Baseline survey & Identifying and contact information –staff

Instrument 1. Baseline survey

Next Generation of Enhanced Employment Strategies Project

Baseline Survey

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is XXXX-XXXX. The time required to complete this information collection is estimated to average 25 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. This includes the time it takes to provide identifying and contact information. Send comments regarding this burden estimate to XXX. OMB expiration date xx/xx/xxxx.

A. INTRODUCTIONS

Staff-administered (Computer Aided Telephone Interview (CATI)): Thank you for agreeing to participate in the Next Generation of Enhanced Employment Strategies Project. First, I would like to ask you some questions about your background.

Self-administered (Computer Aided Web Interview (CAWI)): Thank you for agreeing to participate in the Next Generation of Enhanced Employment Strategies Project.

• There are no right or wrong answers.

• To answer a question, click the box that indicates your response or fill in your response.

• To continue to the next webpage, press the "Next" button.

• To go back to the previous webpage, click the "Back" button. Please note that this command is only available in some sections.

• Do not use the navigation arrows in your browser.

• Select “Next” to begin the survey.

First, we would like to ask you some questions about your background.

B. DEMOGRAPHIC AND SOCIOECONOMIC CHARACTERISTICS

CATI/CAWI: All

If CAWI DO NOT SHOW dK OR rEF

B1.* Are you Hispanic, Latino/a, or Spanish origin?

Select one or more

 No, not of Hispanic, Latino/a, or Spanish origin 1

 Yes, Mexican, Mexican American, Chicano/a 2

 Yes, Puerto Rican 3

 Yes, Cuban 4

 Yes, Another Hispanic, Latino/a, or Spanish origin 5

 DON’T KNOW d

 REFUSED r

CATI/CAWI: All

If CAWI DO NOT SHOW dK OR rEF

B2.* What is your race?

Select one or more

 AMERICAN INDIAN OR ALASKA NATIVE 1

 ASIAN 2

 BLACK OR AFRICAN AMERICAN 3

 NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 4

 WHITE 5

 OTHER (SPECIFY) 99

Specify (STRING 100)¹

 DON’T KNOW d

 REFUSED r

IF OTHER SPECIFY (99): SPECIFY OTHER RACE

CATI/CAWI: All

If CAWI DO NOT SHOW dK OR rEF

B3.* What is the primary language spoken in your home? Is it…

Select one only

 English, 1

 Spanish, or 2

 Some other language? 99

Specify (STRING 100)

 DON’T KNOW d

 REFUSED r

if program = [program name, whose participants are youth]

If CAWI DO NOT SHOW dK OR rEF

B4. Are you currently in high school?

Select one only

 YES 1

 NO 2

 DON’T KNOW d

 REFUSED r

IF PROGRAM = [PROGRAM NAME, WHOSE PARTICIPANTS ARE YOUTH] AND

CATI/CAWI: b4 ne 1

FOR ALL OTHER PROGRAMS ASK B5 FOR EVERYONE

If CAWI DO NOT SHOW dK OR rEF

B5. What is the highest degree or year of school that you have attained?

Select one only

 LESS THAN A HIGH SCHOOL DIPLOMA 1

 GED or GENERAL EDUCATION DEVELOPMENT 2

 REGULAR HIGH SCHOOL DIPLOMA (NOT A GED) 3

 SOME COLLEGE 4

 A TWO-YEAR DEGREE (ASSOCIATE’S DEGREE) 5

 A FOUR-YEAR DEGREE (BACHELOR’S DEGREE) 6

 A GRADUATE OR PROFESSIONAL DEGREE OR HIGHER 7

 DON’T KNOW d

 REFUSED r

IF PROGRAM=[PROGRAM NAME, WHOSE PARTICIPANTS are not youth]

IF CAWI DO NOT SHOW DK OR REF

B6. What is your current marital status—are you now married, separated, divorced, widowed, or have you never been married?

 MARRIED 1

 SEPARATED 2

 DIVORCED 3

 WIDOWED 4

 NEVER MARRIED 5

 DON’T KNOW d

 REFUSED r

IF PROGRAM=[PROGRAM NAME, WHOSE PARTICIPANTS are not youth]

IF CAWI DO NOT SHOW DK OR REF

B7. Now [I/we] would like to ask you some questions about the people who live with you. Do you have a spouse or partner who lives in your household?

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

IF PROGRAM=[PROGRAM NAME, WHOSE PARTICIPANTS ARE NOT YOUTH]

IF CAWI DO NOT SHOW DK OR REF

B7a. How many children under the age of 18 are in your household?

Number of children under age 18

(0-15)

 DON’T KNOW d

 REFUSED r

IF PROGRAM=[PROGRAM NAME, WHOSE PARTICIPANTS are not youth]

IF CAWI DO NOT SHOW DK OR REF

B7b. How many adults age 18 or older, including yourself, are in your household?

Number of adults age 18 or older

(1-15)

 DON’T KNOW d

 REFUSED r

if program=[program name, whose participants may be likely to care for someone with disability]

IF CAWI DO NOT SHOW DK OR REF

B8. Do you currently care for someone in your household with a disability?

PROBE: Do not count care that you may provide for yourself.

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

IF PROGRAM=[PROGRAM NAME, WHOSE PARTICIPANTS are not youth]

IF CAWI DO NOT SHOW DK OR REF

B9. Which of the following best describes your housing during the past month?

 Own your own home or apartment, 1

 Rent your home or apartment, 2

 Homeless or live in emergency or temporary housing, such as a shelter, 3

 Live in a halfway house, sober house, or other transitional housing, 4

 Live in a group home, 5

 Live with friends or relatives and pay rent to them, 6

 Live with friends or relatives and do not pay rent to them, 7

 Or some other arrangement? 99

Specify (STRING 250)

 DON’T KNOW d

 REFUSED r

program = [program name, whose participants are youth]

IF CAWI DO NOT SHOW DK OR REF

B9a. Which of the following best describes your housing during the past month?

Select one only

 Live with a parent or guardian 1

 Rent your home or apartment, 2

 Homeless or live in emergency or temporary housing, such as a shelter, 3

 Live in a halfway house, sober house, or other transitional housing, 4

 Live in a group home, 5

 Live with friends or relatives and pay rent to them, 6

 Live with friends or relatives and do not pay rent to them, 7

 Or some other arrangement? 99

Specify (STRING 250)

 DON’T KNOW d

 REFUSED r

if program = [program name that serves homeless population]

CATI/CAWI: B9 NE 3 and B9A ne 3

IF CAWI DO NOT SHOW DK OR REF

B10. Have you been homeless at any time in the last three months?

PROBE: Include living on the street, in your car, in an abandoned building, in a homeless or domestic violence shelter, or staying at someone else’s home because you have nowhere else to go.

 YES 1 B10A

 NO 0 B11

 DON’T KNOW d B11

 REFUSED r B11

IF PROGRAM = [PROGRAM NAME THAT SERVES HOMELESS POPULATION]

CATI/CAWI: B10=1 or b9=3 or b9a=3

IF CAWI DO NOT SHOW DK OR REF

B10a. If you add up all the days you have been homeless in the last three months, about how many days have you been homeless? Your best guess is fine.

Number of days homeless during the last three months

(1-93)

 DON’T KNOW d

 REFUSED r

if program = [program name that serves those likely to be receiving child support]

CATI/CAWI: if number of children under 18 in b7a > 0

IF CAWI DO NOT SHOW DK OR REF

B11. Are you currently receiving child support?

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

IF PROGRAM = [PROGRAM NAME THAT SERVES THOSE LIKELY TO BE paying CHILD SUPPORT]

IF CAWI DO NOT SHOW DK OR REF

B12. Are you currently expected to pay child support?

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

IF PROGRAM=[PROGRAM NAME, WHOSE PARTICIPANTS ARE NOT YOUTH]

IF CAWI DO NOT SHOW DK OR REF

B13. During the past year, did you or anyone in your household receive income or assistance from any of the following sources?

Select all that apply

 Disability benefits from the Social Security Administration. These are also called Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) 1

 Temporary Assistance for Needy Families (TANF) or [STATE SPECIFIC TANF NAME] 2

 Unemployment Insurance 3

 Worker’s Compensation 4

 Short-term disability 5

 Food Stamps/Supplemental Nutrition Assistance Program (SNAP) /[STATE-SPECIFIC PROGRAM]] 6

 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 7

 Housing Choice Voucher, also known as Section 8 or Public Housing 8

 Veterans Benefits 9

 Medicaid or [STATE SPECIFIC MEDICAID] or Children’s Health Insurance Program (CHIP) 10

 NONE OF THE ABOVE 0

 DON’T KNOW d

 REFUSED r

IF PROGRAM = [PROGRAM NAME THAT SERVES SSA target population]

CATI/CAWI: If rapter age18flag = 1

IF CAWI DO NOT SHOW DK OR REF

B14. For these next questions, please consider only yourself, not anyone else in your household. Have you received a check or electronic payment from the Social Security Administration because of a disability in the past year as an adult?

PROBE: These could have been payments from Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI).

PROBE: “As an adult” means payments for which you were determined eligible after reaching age 18.

 YES 1 B15

 NO 0 B16

 DON’T KNOW d B16

 REFUSED r B16

IF PROGRAM = [PROGRAM NAME THAT SERVES SSA TARGET POPULATION]

CATI/CAWI: B14=1 and rapter age18flag = 1

IF CAWI DO NOT SHOW DK OR REF

B15. Are you currently receiving checks or electronic payments from the Social Security Administration because of a disability?

PROBE: These can also be called Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI).

 YES 1 B18

 NO 0 B18

 DON’T KNOW d B18

 REFUSED r B18

IF PROGRAM = [PROGRAM NAME THAT SERVES SSA TARGET POPULATION]

CATI/CAWI: b14 ne 1 and rapter age18flag = 1

IF CAWI DO NOT SHOW DK OR REF

B16. As an adult, in the past five years, have you applied to the Social Security Administration to receive checks or electronic payments because of a disability?

PROBE: Include any applications for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI).

PROBE: Include any age 18 redeterminations. Age 18 redeterminations occur in the year following your 18th birthday.

PROBE: “As an adult” means payments for which you were determined eligible after reaching age 18.

 YES 1 B17

 NO 0 B18

 DON’T KNOW d B17

 REFUSED r B17

IF PROGRAM = [PROGRAM NAME THAT SERVES SSA TARGET POPULATION]

CATI/CAWI: B16=1,D,R and rapter age18flag = 1

IF CAWI DO NOT SHOW DK OR REF

B17. Are you currently awaiting a decision by the Social Security Administration on a pending disability application?

PROBE: This could include a decision on your first application for disability (SSI or SSDI) benefits, a decision on a denial that you appealed, or an age 18 redetermination.

Probe: Age 18 redeterminations occur in the year following your 18th birthday.

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

B18.* If you had an emergency, would you be able to count on someone to help you?

Select one only

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

B19.* Is there someone you could turn to if you suddenly needed to borrow $100?

Select one only

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

C. EMPLOYMENT STATUS AND CHALLENGES

CATI: Now, I would like to ask you some questions about working for pay.

CAWI: The next questions are about work you have done for pay.

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

C0.* Have you ever worked for pay?

Working for pay can include regular paid jobs, odd jobs, temporary jobs, work done in your own business, jobs or tasks you find using a web or mobile app, “under the table” work, “off the books” work, apprenticeships, or any other types of work you have done for pay.

 YES 1 C1

 NO 0 C5

 DON’T KNOW d C1

 REFUSED r C1

CATI/CAWI: c0=1,d,r

IF CAWI DO NOT SHOW DK OR REF

C1. Are you currently working for pay?

Working for pay can include regular paid jobs, odd jobs, temporary jobs, work done in your own business, jobs or tasks you find using a web or mobile app, “under the table” work, “off the books” work, apprenticeships, or any other types of work you have done for pay.

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

CATI/CAWI: c0=1,d,r

IF CAWI DO NOT SHOW DK OR REF

C2. In total, how many months did you work for pay during the past year (including your current job)?

PROBE: Please include any regular paid jobs, odd jobs, temporary jobs, work done in your own business, jobs or tasks you find using a web or mobile app, “under the table” work, “off the books” work, apprenticeships, or any other types of work you have done.

 DID NOT WORK IN PAST YEAR 0

 LESS THAN 4 MONTHS 1

 4-6 MONTHS 2

 7-9 MONTHS 3

 10 OR MORE MONTHS 4

 DON’T KNOW d

 REFUSED r

PROGRAMMER SKIP BOX C2

IF C1=1, GO TO C3A, ELSE GO TO C3

CATI/CAWI: C1=0,D,R

IF CAWI DO NOT SHOW DK OR REF

C3. In what month and year did you last work for pay?

PROBE: Please include any regular paid jobs, odd jobs, temporary jobs, work done in your own business, jobs or tasks you find using a web or mobile app, “under the table” work, “off the books” work, apprenticeships, or any other types of work you have done.

C3A

MONTH YEAR

(1-12) (1957-2020)

 DON’T KNOW d C3A

 REFUSED r C3A

CATI/CAWI: c0=1,d,r

IF CAWI DO NOT SHOW DK OR REF

C3a. How much [do/did] you get paid before taxes and deductions, at your [current/most recent] job?

PROBE: If your pay [varies/varied], please provide an average amount. If you are paid per job or for completing a particular task, please tell [us/me] the total amount you usually made per week or per month while doing this type of work.

IF THE RESPONDENT DOES NOT PROVIDE A PAY PERIOD THEN PROBE: And, is that per hour, per week, per month, once every two weeks, twice a month, per year, per day/daily, or something else?

INSTRUCTION: ACCEPT MOST CONVENIENT PAY PERIOD.

INSTRUCTION: IF ANSWER IS GREATER THAN $50 PER HOUR, $2000 PER WEEK, $4000 ONCE EVERY 2 WEEKS, $4000 TWICE A MONTH, $100,000 PER YEAR, $400 DAY/DAILY, OR $8000 MONTH, SAY: “I recorded [c3a and c3a amount answer]. Is that correct?”

(0-999,999.99) AMOUNT

Select one only

 PER HOUR 1

 PER WEEK 2

 MONTH 3

 ONCE EVERY TWO WEEKS 4

 TWICE A MONTH 5

 PER YEAR 6

 DAY/DAILY 7

 OTHER (SPECIFY) 99

Specify (STRING 100)

 DON’T KNOW d

 REFUSED r

CATI/CAWI: c0=1,d,r

IF CAWI DO NOT SHOW DK OR REF

C4. How many hours per week, including regular overtime hours, did you usually work on your [current/most recent] job? Your best estimate is fine.

| | | HOURS PER WEEK C5

DON’T KNOW d C4A

REFUSED r C4A

CATI ONLY: C4= D or r

C4a. How many hours (do/did) you usually work per week at your [current/most recent] job? Is it…

Select one only

 1-10 hours, 0

 11-20 hours, 1

 21-35 hours, 2

 36-40 hours, 3

 41 hours or more 4

 DON’T KNOW d

 REFUSED r

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

C5.* The next questions are about things that some people find challenging when they try to work or pursue education or training. First, does a physical, mental, or emotional condition limit the kind or amount of work you can do?

Select one only

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

if program = [PROGRAM NAME, WHOSE PARTICIPANTS ARE YOUTH] THEN do not ask c6.L or c6.Q

CATI/CAWI: ELSE, ALL

IF CAWI DO NOT SHOW DK OR REF

C6. Now, please indicate if each of the following has made it not at all hard, slightly hard, moderately hard, or very hard for you to work or pursue education or training in the past three months. CATI: If something I say does not apply to you, you can say “does not apply.”

Would you say that [FILL a-r] made it not at all hard, slightly hard, moderately hard, or very hard for you to work or pursue education or training in the past three months?

Select one per row

	NOT AT ALL HARD	SLIGHTLY HARD	MODERATELY HARD	VERY HARD	N/A	DK	REF
a. Not having reliable transportation	0 	1 	2 	3 	n 	d 	r 
b. Not having a driver’s license or a valid driver’s license	0 	1 	2 	3 	n 	d 	r 
c. Not having stable housing	0 	1 	2 	3 	n 	d 	r 
d. A pregnancy or recent childbirth	0 	1 	2 	3 	n 	d 	r 
e. Not having good enough care for a child or someone else in your household who needs care	0 	1 	2 	3 	n 	d 	r 
f. Not having the right clothes or tools for work	0 	1 	2 	3 	n 	d 	r 
g. Not having the right skills or education	0 	1 	2 	3 	n 	d 	r 
h. Having difficulty speaking or reading English	0 	1 	2 	3 	n 	d 	r 
i. Having difficulty completing job applications on my own	0 	1 	2 	3 	n 	d 	r 
j. Having a criminal record	0 	1 	2 	3 	n 	d 	r 
k. Having problems with alcohol or drugs	0 	1 	2 	3 	n 	d 	r 
l. Having a gap in employment	0 	1 	2 	3 	n 	d 	r 
m. Lack of support or resistance from friends or relatives related to finding a job or working	0 	1 	2 	3 	n 	d 	r 
n. Experiencing abuse by a spouse or partner	0 	1 	2 	3 	n 	d 	r 
o. A learning disability	0 	1 	2 	3 	n 	d 	r 
p. Not finding the right kind of disability-related supports or accommodations	0 	1 	2 	3 	n 	d 	r 
q. Losing benefits you need such as Social Security, disability insurance, workers’ compensation, or Medicaid if you took a job or worked more hours	0 	1 	2 	3 	n 	d 	r 
r. Other problems that made work or pursuing education or training difficult (SPECIFY)	0 	1 	2 	3 	n 	d 	r 

IF PROGRAM = [PROGRAM NAME focuses on goal setting and attainment]

CATI/CAWI: if c1=yes (currently employed) then do not ask c7d.

IF CAWI DO NOT SHOW DK OR REF

C7. The next questions are about work goals and looking for jobs.

Please indicate if you strongly disagree, disagree, agree, or strongly agree with the following statements.

Select one per row

	STRONGLY DISAGREE	DISAGREE	AGREE	STRONGLY AGREE	DK	REF
a. I set long-term employment goals that I hope to achieve within a year, such as finding a job, finding a better job, getting promoted, or enrolling in further education.	1 	2 	3 	4 	d 	r 
b. I set specific short-term goals that will allow me to achieve my long-term employment goals.	1 	2 	3 	4 	d 	r 
c. I think I should work on finding a job or a better job.	1 	2 	3 	4 	d 	r 
d. I think there is nothing I can do about being out of work right now…………………………………….	1 	2 	3 	4 	d 	r 

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

C8.* Now [I/we] would like to ask you a few questions about your experience with the criminal justice system. Have you ever been arrested?

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

IF PROGRAM = [PROGRAM NAME THAT SERVES THOSE WITH current or prior CRIMINAL JUSTICE SYSTEM INVOLVEMENT]

CATI/CAWI: c8=1,d,r

IF CAWI DO NOT SHOW DK OR REF

C9. Have you ever been convicted of a crime?

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

IF PROGRAM = [PROGRAM NAME THAT SERVES THOSE WITH current or prior CRIMINAL JUSTICE SYSTEM INVOLVEMENT]

CATI/CAWI: c8=1,d,r

IF CAWI DO NOT SHOW DK OR REF

C10. Are you currently on parole or probation?

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

IF PROGRAM = [PROGRAM NAME THAT SERVES THOSE WITH current or prior CRIMINAL JUSTICE SYSTEM INVOLVEMENT]

CATI/CAWI: c8=1,d,r

IF CAWI DO NOT SHOW DK OR REF

C11. Have you ever been incarcerated in a juvenile or adult facility, such as a detention center, jail, or prison?

 YES 1 C12

 NO 0 D1

 DON’T KNOW d D1

 REFUSED r D1

IF PROGRAM = [PROGRAM NAME THAT SERVES THOSE WITH current/prior CRIMINAL JUSTICE SYSTEM INVOLVEMENT]

CATI/CAWI: C11=1

IF CAWI DO NOT SHOW DK OR REF

C12. What is the total amount of time you have spent in incarceration?

Your best estimate is fine.

Amount of time

(1-99999)

Period of time

▼

PROGRAMMER: USE TIME PERIOD OPTIONS BELOW

 Hours 1

 Days 2

 Weeks 3

 Months 4

 Years 5

 DON’T KNOW d

 REFUSED r

D. PHYSICAL AND MENTAL HEALTH

CATI: Now, I’d like to ask you some questions about your health.

CAWI: Now, we have some questions about your health.

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

D1.* In general, would you say your health is:

Select one only

 Excellent, 1

 Very Good, 2

 Good, 3

 Fair or, 4

 Poor 5

 DON’T KNOW d

 REFUSED r

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

D2.* The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

CATI: The first question is about…

Select one per row

	YES, LIMITED A LOT	YES, LIMITED A LITTLE	NO, NOT LIMITED AT ALL	DK	REF
a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf CATI: Would you say you are limited a lot, limited a little, or not at all?	1 	2 	3 	d 	r 
b. CATI: The second question is about… Climbing several flights of stairs CATI: Would you say you are limited a lot, limited a little, or not at all?	1 	2 	3 	d 	r 

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

D3.* During the past 4 weeks how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

CATI: The first statement is that you…

Select one per row

	ALL OF THE TIME	MOST OF THE TIME	SOME OF THE TIME	A LITTLE OF THE TIME	NONE OF THE TIME	DK	REF
a. Accomplished less than you would like CATI: Would you say that you accomplished less than you would like all of the time, most of the time, some of the time, a little of the time, or none of the time as a result of your physical health?	1 	2 	3 	4 	5 	d 	r 
b. CATI: The second statement is that you… Were limited in the kind of work or other activities CATI: Would you say that you were limited in the kind of work or other activities all of the time, most of the time, some of the time, a little of the time, or none of the time as a result of your physical health?	1 	2 	3 	4 	5 	d 	r 

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

D4.* During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

CATI: The first item is that you…

Select one per row

	ALL OF THE TIME	MOST OF THE TIME	SOME OF THE TIME	A LITTLE OF THE TIME	NONE OF THE TIME	DK	REF
a. Accomplished less than you would like CATI: Would you say that you accomplished less than you would like all of the time, most of the time, some of the time, a little of the time, or none of the time as a result of any emotional problems?	1 	2 	3 	4 	5 	d 	r 
b. CATI: The second item is that you… Did work or other activities less carefully than usual CATI: Would you say that did work or other activities less carefully than usual all of the time, most of the time, some of the time, a little of the time, or none of the time as a result of any emotional problems?	1 	2 	3 	4 	5 	d 	r 

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

D5.* During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? Would you say…

 Not at all, 1

 A little bit, 2

 Moderately, 3

 Quite a bit or, 4

 Extremely 5

 DON’T KNOW d

 REFUSED r

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

D6.* 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 the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks:

Have you felt calm and peaceful?

All of the time, 1

Most of the time, 2

Some of the time, 3

A little of the time, or 4

None of the time 5

DON’T KNOW d

REFUSED r

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

D7.* How much of the time during the past 4 weeks did you have a lot of energy?

All of the time, 1

Most of the time, 2

Some of the time, 3

A little of the time, or 4

None of the time 5

DON’T KNOW d

REFUSED r

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

D8.* How much of the time during the past 4 weeks have you felt downhearted and depressed?

All of the time, 1

Most of the time, 2

Some of the time, 3

A little of the time, or 4

None of the time 5

DON’T KNOW d

REFUSED r

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

D9.* 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, relatives, etc.)? Would you say…

All of the time, 1

Most of the time, 2

Some of the time, 3

A little of the time, or 4

None of the time 5

DON’T KNOW d

REFUSED r

IF PROGRAM = [PROGRAM NAME THAT SERVES SSA TARGET POPULATION]

IF CAWI DO NOT SHOW DK OR REF

D10. Are you deaf or do you have serious difficulty hearing?

Select one only

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

IF PROGRAM = [PROGRAM NAME THAT SERVES SSA TARGET POPULATION]

IF CAWI DO NOT SHOW DK OR REF

D11. Are you blind or do you have serious difficulty seeing, even when wearing glasses?

Select one only

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

IF PROGRAM = [PROGRAM NAME THAT SERVES SSA TARGET POPULATION]

IF CAWI DO NOT SHOW DK OR REF

D12. CAWI: The next questions may seem similar to previous questions, but it is important to get your answers.

Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

Select one only

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

IF PROGRAM = [PROGRAM NAME THAT SERVES SSA TARGET POPULATION]

IF CAWI DO NOT SHOW DK OR REF

D13. Do you have serious difficulty walking or climbing stairs?

Select one only

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

IF PROGRAM = [PROGRAM NAME THAT SERVES SSA TARGET POPULATION]

IF CAWI DO NOT SHOW DK OR REF

D14. Do you have difficulty dressing or bathing?

Select one only

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

IF PROGRAM = [PROGRAM NAME THAT SERVES SSA TARGET POPULATION]

IF CAWI DO NOT SHOW DK OR REF

D15. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

Select one only

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

IF PROGRAM = [PROGRAM NAME THAT SERVES THOSE WITH MENTAL HEALTH CONDITIONS]

IF CAWI DO NOT SHOW DK OR REF

D16. Have you ever been treated for any mental health condition?

Select one only

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

IF PROGRAM = [PROGRAM NAME THAT SERVES SSA TARGET POPULATION]

CATI/CAWI: C5=1

IF CAWI DO NOT SHOW DK OR REF

D17. Earlier, you said that a physical, mental, or emotional condition limits the kind or amount of work you can do. What physical, mental, or emotional condition is the main reason you are limited?

PHYSICAL OR MENTAL CONDITION

(STRING 100)

 DON’T KNOW d

 REFUSED r

IF PROGRAM = [PROGRAM NAME THAT SERVES THOSE WITH MENTAL HEALTH CONDITIONS]

IF CAWI DO NOT SHOW DK OR REF

D18. CATI: Now I will read you a list of statements about the last 30 days. Please tell me if the following applies to you all of the time, most of the time, some of the time, a little of the time, or none of the time.

During the last 30 days, about how often did you…

Select one per row

	ALL THE TIME	MOST OF THE TIME	SOME OF THE TIME	A LITTLE OF THE TIME	NONE OF THE TIME	DK	REF
a. Feel so depressed that nothing could cheer you up?	4 	3 	2 	1 	0 	d 	r 
b. Feel hopeless?	4 	3 	2 	1 	0 	d 	r 
c. Feel restless or fidgety?	4 	3 	2 	1 	0 	d 	r 
d. Feel that everything was an effort?	4 	3 	2 	1 	0 	d 	r 
e. Feel worthless?	4 	3 	2 	1 	0 	d 	r 
f. Feel nervous?	4 	3 	2 	1 	0 	d 	r 

AUDIT-C QUESTIONNAIRE

CATI: The next questions are about your use of alcohol. If you do not drink alcohol at all, just say so.

CAWI: The next questions are about your use of alcohol.

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

D19.* How often do you have a drink containing alcohol, such as beer, wine or liquor? Would you say…

 Never, 1 D24

 Monthly or less, 2 D22

 2 to 4 times a month, 3 D22

 2 to 3 times a week, or 4 D22

 4 or more times a week 5 D22

 DON’T KNOW d D24

 REFUSED r D24

CATI/CAWI: D19 = 2, 3, 4, or 5

IF CAWI DO NOT SHOW DK OR REF

D20. How many drinks containing alcohol do you have on a typical day when you are drinking? Would you say …

PROBE: A standard drink is a 5-ounce glass of wine, a 12-ounce can of beer, or a 1.5-ounce shot.

 1 or 2 per day, 1

 3 or 4, 2

 5 or 6, 3

 7 to 9, or 4

 10 or more per day 5

 DON’T KNOW d

 REFUSED r

CATI/CAWI: D19 = 2, 3, 4, or 5

IF CAWI DO NOT SHOW DK OR REF

D21. How often do you have six or more drinks on one occasion? Would you say…

 Never, 1

 Less than monthly, 2

 Monthly, 3

 Weekly, or 4

 Daily or almost daily 5

 DON’T KNOW d

 REFUSED r

DAST-10 QUESTIONNAIRE

CATI: Next, I would like to ask you about your use of drugs, not including alcohol, in the past 12 months. For these questions, using drugs means taking more of a prescription drug than prescribed, taking more of an over-the-counter drug than the directions say, or using any drug for nonmedical reasons. The types of drugs may include cannabis (such as marijuana or hashish), inhalants (such as paint thinner), tranquilizers (such as Valium), barbiturates (such as downers), cocaine (such as crack), stimulants (such as Ritalin or speed), hallucinogens (such as LSD, peyote), or narcotics (such as heroin or pain killers).

Remember, do not include alcohol.

If you have difficulty with a yes or no statement, let me know the response that is mostly right.

CAWI: The following questions ask about your use of drugs (not including alcohol) in the past 12 months.

For these questions, using drugs means (1) taking more of a prescription than prescribed, (2) taking more of an over‐the‐counter drug than the directions say, or (2) using any drug for nonmedical reasons.

The types of drugs may include cannabis (e.g., marijuana, hashish), inhalants (e.g., paint thinner), tranquilizers (e.g., Valium), barbiturates (e.g., downers), cocaine (e.g., crack), stimulants (e.g., Ritalin, speed), hallucinogens (e.g., LSD, peyote), or narcotics (e.g., heroin, pain killers).

Remember, do not include alcohol.

Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right.

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

D22.* In the past 12 months have you used drugs other than those required for medical reasons?

 YES 1 D23

 NO 2 D32

 DON’T KNOW d D23

 REFUSED r D23

CATI/CAWI: D22=1,D,R

IF CAWI DO NOT SHOW DK OR REF

D23. Do you use more than one drug at a time?

PROBE: Consider your use of drugs, not including alcohol, in the past 12 months.

 YES 1

 NO 2

 DON’T KNOW d

 REFUSED r

CATI/CAWI: D22=1,D,R

IF CAWI DO NOT SHOW DK OR REF

D24. Are you always able to stop using drugs when you want to?

PROBE: Consider your use of drugs, not including alcohol, in the past 12 months.

 YES 1

 NO 2

 DON’T KNOW d

 REFUSED r

CATI/CAWI: D22=1,D,R

IF CAWI DO NOT SHOW DK OR REF

D25. Have you ever had blackouts or flashbacks as a result of drug use?

PROBE: Consider your use of drugs, not including alcohol, in the past 12 months.

 YES 1

 NO 2

 DON’T KNOW d

 REFUSED r

CATI/CAWI: D22=1,D,R

IF CAWI DO NOT SHOW DK OR REF

D26. Do you ever feel bad or guilty about your drug use?

PROBE: Consider your use of drugs, not including alcohol, in the past 12 months.

 YES 1

 NO 2

 DON’T KNOW d

 REFUSED r

CATI/CAWI: D22=1,D,R

IF CAWI DO NOT SHOW DK OR REF

D27. Does anyone ever complain about your involvement with drugs?

PROBE: Consider your use of drugs, not including alcohol, in the past 12 months.

 YES 1

 NO 2

 DON’T KNOW d

 REFUSED r

CATI/CAWI: D22=1,D,R

IF CAWI DO NOT SHOW DK OR REF

D28. Have you neglected your family because of your drug use?

PROBE: Consider your use of drugs, not including alcohol, in the past 12 months.

 YES 1

 NO 2

 DON’T KNOW d

 REFUSED r

CATI/CAWI: D22=1,D,R

IF CAWI DO NOT SHOW DK OR REF

D29. Have you engaged in illegal activities in order to obtain drugs?

PROBE: Consider your use of drugs, not including alcohol, in the past 12 months.

 YES 1

 NO 2

 DON’T KNOW d

 REFUSED r

CATI/CAWI: D22=1,D,R

IF CAWI DO NOT SHOW DK OR REF

D30. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

PROBE: Consider your use of drugs, not including alcohol, in the past 12 months.

 YES 1

 NO 2

 DON’T KNOW d

 REFUSED r

CATI/CAWI: D22=1,D,R

IF CAWI DO NOT SHOW DK OR REF

D31. Have you had medical problems as a result of your drug use (for example, memory loss, hepatitis, convulsions, or bleeding)?

PROBE: Consider your use of drugs, not including alcohol, in the past 12 months.

 YES 1

 NO 2

 DON’T KNOW d

 REFUSED r

CATI/CAWI: ALL

IF CAWI DO NOT SHOW DK OR REF

D32.* The next question asks about using prescription pain relievers in any way a doctor did not direct you to use them.

When you answer this question, please think only about your use of the drug in any way a doctor did not direct you to use it, including:

• Using it without a prescription of your own

• Using it in greater amounts, more often, or longer than you were told to take it

• Using it in any other way a doctor did not direct you to use it

Are you currently taking a prescription painkiller (such as OxyContin, Percocet, or Vicodin) without a prescription or in any way not directed by a doctor?

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

END. PROGRAMMER: RETURN TO RAPTER TO COLLECT CONTACT INFORMATION

1 “(STRING (NUM))” is a programmer instruction indicating the number of characters allowed in the open response field.

1