 minutes.
Do you have any questions? [ANSWER ALL QUESTIONS.]
Finally, with your permission, we would like to record this interview to help us recall what was said. Are you
okay with us recording? [PAUSE FOR RESPONSE.]
I’d like to start the audio recording now. [TURN ON THE RECORDER.]
For the purpose of recording I am going to ask you: Are you willing to participate in the interview?
Are you willing to have the interview audio-recorded? [PAUSE FOR RESPONSE.]
OK let’s begin.

1

6464 Supported Employment Demonstration Attachment N2. Key Informant Interview Administrator Follow Up 05-03-17

I.

INTRODUCTION
[FOR NEW INTERVIEWEE]: I’d like to start by asking you to describe your background and role in
this clinic. Please tell me how long you have been working at this site, and what you do here, and your
area of training (psychiatry, clinical psychology, social work, etc., etc.).
[FOR FOLLOW UP]: How has your role at this clinic changed over the past year, if at all?

II.

FOLLOW UP QUESTIONS FROM SUPPORTED EMPLOYMENT FIDELITY ASSESSMENT
[The interviewers will have attended interviews for the Supported Employment Fidelity Review
conducted earlier in the site visit. Interviewers will have noted follow-up questions about the services
offered as part of the Supported Employment Demonstration and will use the first portion of the
interview to ask those questions. Potential questions may focus on: staffing, integration of services, staff
and clinician roles, services delivered to participants, job development, and community services. This
portion of the interview will not exceed 15 minutes.]

III.

OVERVIEW OF IMPLEMENTATION
I’d like to start by having you describe your experiences with the Supported Employment Demonstration
project thus far.
A. What were your objectives for the Supported Employment Demonstration over the past year? In
what ways, if at all, have your objectives changed since the first year? Please explain.
B. Please describe how you have provided education and training for Supported Employment
Demonstration staff and providers this year.
C. What changes, if any, have been made to your original implementation plan and why?
D. How do you provide effective leadership for the Supported Employment Demonstration program?
What seems to work?

IV.

AGENCY FUNDING SOURCES
We’d like to ask you some information about the past calendar or fiscal year. These questions pertain to
financing for services offered across the agency, not the Supported Employment Demonstration.
A. Does your organization follow a calendar year or a fiscal year?
B. I’m going to read a list of typical sources of funding for agencies. Please tell me which were sources
contributed to your agency during the past [CALENDAR OR FISCAL] year?


Federal grant of contract



Private foundation grant
2

6464 Supported Employment Demonstration Attachment N2. Key Informant Interview Administrator Follow Up 05-03-17

V.



State or county grant or contract



Special program or study (similar to Supported Employment Demonstration)



Medicare



Medicaid



Private insurance



Other insurance (state or county)



Client payment for services



Client payment, sliding scale



Ticket to work, subcontract work



School contracts, donations



Agency fundraising, donations, or endowments

SUPPORTED EMPLOYMENT DEMONSTRATION COMPONENTS AND ACTIVITIES
Now we’d like to focus on the primary activities and how services are delivered to Supported
Employment Demonstration participants. We’d like to capture all the components of the program that
are being offered.
A. Intake, engagement, and service coordination
1. Are there any difficulties with the process you have in place to get participants connected with
the services they need? If so, please describe.
2. What is your experience working with the staff hired specifically for the Supported Employment
Demonstration (i.e., Nurse Care Coordinator, Research Assistant, additional IPS specialists)?
3. What is your experience working with existing staff of your clinic to implement the Supported
Employment Demonstration?
4. Has the approach of using existing staff to accomplish some tasks and new staff for others,
balanced, or has it overburdened staff, or do staffing demands vary?
B. Employment and job-related services
1. How do IPS services fit into this center?
2. How do you know when IPS services are successful?
3. Does the state department of vocational rehabilitation have any role in your center? [IF YES]:
What are their roles?
4. Was funding for any mental health or case management services to Supported Employment
Demonstration participants a problem for your site? Do you anticipate that funding for these
3

6464 Supported Employment Demonstration Attachment N2. Key Informant Interview Administrator Follow Up 05-03-17

services will be problematic for your site after the contract ends? Please describe the situation and
your thoughts about problem resolution, if applicable.
5. What services, besides IPS, are the greatest priority for participants you are seeing? Please
describe.
C. Professional development: information and training for staff on the Supported Employment
Demonstration
Now we’d like to discuss training issues for staff involved with the Supported Employment
Demonstration.
1. Did you encounter any problems with the training provided to existing and new staff on
Supported Employment Demonstration components over the past year? If so, please describe.
2. Did you personally participate in any training activities over the past year? Do you think they
were helpful in working with participants? Has any topic or training been particularly useful? If
yes, why?
3. Are there other training areas of which you are aware that you think would better prepare staff to
work with participants?
D. [FOR FINAL YEAR ONLY] Sustaining Supported Employment Demonstration program elements
1. Please describe the components of the Supported Employment Demonstration program that you
think should be sustained in the future. If not all components could be sustained, which of them
are the most important? [USE THE CHECKLIST BELOW FOR PROBES.]


Nurse Care Coordinator



Systematic Medication Management



Assistance with Cost-Sharing for Medications



IPS Supported Employment Integrated with Behavioral Health Care



Assistance with Behavioral Health Care Expenses



Assistance with Employment-Related Expenses

2. What are the plans (emerging or in place) to sustain these elements after the Supported
Employment Demonstration contract period?
3. Is the sustainability of either the Basic Service or Full Service Treatment arms of the Supported
Employment Demonstration a priority for your agency? Do you think either treatment arm
should be sustained?

4

6464 Supported Employment Demonstration Attachment N2. Key Informant Interview Administrator Follow Up 05-03-17

4. What funding sources will be available to support program services during and after the contract
period?
5. Are there federal, state, or local public sector commitments to sustaining Supported Employment
Demonstration activities (that is, have there been changes to policy, procedures, or relevant
legislation)? Please explain.
E. Policy
Now we’d like your perspectives on policy changes that might address barriers you have identified in
launching the Supported Employment Demonstration, and how supporting individuals with mental
illnesses who are denied disability benefits might be strengthened here.
1. Have you encountered problems funding some of the services used by Supported Employment
Demonstration participants that are associated with existing policies (e.g., clients do not meet
income threshold for Medicaid available in your state)? Please describe.
2. Do you or others at your site have any policy recommendations for funding or implementing
services for individuals who want to work and have a mental illness? Recommendations may be
made for the local, state, or federal, level.
VI.

RECOMMENDATIONS AND CLOSING
A. Participants are persons at risk of dropping out of the work force due to a psychiatric problem. What
suggestions do you have for how they, and others who are at risk, may be better served?
B. Is there anything we didn’t ask about that you think is important for us to know about the Supported
Employment Demonstration services and participants?

Thank you for your time.

5

6464 Supported Employment Demonstration Attachment N3. Key Informant Interview Clinician Initial 05-03-17

Supported Employment Demonstration
Demonstration Year 1
Initial Interview for Clinicians
Thank you for agreeing to participate in this interview. My name is [NAME] and this is my colleague [NAME].
We work for Westat, a research organization based in Rockville, MD. The Social Security Administration, or
SSA, has contracted with Westat to carry out the Supported Employment Demonstration on its behalf. The
study aims to find out if providing high quality employment services and behavioral health services helps people
who were recently denied Social Security disability benefits to find good jobs they want and to function better
overall in their daily lives. SSA also wants to know which services and treatments work best and what they cost.
Today we’d like to hear your opinions about the successes and challenges involved in implementing the services
offered through this study. We are also interested in your views on the progress participants are making towards
employment and health goals.
Before we get started, there are a few things I should mention. This is a research project. Your participation in
this interview is voluntary. There is no penalty if you decide not to participate. It will not have affect your work
on behalf of the Supported Employment Demonstration. If any questions make you uncomfortable, you can
take a break, skip questions or stop the interview.
We are speaking with clinicians working in the Supported Employment Demonstration across the country. After
each site visit, we submit a report to the Social Security Administration that summarizes the major findings. At
the end of the study, we will also submit a final report that evaluates the implementation and outcomes of the
Supported Employment Demonstration across all sites. We may use quotes from you or other interviewees in
our reports but no names will be linked to any responses.
We have planned for this interview to last about 60 minutes.
Do you have any questions? [ANSWER ALL QUESTIONS.]
Finally, with your permission, we would like to record this interview to help us recall what was said. Are you
okay with us recording? [PAUSE FOR RESPONSE.]
I’d like to start the audio recording now. [TURN ON THE RECORDER.]
For the purpose of recording I am going to ask you: Are you willing to participate in the interview?
Are you willing to have the interview audio-recorded? [PAUSE FOR RESPONSE.]
OK let’s begin.

1

6464 Supported Employment Demonstration Attachment N3. Key Informant Interview Clinician Initial 05-03-17

I.

INTRODUCTION
I’d like to start by asking you to describe your background and role in the Supported Employment
Demonstration and this clinic. Please tell me how long you have been working at this site, and what you
do here, and your area of training (social worker, psychologist, IPS specialist, substance abuse counselor,
etc.). Also, please describe your role in providing services to Supported Employment Demonstration
participants.

II.

FOLLOW UP QUESTIONS FROM SUPPORTED EMPLOYMENT FIDELITY ASSESSMENT
[The interviewers will have attended interviews for the Supported Employment Fidelity Review
conducted earlier in the site visit. Interviewers will have noted follow-up questions about the services
offered as part of the Supported Employment Demonstration and will use the first portion of the
interview to ask those questions. Potential questions may focus on: staffing, integration of services, staff
and clinician roles, services delivered to participants, job development, and community services. This
portion of the interview will not exceed 15 minutes.]

III.

PARTICIPANTS
My first questions have to do with how Supported Employment Demonstration participants fit into the
services offerings at your site.
A. Compared to the patients you usually see at this facility, how are participants different?
B. What sorts of modifications need to be made to your usual treatment protocols to accommodate the
needs of participants?
C. Are you able to make these modifications? Why or why not?

IV.

EMPLOYMENT
A. IPS-related services
Let’s talk about working with study participants to help them find a job and continue employment.
1. What do participants need in order to get and keep a job?
2. What strategies work well to help participants find jobs?
3. What do you do to help participants maintain their employment?
4. What are your strategies for assisting participants who appear to lack job readiness?
5. [FOR IPS specialists]: When a participant is unhappy with their job, what kind of assistance can
you provide?

2

6464 Supported Employment Demonstration Attachment N3. Key Informant Interview Clinician Initial 05-03-17

6. [FOR IPS specialists]: How do you analyze previous job experiences with participants for lessons
learned? Please give an example.
B. Employment outcomes
1. What are the goals of employment for participants? How should they benefit from employment?
[PROBES]: Able to support self independently of family; participant does not seek SSI or SSDI;
increased social interaction; greater self-confidence, etc.
2. Please tell me how you define successful employment for Supported Employment
Demonstration participants.
[PROBES]: Length of time employed, number of hours, income from employment, match to
skills and interests, etc.
3. How does a typical outcome differ from the ideal outcome?
4. What prevents Supported Employment Demonstration participants from achieving an ideal
outcome?
5. What does an unsuccessful employment outcome look like for participant?
6. What do you think makes some outcomes are successful and others unsuccessful?
C. Barriers to, and supports for, employment
1. What are the challenges that Supported Employment Demonstration participants face in getting
and keeping a job?
2. How do family members support or discourage participants in their work?
3. Regarding the communities in which participants live, do you find that friends and associates of
participants support or discourage participants from working? You may not be able to generalize
across all participants you see, but you may have noticed some patterns. Please explain.
4. Are there specific subgroups of participants who have unique barriers? For example, participants
with specific health issues (e.g. co-occurring substance use and mental illness), or specific
demographic characteristics (e.g. minorities, LGBT)? What do you think is creating the barrier for
members of these populations?
V.

BEHAVIORAL HEALTH
A. Behavioral health service choices
1. What behavioral health services are offered to Supported Employment Demonstration
participants? [Interviewer should make a list of services for follow-up questions.]
3

6464 Supported Employment Demonstration Attachment N3. Key Informant Interview Clinician Initial 05-03-17

2. Are these services provided at this location? [Interviewer should go down the list and make a
note. If a service is off campus, ask where and how far participants must go to receive it.]
3. What services do participants use the most and why? Which services do they prefer?
4. What options are available if participants are not happy with the service or with the clinician?
5. How is it working with the nurse care coordinator to assist participants?
B. Outcomes
1. Have participants’ mental health problems improved? How do you know when they have
improved?
2. What types of behavioral health services have been the most successful with helping participants
manage their symptoms? Why do you think those services are successful?
3. Do you have participants who continue to engage with employment services, but not treatment?
Why do participants drop out of treatment?
VI.

RECOMMENDATIONS AND CLOSING
1. Participants are persons at risk of dropping out of the work force due to a psychiatric problem. What
suggestions do you have for how they, and others who are at risk, may be better served?
2. Is there anything we didn’t ask about that you think is important for us to know about the Supported
Employment Demonstration services and participants?

Thank you for your time.

4

6464 Supported Employment Demonstration Attachment N4. Key Informant Interview Clinician Follow Up 05-03-17

Supported Employment Demonstration
Demonstration Years 2, 3, and 4
Follow Up Interview for Clinicians
Thank you for agreeing to participate in this interview. My name is [NAME] and this is my colleague [NAME].
We work for Westat, a research organization based in Rockville, MD. Westat is under contract with the Social
Security Administration (SSA) to study how the Supported Employment Demonstration Study affects
participants who do not receive disability benefits. Supported Employment Demonstration services include IPS
supported employment, behavioral health care, and the work of the nurse care coordinator on behalf of fullservice treatment participants.
Today we’d like to hear your opinions about the successes and challenges involved in implementing this package
of services. We are also interested in your views on the progress participants are making towards employment
and health goals.
Before we get started, there are a few things I should mention. This is a research project. Your participation in
this interview is voluntary. There is no penalty if you decide not to participate. It will not have affect your work
on behalf of the Supported Employment Demonstration. If any questions make you uncomfortable, you can
take a break, skip questions or stop the interview.
We are speaking with clinicians working in the Supported Employment Demonstration all across the country.
After each site visit, we submit a report to the Social Security Administration that summarizes the major findings.
At the end of the study, we will also submit a final report that evaluates the implementation and outcomes of the
Supported Employment Demonstration across all sites. We may use quotes from you or other interviewees in
our reports but no names will be linked to any responses.
We have planned for this interview to last about 60 minutes.
Do you have any questions? [ANSWER ALL QUESTIONS.]
Finally, with your permission, we would like to record this interview to help us recall what was said. Are you
okay with us recording? [PAUSE FOR RESPONSE.]
I’d like to start the audio recording now. [TURN ON THE RECORDER.]
For the purpose of recording I am going to ask you: Are you willing to participate in the interview?
Are you willing to have the interview audio-recorded? [PAUSE FOR RESPONSE.]
OK let’s begin.

1

6464 Supported Employment Demonstration Attachment N4. Key Informant Interview Clinician Follow Up 05-03-17

I.

INTRODUCTION
[FOR NEW INTERVIEWEE]: I’d like to start by asking you to describe your background and role in
this clinic. Please tell me how long you have been working at this site, and what you do here, and your
area of training (psychiatry, clinical psychology, social work, etc., etc.).
[FOR FOLLOW UP]: How has your role at this clinic changed over the past year, if at all?

II.

FOLLOW UP QUESTIONS FROM SUPPORTED EMPLOYMENT FIDELITY ASSESSMENT
[The interviewers will have attended interviews for the Supported Employment Fidelity Review
conducted earlier in the site visit. Interviewers will have noted follow-up questions about the services
offered as part of the Supported Employment Demonstration and will use the first portion of the
interview to ask those questions. Potential questions may focus on: staffing, integration of services, staff
and clinician roles, services delivered to participants, job development, and community services. This
portion of the interview will not exceed 15 minutes.]

III.

PARTICIPANTS
My first questions have to do with how Supported Employment Demonstration participants fit into the
services offerings at your site.
A. Compared to the patients you usually see at this facility, how are Supported Employment
Demonstration participants different?
B. What sorts of modifications need to be made to your usual treatment protocols to accommodate the
needs of participants?
C. Are you able to make these modifications? Why or why not?

IV.

EMPLOYMENT
A. IPS-related services
Let’s talk about working with study participants to help them find a job and continue employment.
1. What do Supported Employment Demonstration participants need in order to get and keep a
job?
2. What strategies work well to help participants find jobs?
3. What do you do to help participants maintain their employment?
4. What are your strategies for assisting participants who appear to lack job readiness?
5. [FOR IPS specialists]: When a participant is unhappy with their job, what kind of assistance can
you provide?
2

6464 Supported Employment Demonstration Attachment N4. Key Informant Interview Clinician Follow Up 05-03-17

6. [FOR IPS specialists]: How do you analyze previous job experiences with participants for lessons
learned? Please give an example.
B. Employment outcomes
1. What are the goals of employment for participants? How should they benefit from employment?
[PROBES]: Able to support self independently of family; participant does not seek SSI or SSDI;
increased social interaction; greater self-confidence, etc.
2. Please tell me how you define successful employment for Supported Employment
Demonstration participants.
[PROBES]: Length of time employed, number of hours, income from employment, match to
skills and interests, etc.
3. How does a typical outcome differ from the ideal outcome?
4. What prevents participants from achieving an ideal outcome?
5. What does an unsuccessful employment outcome look like for a Supported Employment
Demonstration participant?
6. What do you think makes some outcomes are successful and others unsuccessful?
C. Barriers to, and supports for, employment
1. What are the challenges that participants face in getting and keeping a job?
2. How do family members support or discourage participants in their work?
3. Regarding the communities in which participants live, do you find that friends and associates of
participants support or discourage participants from working? You may not be able to generalize
across all participants you see, but you may have noticed some patterns. Please explain.
4. Are there specific subgroups of participants who have unique barriers? For example, participants
with specific health issues (e.g. co-occurring substance use and mental illness), or specific
demographic characteristics (e.g. minorities, LGBT)? What do you think is creating the barrier for
members of these populations?
V.

BEHAVIORAL HEALTH
A. Behavioral health service choices
1. What behavioral health services are offered to Supported Employment Demonstration
participants? [Interviewer should make a list of services for follow-up questions.]

3

6464 Supported Employment Demonstration Attachment N4. Key Informant Interview Clinician Follow Up 05-03-17

2. Are these services provided at this location? [Interviewer should go down the list and make a
note. If a service is off campus, ask where and how far participants must go to receive it.]
3. What services do participants use the most and why? Which services do they prefer?
4. What options are available if participants are not happy with the service or with the clinician?
5. How is it working with the nurse care coordinator to assist participants?
B. Outcomes
1. Have participants’ mental health problems improved? How do you know when they have
improved?
2. What types of behavioral health services have been the most successful with helping participants
manage their symptoms? Why do you think those services are successful?
3. Do you have participants who continue to engage with employment services, but not treatment?
Why do participants drop out of treatment?
VI.

Recommendations and Closing
1. Participants are persons at risk of dropping out of the work force due to a psychiatric problem. What
suggestions do you have for how they, and others who are at risk, may be better served?
2. Is there anything we didn’t ask about that you think is important for us to know about the Supported
Employment Demonstration services and participants?

Thank you for your time.

4

6464 Supported Employment Demonstration Attachment O1. Participant Focus Group Invitation Letter 05-03-17

[Study Letterhead]
[Date]
Dear [Participant Name]:
You have been selected to share your opinions about your experiences with the
services that you have received as part of the Supported Employment
Demonstration. I work for Westat, a research organization that is carrying out the
study on behalf of the Social Security Administration.
We would like for you to participate in a focus group on [date] at [time] at
[location] to share your opinions about the services. The focus group will last
about 60 minutes. Afterwards, you will receive $40 to thank you for your
participation.
The purpose of the focus group is to learn from you whether the services offered
through the study have been helpful. The focus group will have between six and
ten people like yourself who are participating in the study. The leader of the focus
group will ask you what you think about the employment and health services you
have received and what you think might improve them. You are free to share as
little or as much as you would like. By sharing your experience, you will help
people who share your circumstances because this study will likely affect national
policy on work and disability for many years.
I will call you in the coming week to discuss your participation. We very much
look forward to seeing you.
You can wait for my call or if you want, you can call me at (xxx) xxx-xxxx.
Sincerely,

[Site visitor’s name]

6464 Supported Employment Demonstration Attachment O2. Participant Focus Group Phone Call Sample Script 05-03-17

Sample Script for Participant Focus Group Invitation Phone Call
Hello, may I speak with [participant’s name]?
If respondent asks who’s calling:
My name is [site visitor’s name] and I am calling about an important research
study by the Social Security Administration.
If respondent insists on more information:
I am calling to invite [participant’s name] to give [his/her] feedback.
If participant is not available (depending on respondent’s response):
When is a good time to reach [participant’s name]?
May I leave a message for [participant’s name]?
I will try to reach [participant’s name] again.
Thank you for your time and have a good day.
If leaving a message for participant:
My name is [site visitor’s name]. I am calling about the Supported Employment
Demonstration. I would like to invite you to share your feedback. Please call me
at [site visitor’s contact number] or email me at xxxx@westat.com.
Once participant is on the phone:
My name is [site visitor’s name]. I am calling about the Supported Employment
Demonstration. I work at Westat, the research organization that is carrying out
this study on behalf of the Social Security Administration. I’d like to invite you to
participate in a focus group about the employment services you are receiving. The
focus group will last about 60 minutes. Afterwards, you will receive $40 to thank
1

6464 Supported Employment Demonstration Attachment O2. Participant Focus Group Phone Call Sample Script 05-03-17

you for your participation. Did you receive a letter about the focus group in the
mail?
If the participant cannot recall the letter, provide prompts as follows:
The letter invited you to participate in a focus group to share your opinions about
the services you are receiving. It also said that someone would call you about it.
If participant did not receive the letter:
I sent the letter to [address on file] on [insert date or approximate date]. Is this
your current address?
If yes: I will resend the letter to you today.
If no: Please provide me with your current address so I can mail the letter
to you today.
If participant received the letter:
Would you be able to participate in a focus group on [date] at [time]?
If no: That is too bad. Have a good day. Goodbye.
If yes: Great! I will see you [confirm date and time] at [confirm location].
If you have questions or need to cancel, please call me at [site
visitor’s contact number].
Thank you and have a good day. Goodbye.

2

6464 Supported Employment Demonstration Attachment O3. Participant Focus Group Guide 05-03-17

Supported Employment Demonstration
Demonstration Years 2 and 4
Study Participant Focus Group Guide
Thank you for participating in this focus group. My name is [NAME] and this is my colleague [NAME]. We work
for Westat, a research organization based in Rockville, MD. We work for Westat, a research organization based in
Rockville, MD. The Social Security Administration, or SSA, has contracted with Westat to carry out the Supported
Employment Demonstration on its behalf.
As a reminder, the purpose of this study is to find out if providing high quality employment services and behavioral
health services helps people who were recently denied Social Security disability benefits to find good jobs they want
and to function better overall in their daily lives. SSA also wants to know which services and treatments work best
and what they cost.
Today we’d like to hear about your experiences with the services you have received. These services include
supported employment and behavioral health care. SSA wants to know if these services are useful to study
participants and why they are helpful or not helpful.
Before we get started, there are a few things I should mention. This is a research project. Your participation in this
focus group is voluntary. There is no penalty if you decide not to participate. You can still participate in the study. If
any questions make you feel uncomfortable, you can take a break, skip any questions or stop participating in the
focus group. If you get upset, we may offer you a referral to crisis management services that you can use if you
wish. However, if you tell us that you are planning to hurt yourself or someone else, this will be reported to the
appropriate authorities. I also ask everyone to respect each other’s privacy and that whatever is said in this room
stays in this room.
We are doing focus groups with participants in the Supported Employment Demonstration across the country. At
the end of the study, we will present a report to SSA summarizing the challenges and successes of this study. We
may use quotes from you or other participants in our reports but no names will be linked to any responses.
We have planned for this focus group to last about 60 minutes. You will receive $40 to thank you for your
participation. Do you have any questions? [ANSWER ALL QUESTIONS.]
Finally, with your permission, we would like to record this interview to help us recall what was said.
Are you okay with us recording? [PAUSE FOR RESPONSE.]
I’d like to start the audio recording now. [TURN ON THE RECORDER.]
For purposes of the recording, I am going to ask you:
Are you willing to participate in the interview? Are you willing to have the interview audio-recorded?
[PAUSE FOR RESPONSE.]
OK let’s begin.
1

6464 Supported Employment Demonstration Attachment O3. Participant Focus Group Guide 05-03-17

I.

INTRODUCTIONS
I’d like to start by asking each of you to introduce yourselves. Please tell me your first name only, how long
you have been participating in the study, whether or not you are currently employed. If you are employed,
please tell us for how long and what kind of job you have.

II.

EMPLOYMENT
A. IPS-related services
Let’s start by talking about your work with the IPS specialist—the person at the [clinic or name of
location] who is helping you to find a job, or helping you to continue in your job. I’m going to ask some
questions and we’d like to hear from any of you who’d like to share your experiences and opinions
about IPS.
1. What have you been working on with the IPS specialist? What does he or she do for you?
2. How has your work with that person been going? Are you satisfied or not satisfied?
3. Do you think he or she will be able to assist you in finding or keeping a job? Why or why not?
4. What do you hope to get out of working with the IPS specialist?
5. What kinds of employment expenses have been covered for you through the study?
B. Current employment or current plans for employment
1. Among those of you who are working, we’d like to know:
a. What kind of job do you have?
b. Is it different than what you’ve done before? Please explain.
c. Do you like your job? Please explain.
d. Do you think you’ll stay in your job? Why or why not?
2. Among those of you who are not working, we’d like to hear about:
a. How is your job search going?
b. What kind of work are you looking for?
c. What kind of job would you like to get?
d. Is the kind of job you’d like the same as the work you have done before? Please explain.
C. Barriers to working
The next questions are about what makes working difficult for you. For any of you who feel
comfortable answering, we’d like to know:
1. What challenges do you face that make working difficult?
2

6464 Supported Employment Demonstration Attachment O3. Participant Focus Group Guide 05-03-17

2. How does your disability affect your work?
3. What do you think would help you to find a job and/or remain employed?
D. Support and resources in family and community
Now I’d like to know how your family and friends support or do not support your efforts to get or keep
employment. Sometimes the people in your life have very strong opinions that may not be the same as
yours, but even so, they may have an impact on you.
1. Does your family support or discourage you from working? Please explain.
a. [IF SUPPORTIVE]: How do they provide support?
b. [IF DISCOURAGING]: How do they discourage you from working?
2. Do your friends, or others in your community, such as fellow church parishioners, your children’s
friend’s parents, or others with whom you might associate, support or discourage you from
working?
a. [IF SUPPORTIVE]: How do they provide support?
b. [IF DISCOURAGING]: How do they discourage you from working?
3. Outside of your participation in the study, are there other resources you can use to help find
employment? Have you tried them? Why or why not?
4. Are there resources in the community for individuals who have a physical or mental problem that
makes working difficult? Have you sought help from these resources? Why or why not?
III.

BEHAVIORAL HEALTH
A. Use of behavioral health care resources
As part of the Study, you may receive health care for physical and psychological problems that you
might be experiencing. We’d like to ask about some of the services you have used and how they have
affected your work experience.
1. Have you received any behavioral health care services, including treatment with medication,
psychotherapy, groups, or case management?
2. What kind of health care have you received and how has it been working for you?
a. [FOLLOW UP]: Is that service provided by [this location, center]?
b. [IF GROUP MEMBERS REPORT MEDICATION]: How is your [psychiatrist or nurse
practitioner] working with you to find the right medication for you?
3. Has the assistance with paying for services permitted you to pursue treatment that you would not
have been able to before?
3

6464 Supported Employment Demonstration Attachment O3. Participant Focus Group Guide 05-03-17

a. [IF YES]: How so?
b. How did you manage before without assistance? e.g., took less medication than prescribed so it
would last longer, received free counseling services.
B. Current health
1. Do you think your disability, physical or mental problem is getting better, staying the same, or
getting worse? Please explain.
2. What do you think would help you get better?
C. [FULL SERVICE TREATMENT PARTICIPANTS]: Nurse Care Coordinator
The Nurse Care Coordinator is the nurse who may be talking to your doctors to help you improve your
symptoms and health. We’d like to hear about what working with him or her is like, for those of you
who are comfortable describing your experiences.
1. When you go see the nurse care coordinator, what happens?
2. What are you working on with him or her?
3. Do you think that providers speak to each other about your care? How do you know?
D. Recommendations
1. What suggestions do you have for how the services offered as part of the study could be enhanced
or improved?
2. What would keep you coming back if you need help?
E. Closing
Is there anything we didn’t ask about that you think is important for us to know to understand your
experiences receiving Supported Employment Demonstration services?
Thank you for your time.

4

6464 Supported Employment Demonstration Attachment P1. Ethnographic Observation Gatekeeper
Invitation Letter 05-03-17

[Study Letterhead]
[Date]
Dear [Gatekeeper]:
As part of the Supported Employment Demonstration, a national study by the
Social Security Administration (SSA), my colleague, [insert name], and I would
like to visit [name of event, meeting, organization]. We work for Westat, a research
organization based in Rockville, MD that is carrying out the study on behalf of
SSA.
The purpose of the Supported Employment Demonstration is to find out if
providing high quality employment services and behavioral health services helps
people who were recently denied Social Security disability benefits to find good
jobs they want and to function better overall in their daily lives. SSA also wants to
know which services and treatments work best and what they cost.
For this study, we are interested in learning about the contexts in which people
with disabilities live and seek employment. Attending [name of event, meeting, or
organization] may provide some insight into the challenges faced by disabled
individuals who seek employment, or seek to remain employed, in this community.
Therefore, we would like to observe [name of event, meeting, or organization] and
speak with individuals about their experiences.
We look forward to telling you more about the study and our visit to [name of
event, meeting, or organization]. We will call you in the coming week to discuss
our visit.
You can wait for our call if you want, or you can call [Site visitor’s name] at (xxx)
xxx-xxxx.
Sincerely,

[Site Visitors’ names]

6464 Supported Employment Demonstration Attachment P2. Ethnographic Observation Gatekeeper Phone Call Sample
Script 05-03-17

Sample Script for Gatekeeper Ethnographic Observation Invitation Phone Call
Hello, may I speak with [gatekeeper’s name]
If respondent asks who’s calling:
My name is [site visitor’s name] and I am calling about the Supported Employment
Demonstration, a national study by the Social Security Administration or SSA. I work for
Westat, a research organization that is carrying out the study on behalf of SSA.
If respondent insists on more information:
I am calling to seek [gatekeeper’s name] permission to attend [name of event, meeting, or
organization].
If gatekeeper is not available (depending on respondent’s response):
When is a good time to reach [gatekeeper’s name]?
May I leave a message for [gatekeeper’s name]?
I will try to reach [gatekeeper’s name] again.
Thank you for your time and have a good day.
If leaving a message for gatekeeper:
My name is [site visitor’s name]. I am calling about the Supported Employment
Demonstration, a national study by the Social Security Administration or SSA. I work at
Westat, a research organization that is carrying out the study on behalf of SSA. I would
like to attend [name of event, meeting, or organization] to observe and speak with
individuals about their experiences seeking employment in this community. Please call
me at [site visitor’s contact number] or email me at xxxx@westat.com.
Once gatekeeper is on the phone:
My name is [site visitor’s name]. I am calling about the Supported Employment
Demonstration, a national study by the Social Security Administration or SSA. I work at
Westat, a research organization that is carrying out the study on behalf of SSA. I am
calling to ask to attend [name of event, meeting, or organization] to gain insight into the
1

6464 Supported Employment Demonstration Attachment P2. Ethnographic Observation Gatekeeper Phone Call Sample
Script 05-03-17

challenges faced by people with disabilities who seek employment, or seek to remain
employed, in this community. Did you receive our letter about this in the mail?
If the gatekeeper cannot recall the letter, provide prompts as follows:
The letter explained that we are interested in attending [name of event, meeting, or
organization] in order to learn more about the contexts in which people with disabilities
live and seek employment in this community. It also said that someone would call you
about our visit.
We would like to observe [name of event, meeting, or organization] and ask to speak
with individuals about their experiences.
If gatekeeper did not receive the letter:
I sent the letter to [address on file] on [insert date or approximate date]. Is this your
current address?
If yes: I will resend the letter to you today.
If no: Please provide me with your current address so I can mail the letter to you
today.
If gatekeeper received the letter:
May we attend [name of event, meeting, or organization] on [date] at [time]?
If no: Would [second date] at [second time] be better for you?
When would be a good time for you during the week of [range of dates]?
If yes: Great! What time would be good for you on that date?
Where should we plan to meet you?
I will see you [confirm date and time] at [confirm location]. If you have
questions or need to cancel, please call me at [site visitor’s contact number].
Thank you and have a good day. Goodbye.

2

6464 Supported Employment Demonstration Attachment P3. Ethnographic Observation Participant Invitation
Letter 05-03-17

[Study Letterhead]
[Date]
Dear [name]:
As part of the Supported Employment Demonstration, a national study by the Social
Security Administration (SSA), my colleague, [insert name], and I would like to spend a
few hours observing you go about your daily life. We work for Westat, a research
organization based in Rockville, MD, that is carrying out the study on behalf of SSA.
The purpose of the Supported Employment Demonstration is to find out if providing
high quality employment services and behavioral health services helps people who were
recently denied Social Security disability benefits to find good jobs they want and to
function better overall in their daily lives. SSA also wants to know which services and
treatments work best and what they cost.
For this study, we are interested in learning about the contexts in which you live, work
and relax. If possible, we would like to spend about 3 or 4 hours with you as you go
about your day. This could be time you spend at your workplace, at home with your
family, or doing a leisure activity. Observing what your daily life is like will help us
understand the challenges you face in regards to your disability and employment. For
those hours, you shouldn’t plan to do anything special or out-of-the-ordinary. We are
interested in what you normally do.
Since this is part of a research study, whether you allow us to observe is voluntary and
you can stop having us observe at any time. We are doing similar observations with
people all across the country. At the end of the study, we will present a report to SSA
summarizing the study findings. We may use quotes from you or others in our reports
but no names will be used.
We will call you in the coming week to discuss our visit. You can wait for our call if
you want, or you can call [Site visitor’s name] at (xxx) xxx-xxxx.
Sincerely,

[Site Visitors’ names]

6464 Supported Employment Demonstration Attachment P4. Ethnographic Observation Participant Phone Call Sample
Script 05-03-17

Sample Script for Participant-Centered Ethnographic Observation Invitation Phone Call
Hello, may I speak with [participant’s name]
If respondent asks who’s calling:
My name is [site visitor’s name] and I am calling about the Supported Employment
Demonstration, a national study by the Social Security Administration or SSA. I work for
Westat, a research organization that is carrying out the study on behalf of SSA.
If respondent insists on more information:
I am calling to invite [participant’s name] to participate in research that can help improve
people’s health and employment.
If participant is not available (depending on respondent’s response):
When is a good time to reach [participant’s name]?
May I leave a message for [participant’s name]?
I will try to reach [participant’s name] again.
Thank you for your time and have a good day.
If leaving a message for participant:
My name is [site visitor’s name]. I am calling about the Supported Employment
Demonstration, a national study by the Social Security Administration or SSA. I work at
Westat, a research organization that is carrying out the study on behalf of SSA. I would
like to invite you to participate in research that can help improve people’s health and
employment experiences. Please call me at [site visitor’s contact number] or email me at
xxxx@westat.com.
Once participant is on the phone:
My name is [site visitor’s name]. I am calling about the Supported Employment
Demonstration, a national study by the Social Security Administration or SSA. I work at
Westat, a research organization that is carrying out the study on behalf of SSA. I am
1

6464 Supported Employment Demonstration Attachment P4. Ethnographic Observation Participant Phone Call Sample
Script 05-03-17

calling to invite you to participate in research that will help us understand the challenges
you face in regards to your disability and employment. Did you receive our letter about
this in the mail?
If the participant cannot recall the letter, provide prompts as follows:
The letter invited you to participate in research about your daily life. We would like to
spend about about 3 or 4 hours with you as you go about your day. For those hours, you
shouldn’t plan to do anything special or out-of-the-ordinary. We are interested in what
you normally do. It could be time you spend at your workplace, at home with your
family, or doing a leisure activity. The letter we sent also said that someone would call
you.
If participant did not receive the letter:
I sent the letter to [address on file] on [insert date or approximate date]. Is this your
current address?
If yes: I will resend the letter to you today.
If no: Please provide me with your current address so I can mail the letter to you
today.
If participant received the letter:
Would you be able to have us observe anytime between [insert range of dates]?
If no: Would [second date] at [second time] be better for you?
When would be a good time for you during the week of [range of
dates]?
If yes: Great! What time would be good for you on that date?
Where should we plan to meet you?
I will see you [confirm date and time] at [confirm location]. If you have
questions or need to cancel, please call me at [Site visitor’s contact
number].
Thank you and have a good day. Goodbye.

2

6464 Supported Employment Demonstration Attachment P5. Ethnographic Observation Ad Hoc Consent
Script 05-03-17

Sample Consent Scripts for Ad Hoc Ethnographic Observations

For participant-centered observations:
Hi, my name is [site visitor’s name] and this is my colleague, [colleague’s name]. I
am spending some time today with [name of participant] to learn about [his/her]
daily life as part of the Supported Employment Demonstration, a national study
about employment and health by the Social Security Administration or SSA. I
work for Westat, a research company that is carrying out the study on behalf of
SSA. Is it alright if I observe?

For event/meeting/organization-centered observations:
Hi, my name is [site visitor’s name] and this is my colleague, [colleague’s name]. I
am spending time today at [name of event, meeting or organization] as part of the
Supported Employment Demonstration, a national study about employment and
health by the Social Security Administration or SSA. I work for Westat, a research
company that is carrying out the study on behalf of SSA. SSA is interested in
learning about the challenges faced by people with disabilities who seek
employment, or seek to remain employed, in this community. Is it alright if I
observe?

1

6464 Supported Employment Demonstration Attachment P6. Ethnographic Observation Template 05-03-17

Supported Employment Demonstration Ethnographic Observation Template
For Natural Settings
The site visit team will conduct observations in selected natural settings during the week. Settings
may include workplaces, family homes, treatment settings, leisure activities, and other locations that
may be important for understanding the layered contexts in which participants live. Our
observations will focus on specific areas of inquiry that will inform our conceptualization of the
values, assumptions, constraints and opportunities that influence participants’ employment and
health. The content of this template may be modified based on data gathered earlier in the site visit
from individual interviews and focus groups with patients and providers.
Date: ____________ Time: ____________ Location: _________________________________
Observer: ____________________ Participants: _____________________________________
1. Overall description of activities and observations:

2. Description of activities and observations that reflect participants’ goals, needs, skills, and
beliefs, and how they affect experiences of employment and disability:

3. Description of activities and observations that reflect contextual factors (e.gs., social
networks, cultural beliefs) or ascribed characteristics (e.gs., SES, race, ethnicity) and how
they affect experiences of employment and disability:

4. Other observations:

5. Observers’ reflections and reactions (what you have learned, what information you do not
have, what stands out, etc.):

6464 Supported Employment Demonstration Attachment Q1. Person-Centered Interview Invitation Letter
05-03-17

[Study Letterhead]
[Date]
Dear [Participant Name]:
You have been selected to participate in an interview about your experiences of
disability and employment. This interview is part of the Supported Employment
Demonstration, a national study by the Social Security Administration (SSA). My
colleague, [insert name], and I work for Westat, a research organization based in
Rockville, MD, that is carrying out the study on behalf of SSA.
We would like to interview you during the week of [insert range of dates]. The
interview will last about 60 minutes. Afterwards, you will receive $40 to thank you
for your participation.
The purpose of the interview is to learn what your daily life is like and understand
the challenges you face in regards to your disability and employment. By sharing
your experience, you will help people who share your circumstances because this
study will likely affect national policy on work and disability for many years.
We will call you within one week to discuss your participation. We very much
look forward to meeting with you.
You can wait for our call or if you want, you can call us at (xxx) xxx-xxxx.
Sincerely,

[Site Visitors’ names]

6464 Supported Employment Demonstration Attachment Q2. Person-Centered Interview Phone Call Sample Script 05-03-17

Sample Script for Person-Centered Interview Invitation Phone Call
Hello, may I speak with [respondent’s name]?
If person asks who’s calling:
My name is [site visitor’s name] and I am calling about an important research study by
the Social Security Administration.
If person insists on more information:
I am calling to invite [respondent’s name] to participate in research that can help improve
people’s health and employment.
If respondent is not available (depending on person’s response):
When is a good time to reach [respondent’s name]?
May I leave a message for [respondent’s name]?
I will try to reach [respondent’s name] again.
Thank you for your time and have a good day.
If person indicates that the respondent is no longer at resident or that address:
Can you provide me with [respondent’s name] current telephone number and/or address?
Can you provide me with the contact information for someone who has [his/her] contact
information?
Can you forward a message to [respondent’s name] and ask [him/her] to contact me at
his/her earliest convenience?
If leaving a message for respondent:
My name is [site visitor’s name]. I am calling about a research study by the Social
Security Administration. I would like to invite you to participate in an interview about
your health and employment experiences. Please call me at [site visitor’s contact
number] or email me at xxxx@westat.com.

1

6464 Supported Employment Demonstration Attachment Q2. Person-Centered Interview Phone Call Sample Script 05-03-17

Once respondent is on the phone:
My name is [site visitor’s name]. I am calling about the Supported Employment
Demonstration. I work for Westat, the research organization that is carrying out this study
on behalf of the Social Security Administration. I’d like to invite you to participate in an
interview about your experiences of disability and employment. The interview will last
about 60 minutes. Afterwards, you will receive $40 to thank you for your participation.
Did you receive a letter about this interview in the mail?
If the respondent cannot recall the letter, provide prompts as follows:
The letter invited you to share what your daily life is like and the challenges you face in
regards to your disability and employment. It also said that someone would call you to set
up the interview.
If respondent did not receive the letter:
I sent the letter to [address on file] on [insert date or approximate date]. Is this your
current address?
If yes: I will resend the letter to you today.
If no: Please provide me with your current address so I can mail the letter to you
today.
If participant received the letter:
Would you be able to participate in an interview on [date] at [time]?
If no: Would [second date] at [second time] be better for you?
When would be a good time for you during the week of [range of dates]?
If yes: Great! I will see you [confirm date and time] at [confirm location].
If you have questions or need to cancel, please call me at [site visitor’s
contact number].
Thank you and have a good day. Goodbye.

2

6464 Supported Employment Demonstration Attachment Q3. Person-Centered Interview Initial 05-03-17

Supported Employment Demonstration
Demonstration Year 1
Initial Person-Centered Interview for Study Participants and Non-Participants
Thank you for agreeing to participate in this interview. My name is [NAME] and this is my colleague [NAME]. We
work for Westat, a research organization based in Rockville, MD. The Social Security Administration, or SSA, has
contracted with Westat to carry out the Supported Employment Demonstration on its behalf. SSA is interested in
your experiences of employment while having a disability or illness. By sharing your experience, you will help SSA
better understand how to assist people who do not receive disability benefits.
Today we’d like to hear about your journey, your experience having a disability, whether physical or mental, and
how your disability affects your work experience and other aspects of your life. We’d also like to ask your thoughts
about your goals and your future.
Before we get started, there are a few things I should mention. This is a research project. Your participation in this
interview is voluntary. There is no penalty if you decide not to participate. If any questions make you feel
uncomfortable, you can take a break, skip any questions or stop the interview. If you get upset, we may offer you a
referral to crisis management services that you can use if you wish. However, if you tell us that you are planning to
hurt yourself or someone else, this will be reported to the appropriate authorities.
We are interviewing people all across the country who do not receive Social Security disability benefits. At the end
of the study, we will present a report to SSA summarizing the challenges and successes of people who live with a
disability. We may use quotes from you or other interviewees in our reports but no names will be linked to any
responses.
We have planned for this interview to last about 60 minutes. You will receive $40 to thank you for your
participation.
Do you have any questions? [ANSWER ALL QUESTIONS.]
Finally, with your permission, we would like to record this interview to help us recall what was said.
Are you okay with us recording? [PAUSE FOR RESPONSE.]
I’d like to start the audio recording now. [TURN ON THE RECORDER.]
For purposes of the recording, I am going to ask you:
Are you willing to participate in the interview? Are you willing to have the interview audio-recorded?
[PAUSE FOR RESPONSE.]
OK let’s begin.

1

6464 Supported Employment Demonstration Attachment Q3. Person-Centered Interview Initial 05-03-17

I.

BACKGROUND—SERVICE USAGE
I’d like to start off by asking what services, if any, have you been received from [NAME OF SITE]:
A. [Full Service Treatment and Basic Service Treatment Recipients]
1. What employment services have you received?
PROBES: What have you been working on with the IPS specialist? How has that been going?
What do you hope to get out of work with the IPS specialist?
What are your goals for employment? Have your goals changed since you started the program?
2. What types of mental health services have you received so far (including treatment with medication,
psychotherapy, groups, case management, etc.)?
PROBES: How has that [medication, group, therapy] been working for you?
[IF PATIENT REPORTS MEDICATION]: How is your psychiatrist/ nurse practitioner working
with you to find the right medication for you?
3. What types of assistance have you received with employment and mental health expenses?
PROBES: Has the assistance with paying for services permitted you to pursue treatment that you
would not have been able to before?
[IF YES]: How so? How did you manage before without assistance (e.g., took less medication than
prescribed so it would last longer, received free counseling services)?
What kinds of employment expenses have been covered for you?
B. [Full Service Treatment Recipients]
1. Tell me about your work with the nurse care coordinator.
PROBES: When you go see the nurse care coordinator, what happens?
What are you working on with him or her?
C. [Usual Behavioral Health Services Recipients]
1. Have you sought professional assistance with finding a job, or receiving job training or education?
[IF YES:] Who provides the assistance and where? How is that working for you?
2. Do you take medication for a psychiatric problem? What about for a physical problem?
[IF YES:] Who provides medication and where? How is that working for you?
3. Do you see a counselor or therapist?
[IF YES]: How is that working for you?
4. Do you attend a support group?
[IF YES]: How is that working for you?
2

6464 Supported Employment Demonstration Attachment Q3. Person-Centered Interview Initial 05-03-17

5. What kinds of services do you think would help you?
II.

PERSON-CENTERED ETHNOGRAPHIC INTERVIEW
As I mentioned earlier, we are interested in learning about the challenges and struggles of living and working
with a physical or mental health problem. I’d like to start off by having you tell me your story about how
your health has affected your work. I’m particularly interested in hearing what happened that made you
decide to seek disability benefits and what your journey has been like applying for benefits. You can start
your story wherever you like and you can talk as long as you like—but tell me whatever you think is
important for me to hear to understand your journey that resulted in your application to seek disability
income.
A. Work
Tell me about your employment history, and your journey working, not working and applying for
disability benefits.
[PROBES]: What kind of work do [did] you do? What kind of jobs have you had? What skills did you
need to do those jobs? [Interviewer should probe to make sure he or she understands the nature of the
work and the skills, physical, emotional, and intellectual requirements needed to perform it. Interviewer
should also probe about changes between types of jobs. Pay attention to accounts of moving from jobs
requiring more skill to those requiring less.]
1. [PROBES FOR INDIVIDUALS WHO WANT TO WORK]:
What has made it difficult or challenging for you to find a job and keep it?
What has helped you in the past to find a job and keep it? (e.gs. skills, financial, family, etc.)
What do you think would make it possible for you to get a job and stay in that job?
What are your goals for employment?
What keeps you motivated to work?
a. [IF NOT WORKING]: Do you think you’ll get a job and stay with it? Why or why not?
Do you want the same type of work you used to do, or something else? Please explain.
How do you support yourself when not working?
What do you think could help you now while you look for work?
b. [IF WORKING]: Do you think you’ll stay in this job? Why or why not?
What kind of job is it? Is it different from what you’ve done before? Please explain.
Do you like your job? Please explain.
When you weren’t working, how did you support yourself?
What would have helped you at the times you weren’t working?
3

6464 Supported Employment Demonstration Attachment Q3. Person-Centered Interview Initial 05-03-17

2. [PROBES FOR INDIVIDUALS WHO DO NOT WANT TO WORK]:
What has made you decide not to try to go back to work?
How do you support yourself when not working?
B. History of disability
Tell me about your mental or physical problem. How did the problem start? When did it start?
1. What got in the way of you finding work and keeping a job?
How long ago did those challenges start?
2. How does your disability affect your work? Thinking back, when did you first realize that your
physical or mental health was interfering in your work? How did you know? What was happening
then?
3. What did you do to cope with these problems? How successful was that?
4. Since you first noticed that your health interferes with your work, do you think the problem has
gotten worse, stayed the same, or gotten better? Please explain.
5. Did others at work notice you were having trouble? Please explain.
6. Did anyone at work help you or provide support? Please explain. [IF YES, also probe for stigma]
7. Did anyone in your family help you or provide support? Please explain.
8. How does your family feel about your applying for disability benefits?
9. [IF INDIVIDUAL WANTS TO WORK]: How does your family feel about your wanting to work
even though you have this problem?
10. [IF YES]: Did they try to help? How did that work out?
C. Treatment and rehabilitation history
1. Before you became part of this study, did you receive any medical or psychological help for you
problem?
[IF YES]: What kinds of professional help do you try? How did that work out?
[IF NO]: Why didn’t you get treatment for this problem? Do you think you’ll seek treatment in the
future?
2. Before you became part of this study, did you ever seek help from a vocational counselor or a
rehabilitation specialists or another professional who helps people find employment or develop jobrelated skills?
[IF YES]: Who did you see? How did that work out?

4

6464 Supported Employment Demonstration Attachment Q3. Person-Centered Interview Initial 05-03-17

D. The future
1. Do you think your disability is getting better, staying the same, or getting worse? Why?
[IF SAME OR WORSE]: What do you think would help you get better?
[IF BETTER]: What do you think helped?
2. What do you imagine your life would be like if you received disability benefits?
What would you do with your time?
3. What do you imagine your life will be like in 5 years? In 10 years?

5

6464 Supported Employment Demonstration Attachment Q4. Person-Centered Interview Follow Up 05-03-17

Supported Employment Demonstration
Demonstration Years 2, 3, and 4
Follow Up Person-Centered Interview for Study Participants and Non-Participants

Thank you for agreeing to participate in this interview. My name is [NAME] and this is my colleague [NAME]. We
work for Westat, a research organization based in Rockville, MD. The Social Security Administration, or SSA, has
contracted with Westat to carry out the Supported Employment Demonstration on its behalf. SSA is interested in
your experiences of employment while having a disability or illness. By sharing your experience, you will help SSA
better understand how to assist people who do not receive disability benefits.
Today we’d like to hear about your journey, your experience having a disability, whether physical or mental, and
how your disability affects your work experience and other aspects of your life. We’d also like to ask your thoughts
about your goals and your future.
Before we get started, there are a few things I should mention. This is a research project. Your participation in this
interview is voluntary. There is no penalty if you decide not to participate. If any questions make you feel
uncomfortable, you can take a break, skip any questions or stop the interview. If you get upset, we may offer you a
referral to crisis management services that you can use if you wish. However, if you tell us that you are planning to
hurt yourself or someone else, this will be reported to the appropriate authorities.
We are interviewing people all across the country who do not receive Social Security disability benefits. At the end
of the study, we will present a report to SSA describing these challenges and successes of people who live with a
disability. We may use quotes from you or other interviewees in our reports but no names will be linked to any
responses.
We have planned for this interview to last about 60 minutes. You will receive $40 to thank you for your
participation.
Do you have any questions? [ANSWER ALL QUESTIONS.]
Finally, with your permission, we would like to record this interview to help us recall what was said.
Are you okay with us recording? [PAUSE FOR RESPONSE.]
I’d like to start the audio recording now. [TURN ON THE RECORDER.]
For purposes of the recording, I am going to ask you:
Are you willing to participate in the interview? Are you willing to have the interview audio-recorded?
[PAUSE FOR RESPONSE.]
OK let’s begin.

1

6464 Supported Employment Demonstration Attachment Q4. Person-Centered Interview Follow Up 05-03-17

I.

BACKGROUND—SERVICE USAGE
I’d like to start off by asking what services, if any, have you been received from [NAME OF SITE]:
A. [Full Service Treatment and Basic Service Treatment Recipients]
1. What employment services have you received in the past year?
PROBES: What have you been working on with the IPS specialist? How has that been going?
What do you hope to get out of work with the IPS specialist? What are your goals for
employment? Have your goals changed since you started the program?
2. What types of mental health services have you received so far? (including treatment with medication,
psychotherapy, groups, case management, etc.)
PROBES: How has that [medication, group, therapy] been working for you?
[IF PATIENT REPORTS MEDICATION]: How is your psychiatrist/ nurse practitioner working
with you to find the right medication for you?
3. What types of assistance have you received with employment and mental health expenses in the past
year?
PROBES: Has the assistance with paying for services permitted you to pursue treatment that
you would not have been able to before?
[IF YES]: How so? How did you manage before without assistance? e.g., took less medication than
prescribed so it would last longer, received free counseling services.
What kinds of employment expenses have been covered for you?
B. [Full Service Treatment Recipients]
1. Tell me about your work with the nurse care coordinator this year.
PROBES: When you go see the nurse care coordinator, what happens?
What are you working on with him or her?
C. [Usual Behavioral Health Services Recipients]
1. Have you sought professional assistance with finding a job, or receiving job training or education?
[IF YES:] Who provides the assistance and where? How is that working for you?
2. Do you take medication for a psychiatric problem? What about for a physical problem?
[IF YES:] Who provides medication and where? How is that working for you?
3. Do you see a counselor or therapist?
[IF YES]: How is that working for you?
4. Do you attend a support group?
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6464 Supported Employment Demonstration Attachment Q4. Person-Centered Interview Follow Up 05-03-17

[IF YES]: How is that working for you?
5. What kinds of services do you think would help you?
II.

PERSON-CENTERED ETHNOGRAPHIC INTERVIEW
As I mentioned earlier, we are interested in learning about the challenges and struggles of living and working
with a physical or mental health problem. I’d like to start off by having you tell me your story about how
your health has affected your work. I’m particularly interested in hearing what has happened in your life in
the past year pertaining to your disability. I am also interested in whether you are working, whether you plan
to work, or whether you plan to apply for disability income again, and any other plans you may have for
your future. You can start your story wherever you like and you can talk as long as you like—but tell me
whatever you think is important for me to hear to understand your journey living with your disability over
the past year.
A. Work
Tell me about your employment history, and your journey working, not working and applying for
disability benefits over the past year.
[PROBES]: What kind of work have you done this year? What kind of jobs have you had? What kind of
jobs have you been applying for? What skills did you need to do those jobs? [Interviewer should probe
to make sure he or she understands the nature of the work and the skills, physical, emotional, and
intellectual requirements needed to perform it. Interviewer should also probe about changes between
types of jobs. Pay attention to accounts of moving from jobs requiring more skill to those requiring
less.]
1. [PROBES FOR INDIVIDUALS WHO WANT TO WORK]:
What has made it difficult or challenging for you to find a job and keep it?
What has helped you in the past to find a job and keep it? (e.gs. skills, financial, family, etc.)
What do you think would make it possible for you to get a job and stay in that job?
What are your goals for employment?
What keeps you motivated to work?
a. [IF NOT WORKING]: Do you think you’ll get a job and stay with it? Why or why not?
Do you want the same type of work you used to do, or something else? Please explain.
How do you support yourself when not working?
What do you think could help you now while you look for work?
b. [IF WORKING]: Do you think you’ll stay in this job? Why or why not?
What kind of job is it? Is it different from what you’ve done before? Please explain.
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6464 Supported Employment Demonstration Attachment Q4. Person-Centered Interview Follow Up 05-03-17

Do you like your job? Please explain.
When you weren’t working, how did you support yourself?
What would have helped you at the times you weren’t working?
2. [PROBES FOR INDIVIDUALS WHO DO NOT WANT TO WORK]:
What has made you decide not to try to go back to work?
How have you been supporting yourself when not working?
B. History of disability
Tell me about your mental or physical problem. How has your health been in the past year?
1. Are these new problems?
[IF YES]: Please explain.
a. How long ago did those problems start? How does your disability affect work?
b. What have you done to cope with these problems? How successful was that?
2. Are these problems you’ve had for a number of years?
[IF YES]: Please explain.
a. How has the problem changed over the past year, if at all?
b. Over the past year, do you think it has gotten worse, stayed the same, or gotten better?
3. Does anyone in your family help you or provide support? Please explain.
4. How does your family feel about your applying for disability benefits?
5. [IF INDIVIDUAL WANTS TO WORK]: How does your family feel about your wanting to work
even though you have this problem?
[PROBE]: Did they try to help? How did that work out?
C. The future
1. Do you think your disability is getting better, staying the same, or getting worse? Why?
[IF SAME OR WORSE]: What do you think would help you get better?
[IF BETTER]: What do you think helped?
2. What do you imagine your life would be like if you received disability benefits? What would you do
with your time?
3. What do you imagine your life will be like in 5 years? In 10 years?

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6464 Supported Employment Demonstration Attachment R. Distressed Participant Protocol 05-03-17

Supported Employment Demonstration
Distressed Participant Protocol
Introduction
There exists the possibility that some respondents may become psychologically distressed during their
participation in study-related activities. All of the community mental health centers (CMHCs) selected
as sites for the Supported Employment Demonstration will have existing crisis management
services. These services range from in-house services to on-call services, to collaborations with local
emergency rooms. When possible, participants who experience distress during study-related activities
will be offered a referral, if they wish, to the existing services available at the local CMHC. The
following procedures are geared toward staff conducting study-related activities such as interviews,
whether in-person or by telephone, and focus groups.

Who is a distressed respondent?
A distressed respondent is one who shows significant signs of emotional distress during the interview.
These signs can appear in a variety of forms and can occur in different combinations. They may vary
in intensity.
In general, be alert to the following signs of serious distress and be prepared to act immediately:
The interviewee says…








They plan to hurt themselves or someone else.
They might hurt themselves or someone else.
They want to die.
They want to kill someone else.
They find life without purpose.
They have lost a reason to live.
They tell you they are planning or thinking about using a firearm or other weapon.

Other signs of distress:
 The respondent appears agitated:
o Emotional outburst
o Statements that they are upset
 The respondent doesn’t make sense when talking.

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6464 Supported Employment Demonstration Attachment R. Distressed Participant Protocol 05-03-17

What to do if your respondent, another person, or you are in immediate danger:


If you believe your respondent or someone else is in immediate danger, stop the interview and call 9-1-1.
Try to engage your respondent in non-threatening conversation until help arrives.



For in-person interviews, if the respondent does not want to talk, try to keep a visual on him(her) until help
arrives (e.g., if he goes outside for a cigarette, try to keep him in your line of vision). If you believe you are
in immediate danger, stop the interview and get yourself to a safe place away from your respondent. Then
call 9-1-1 and maintain your own safety until help arrives.

What to do if your respondent appears upset, but does not present an immediate
danger to himself or someone else:


When a respondent becomes distressed, the interviewer will make a decision about whether or not to
terminate the interview. Any sign of distress will generally end the interview, but in some cases it may be
possible to skip the section of the interview that is causing stress to the respondent.



If the respondent shows increasing signs of distress or becomes upset or irritated, do not wait. Tell the
respondent you would like to take a 5-minute break and that you will continue the interview after the break.
Try to engage her/him in casual conversation until s/he appears to have calmed down. For in-person
interviews, offer some coffee or water.



If the respondent is unable to continue, end the interview and thank the respondent for his/her time. Ask the
respondent if s/he would like to talk with someone who can help.



If the respondent wishes to speak to someone who can help, initiate a phone call to the crisis manager on
call at the local CMHC. Offer to stay on the line until the appropriate party takes over the call with the
respondent.

Protocol for Notification


In cases where the interviewer observes a distressed respondent, immediately following the session the
interviewer will notify his or her Westat supervisor; in turn, the Westat Project Director will be notified.



The Westat Project Director or designee will inform Westat IRB in accordance with the appropriate
reporting requirements.

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6464 Supported Employment Demonstration Attachment S. Study Withdrawal Forms 05-03-17

SUPPORTED EMPLOYMENT DEMONSTRATION
SOCIAL SECURITY ADMINISTRATION
Study Withdrawal Form: Full-Services Treatment Group

By signing this form, I withdraw my participation from the Supported Employment Demonstration.
After I withdraw, I cannot re-enroll in the study and I will no longer receive the following benefits:


Supported employment services from the study site



Behavioral health and related services from the study site



Assistance from the study nurse care coordinator



Reimbursement for out-of-pocket expenses associated with approved behavioral health services
and treatments not covered by my insurance, and reimbursement for approved work-related
expenses

In addition, I will not be asked to participate in any future study interviews. However, any information
collected about me for this study before my withdrawal date may be used for research purposes, to
evaluate the Supported Employment Demonstration.

Signature of Participant

Date

__________________________________________
Printed Name of Participant

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6464 Supported Employment Demonstration Attachment S. Study Withdrawal Forms 05-03-17

SUPPORTED EMPLOYMENT DEMONSTRATION
SOCIAL SECURITY ADMINISTRATION
Study Withdrawal Form: Basic-Services Treatment Group

By signing this form, I withdraw my participation from the Supported Employment Demonstration.
After I withdraw, I cannot re-enroll in the study and I will no longer receive the following benefits:


Supported employment services from the study site



Behavioral health and related services from the study site



Reimbursement for out-of-pocket expenses associated with approved behavioral health services
and treatments not covered by my insurance, and reimbursement for approved work-related
expenses

In addition, I will not be asked to participate in any future study interviews. However, any information
collected about me for this study before my withdrawal date may be used for research purposes, to
evaluate the Supported Employment Demonstration.

Signature of Participant

Date

__________________________________________
Printed Name of Participant

2

6464 Supported Employment Demonstration Attachment S. Study Withdrawal Forms 05-03-17

SUPPORTED EMPLOYMENT DEMONSTRATION
SOCIAL SECURITY ADMINISTRATION
Study Withdrawal Form: Usual Services Group (Control Group)

By signing this form, I withdraw my participation from the Supported Employment Demonstration.
After I withdraw, I cannot re-enroll in the study and I will not be asked to participate in any future
study interviews. However, any information collected about me for this study before my withdrawal
date may be used for research purposes, to evaluate the Supported Employment Demonstration.

Signature of Participant

Date

__________________________________________
Printed Name of Participant

3