Promoting Opportunity Demonstration (POD) Baseline Quest

Promoting Opportunity Demonstration (POD)
Baseline Questionnaire

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by
section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. The OMB control number for this information collection is 0960-0XXX, expiring
xx-xxx-20xx. We estimate that it will take about 20 minutes to read the instructions, gather the facts, and answer the questions.
You may send comments about our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.

Mathematica Policy Research is conducting a study for the Social Security
Administration (SSA). As part of this study, we will interview thousands of people
who currently receive Social Security Disability Benefits.
The study is about a new program that SSA is administering called the Promoting
Opportunity Demonstration or POD. Thank you for volunteering to participate in
this program. We are asking all who volunteer to complete this survey.
Participation in the survey is voluntary but very important.
We will send you a $25 check in appreciation for completing and returning the
survey. The survey takes about 20 minutes to complete. You may skip any
question you do not wish to answer. Your responses will be kept private and
used only for research purposes. Your responses will be combined and reported
with other responses in total; no individual names or responses will be reported
Thank you for taking the time to complete this survey!
If you have any questions about the survey or would like to complete it by
telephone, please contact the POD helpline at 1-888-771-9188 (this is a toll-free
call).
When you finish the survey, please mail it back with the last two pages of the
consent form filled out (page 3 with the checkboxes and page 4 with your name
and signature) in the envelope provided. Just insert the completed form and
consent form pages into the envelope, seal it, and put it in the mail. No postage is
necessary. The form is preprinted with Mathematica’s mailing address:

POD Study Team
Mathematica Policy Research
P.O. Box 2393
Princeton, NJ 08540

INSTRUCTIONS FOR FILLING OUT THE SURVEY
You may complete this form using a blue or black pen or a pencil. Please provide only one
answer to each question unless the question asks for more than one answer. Start at the top
of the next page with the first item –Question 1. After you read the question, pick the answer
that best applies to you. Continue on to each question that follows.
Please answer questions by clearly writing your answer in the space provided or by marking
the box that best matches your answer as shown in the examples below.
Write your answers like this:
1

Very satisfied

2

Somewhat satisfied

Not like this:
1

Very satisfied

2

Somewhat satisfied

For figures or amounts:
Write your answers like this:
$

2

5

0

0

0

0

.

Not like this:
2

5

.

If you want to change your response, circle the correct answer and draw a line through
the incorrect answer:
1

Very satisfied

2

Somewhat satisfied

Some questions you will not need to answer. For these questions, there will be instructions
to tell you which question to “skip” to next.
1.

Do you ever eat chocolate?
1

0

2.

Yes
No

SKIP TO QUESTION 3

In the last seven (7) days, how many chocolate bars have you eaten?
BARS

APPENDIX A

Before we begin, please identify who is filling out this survey.
1.

Who is completing this form?
1

0

2.

I am completing it myself or with help
SKIP TO QUESTION 6 ON NEXT PAGE
Someone is completing it for me - on my behalf

How is this person related to you?
MARK ONE ONLY

3.

1

Spouse/Partner

2

Parent

3

Legal guardian

4

Friend

5

Other relative or some other relationship - specify

What is this person’s name?

FIRST NAME

LAST NAME

4.

Is the person who is completing this form the most knowledgeable about the person
receiving Social Security Disability Insurance (SSDI) benefits and his or her day-today activities? This includes knowledge of services or supports that he or she may
have received.
Yes
No

1

0

5.

This form should be completed by the person who is most knowledgeable
about the individual receiving SSDI. Please have that person complete
this form or have him/her call Mathematica at 888-771-9188 to complete
the survey by telephone. Thank you!

Do you live with the person filling out the form?
1

Yes

0

No

APPENDIX A

The first questions are about the Promoting Opportunity Demonstration (POD).
6.

Enrolling in POD is voluntary. This means that...
MARK ONE ONLY

7.

1

You have no choice and must enroll in POD

2

You can choose whether or not you want to enroll in POD

A primary goal of POD is to help you…
MARK ONE ONLY
1

Increase work and earnings

2

Go back to school

3

Get health insurance

The next questions are about employment.
8.

Are you currently working at a job or business for pay or profit? This includes work
you may do for a business that you own. By ‘working at a job for pay or profit’ we
mean at a job where you get paid money for the work you do.
1

0

9.

Yes
No

SKIP TO QUESTION 11

When did you last work for pay? Your best guess is fine.
YEAR

10.

11.

Think about the last four weeks. Have you been looking for work during the last four
weeks?
By looking for work, we mean looking for a job, either full-time or part-time, for which
you will be paid.
1

Yes

0

No

In the last 12 months, did you work at a job that paid you more than $1,000 a month
(before taxes and deductions)?
1

0

Yes
No

APPENDIX A

11a.

During the next 12 months, how likely do you think it is that you will be working at a
job for pay? Do you think it is …
MARK ONE ONLY

12.

1

Very likely

2

Somewhat likely

3

Not very likely

4

Not at all likely

For each of the statements below, please mark whether you strongly agree,
agree, disagree, or strongly disagree.
MARK ONE PER ROW
STRONGLY
AGREE

a.

It is difficult for me to work because I
am afraid I will lose my disability cash
benefits.

b.

It is difficult for me to work because I
am afraid I will lose my health
insurance.

c.

I am limited in my ability to work
because of a physical or mental
condition.

d.

I am limited in my ability to work
because I do not have reliable
transportation to and from work.

e.

I am limited in my ability to work
because I am caring for children or
others.

f.

I am limited in my ability to work
because I am finishing a school or
training program.

g.

I don’t have the skills or training I need
to return to work.

h.

Many workplaces are not accessible to
people with my disability.

i.

It will be difficult to receive Social
Security disability benefits in the
future if I work.

AGREE

DISAGREE

STRONGLY
DISAGREE

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

APPENDIX A

13.

Did you receive any on the job training, job coaching, or support services in the past
year?
MARK ONE ONLY

14.

1

Yes

2

No

3

Not needed/Not used

SKIP TO QUESTION 15

Where did you go to receive on the job training, job coaching, or support services in
the past year?
MARK ONE OR MORE BOXES

15.

1

A vocational rehabilitation agency

2

A welfare agency

3

A mental health agency

4

A state agency

5

A workforce center or unemployment office

6

An employer

7

Some other place - specify

Have you ever spoken with or received services from a benefit specialist or Work
Incentive Planning Assistance (WIPA) program provider? These are programs
funded by Social Security to provide information to beneficiaries about how their
earnings from work affect their benefits.
1

Yes

0

No

APPENDIX A

The next questions are about your health.
16.

In general, would you say your health is…
MARK ONE ONLY

17.

1

Excellent

2

Very good

3

Good

4

Fair

5

Poor

Do you have health insurance coverage now?
That is, are you covered by a plan that someone else in your family has, or through a
health plan your employer provides, or Medicare, Medicaid, or a plan you bought on
your own?
1

0

18.

Yes
No

SKIP TO QUESTION 19

What kinds of health coverage do you have?
MARK ONE OR MORE BOXES
1

Medicare

2

Medicaid also known as {FILL STATE SPECIFIC NAME}

7

Private insurance through own employer

8

Private insurance through spouse/partner/parent

9

Private insurance paid by self/family

11

Other plan - specify

APPENDIX A

The next questions are about your background, education and earnings.
19.

20.

What is your ethnic background? Are you…
1

Hispanic or Latino

2

Not Hispanic or Latino

What is your race? Do you think of yourself as…
MARK ONE OR MORE BOXES

21.

22.

1

Alaska Native or American Indian

2

Asian

3

Black or African/American

4

Native Hawaiian or other Pacific Islander

5

White

6

Other - specify

Are you currently living with a spouse or with someone who is like a spouse to you?
1

Yes

0

No

This question is about your current living situation. Thinking about the place you
live, would you say that this place is a…
MARK ONE ONLY
1

Single family home, mobile home, or regular apartment

2

Other situation, such as a group home, personal care or something else?

APPENDIX A

23.

What is the highest year or grade in school that you have completed?
MARK ONE ONLY

GRADE(1-12)
1

24.

High school diploma, GED or certificate of completion

2

2-year college degree

3

4-year college degree (bachelor’s degree)

4

Other - specify

In the last 12 months, what was the total income of all members of your household
from all sources before taxes and other deductions? Please include any money from
jobs, public assistance programs, or any other source.
Household means people who live in your house on a permanent basis and
contribute to the household financially. Please include your own income and the
income of everyone living with you. Do not include income from people who live in
your household temporarily. If you live in a group home, please include only your
own income.
MARK ONE ONLY
1

Less than $10,000

2

$10,000 to less than $20,000

3

$20,000 to less than $30,000

4

$30,000 to less than $40,000

5

$40,000 to less than $50,000

6

$50,000 or more

APPENDIX A

We would like to send you $25 in appreciation for completing and returning the survey.
Please write your mailing address below so that we can send you $25. We will also reach
out to you in a year for your second survey.
25.

What is your mailing address?

STREET

COMPLEX/BUILDING/APARTMENT NUMBER

CITY

STATE

26.

ZIP CODE

What is the best telephone number to call to reach you?

(

)

AREA CODE

27.

NUMBER

Is this number a …
MARK ONE ONLY

28.

1

Cell phone

2

Landline

3

Work/office

What is another telephone number to call to reach you?

(
AREA CODE

)

NUMBER

APPENDIX A

29.

Is this number a …
MARK ONE ONLY

30.

1

Cell phone

2

Landline

3

Work/office

When we contact you for the next survey in about a year, may we send you a text
message on your cell phone? Depending on your service plan, standard text message
rates may apply.
1

0

30a.

Yes
No

What is the best e-mail address where we may send you study-related information?
Study information may include sending an email to verify your address and telephone
number, an invitation to complete a survey, or a reminder about the survey.

EMAIL ADDRESS

To help us to get back in touch with you in a year for your second survey, please provide the
name, address and telephone number of two people who will always know how to reach you.
This information will be kept private and will only be used if we are unable to reach you.
FIRST PERSON
31.

Please provide the name of someone who lives with you and will always know how to
contact you. If you live alone, please provide the name of someone who will always
know how to contact you.

FIRST NAME

LAST NAME

APPENDIX A

32.

What is this person’s street address if he/she does not live with you?

STREET

COMPLEX/BUILDING/APARTMENT NUMBER

CITY

STATE

33.

ZIP CODE

What is the best telephone number to reach this person?

(

)

AREA CODE

34.

NUMBER

Is this number a …
MARK ONE ONLY

35.

1

Cell phone

2

Landline

3

Work/office

What is this person’s relationship to you?
MARK ONE ONLY
1

Spouse/Partner

2

Parent

3

Legal guardian

4

Friend

5

Other relative or some other relationship - specify

APPENDIX A

SECOND PERSON
36.

Please provide the name of someone who does not live with you and will always know
how to contact you.

FIRST NAME

LAST NAME

37.

What is this person’s street address?

STREET

COMPLEX/BUILDING/APARTMENT NUMBER

CITY

STATE

38.

What is the best telephone number to reach this person?

(

)

AREA CODE

39.

ZIP CODE

Is this number a …
MARK ONE ONLY
1

Cell phone

2

Landline

3

Work/office

NUMBER

APPENDIX A

40.

What is this person’s relationship to you?
MARK ONE ONLY
1

Spouse/Partner

2

Parent

3

Legal guardian

4

Friend

5

Other relative or some other relationship - specify

Thank you for completing this survey!
Please return the completed survey and last two pages of the consent
form (checkboxes and signature pages) in the
self-addressed, postage-paid envelope provided
or mail to:
POD Survey Team
Mathematica Policy Research
P.O. Box 2393
Princeton, NJ 08540