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pdfOMB Control No.: 0960-0809
Expiration Date: 11/30/2020
PROMOTING OPPORTUNITY
DEMONSTRATION
12- and 24-Month Follow-up Survey Instrument
December 10, 2018
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. We estimate that it will take about 30 minutes to read the instructions and answer
the questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
Send only comments relating to our time estimate to this address.
Declaración de la Ley de Reducción de Trámites - Esta recopilación de información cumple con los requisitos de 44 U.S.C. §
3507, según enmendado por la sección 2 de la Ley de Reducción de Trámites de 1995. Usted no necesita contestar estas
preguntas a menos que exhibamos un número de control válido de la Oficina de Administración y Presupuesto (OMB, por sus
siglas en inglés). Estimamos que tardará unos 30 minutos en leer las instrucciones, y responder a las preguntas de la
encuesta. Usted puede enviar comentarios sobre nuestra estimación de tiempo a: SSA, 6401 Security Blvd., Baltimore, MD
21235-6401. Envie solamente comentarios relacionados con nuestra estimación de tiempo a esta dirección.
CONTENTS
Section
Page
A.
RESPONDENT SCREENER AND INTRODUCTION ...................................................36
B.
EDUCATION AND TRAINING .....................................................................................42
C.
EMPLOYMENT AND EARNINGS ................................................................................47
D.
EMPLOYMENT GOALS AND SSDI / POD UNDERSTANDING ................................... 62
E.
INCOME ......................................................................................................................66
F.
HEALTH AND FUNCTIONAL STATUS ........................................................................74
G.
HEALTH INSURANCE .................................................................................................83
H.
RESPONDENT CONTACT INFORMATION ................................................................86
1
ADMINISTRATIVE NOTES:
The purpose of this template is to provide standard logic for all projects using computer-assisted
telephone interviewing. Survey staff will customize the text fills in this template for each project.
Customized text should be highlighted for programmers and translation staff to identify clearly.
All Spanish Text will be in red
INTERVIEWER INSTRUCTIONS IN CAPS
Interview text to read to the respondent will be in bold
ii
Project Decision Points:
Variable
Description
Values
FedProject
Study is federally funded
Yes (1),
RecordProject
Project will record all calls
Yes (1),
UseLocating
Project will include a locating component
No (0)
UseField
Project includes an in-person field component
No (0)
Fieldcalls
Project allows field staff (either Mathematica or from a
grantee site) to call in and complete survey with phone
interviewer. Requires that project provides list of possible
staff calling in for dropdown selection by phone
interviewer.
No (0)
ProxyOkay
Project allows completion of survey with a proxy.
Yes (1)
InterpOkay
Project allows completion of survey with a household
translator.
Yes (1)
InstLang
Languages the instrument has been programmed for
English, Spanish,
ExtraTrans
Project will use an external translation services for languages
other than English, Spanish
No (0)
ExtraTransLang
Languages supported by external translation services
N/A
HandleDeceased
Project decision on how to handle cases where the sample
member is reported as deceased
Terminate (0),
HandlePrison
Project decision on how to handle cases where the sample
member is reported as incarcerated. If locating is selected
and proxyok=1, we will attempt to contact the respondent
through locating first before using a proxy.
Terminate (0),
AdvRemails
Project decision on whether advance letter remails are
allowed
Yes (1),
AdvEmails
Project decision on whether advance emails are allowed
n/a
PaymentType
The type of payment triggered by a completed survey, or
indication that there is no incentive.
, None (0)
AllowWeb
The project will allow respondents to complete on web
No (0)
SMUpdateName
Project wants to collect an updated name for sample member
Yes (1),
SMUpdatePhone
Project wants to collect updated contact phone information
for sample member
Yes (1),
SMUpdateAddress
Project wants to collect updated contact address information
for sample member
Yes (1),
SMUpdateEmail
Project wants to collect updated contact email address
information for sample member
Yes (1),
SMAltContacts
Project wants to collect updated contact alternative contacts
for sample member
Yes (1),
NumAltContacts
Number of alternative contacts collected
Numeric (0-10) 2
iii
Frequently Used Fills
In the boxes below, please list fills that are repeated frequently in your questionnaire requirements. These
must come from a single source (whether from a preload or a question). The fills specified here do not
need to be specified in the fill condition box each time they appear in a question.
Fill
Source / Condition
First Used at Question #:
[FULLNAME]
Fill from Preload File: Respondent
Name
(prefix+first+middle+last+suffix)
Hello/MessageScript
[SampMembFULLNAME]
Fill from Preload File: Sample
Member Name
(prefix+first+middle+last+suffix)
NeedRep
[FIRST NAME]
Fill from Preload File: Respondent
First Name
Verified/Hello
[INTERVIEWER NAME]
Fill based on interviewer logged
into case
Hello
[him / her / him or her]
him IF SAMPMEMBSEX = MALE;
her IF SAMPMEMBSEX =
FEMALE; him or her IF
SAMPMEMBSEX = UNKNOWN
AmpRelay
[él / ella / él o ella]
él IF SAMPMEMBSEX = MALE;
ella IF SAMPMEMBSEX =
FEMALE; él o ella IF
SAMPMEMBSEX = UNKNOWN
AmpRelay
[his/her]
his IF SAMPMEMBSEX = MALE;
her IF SAMPMEMBSEX =
FEMALE;
SampMemb
[él/ella]
él IF SAMPMEMBSEX = MALE;
ella IF SAMPMEMBSEX =
FEMALE;
SampMemb
[you/[FIRST NAME]]
“you” if HELLO = 1 OR 2;
Fill [FIRST NAME] if NeedRep=1
OR 3, OR proxy from sample load
file
A1
[usted/[FIRST NAME]]
“usted” if HELLO = 1 OR 2;
Fill [FIRST NAME] if NeedRep=1
OR 3, OR proxy from sample load
file
A1
[Your/[[FIRST NAME]’s]
“your” if HELLO = 1 OR 2;
Fill [FIRST NAME] if NeedRep=1
OR 3, OR proxy from sample load
file
A2
(He/She)
He IF SAMPMEMBSEX = MALE;
Her IF SAMPMEMBSEX =
FEMALE;
A2
iv
(Él/Ella)
él IF SAMPMEMBSEX = MALE;
ella IF SAMPMEMBSEX =
FEMALE;
A2
[You/(He/She)]
“you” if HELLO = 1 OR 2;
“He” if NeedRep=1 OR 3, OR
proxy from sample load file
A2
[Usted/(Él/Ella)]
“Usted” if HELLO = 1 OR 2;
“Él/Ella” if NeedRep=1 OR 3, OR
proxy from sample load file
A2
[you/(him/her)]
“you” if HELLO = 1 OR 2;
“him/her” if NeedRep=1 OR 3, OR
proxy from sample load file
A2
[Are you /Is (he/she)]
“Are you” if HELLO = 1 OR 2; “Is
(he/she)” if NeedRep=1 OR 3, OR
proxy from sample load file
B1
[have you/has (he/she)]
[usted/(él/ella)]
“have you” if HELLO = 1 OR 2;
“has (he/she)” if NeedRep=1 OR
3, OR proxy from sample load file
B3
[your/(his/her)]
“your” if HELLO = 1 OR 2;
“his/her” if NeedRep=1 OR 3, OR
proxy from sample load file
B3
[suyas/de [FIRST NAME]]
“suyas” if HELLO = 1 OR 2; “de
[FIRST NAME]” if NeedRep=1 OR
3, OR proxy from sample load file
C1
[have/has]
“have” if HELLO = 1 OR 2;
“has” if NeedRep=1 OR 3, OR
proxy from sample load file
C1
[suyo/de (él/ella)]
“suyo” if HELLO = 1 OR 2; “de
(él/ella)” if NeedRep=1 OR 3, OR
proxy from sample load file
C6
[is/was]
IF C5=1, FILL “is”; IF C5=0, FILL
“was”
C6
[suyos/de (él/ella)]
“suyos” if HELLO = 1 OR 2; “de
(él/ella)” if NeedRep=1 OR 3, OR
proxy from sample load file
E1
[are/is]
IF SELF RESPONSE, FILL “are”;
IF PROXY, FILL “is”
C13
[suya/de (él/ella)]
“suya” if HELLO = 1 OR 2; “de
(él/ella)” if NeedRep=1 OR 3, OR
proxy from sample load file
C14
v
Groups:
Treatment (T1 and T2)
Treatment withdrew from offset
Control
Y1=2019, Y2=2020
vi
History Review
History.
PROGRAMMER:
PULL IN FIELDS FROM HISTORY FILE FOR INTERVIEWER REVIEW
Call Attempt:
HISTORY REVIEWED OR DAILRESULT = 6
FILL RESPONDENT PHONE NUMBER AND EXTENSION FROM PRELOAD
DISABLE CLICK TO DIAL (1) IF FEDPROJECT = 0 AND (CURPHNTYPE = CELL (C) OR UNKNOWN
(U) OR EMPTY)
DISABLE FIELD STAFF CALLING IN IF FIELDCALLS = 0
DialNumber.
phone number details:
phone number= [phone number]
extension= [extension]
CODE ONE ONLY
CLICK TO DIAL ..................................................................................................... 1
DIALRESULT
MANUAL DIAL ...................................................................................................... 2
MANUALDIAL
QUICK EXIT .......................................................................................................... 3
EXIT, NO
STATUSUPDATE
RESPONDENT CALLING IN ................................................................................ 4
CALLIN
TRANSFER FROM ANOTHER INTERVIEWER .................................................. 5
CALLIN
FIELDCALLS = 1 AND DIALNUMBER = 6
FieldInfo.
Hello, my name is [INTERVIEWER NAME]. May I have your name?
INSTRUCTION:
SELECT NAME OF FIELD INTERVIEWER/SITE STAFF MEMBER
DROPDOWN:
FILL LIST OF FIELD INTERVIEWERS OR GRANTEE STAFF FROM
PROJECT
PROGRAMMER: GO TO CALLIN
7
DIALNUMBER = 2
ManualDial.
PHONE NUMBER DETAILS:
PHONE NUMBER = [PHONE NUMBER]
EXTENSION = [EXTENSION]
INSTRUCTION:
ENTER PHONE NUMBER ABOVE. NO DASHES.
HARD CHECK: IF ENTERED NUMBER DOES NOT MATCH LOADED NUMBER: THE PHONE
NUMBERS DO NOT MATCH. PLEASE CORRECT.
DIALNUMBER = 1 OR MANUALDIAL = RESPONSE
DialResult.
INSTRUCTION:
CODE RESULT OF DIALING
CODE ONE ONLY
SOMEONE ANSWERS......................................................................................... 1
HELLO
NO ANSWER ........................................................................................................ 2
(DISP = 31)
FINISHED
BUSY..................................................................................................................... 3
(DISP = 2)
VOICEMAIL/ANSWERING DEVICE ..................................................................... 4
FINISHED
SKIP BOX
DIALRESULT
PHONE/LINE PROBLEMS (NOT IN SERVICE, DISCONNECTED) .................... 5
(DISP = 32)
FINISHED
NEED TO REDIAL THE NUMBER ....................................................................... 6
DIALNUMBER
PROGRAMMER SKIP BOX DIALRESULT:
IF DIALRESULT = 4 AND VMFREQ = LEAVEMESSAGE, GO TO
MESSAGESCRIPT. ELSE, GO TO FINISHED AND SET DISP = 33.
DIALRESULT = 4 AND VMFREQ = LEAVE MESSAGE
FILL TEXT IF DIAL ATTEMPT =1, ELSE LEAVE BLANK
MessageScript.
[This message is for [FullName]. I am calling from Mathematica Policy
Research about a study we are conducting for the Social Security
Administration. We recently contacted you to complete a survey. Please
call us at 1-833-832-0470between 9 a.m. and 9 p.m. eastern standard time.
After selecting your language preference, please select option X to
complete the survey over the phone. Thanks very much!]
[Este mensaje es para [FullName]. Estoy llamando de Mathematica Policy
Research acerca de un estudio que estamos llevando a cabo para la
Administración del Seguro Social. Le contactamos recientemente para
completar una encuesta. Por favor llámenos al 1-833-832-0470entre las 9 de
8
la mañana y las 9 de la noche hora estándar del Este. Después de
seleccionar su preferencia de idioma, por favor seleccione la opción X para
completar la encuesta por teléfono. ¡Muchas gracias!]
INSTRUCTION:
DID YOU LEAVE THE MESSAGE?
CODE ONE ONLY
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
PROGRAMMER SKIP BOX MESSAGE SCRIPT
IF MESSAGESCRIPT = 1, GO TO FINISHED AND SET DISP = 34.
IF MESSAGESCRIPT = 2, GO TO FINISHED AND SET DISP = 33.
9
FirstContact:
DIALRESULT=1
Hello.
Hello, I am calling on behalf of the Social Security Administration about a study. May I
please speak to [FULLNAME]?
Hola, mi nombre es [INTERVIEWER NAME]. Estoy llamando de parte de la
Administración del Seguro Social acerca de un estudio. ¿Puedo hablar con
[FULLNAME], por favor?
CODE ONE ONLY
SPEAKING TO [FIRSTNAME] .............................................................................. 1
SAMPMEMB
[FIRSTNAME] COMES TO THE PHONE ............................................................. 2
SAMPMEMB
NEED TO CALLBACK (NO APPT) ....................................................................... 3
THANKS (DISP = 36)
NEED TO CALLBACK (SET APPT) ..................................................................... 4
SETAPPT
[FIRSTNAME] HAS A HEALTH PROBLEM.......................................................... 5
HEALTHPROB
[FIRSTNAME] IS IN AN INSTITUTION (HOSPITAL, GROUP HOME, JAIL) ....... 6
INSTITUTION
[FIRSTNAME] HAS MOVED/HAS NEW NUMBER .............................................. 7
KNOWWHERE
[FIRSTNAME] DOES NOT SPEAK ENGLISH...................................................... 8
LANG
NEVER HEARD OF [FULLNAME]/WRONG NUMBER ........................................ 9
THANKS (DISP = 37)
HUNG UP DURING INTRODUCTION (HUDI) ..................................................... 10 FINISHED (DISP=35)
[FIRSTNAME] IS DECEASED .............................................................................. 11 DECEASED
INSTITUTION-CANNOT CONFIRM/DENY SAMPLE MEMBER………………….12 THANKS (DISP=43)
PROGRAMMER SMVERIFIED BOX HELLO
IF HELLO=1 OR 2 AND SMVERIFIED = 0, SET SMVERIFIED = 1.
10
DIALNUMBER = 4 OR 5
CallIn.
Hello, my name is [INTERVIEWER NAME]. I’m an interviewer from Mathematica Policy
Research. We are working on behalf of the Social Security Administration or SSA. May
I ask your name?
Hola, mi nombre es [INTERVIEWER NAME]. Soy un entrevistador de Mathematica Policy
Research. Estamos trabajando de parte de la Administración del Seguro Social o SSA por
sus siglas en inglés. ¿Puedo preguntarle su nombre?
CODE ONE ONLY
SPEAKING TO [FIRSTNAME] .............................................................................. 1
SKIP BOX CALLIN
[FIRSTNAME] CALLED TO MAKE APPOINTMENT ............................................ 2
SETAPPT
[FIRSTNAME] CALLED TO REFUSE................................................................... 3
REFUSALREASON
SOMEONE ELSE CALLED TO REFUSE ............................................................. 4
REFUSALREASON
SOMEONE ELSE CALLED TO SAY [FIRSTNAME] DECEASED ....................... 5
DECEASED
[FIRSTNAME] HAS A HEALTH PROBLEM.......................................................... 6
HEALTHPROB
[FIRSTNAME] IS IN AN INSTITUTION (HOSPITAL, GROUP HOME, JAIL) ....... 7
INSTITUTION
[FIRSTNAME] HAS MOVED/HAS NEW NUMBER .............................................. 8
KNOWWHERE
[FIRSTNAME] DOES NOT SPEAK ENGLISH...................................................... 9
LANG
PROGRAMMER SMVERIFIED BOX CALLIN
IF CALLIN = 1 AND SMVERIFIED = 0, SET SMVERIFIED = 1
PROGRAMMER SKIP BOX CALLIN
IF CALLIN = 1 AND PHONE NUMBER LOADED, GO TO CALLINNUM.
IF CALLIN = 1 AND NO PHONE NUMBER LOADED, GO TO
CALLINBESTNUM.
CALLIN = 1 AND PHONE NUMBER LOADED
FILL NUMBER FROM CURRENT LOADED NUMBER
CallInNum.
INTERVIEWER:
DID THE RESPONDENT CALL IN FROM [FILL NUMBER]?
CODE ONE ONLY
YES ....................................................................................................................... 1
SAMPMEMB
NO, DIFFERENT NUMBER .................................................................................. 2
CALLINBESTNUM
UNKNOWN OR RESTRICTED NUMBER ............................................................ 3
CALLINBESTNUM
PROGRAMMER CALLINNUM CALL HISTORY BOX
IF CALLINNUM = 1, SET CURRENT PHONE AS PHONE NUM IN CALL
HISTORY RECORD.
11
(CALLNUM = 2 – 3) OR (CALLIN = 1 AND NO NUMBER LOADED)
CallInBestNum.
In case we get disconnected, is the phone number you are calling from the
best one to use to call you back?
Por si nos desconectamos, ¿es el número de teléfono del que llama el
mejor para llamarle de vuelta?
CODE ONE ONLY
YES ....................................................................................................................... 1
CALLINNEWNUM
NO ......................................................................................................................... 0
CALLINNEWNUM
DON’T KNOW ....................................................................................................... d
BOX CALLIN
SETPHONE
REFUSED ............................................................................................................. r
BOX CALLIN
SETPHONE
CALLINBESTNUM = 0 OR 1
PROGRAMMER- EXTENSION MAY BE MISSING
CallInNewNum.
IF CALLINBESTNUM = 1
Please tell me the number you are calling from, area code first.
Por favor dígame el número del que llama, empezando con el código de
área.
IF CALLINBESTNUM = 0
Please give me the best telephone number to use, area code first.
Por favor dígame el mejor número de teléfono para llamarle, empezando
con el código de área.
INSTRUCTION:
CONFIRM PHONE WITH RESPONDENT BEFORE CONTINUING
|
| | |-| | |
(0-999)
(0-999)
|-|
| | |
(0-9999)
|
Is there an extension number?
¿Hay un número de extensión?
|
| | | |
(0-999999)
|
|
DON’T KNOW ....................................................................................................... d
BOX CALLIN
SETPHONE
REFUSED ............................................................................................................. r
BOX CALLIN
SETPHONE
SOFT CHECK: IF PHONE NE 10 DIGITS: PHONE NUMBER SHOULD BE 10 NUMERIC DIGITS, NO
SPACES, DASHES, PARENTHESES OR OTHER PUNCTUATION (OR EMPTY)
SOFT CHECK: IF AREA CODE LE 200: AREA CODE SHOULD BE GREATER THAN 200
SOFT CHECK: IF EXCHANGE LE 199: EXCHANGE SHOULD BE GREATER THAN 199
12
CALLINNEWNUM = PHONE PROVIDED
CallInNewNumTZ.
What time zone is that in?
¿En qué zona horaria está?
IF NEEDED:
WHAT TIME IS IT THERE?
¿Qué hora es ahí?
INSTRUCTION:
A TIME ZONE IS REQUIRED. USE ORIGINAL TIME ZONE OR STATE IF
NEEDED.
CODE ONE ONLY
EASTERN TIME (US & CANADA) [(FILL CURRENT TIME)]............................... 62
INDIANA (EAST) [(FILL CURRENT TIME)] .......................................................... 63
CENTRAL TIME (US & CANADA) [(FILL CURRENT TIME)] ............................... 65
ARIZONA [(FILL CURRENT TIME)] ..................................................................... 68
MOUNTAIN TIME (US & CANADA) [(FILL CURRENT TIME)] ............................ 70
PACIFIC TIME (US & CANADA) [(FILL CURRENT TIME)] ................................. 71
ALASKA [(FILL CURRENT TIME)] ....................................................................... 72
HAWAII [(FILL CURRENT TIME)] ........................................................................ 73
BAJA CALIFORNIA [(FILL CURRENT TIME)] ..................................................... 93
PROGRAMMER BOX CALLIN SETPHONE
IF (CALLINBESTNUM = D OR R) OR (CALLINNEWNUM = D OR R), CHECK IF A PHONE IS
LOADED.
IF A PHONE IS LOADED, USE CURRENT PHONE IN CALL HISTORY.
IF A PHONE IS NOT LOADED, DO NOT USE A PHONE IN CALL HISTORY.
IF PHONE NUMBER COLLECTED AT CALLINNEWNUM:
COMPARE CALLINNEWNUM WITH CURRENT PHONE LOADED.
IF CALLINNEWNUM = CURRENT PHONE, USE CURRENT PHONE IN CALL HISTORY, THEN
COMPARE CALLINNEWNUMTZ WITH CURRENT TZ.
IF CURRENT PHONE TZ NE CALLINNEWNUMTZ, UPDATE CURENT PHONE TZ.
IF CALLINNEWNUM NE CURRENT PHONE, SET CALLINNEWNUM AS NEW CURRENT PHONE
AND USE THIS PHONE IN CALL HISTORY.
ALL SCENARIOS FOR CALLIN GO TO SAMPMEMB.
13
Health Problem Questions:
HELLO = 5 OR CALLIN = 6
HealthProb.
PROBE IF NEEDED: What kind of health problem is it? Is it short-term or longterm?
¿Qué tipo de problema de salud es? ¿Es a corto o largo plazo?
INSTRUCTION:
CODE THE TYPE OF HEALTH PROBLEM
CODE ONE ONLY
SHORT-TERM HEALTH PROBLEM (BETTER DURING PROJECT) ................. 1
LONG-TERM HEALTH PROBLEM (NOT GETTING BETTER SOON) ............... 2
CALLLATER
HEALTHPROBTYPE
HEALTHPROB = 2
HealthProbType.
PROBE IF NEEDED: Can you describe if it’s a sensory, vocal, physical, or
cognitive impairment?
¿Puede describir si es un impedimento sensorial, vocal, físico o cognitivo?
INSTRUCTION:
CODE THE TYPE OF HEALTH PROBLEM
CODE ONE ONLY
SENSORY IMPAIRMENT (DEAF/BLIND) ............................................................ 1
AMPRELAY
VOCAL/SPEECH IMPAIRMENT .......................................................................... 2
AMPRELAY
PHYSICAL IMPAIRMENT ..................................................................................... 3
CALLLATER
COGNITIVE/INTELLECTUAL IMPAIRMENT ....................................................... 4
SKIP BOX
HEALTHPROBTYPE
OTHER IMPAIRMENT .......................................................................................... 5
SKIP BOX
HEALTHPROBTYPE
DECEASED .......................................................................................................... 6
DECEASED
PROGRAMMER SKIP BOX HEALTHPROBTYPE
IF (HEALTHPROBTYPE = 4 OR 5) AND PROXYOKAY = 1, GO TO NEEDREP.
IF (HEALTHPROBTYPE = 4 OR 5) AND PROXYOKAY = 0, GO TO THANKS AND
SET DISP = 40.
14
HEALTHPROBTYPE = 1 OR 2
him IF SAMPMEMBSEX = MALE; her IF SAMPMEMBSEX = FEMALE; him or her IF
SAMPMEMBSEX = UNKNOWN
él IF SAMPMEMBSEX = MALE; ella IF SAMPMEMBSEX = FEMALE; él o ella IF SAMPMEMBSEX =
UNKNOWN
AmpRelay. I can increase the volume of my voice or [FIRSTNAME]'s voice, or we could use a
relay service. Would either of these enable [him / her / him or her] to communicate
with me?
Puedo aumentar el volumen de mi voz o la voz de [FIRSTNAME], o podríamos utilizar
un servicio de retransmisión. ¿Permitiría alguno de éstos que [él / ella / él o ella] se
comunicara conmigo?
CODE ONE ONLY
YES – INCREASE VOLUME ON PHONE ........................................................... 1
RESPAVAIL
YES - USE RELAY SERVICE ............................................................................... 2
RELAYPHONE
NO ........................................................................................................................ 3
SKIP BOX AMPRELAY
DON’T KNOW ....................................................................................................... d
SETAPPT
PROGRAMMER SKIP BOX AMPRELAY
IF AMPRELAY = 3 AND PROXYOKAY = 1, GO TO NEEDREP.
IF AMPRELAY = 3 AND PROXYOKAY = 0, GO TO THANKS AND
SET DISP = 40.
AMPRELAY = 2
RelayPhone.
May I have the telephone number of the relay service we should use to reach
[FIRST NAME]?
¿Podría tener el número de teléfono del servicio de retransmisión que debemos
utilizar para contactar a [FIRSTNAME]?
|
| | |-| | |
(0-999)
(0-999)
|-|
| | |
(0-9999)
|
DON’T KNOW ....................................................................................................... d
SETAPPT
SOFT CHECK: IF PHONE NE 10 DIGITS:
PHONE NUMBER SHOULD BE 10 NUMERIC DIGITS, NO SPACES, DASHES, PARENTHESES OR
OTHER PUNCTUATION (OR EMPTY)
SOFT CHECK: IF AREA CODE LE 200: AREA CODE SHOULD BE GREATER THAN 200
SOFT CHECK: IF EXCHANGE LE 199: EXCHANGE SHOULD BE GREATER THAN 199
15
AMPRELAY = 1 OR (AMPRELAY = 2 AND RELAYPHONE = RESPONSE)
RespAvail.
Is [FIRST NAME] available now?
¿Está [FIRSTNAME] disponible ahora?
CODE ONE ONLY
YES ....................................................................................................................... 1
SKIP BOX RESPAVAIL
NO – NEEDS CALL BACK ................................................................................... 0
SETAPPT
DON’T KNOW ....................................................................................................... d
SETAPPT
PROGRAMMER SKIP BOX RESPAVAIL
IF RESPAVAIL = 1 AND AMPRELAY = 1, GOTO AMPPHONE.
IF RESPAVAIL = 1 AND AMPRELAY = 2, GO TO CALLRELAY.
AMPRELAY = 1 AND RESPAVAIL = 1
AmpPhone.
INSTRUCTION:
INCREASE VOLUME ON PHONE (USING JABBER) AND ASK
GATEKEEPER TO CALL [FIRSTNAME] TO THE PHONE.
CODE ONE ONLY
[FIRSTNAME] COMES TO THE PHONE ............................................................. 1
SAMPMEMB
NEED TO CALLBACK .......................................................................................... 2
SETAPPT
PROGRAMMER SMVERIFIED BOX AMPPHONE
IF AMPPHONE = 1 AND SMVERIFIED = 0, SET SMVERIFIED = 1
RESPAVAIL=1 AND AMPRELAY = 2
CallRelay.
INSTRUCTION:
CALL RELAY SERVICE USING PHONE PROVIDED BY ANSWERING
PARTY. IF THE CONNECTION IS MADE, CODE 1 BELOW AND
CONTINUE. IF NOT, CODE 2.
CODE ONE ONLY
[FIRSTNAME] COMES TO THE PHONE ............................................................. 1
SAMPMEMB
NEED TO CALLBACK .......................................................................................... 2
SETAPPT
PROGRAMMER SMVERIFIED BOX CALLRELAY
IF AMPPHONE = 1 AND SMVERIFIED = 0, SET SMVERIFIED = 1
16
HEALTHPROB = 1 OR HEALTHPROBTYPE = 3
CallLater.
Will [FIRST NAME] be able to talk on the telephone if I call back later?
¿Será [FIRSTNAME] capaz de hablar por teléfono si vuelvo a llamar más tarde?
CODE ONE ONLY
YES/MAYBE - CALLBACK ................................................................................... 1
SETAPPT
NO ......................................................................................................................... 0
SKIP BOX
CALLLATER
DON’T KNOW ....................................................................................................... d
SETAPPT
PROGRAMMER SKIP BOX CALL LATER
IF CALLLATER = 0 AND PROXYOKAY = 1, GO TO NEEDREP.
IF CALLLATER = 0 AND PROXYOKAY = 0, GO TO THANKS AND SET DISP
= 40.
HELLO = 11 OR CALLIN = 5 OR HEALTHPROBTYPE = 6
Deceased.
I am very sorry to hear that. Please accept my condolences. Goodbye.
Siento mucho oír eso. Por favor acepte mis condolencias. Adiós.
CONTINUE ........................................................................................................... 1
17
FINISHED (DISP = 41)
Institution Questions:
HELLO = 6 OR CALLIN = 7
Institution.
INSTRUCTION:
CODE TYPE OF INSTITUTION.
CODE ONE ONLY
HOSPITAL ............................................................................................................ 1
HOMESOON
NURSING HOME .................................................................................................. 2
THANKS [DISP=43]
ASSISTED LIVING FACILITY ............................................................................... 3
THANKS [DISP=43]
GROUP HOME ..................................................................................................... 4
THANKS [DISP=43]
JAIL OR PRISON .................................................................................................. 5
HOMESOON
INSTITUTION = 1 OR 5
the hospital IF INSTITUTION = 1, jail or prison IF INSTITUTION = 5
del hospital IF INSTITUTION = 1, de la cárcel o prisión IF INSTITUTION = 5
HomeSoon.
Do you expect [First Name] to come home from [the hospital / jail or prison] within
2 to 4 weeks?
¿Espera que [First Name] vuelva a casa [del hospital /de la cárcel o prisión] en dos
a cuatro semanas?
CODE ONE ONLY
YES ....................................................................................................................... 1
NEEDREP
NO – NOT HOME SOON ...................................................................................... 0
[DISP=43]
DON’T KNOW ....................................................................................................... d
[DISP=43]
REFUSED ............................................................................................................. r
[DISP=43]
PROGRAMMER SKIP BOX HOMESOON
IF HOMESOON = 0, D OR R, GO TO THANKS.
(INSTITUTION= 2 – 4) OR (INSTITUTION = 1 (HOSPITAL) AND HOMESOON = 0)
him IF SAMPMEMBSEX = MALE; her IF SAMPMEMBSEX = FEMALE; him or her IF
SAMPMEMBSEX = UNKNOWN
he IF SAMPMEMBSEX = MALE; she IF SAMPMEMBSEX = FEMALE; he or she IF SAMPMEMBSEX
= UNKNOWN
his IF SAMPMEMBSEX = MALE; her IF SAMPMEMBSEX = FEMALE; his or her IF SAMPMEMBSEX
= UNKNOWN
himself IF SAMPMEMBSEX = MALE; herself IF SAMPMEMBSEX = FEMALE; himself or herself IF
SAMPMEMBSEX = UNKNOWN
él IF SAMPMEMBSEX = MALE; ella IF SAMPMEMBSEX = FEMALE; él o ella IF SAMPMEMBSEX =
UNKNOWN
18
él mismo IF SAMPMEMBSEX = MALE; ella misma IF SAMPMEMBSEX = FEMALE; él mismo o ella
misma IF SAMPMEMBSEX = UNKNOWN
(INSTITUTION= 2 – 4) OR (INSTITUTION = 1 (HOSPITAL) AND HOMESOON = 0)
him IF SAMPMEMBSEX = MALE; her IF SAMPMEMBSEX = FEMALE; him or her IF
SAMPMEMBSEX = UNKNOWN
he IF SAMPMEMBSEX = MALE; she IF SAMPMEMBSEX = FEMALE; he or she IF SAMPMEMBSEX
= UNKNOWN
his IF SAMPMEMBSEX = MALE; her IF SAMPMEMBSEX = FEMALE; his or her IF SAMPMEMBSEX
= UNKNOWN
himself IF SAMPMEMBSEX = MALE; herself IF SAMPMEMBSEX = FEMALE; himself or herself IF
SAMPMEMBSEX = UNKNOWN
él IF SAMPMEMBSEX = MALE; ella IF SAMPMEMBSEX = FEMALE; él o ella IF SAMPMEMBSEX =
UNKNOWN
él mismo IF SAMPMEMBSEX = MALE; ella misma IF SAMPMEMBSEX = FEMALE; él mismo o ella
misma IF SAMPMEMBSEX = UNKNOWN
Capable.
I am calling about an interview we would like to conduct with [FirstName].
A letter explaining why we are calling was recently sent to [him / her / him or her].
Would [he / she / he or she] be able to answer questions [himself / herself / himself or
herself] or would someone need to answer on [his / her / his or her] behalf?
Estoy llamando sobre una entrevista que nos gustaría llevar a cabo con [FirstName].
Recientemente se le envió una carta a [él / ella / él o ella] explicando por qué estamos
llamando.
¿Sería [él/ella/ él o ella] capaz de responder preguntas [él mismo / ella misma / él
mismo o ella misma] o alguien tendría que responder en su nombre?
CODE ONE ONLY
[FIRSTNAME] IS ABLE TO RESPOND ................................................................ 1
FACILITY
[FIRSTNAME] IS UNABLE TO RESPOND........................................................... 2
CAPABLE
SKIP BOX
DON’T KNOW ....................................................................................................... d
FACILITY
REFUSED ............................................................................................................. r
CAPABLE
SKIP BOX
PROGRAMMER SKIP BOX CAPABLE
IF (CAPABLE = 2 OR R) AND PROXYOKAY= 1, GO TO NEEDREP.
IF (CAPABLE = 2 OR R) AND PROXYOKAY= 0, GO TO THANKS AND SET
DISP = 43.
19
(CAPABLE=1 OR D) OR (HOMESOON = 0 AND INSTITUTION = 5 (PRISON) AND PROXYOKAY = 0
AND HANDLEPRISON = 1 (LOCATING))
Facility.
What is the name of the facility?
¿Cuál es el nombre de la instalación?
CODE ONE ONLY
___________________________________________________ (STRING 60)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
PROGRAMMER SKIP BOX FACILITY
IF INSTITUTION=5 AND HOMESOON = 0 AND HANDLEPRISON = 1 (LOCATING), GO
TO THANKS AND SET DISP = 42 AND LOCTYPE = 2.
IF INSTITUTION=5 AND HOMESOON = 0 AND HANDLEPRISON = 0 (TERMINATE), GO
TO THANKS AND SET DISP = 42.
IF INSTITUTION=1-4 AND (CAPABLE = 1 OR D) AND FACILITY = R, GO TO THANKS
AND SET DISP = 43.
IF INSTITUTION=1-4 AND (CAPABLE = 1 OR D) AND (FACILITY = D OR ANSWERED),
GO TO CONTACT.
(CAPABLE = 1 OR D) AND (FACILITY = D OR ANSWERED)
Contact.
Do you have the name of the administrator or a contact person there?
¿Tiene el nombre del administrador o una persona de contacto allí?
CODE ONE ONLY
YES ....................................................................................................................... 1
.............................................................................................................................. NEWNAMEFAC
NO ......................................................................................................................... 0
FACADDR
DON’T KNOW ....................................................................................................... d
FACADDR
REFUSED ............................................................................................................. r
= 43)
THANKS (DISP
20
CONTACT = 1
PROGRAMMER: REQUIRE THAT SOME AMOUNT OF TEXT BE ENTERED IN FIRST NAME OR LAST
NAME
NewNameFac. Please give me the correct spelling of his or her full name.
Por favor dígame la manera correcta de escribir el nombre completo de él o ella..
INSTRUCTION:
CONFIRM SPELLING OF NAME WITH RESPONDENT BEFORE
CONTINUING
First name?
¿Primer nombre?
___________________________________________________ (STRING 20)
FIRST NAME
Middle initial
¿Inicial de segundo nombre?
___________________________________________________ (STRING 1)
MIDDLE INITIAL
Last name?
¿Apellido?
___________________________________________________ (STRING 30)
LAST NAME
21
(CONTACT= 0 OR D) OR NEWNAMEFAC = ANSWERED
hospital IF INSTITUTION =1; nursing home IF INSTITUTION = 2; assisted living facility
IF INSTITUTION = 3; group home IF INSTITUTION = 4
FacAddr.
What is the address of the [hospital / nursing home / assisted living facility / group
home]?
¿Cuál es la dirección del [hospital/ hogar de ancianos/ /centro de vivienda asistida/
hogar colectivo]?
INSTRUCTION:
CONFIRM ADDRESS WITH RESPONDENT BEFORE CONTINUING
What is the first line of the address?
¿Cuál es la primera línea de la dirección?
___________________________________________________ (STRING (60))
Street Address Line 1
Is there an apartment or unit number for this address?
¿Hay un número de apartamento o unidad en esta dirección?
___________________________________________________ (STRING (60))
Street Address Line 2
And what is the zip code?
¿Cuál es el código postal?
___________________________________________________ (STRING (10))
ZIP Code
Town or city?
¿Pueblo o ciudad?
___________________________________________________ (STRING (20))
City
State?
¿Estado?
___________________________________________________ (STRING (2))
State
DON’T KNOW ....................................................................................................... d
FACPHONE
REFUSED ............................................................................................................. r
= 43)
THANKS (DISP
22
FACADDR = ANSWERED OR D
PROGRAMMER- EXTENSION MAY BE MISSING
hospital IF INSTITUTION =1; nursing home IF INSTITUTION = 2; assisted living facility
IF INSTITUTION = 3; group home IF INSTITUTION = 4
FacPhone. May I please have the telephone number of the [hospital/group home/assisted living
facility]?
¿Puedo tener el número de teléfono del [hospital/hogar colectivo/centro de vivienda
asistida]?
INSTRUCTION:
CONFIRM PHONE WITH RESPONDENT BEFORE CONTINUING
Please give me the telephone number, area code first.
Por favor deme el número de teléfono, empezando con el código de área.
|
| | |-| | |
(0-999)
(0-999)
|-|
| | |
(0-9999)
|
Is there an extension number?
¿Hay un número de extensión?
|
| | | |
(0-999999)
|
|
DON’T KNOW ....................................................................................................... d
= 43)
THANKS (DISP
REFUSED ............................................................................................................. r
= 43)
THANKS (DISP
SOFT CHECK: IF PHONE NE 10 DIGITS: PHONE NUMBER SHOULD BE 10 NUMERIC DIGITS, NO
SPACES, DASHES, PARENTHESES OR OTHER PUNCTUATION (OR EMPTY)
SOFT CHECK: IF AREA CODE LE 200: AREA CODE SHOULD BE GREATER THAN 200
SOFT CHECK: IF EXCHANGE LE 199: EXCHANGE SHOULD BE GREATER THAN 199
23
FACPHONE = PHONE PROVIDED
NewPhoneTZFac.
What time zone is that in?
¿En qué zona horaria está?
IF NEEDED:
What time is it there?
¿Qué hora es ahí?
INSTRUCTION:
A TIME ZONE IS REQUIRED. USE ORIGINAL TIME ZONE OR STATE IF
NEEDED.
CODE ONE ONLY
EASTERN TIME (US & CANADA) [(FILL CURRENT TIME)]............................... 62
INDIANA (EAST) [(FILL CURRENT TIME)] .......................................................... 63
CENTRAL TIME (US & CANADA) [(FILL CURRENT TIME)] ............................... 65
ARIZONA [(FILL CURRENT TIME)] ..................................................................... 68
MOUNTAIN TIME (US & CANADA) [(FILL CURRENT TIME)] ............................ 70
PACIFIC TIME (US & CANADA) [(FILL CURRENT TIME)] ................................. 71
ALASKA [(FILL CURRENT TIME)] ....................................................................... 72
HAWAII [(FILL CURRENT TIME)] ........................................................................ 73
BAJA CALIFORNIA [(FILL CURRENT TIME)] ..................................................... 93
PROGRAMMER SKIP BOX FACPHONE
GO TO THANKS AND SET DISP = 36.
APPEND NEWNAMEFAC, NEWFACADDR, NEWFACPHONE AND
NEWFACPHONETZ TO CALL HISTORY NOTE.
24
Know Where Questions:
HELLO = 7 OR CALLIN = 8
KnowWhere.
Do you or does anyone there have a phone number for [First Name]?
¿Tiene usted o alguien ahí un número de teléfono para [FIRST NAME]?
CODE ONE ONLY
YES ....................................................................................................................... 1
KNOWWHEREPHONE
NO ......................................................................................................................... 0
THANKS (DISP = 37)
DON’T KNOW ....................................................................................................... d
THANKS (DISP = 37)
REFUSED ............................................................................................................. r
THANKS (DISP = 37)
KNOWWHERE = 1
PROGRAMMER- EXTENSION MAY BE MISSING
KnowWherePhone.
Please give me the telephone number, area code first.
Por favor deme el número de teléfono, empezando con el código de área.
INSTRUCTION:
CONFIRM PHONE WITH RESPONDENT BEFORE CONTINUING
|
| | |-| | |
(0-999)
(0-999)
|-|
| | |
(0-9999)
|
Is there an extension number?
¿Hay un número de extensión?
|
| | | |
(0-999999)
|
|
DON’T KNOW ....................................................................................................... d
THANKS (DISP = 37)
REFUSED ............................................................................................................. r
THANKS (DISP = 37)
SOFT CHECK: IF PHONE NE 10 DIGITS: PHONE NUMBER SHOULD BE 10 NUMERIC DIGITS, NO
SPACES, DASHES, PARENTHESES OR OTHER PUNCTUATION (OR EMPTY)
SOFT CHECK: IF AREA CODE LE 200: AREA CODE SHOULD BE GREATER THAN 200
SOFT CHECK: IF EXCHANGE LE 199: EXCHANGE SHOULD BE GREATER THAN 199
25
KNOWWHEREPHONE = PHONE PROVIDED
KnowWherePhoneTZ.
What time zone is that in?
¿En qué zona horaria está?
IF NEEDED:
What time is it there?
¿Qué hora es ahí?
INSTRUCTION:
A TIME ZONE IS REQUIRED. USE ORIGINAL TIME ZONE OR STATE IF
NEEDED.
CODE ONE ONLY
EASTERN TIME (US & CANADA) [(FILL CURRENT TIME)]............................... 62
INDIANA (EAST) [(FILL CURRENT TIME)] .......................................................... 63
CENTRAL TIME (US & CANADA) [(FILL CURRENT TIME)] ............................... 65
ARIZONA [(FILL CURRENT TIME)] ..................................................................... 68
MOUNTAIN TIME (US & CANADA) [(FILL CURRENT TIME)] ............................ 70
PACIFIC TIME (US & CANADA) [(FILL CURRENT TIME)] ................................. 71
ALASKA [(FILL CURRENT TIME)] ....................................................................... 72
HAWAII [(FILL CURRENT TIME)] ........................................................................ 73
BAJA CALIFORNIA [(FILL CURRENT TIME)] ..................................................... 93
PROGRAMMER SKIP BOX KNOWWHEREPHONETZ
GO TO THANKS AND SET DISP = 38 (NEW NUMBER).
26
Language Questions:
HELLO = 8 OR CALLIN = 9
Lang.
INSTRUCTION:
CODE LANGUAGE NEEDED TO COMPLETE INTERVIEW IF KNOWN:
CODE ONE ONLY
SPANISH .............................................................................................................. 10
FRENCH ............................................................................................................... 12
CHINESE .............................................................................................................. 4
RUSSIAN .............................................................................................................. 25
GERMAN .............................................................................................................. 7
OTHER LANGUAGE............................................................................................. 99 OTHERLANG
DON’T KNOW ....................................................................................................... d
PROGRAMMER SKIP BOX LANG
IF LANG = INSTLANG (ONE OF THE PROGRAMMED LANGUAGES, GO TO DIFFLANG.
IF (LANG NE INSTLANG OR LANG = D) AND PROXYOKAY = 1, GO TO NEEDREP.
IF (LANG NE INSTLANG OR LANG = D) AND PROXYOKAY = 0 AND INTERPOKAY = 1, GO TO
NEEDREP.
IF LANG NE INSTLANG AND PROXYOKAY = 0 AND INTERPOKAY = 0 AND EXTRATRANS = 1
AND LANG = EXTRATRANSLANG (EXTERNAL TRANSLATION IN THIS LANGUAGE), GO TO
SETAPPT.
IF LANG NE INSTLANG AND PROXYOKAY = 0 AND INTERPOKAY = 0 AND EXTRATRANS = 1
AND LANG NE EXTRATRANSLANG, GO TO THANKS AND SET DISP = 44.
IF LANG NE INSTLANG AND PROXYOKAY = 0 AND INTERPOKAY = 0 AND EXTRATRANS = 0, GO
TO THANKS AND SET DISP = 44.
LANG = 99
OtherLang. SPECIFY OTHER LANGUAGE
___________________________________________________ (STRING 15)
PROGRAMMER SKIPBOX OTHERLANG.
IF LANG = 99 AND PROXYOKAY = 1, GO TO NEEDREP.
IF LANG = 99 AND PROXYOKAY = 0 AND INTERPOKAY = 1, GO TO NEEDREP.
ELSE, GO TO THANKS AND SET DISP = 44.
27
LANG = INSTLANG
FILL LANG FROM LIST
DiffLang.
Please allow me a moment to locate a [LANG] speaking interviewer.
Por favor deme un momento para localizar a un encuestador que hable [LANG].
INSTRUCTION:
PLACE SAMPLE MEMBER ON HOLD AND ALERT A SUPERVISOR TO
TRY AND LOCATE A [LANG] SPEAKING INTERVIEWER.
IF AN INTERVIEWER IS NOT AVAILABLE, SCHEDULE AN
APPOINTMENT WITH RESPONDENT.
IF AN INTERVIEWER IS AVAILABLE, TRANSFER CALL AND SCHEDULE
A CALLBACK FOR TOMORROW.
TRANSFER TO A [LANG] INTERVIEWER .......................................................... 1
NO INTERVIEWER AVAILABLE .......................................................................... 2
PROGRAMMER SKIPBOX DIFFLANG
IF DIFFLANG = 1, LAUNCH APPOINTMENT BOX, SET LANGUAGE = LANG, GO TO
THANKS AND SET DISP = 1.
IF DIFFLANG = 2, SET LANGUAGE = LANG, GO TO SETAPPT AND SET (DISP = 1).
28
Proxy/Interp Questions:
IF (PROXYOKAY=1 AND (AMPRELAY=3 OR CALLLATER=0 OR (HEALTHPROBTYPE=4 OR 5) OR
HOMESOON=1 OR (CAPABLE = 2 OR R) OR (LANG NE INSTLANG) OR (LANG = D OR 99)))
OR
(PROXYOKAY=0 AND INTERPOKAY=1 AND ((LANG NE INSTLANG) OR (LANG = D OR 99)))
FILL PROXY IF PROXYOKAY = 1, INTERPRETER IF (PROXYOKAY = 0 AND INTERPOKAY = 1)
DISABLE RESEPONES OPTION PROXY LIVES ELSEWHERE (4) ONLY IF PROXYOKAY = 0
NeedRep.
ALL
[SampMembFULLNAME] should have received a letter in the mail recently from SSA
about completing a survey.
[SampMembFULLNAME] debería haber recibido una carta de SSA por correo
recientemente acerca de completar una encuesta.
IF PROXYOKAY = 1
Perhaps there is someone who could answer the questions on behalf of
[SampMembFIRSTNAME].
Quizá haya alguien que puede contestar las preguntas en nombre de
[SampMembFIRST NAME].
Is there a family member or friend who is knowledgeable about
[INSERTPROJECTTEXT]?
¿Hay algún familiar o amigo con conocimiento acerca de [INSERTPROJECTTEXT]?
IF PROXYOKAY = 0 AND INTERPOKAY = 1
We are looking for someone who is 18 years or older who [lives with
[SampMembFULLNAME] to help (him/her) by interpreting the interview for us. Are you
18 years of age or older and live with [SampMembFULLNAME]?]
Estamos buscando a alguien que tenga 18 años o más que [vive con
[SampMembFULLNAME] para ayudarle a (él/ella) interpretando la entrevista para
nosotros. ¿Tiene usted 18 años o más y vive con [SampMembFULLNAME]?]
ALL
Is now a good time?
¿Es buen momento ahora?
CODE ONE ONLY
YES, SPEAKING TO FAMILY MEMBER/FRIEND WHO
WILL ACT AS [PROXY/INTERPRETER].............................................................. 1
SAMPMEMB
YES, SPEAKING TO [PROXY/INTERPRETER], BUT
IT IS NOT A GOOD TIME ..................................................................................... 2
SAMPMEMB
[PROXY/INTERPRETER] COMES TO PHONE ................................................... 3
SAMPMEMB
[PROXY/INTERPRETER] LIVES HERE AND NOT CURRENTLY AVAILABLE .. 4
CALLBACK
PROXY LIVES ELSEWHERE ............................................................................... 5
THANKS [DISP=45]
NO [PROXY/INTERPRETER] AVAILABLE .......................................................... 6
SKIP BOX NEEDREP
DON’T KNOW ....................................................................................................... d
SKIP BOX NEEDREP
29
PROGRAMMER SMVERIFIED BOX NEEDREP
IF NEEDREP = 1 – 4 AND SMVERIFIED = 0, SET SMVERIFIED = 1
NEEDREP = 1 – 5
your su nombre completo IF NEEDREP = 1 – 3; his or her el nombre completo de él o ella IF
NEEDREP = 4 – 5
PROGRAMMER: ONLY MIDDLIE INITIAL IS ALLOWED TO BE MISSING
NewNameRep.
Please give me the correct spelling of [your / his or her] full name.
Por favor dígame la manera correcta de escribir [su nombre completo / el
nombre completo de él o ella].
INSTRUCTION:
CONFIRM SPELLING OF NAME WITH RESPONDENT BEFORE
CONTINUING
SPECIFY NAME
First name?
¿Primer nombre?
___________________________________________________ (STRING 20)
FIRST NAME
Middle initial
¿Inicial del segundo nombre?
___________________________________________________ (STRING 1)
MIDDLE INITIAL
Last name?
¿Apellido?
___________________________________________________ (STRING 30)
LAST NAME
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
PROGRAMMER SKIP BOX NEWNAMEREP.
IF NEWNAMEREP HAS NAME PROVIDED, SET REPTYPE AND GO TO REPREL.
IF NEWNAMEREP = D OR R, GO TO THANKS AND SET DISP = 36 (CALLBACK).
PROGRAMMER SET REPTYPE
IF (NEEDREP = 1 – 4 AND PROXYOKAY = 0 AND INTERPOKAY = 1, SET REPTYPE = 1
(INTERPRETER).
IF (NEEDREP = 1 – 5 AND PROXYOKAY = 1, SET REPTYPE = 2 (PROXY) AND UPDATE
RESPONDENT TO PROXY.
30
NEEDREP = 1 – 5 AND NEWNAMEREP = ANSWERED (NOT D OR R)
They están ellos relacionados IF NEEDREP = 4 – 5, ELSE, you está usted
RepRel.
And how are [they / you] related to [FIRSTNAME]?
¿Y cómo [están ellos relacionados / está usted] relacionado(a) con [FIRSTNAME]?
CODE ONE ONLY
SPOUSE ............................................................................................................... 1
CHILD ................................................................................................................... 2
SIBLING ................................................................................................................ 3
PARENT ................................................................................................................ 4
NIECE/NEPHEW .................................................................................................. 5
FRIEND/NEIGHBOR/OTHER RELATIVE ............................................................ 6
GROUP/FOSTER HOME/ASSISTED LIVING FACILITY
ADMINISTRATOR/CARER ................................................................................... 7
OTHER
(SPECIFY) ............................................................................................................ 8
L
OTHERRE
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
PROGRAMMER SKIP BOX REPREL
IF REPREL = 8, GO TO OTHERREL.
ELSE, GO TO SKIP BOX NEEDREP.
REPREL= 8
OtherRel.
INSTRUCTION:
SPECIFY OTHER RELATIONSHIP.
___________________________________________________ (STRING 20)
NEEDREP
OTHER RELATIONSHIP
31
SKIP BOX
PROGRAMMER SKIP BOX NEEDREP
IF NEEDREP = 1 OR 3 (SPEAKING TO PROXY/INTERPRETER), GO TO SAMPMEMBBOX.
IF NEEDREP = 2 (SPEAKIN TO BUT NOT GOOD TIME), GO TO SETAPPT.
IF NEEDREP = 4 AND REPTYPE = 1 (INTERP NOT AVAILABLE),GO TO SETAPPT.
IF NEEDREP = 4 AND REPTYPE = 2 (PROXY NOT AVAILABLE), GO TO NEEDREPBESTBUM.
IF NEEDREP = 5 (PROXY LIVES ELSEWHERE), GO TO NEEDREPPHONE.
IF (NEEDREP = 6 OR D) AND PROXYOKAY = 1, GO TO THANKS AND SET DISP = 45.
IF (NEEDREP = 6 OR D) AND PROXYOKAY = 0 AND INTERPOKAY = 1, GO TO THANKS AND
SET DISP = 44).
NEEDREP = 4 AND REPTYPE = 2 (PROXY) AND AND NEWNAMEREP = ANSWERED (NOT D OR
R)
[FIRST NAME] FROM NEWNAMEREP
NeedRepBestNum.
Is this telephone number I reached you on the best number to use to call
[PROXY FIRST NAME]?
¿Es este número de teléfono donde le contacté a usted el mejor número
para llamar a [PROXI FIRST NAME]?
CODE ONE ONLY
YES ............................................................................................................. 1
SETAPPT
NO ............................................................................................................... 0
NEEDREPPHONE
DON’T KNOW ............................................................................................. d
THANKS (DISP = 36)
REFUSED ................................................................................................... r
THANKS (DISP = 36)
32
NEEDREP = 5 OR NEEDREPBESTNUM = 0
[FIRST NAME] FROM NEWNAMEREP
PROGRAMMER- EXTENSION MAY BE MISSING
NeedRepPhone.
Please give me [PROXY FIRST NAME]’s telephone number, area code first.
Por favor deme el número de teléfono de [PROXY FIRST NAME],
empezando con el código de área.
INSTRUCTION:
CONFIRM PHONE WITH RESPONDENT BEFORE CONTINUING
|
|
|
(0-999)
|-|
|
|
|-|
(0-999)
|
|
|
|
(0-9999)
Is there an extension number?
¿Hay un número de extensión?
|
| | | |
(0-999999)
|
|
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF PHONE NE 10 DIGITS: PHONE NUMBER SHOULD BE 10 NUMERIC DIGITS, NO
SPACES, DASHES, PARENTHESES OR OTHER PUNCTUATION (OR EMPTY)
SOFT CHECK: IF AREA CODE LE 200: AREA CODE SHOULD BE GREATER THAN 200
SOFT CHECK: IF EXCHANGE LE 199: EXCHANGE SHOULD BE GREATER THAN 199
PROGRAMMER SKIP BOX NEEDREPPHONE
IF (NEEDREPPHONE = D OR R) AND NEEDREP = 5, GO TO THANKS (DISP = 45).
IF (NEEDREPPHONE = D OR R) NEEDREPBESTNUM = 0, GO TO THANKS (DISP = 36).
33
NEEDREPPHONE = PHONE PROVIDED
NeedRepPhoneTZ.
What time zone is that in?
¿En qué zona horaria está?
IF NEEDED:
What time is it there?
¿Qué hora es ahí?
INSTRUCTION:
A TIME ZONE IS REQUIRED. USE ORIGINAL TIME ZONE OR STATE IF
NEEDED.
CODE ONE ONLY
EASTERN TIME (US & CANADA) [(FILL CURRENT TIME)]............................... 62
INDIANA (EAST) [(FILL CURRENT TIME)] .......................................................... 63
CENTRAL TIME (US & CANADA) [(FILL CURRENT TIME)] ............................... 65
ARIZONA [(FILL CURRENT TIME)] ..................................................................... 68
MOUNTAIN TIME (US & CANADA) [(FILL CURRENT TIME)] ............................ 70
PACIFIC TIME (US & CANADA) [(FILL CURRENT TIME)] ................................. 71
ALASKA [(FILL CURRENT TIME)] ....................................................................... 72
HAWAII [(FILL CURRENT TIME)] ........................................................................ 73
BAJA CALIFORNIA [(FILL CURRENT TIME)] ..................................................... 93
PROGRAMMER SKIP BOX NEEDREPPHONETZ
GO TO THANKS AND SET DISP = 38 (NEW NUMBER).
34
SampMemb Questions:
(HELLO = 1 OR 2) OR CALLINNUM = 1 OR AMPPHONE = 1 OR CALLRELAY = 1
IF QUALIFIED LEVEL LT 2 (INT NOT STARTED), DISPLAY RESPONSE CHOICE (2), ELSE HIDE.
FILL [FIRSTNAME] IF PROXY; You/Usted IF SELF RESPONSE
SampMemb.
IF HELLO = 2 (COMES TO PHONE) AND REPTYPE = 0 – 2 (ALL)
I am calling from Mathematica Policy Research on behalf of the Social
Security Administration or SSA. We recently mailed you a letter about
completing an survey for the Promoting Opportunity Demonstration or
POD. Is this a good time to begin?
Estoy llamando de Mathematica Policy Research de parte de la
Administración del Seguro Social o SSA por sus siglas en inglés.
Recientemente le enviamos una carta acerca de completar una encuesta
para la Demostración Promoviendo Oportunidades o POD por sus siglas
en inglés. ¿Es este un buen momento para comenzar?
IF QL LT 2 (INTERVIEW NOT STARTED) AND REPTYPE = 0 – 1
You should have received a letter from the Social Security Administration
or SSA about completing an interview for Promoting Opportunity
Demonstration or POD.
Each person's participation is voluntary, but very important and all
answers will be held in strict confidence. Is this a good time to begin?
Debería haber recibido una carta de la Administración del Seguro Social o
SSA por sus siglas en inglés acerca de completar una entrevista para la
Demostración Promoviendo Oportunidades o POD por sus siglas en inglés.
La participación de cada persona es voluntaria, pero muy importante y
todas las respuestas se mantendrán de manera estrictamente confidencial.
¿Es este un buen momento para comenzar?
IF QL GE 2 (INTERVIEW STARTED) AND REPTYPE = 0 – 2 (ALL)
I’m calling to finish the interview we are conducting about Promoting
Opportunity Demonstration or POD study. Is now a good time?
Estoy llamando para terminar la entrevista que estamos llevando a cabo
sobre la Demostración Promoviendo Oportunidades o estudio POD por sus
siglas en inglés. ¿Es buen momento ahora?
IF QL LT 2 (INTERVIEW NOT STARTED) AND REPTYPE = 2 (PROXY)
We are conducting interviews about a study for the Social Security
Administration or SSA called Promoting Opportunity Demonstration or
POD study and wanted to interview [SampMembFULLNAME]. But I
understand that [SampMembFULLNAME] in unable to be interviewed and
[you volunteered/your name was given] as someone who could answer on
[his/her] behalf. Is this a good time to begin?
Estamos haciendo entrevistas acerca de un estudio para la Administración
del Seguro Social o SSA por sus siglas en inglés, llamado la Demostración
Promoviendo Oportunidades o estudio POD, y queríamos entrevistar a
[SampMembFULLNAME]. Pero entiendo que [SampMembFULLNAME] no
puede ser entrevistado(a) y [usted se ofreció/nos dieron su nombre] como
alguien que podría responder por [él/ella]. ¿Es este un buen momento para
comenzar?
CODE ONE ONLY
35
BEGIN INTERVIEW .............................................................................................. 1
SAMPMEMBBOX
DID NOT RECEIVE OR DOES NOT RECALL THE LETTER .............................. 2
NOLETTER
NOT A GOOD TIME.............................................................................................. 3
SETAPPT
HUNG UP DURING INTRODUCTION.................................................................. 4
VERSMCONTACT
PROGRAMMER SMVERIFIED BOX SAMPMEMB
IF SAMPMEMB = 1 AND SMVERIFIED = 0, SET SMVERIFIED = 1.
PROGRAMMER SKIP BOX SAMPMEMB
IF (CURPHNTYPE = CELL (C) OR UNKNOWN (U) OR EMPTY) AND (DIALNUMBER = 1, 2 4, OR 5),
GO TO SAFETY.
IF (CURPHNTYPE = CELL (C) OR UNKNOWN (U) OR EMPTY) AND DIALNUMBER = 6 (FIELD
CALL IN), GO TO CONFIRMREC BOX.
IF CURPHNTYPE = LANDLINE (L) AND REPREL= 1 – 7, GO TO CONFIRMREC BOX.
IF CURPHNTYPE = LANDLINE (L) AND SAMPMEMB = 1, GO TO CONFIRMREC BOX.
36
No Letter Questions:
SAMPMEMB = 2
NoLetter.
The letter explained we are conducting a study for the Social Security
Administration to find out more about the experiences of people receiving Social
Security Disability Benefits.
The purpose of this survey is to learn more about the experiences that people like
you may have, including job experience, job training, school and other things.
Can we begin now?
La carta explicaba que estamos llevando a cabo un estudio para la Administración
del Seguro Social para conocer más acerca de las experiencias de las personas
que están recibiendo Beneficios del Seguro Social por Incapacidad.
El propósito de esta encuesta es aprender más sobre las experiencias que las
personas como usted pueden tener, incluyendo experiencias de trabajo,
capacitación en el trabajo, educación y otras cosas.
¿Podemos empezar ahora?
CODE ONE ONLY
BEGIN INTERVIEW .............................................................................................. 1
SKIP BOX
SAMPMEMB
WANTS ANOTHER LETTER ................................................................................ 2
READLETTER
NOT A GOOD TIME.............................................................................................. 3
SETAPPT
NOLETTER = 2
ReadLetter.
May I read the letter to you and then we can begin?
¿Puedo leerle la carta y luego podemos empezar?
INSTRUCTION:
READ LETTER TO RESPONDENT AND CONTINUE.
[INSERTPROJECTTEXT]
[INSERTPROJECTTEXT]
CODE ONE ONLY
YES, READ THE LETTER .................................................................................... 1
SKIP BOX
SAMPMEMB
NO, WANTS ANOTHER LETTER FIRST ............................................................. 0
SKIP BOX
READLETTER
PROGRAMMER SKIP BOX READLETTER
IF ADVEMAILS = 1, GO TO EMAILEXIT.
IF ADVEMAILS = 0 AND ADVREMAILS = 1, GO TO SENDLETTEREXIT.
IF ADVEMAILS = 0 AND ADVREMAILS = 0, GO TO THANKS AND SET DISP = 5.
37
Standard Questions:
(DIALNUMBER = 1, 2 4, OR 5) AND (CURPHNTYPE = CELL (C) OR UNKNOWN (U) OR EMPTY)
AND ((SAMPMEMB = 1 – 2) OR (REPREL= 1 – 8))
Safety.
Are you in a place where you can safely talk on the phone and answer my
questions?
¿Está en un lugar donde puede hablar por teléfono y responder a mis preguntas
de forma segura?
PROBE IF NEEDED:
For example, are you driving?
Por ejemplo, ¿está conduciendo?
CODE ONE ONLY
YES, BEGIN INTERVIEW ..................................................................................... 1
SKIP BOX
CONFIRMREC
NOT A GOOD TIME.............................................................................................. 2
SETAPPT
DON’T KNOW ....................................................................................................... d
SETAPPT
REFUSED ............................................................................................................. r
SETAPPT
PROGRAMMER SKIP BOX CONFIRMREC
IF RECORDPROJECT = 0 (NO), SKIP TO NEXT QUESTION TO BEGIN INTERVIEW.
IF RECORDPROJECT = 1 (YES), CONTINUE TO CONFIRMREC.
RECORDPROJECT = 1 (YES)
ConfirmRec.
This call may be monitored or recorded for quality assurance purposes.
Esta llamada puede ser monitoreada o grabada para control de calidad.
INSTRUCTION: CODE 0 ONLY IF RESPONDENT OBJECTS TO BEING RECORDED.
CODE ONE ONLY
BEGIN INTERVIEW .............................................................................................. 1
A1
BEGIN INTERVIEW – PERMANENTLY STOP RECORDING THIS CALL ......... 0
A1
SOFT CHECK: IF CONFIRMREC = 0, INTERVIEWER PLEASE CONFIRM THE RESPONDENT
SAYS HE/SHE DOES NOT WANT TO BE RECORDED.
38
APPOINTMENTS & BREAKOFFS:
HELLO = 4 OR CALLIN = 2 OR AMPRELAY = D OR RELAYPHONE = D OR (RESPAVAIL = 0 OR D)
OR AMPPHONE = 2 OR CALLRELAY = 2 OR (CALLLATER = 1 OR D) OR (HOMESOON = 1, D OR
R) OR (LANG NE INSTLANG AND PROXYOKAY = 0 AND INTERPOKAY = 0 AND EXTRATRANS = 1
AND LANG = EXTRATRANSLANG) OR DIFFLANG = 2 OR ((NEEDREP = 2 OR (NEEDREP = 4 AND
REPTYPE = 1)) AND ((REPREL = 1 – 7, D, OR R) OR OTHERREL = ANSWERED)) OR SAMPMEMB
= 3 OR NOLETTER = 3 OR (SAFETY = 2, D, OR R)
SetAppt.
When would be a good time to callback?
¿Cuándo sería una hora conveniente para volver a llamar?
INSTRUCTION:
MAKE AN APPOINTMENT USING THE 'APPOINTMENT' ICON OR PRESS
TO INVOKE THE APPOINTMENT MAKING DIALOG.
PROGRAMMER: NO FORWARD OPTION
PROGRAMMER SKIP BOX SETAPPT
IS PHONE LOADED FOR CURRENT RESPONDENT, GO TO
CONFPHONEEXIT.
IF NO PHONE LOADED FOR CURRENT RESPONDENT, GO TO
NEWPHONEEXIT.
IF TERMINATE BUTTON SELECTED
DISABLE WEBFINISH (5) IF ALLOWWEB = 0
If you prefer… IF ALLOWWEB = 1
Si prefiere… IF ALLOWWEB = 1
KindOfExit.
INSTRUCTION:
RECORD THE KIND OF EXIT.
[If you prefer, you can complete the survey on the web.]
[Si prefiere, puede completar la encuesta por Internet.]
CODE ONE ONLY
REFUSES TO CONTINUE ................................................................................... 1
REFUSALREASON
RESPONDENT WILL CALL US BACK ................................................................. 2
THANKS (DISP = 47)
RESPONDENT REQUESTED LETTER ............................................................... 3
NOLETTEREXIT
CALL DROPPED/BREAK-OFF ............................................................................. 4
SKIP BOX THANKS
(DISP = 49)
WEBFINISH .......................................................................................................... 5
EMAILEXIT
CALL BACK ON NEW PHONE NUMBER ........................................................... 6
NEWPHONEEXIT
DO NOT TERMINATE AND GO BACK TO LAST QUESTION ............................ 7
LAST QUESTION
39
KINDOFEXIT=1 OR (CALLIN = 3 OR 4)
RefusalReason.
INSTRUCTION:
INDICATE REASON FOR REFUSAL.
CODE ONE ONLY
CONFIDENTIALITY ...................................................................................... 1
NOT INTERESTED ....................................................................................... 2
INTERVIEW TOO LONG .............................................................................. 3
DOESN'T BELIEVE STUDY WILL MAKE A DIFFERENCE ......................... 4
DOESN'T LIKE TOPIC OR ORGANIZATION ............................................... 5
DID NOT SPECIFY/NO REASON GIVEN .................................................... 6
OTHER REASON (SPECIFY) ....................................................................... 7
REFUSALREASON = 7
OtherRefusalReason.
INSTRUCTION: SPECIFY THE OTHER REASON.
___________________________________________________ (STRING 200)
PROGRAMMER REFUSALREASON CALL HISTORY BOX
APPEND REFUSAL REASON TO THE END OF THE CALL HISTORY
NOTE. IF REFUSAL REASPON = 7, APPEND
OTHERREFUSALREASON TEXT.
REFUSALREASON = 1 – 6 OR OTHERREFUSALREASON = ANSWERED
RefusalSeverity.
INSTRUCTION:
SELECT SEVERITY OF REFUSAL.
CODE ADAMANT (2) IF RESPONDENT:
MENTIONED CALLING POLICE
THREATENED LEGAL ACTION (LAWYER OR ATTORNEY GENERAL) OR
VIOLENCE
STATED DO NOT CALL ME AGAIN
ELSE, CODE SOFT REFUSAL (1)
CODE ONE ONLY
SOFT ..................................................................................................................... 1
THANKS (DISP = 5)
ADAMANT ............................................................................................................. 2
THANKS (DISP = 39)
40
KINDOFEXIT = 3
NoLetterExit. The letter explained we are conducting a study for the Social Security
Administration to find out more about the experiences of people receiving Social
Security Disability Benefits.
The purpose of this survey is to learn more about the experiences that people like
you may have, including job experience, job training, school and other things.
La carta explicaba que estamos llevando a cabo un estudio para la Administración
del Seguro Social para conocer más acerca de las experiencias de las personas
que están recibiendo Beneficios del Seguro Social por Incapacidad.
El propósito de esta encuesta es aprender más sobre las experiencias que las
personas como usted pueden tener, incluyendo experiencias de trabajo,
capacitación en el trabajo, educación y otras cosas.
CODE ONE ONLY
CONTINUE INTERVIEW ...................................................................................... 1
LAST QUESTION
WANTS ANOTHER LETTER ................................................................................ 2
READLETTEREXIT
NOLETTEREXIT = 2
ReadLetterExit.
May I read the letter to you?
¿Puedo leerle la carta?
[INSERTPROJECTTEXT]
CODE ONE ONLY
YES, READ THE LETTER .................................................................................... 1
LAST QUESTION
NO, WANTS ANOTHER LETTER FIRST ............................................................. 0
SKIP BOX
READLETTEREXIT
PROGRAMMER SKIP BOX READLETTEREXIT
IF ADVEMAILS = 1, GO TO EMAILEXIT.
IF ADVEMAILS = 0 AND ADVREMAILS = 1, GO TO SENDLETTEREXIT.
IF ADVEMAILS = 0 AND ADVREMAILS = 0, GO TO THANKS AND SET DISP = 5.
41
KINDOFEXIT = 5 OR ((READLETTEREXIT = 0 OR READLETTER = 0) AND ADVEMAILS = 1)
EmailExit.
IF (READLETTEREXIT = 0 OR READLETTER = 0) AND ADVEMAILS = 1
If you provide me with your email address, I can email you the letter right now and
will call back in a couple of days. What is the best email address for you?
Si me da su correo electrónico, puedo enviarle una carta ahora mismo y le llamaré
en un par de días. ¿Cuál es la mejor dirección de correo electrónico para usted?
IF KINDOFEXIT = 5
We’d be happy to provide you with another email which will include your web
survey login information.
Nos complacería enviarle otro correo electrónico que incluirá su información para
entrar en la encuesta en Internet.
CODE ONE ONLY
ENTER 1 TO CONTINUE ..................................................................................... 1
NEWEXITEMAIL
DOESN’T HAVE EMAIL/KNOW EMAIL................................................................ 2
SKIP BOX EMAILEXIT
NOT INTERESTED IN NEW EMAIL OPTION ...................................................... 3
SKIP BOX EMAILEXIT
PROGRAMMER SKIP BOX EMAILEXIT
IF EMAILEXIT = 1, GO TO NEWEXITEMAIL.
IF KINDOFEXIT = 5 AND (EMAILEXIT = 2 – 3), GO TO THANKS AND SET DISP = 48.
IF (READLETTER = 0 OR READLETTEREXIT = 0) AND ADVEMAILS = 1 AND (EMAILEXIT
= 2 – 3) AND ADVREMAILS = 1, GO TO SENDLETTEREXIT.
IF (READLETTER = 0 OR READLETTEREXIT = 0) AND ADVEMAILS = 1 AND (EMAILEXIT
= 2 – 3) AND ADVREMAILS = 0, GO TO THANKS AND SET DISP = 5.
KINDOFEXIT = 5 OR EMAILEXIT = 1
NewExitEmail. Please provide me the email address.
Por favor deme la dirección de correo electrónico.
INSTRUCTION:
CONFIRM EMAIL ADDRESS WITH RESPONDENT BEFORE CONTINUING
SPECIFY EMAIL
_______________________________________________ (STRING (50)
EMAIL
PROGRAMMER SKIP BOX EXITEMAIL
IF KINDOFEXIT = 5 AND EMAILEXIT = 1, GO TO THANKS, SET DISP = 48 AND
SEND WEBLOGIN EMAIL.
IF (READLETTER = 0 OR READLETTEREXIT = 0) AND ADVEMAILS = 1 AND
EMAILEXIT= 1, GO TO THANKS, SET DISP = 51 AND SEND ADVANCE EMAIL.
42
((READLETTER = 0 OR READLETTEREXIT = 0) AND ADVEMAILS = 0 AND ADVREMAILS = 1) OR
((READLETTER = 0 OR READLETTEREXIT = 0) AND ADVEMAILS = 1 AND (EMAILEXIT= 2 – 3) AND
ADVREMAILS = 1)
SendLetterExit.
Okay, I'll send another letter and will call back in a few days.
Muy bien, le enviaré otra carta y le llamaré de nuevo en unos días.
CODE ONE ONLY
ENTER 1 TO COLLECT/CONFIRM ADDRESS ................................................... 1
SENDLETTEREXIT
SKIP BOX
PROGRAMMER SKIP BOX SENDLETTEREXIT
IF ADDRESS LOADED, GO TO CONFLETTERADDRESS.
IF NO ADDRESS LOADED, GO TO NEWLETTERADDRESS.
SENDLETTEREXIT = 1 AND ADDRESS LOADED
FILL ADDRESS WITH RESPONDENTS ADDRESS FROM PRELOAD
ConfLetterAddress.
Please confirm the address we have on file.
Por favor confirme la dirección que tenemos en archivo.
The address we have is:
La dirección que tenemos es:
ADDRESS: [ADDRESS]
Is that correct?
¿Es correcta?
CODE ONE ONLY
YES, CORRECT ................................................................................................... 1
THANKS (DISP = 46)
NO, EDIT ADDRESS ............................................................................................ 2
NEWLETTERADDRESS
NO, SEND TO NEW ADDRESS ........................................................................... 3
NEWLETTERADDRESS
43
(CONFLETTERADDRESS = 2 OR 3) OR (SENDLETTEREXIT = 1 AND ADDRESS = BLANK)
IF CONFLETTERADDRESS = 2, FILL ADDRESS WITH ADDRESS
NewLetterAddress.
Please tell me the best address to send the letter.
Por favor dígame la mejor dirección para enviar la carta.
INSTRUCTION:
CONFIRM ADDRESS WITH RESPONDENT BEFORE CONTINUING
What is the first line of the address?
¿Cuál es la primera línea de la dirección?
___________________________________________________ (STRING (60))
Street Address Line 1
Is there an apartment or unit number for this address?
¿Hay un número de apartamento o unidad en esta dirección?
___________________________________________________ (STRING (60))
Street Address Line 2
__________________________________________________ (STRING (60))
Street Address Line 3
___________________________________________________ (STRING (60))
Street Address Line 4
And what is the zip code?
¿Cuál es el código postal?
___________________________________________________ (STRING (10))
ZIP Code
Town or city?
¿Pueblo o ciudad?
___________________________________________________ (STRING (20))
City
State?
¿Estado?
___________________________________________________ (STRING (2))
State
REFUSED ............................................................................................................. r
PROGRAMMER SKIP BOX NEWLETTERADDRESS
IF NEWLETTERADDRESSADDRESSHAS ADDRESS, GO TO THANKS AND
SET DISP = 46.
IF NEWLETTERADDRESS = R, GO TO THANKS AND SET DISP = 5.
44
SETAPPT = APPT
FILL PHONE WITH SAMPLE MEMBERS PHONE FROM PRELOAD
ConfPhoneExit.
Please confirm the phone number we have on file.
Por favor confirme el número de teléfono que tenemos en archivo.
The phone number we have is:
El número de teléfono que tenemos es:
PHONE:
[PHONE]
Is that correct?
¿Es correcto?
CODE ONE ONLY
YES, CORRECT ................................................................................................... 1
SKIPBOX
PHONEEXIT
NO, EDIT PHONE ................................................................................................. 2
NEWPHONEEXIT
NO, NEW PHONE................................................................................................. 3
NEWPHONEEXIT
CALL ENDED BEFORE ASKING ......................................................................... 4
SKIPBOX
PHONEEXIT
REFUSED ............................................................................................................. r
SKIPBOX
PHONE EXIT
PROGRAMMER SKIP BOX CONFPHONEEXIT
IF (CONFPHONEEXIT = 1 OR R), GO TO THANKS AND SET DISP = 1. KEEP CURRENT PHONE.
IF CONFPHONEEXIT = 4, GO TO FINISHED AND SET DISP = 1. KEEP CURRENT PHONE.
IF CONFPHONEEXIT = 2 – 3, GO TO NEWPHONEEXIT.
45
(SETAPPT = APPT AND (CONFPHONEEXIT = 2 OR 3 OR NO PHONE LOADED)) OR KINDOFEXIT
=6
IF CONFPHONE = 2, FILL LOADED PHONE
PROGRAMMER- EXTENSION MAY BE MISSING
FILL SECOND INTERVIEWER INSTRUCTION ONLY IF KINDOFEXIT = 6
NewPhoneExit.
Starting with the area code, please give me the best telephone number to
use to call you back.
Comenzando con el código de área, por favor deme el mejor número de
teléfono para llamarle de vuelta.
INSTRUCTION:
CONFIRM PHONE WITH RESPONDENT BEFORE CONTINUING
IF KINDOFEXIT = 6 DISPLAY THE FOLLOWING INSTRUCTION:
INSTRUCTION:
MAKE NOTE OF MPRID SO YOU CAN CALL RESPONDENT BACK AFTER
COLLECTING NUMBER.
|
| | |-| | |
(0-999)
(0-999)
|-|
| | |
(0-9999)
|
Is there an extension number?
¿Hay un número de extensión?
|
| | | |
(0-999999)
|
|
CALL ENDED BEFORE ASKING ......................................................................... 1
SKIP BOX
NEWPHONEEXIT
DON’T KNOW ....................................................................................................... d
SKIP BOX
NEWPHONEEXIT
REFUSED ............................................................................................................. r
SKIP BOX
NEWPHONEEXIT
SOFT CHECK: IF PHONE NE 10 DIGITS: PHONE NUMBER SHOULD BE 10 NUMERIC DIGITS, NO
SPACES, DASHES, PARENTHESES OR OTHER PUNCTUATION (OR EMPTY)
SOFT CHECK: IF AREA CODE LE 200: AREA CODE SHOULD BE GREATER THAN 200
SOFT CHECK: IF EXCHANGE LE 199: EXCHANGE SHOULD BE GREATER THAN 199
PROGRAMMER SKIP BOX NEWPHONEEXIT
IF (NEWPHONEEXIT = D OR R) AND (SETAPPT = APPT AND (CONFPHONEEXIT = 2 OR 3
OR NO PHONE LOADED)), GO TO THANKS AND SET DISP = 1. KEEP CURRENT PHONE.
IF NEWPHONEEXIT = 1 AND (SETAPPT = APPT AND (CONFPHONEEXIT = 2 OR 3 OR NO
PHONE LOADED)), GO TO FINISHED AND SET DISP = 1. KEEP CURRENT PHONE.
IF (NEWPHONEEXIT = D OR R) AND KINDOFEXIT = 6, GO TO THANKS AND SET DISP =
36. KEEP CURRENT PHONE.
IF NEWPHONEEXIT = 1 AND KINDOFEXIT = 6, GO TO FINISHED AND SET DISP = 36.
KEEP CURRENT PHONE.
IF PHONE COLLECTED AT NEWPHONEEXIT, CONTINUE TO NEWPHONETZEXIT.
46
NEWPHONEEXIT HAS PHONE PROVIDED
NewPhoneTZExit.
What time zone is that in?
¿En qué zona horaria está?
IF NEEDED:
What time is it there?
¿Qué hora es ahí?
INSTRUCTION:
A TIME ZONE IS REQUIRED. USE ORIGINAL TIME ZONE OR STATE IF
NEEDED.
CODE ONE ONLY
Eastern Time (US & Canada) [(FILL CURRENT TIME)] ...................................... 62
Indiana (East) [(FILL CURRENT TIME)] ............................................................... 63
Central Time (US & Canada) [(FILL CURRENT TIME)] ....................................... 65
ARIZONA [(FILL CURRENT TIME)] ..................................................................... 68
MOUNTAIN TIME (US & CANADA) [(FILL CURRENT TIME)] ............................ 70
PACIFIC TIME (US & CANADA) [(FILL CURRENT TIME)] ................................. 71
ALASKA [(FILL CURRENT TIME)] ....................................................................... 72
HAWAII [(FILL CURRENT TIME)] ........................................................................ 73
BAJA CALIFORNIA [(FILL CURRENT TIME)] ..................................................... 93
PROGRAMMER SKIPBOX NEWPHONETZEXIT
IF (SETAPPT = APPT AND (CONFPHONEEXIT = 2 OR 3 OR NO PHONE
LOADED)), GO TO THANKS AND SET DISP = 1. SET NEWPHONE AS NEW
PHONE.
IF KINDOFEXIT = 6, GO TO THANKS AND SET DISP = 36. SET NEWPHONE AS
NEW PHONE.
DISP = ANY (1, 5, 13, 36, 37, 38, 39, 40, 42, 43, 44, 45, 46, 47, 48, 50, 51)
Thanks.
Thank you very much for your time.
Muchísimas gracias por su tiempo.
CODE ONE ONLY
ENTER 1 TO CONTINUE ..................................................................................... 1
SKIP BOX THANKS
PROGRAMMER SKIP BOX THANKS
IF SMVERIFIED = 0 AND (SETAPPT = APPT OR (KINDOFEXIT=1 – 6) OR
READLETTEREXIT = 0 OR (REFUSALSEVERITY = 1 OR 2) OR HELLO = 8 OR
CALLIN = 9 OR SAMPMEMB = 4), GO TO VERSMCONTACT.
ELSE, GO TO FINISHED.
47
SMVERIFIED = 0 AND (SETAPPT = APPT OR (KINDOFEXIT=1 – 6) OR READLETTEREXIT = 0 OR
(REFUSALSEVERITY = 1 OR 2) OR HELLO = 8 OR CALLIN = 9 OR SAMPMEMB = 4)
[SAMPLE MEMBER NAME] IF REPTYPE = 0 – 1
[SAMPLE MEMBER NAME] OR HIS/HER PROXY IF REPTYPE = 2 (PROXY)
[SAMPLE MEMBER NAME] IF REPTYPE = 0 – 1
[SAMPLE MEMBER NAME] OR PROXY IF REPTYPE = 2 (PROXY)
FILL SAMPLE MEMBER NAME FROM PRELOAD
VerSMContact.
INSTRUCTION:
INDICATE IF [SAMPLE MEMBER NAME] HAS BEEN VERIFIED AT THIS
NUMBER.
INSTRUCTION:
VERIFIED MEANS YOU SPOKE TO [[SAMPLE MEMBER NAME] /
[SAMPLE MEMBER NAME] OR VIA AN INTERPRETER / [SAMPLE
MEMBER NAME] OR HIS/HER PROXY].
CODE ONE ONLY
VERIFIED. SPOKE WITH [[SAMPLE MEMBER NAME] /
[SAMPLE MEMBER NAME] OR PROXY] AT THIS NUMBER............................. 1
FINISHED
NOT VERIFIED. DID NOT SPEAK WITH [[SAMPLE MEMBER NAME] /
[SAMPLE MEMBER NAME] OR PROXY] AT THIS NUMBER............................. 2
FINISHED
UNSURE WHO YOU WERE SPEAKING TO ....................................................... 3
FINISHED
PROGRAMMER SMVERIFIED BOX VERSMVERIFIED
IF VERSMCONTACT = 1, SET SMVERIFIED FLAG = 1.
ALL
Finished.
THE STATUS OF CASE [MPRID] IS:
[LOGICAL STATUS] [STATUS DESCRIPTION]
ONLY LEAVE A NOTE IF NECESSARY. OTHERWISE, CLICK CONTINUE.
SEE A SUPERVISOR IF THE STATUS DOES NOT MATCH THE OUTCOME OF THE CALL
ATTEMPT.
INSTRUCTION: ENTER CASE NOTES.
___________________________________________________ (STRING 200)
48
SECTION A: RESPONDENT SCREENER AND INTRODUCTION
ALL CATI
FILL “20” IF Y1; FILL “25” IF Y2
A1.
We are conducting a study for the Social Security Administration to find out more about
the experiences of people receiving Social Security Disability Benefits.
The purpose of this interview is to learn more about [your/[FIRST NAME’s] experiences
over the past year, including job experience, job training, school and other things.
SampMemb
The survey takes about 30 minutes to complete. At the end of the interview, we will mail
you a check for $[20/25] to thank you for your time.
Estamos llevando a cabo un estudio para la Administración del Seguro Social para
aprender más acerca de las experiencias de las personas que están recibiendo Beneficios
del Seguro Social por Incapacidad.
El propósito de esta entrevista es aprender más acerca de las experiencias que pueden
tener personas como [usted/[FIRST NAME]], incluyendo experiencia laboral, capacitación
en el trabajo, educación y otras cosas.
Completar la encuesta lleva unos 30 minutos. Al final de la entrevista, le enviaremos un
cheque por $[20/25] por correo para agradecerle por su tiempo.
CODE ONE ONLY
BEGIN INTERVIEW .............................................................................................. 1
A2
DID NOT RECEIVE OR DOES NOT RECALL LETTER ...................................... 2
NoLetter
NOT A GOOD TIME.............................................................................................. 3
Callback
HUNG UP DURING INTRODUCTION.................................................................. 4
HUDI
SUPERVISOR REVIEW ....................................................................................... 5
SUP REV
WILL CALL MPR BACK ........................................................................................ 6
RCB
REFUSED ............................................................................................................. r
REF
49
CATI A1=1
A2.
[Your/[FIRST NAME’s]] participation in this study is completely voluntary. It will in no way
affect [your/[FIRST NAME]’s] current or future receipt of benefits. [You/(He/She)] can stop
the interview at any time. If any question makes [you/(him/her)] feel uncomfortable,
[you/(he/she)] can refuse to answer that question.
If you get tired or need a break at any time, please tell me and we can take a break or I will
call back later to finish the interview.
Let’s start the interview now.
[Su participación/La participación de [FIRST NAME]] en este estudio es completamente
voluntaria. No afectará en ninguna forma los beneficios actuales o futuros que reciba
[usted/[FIRST NAME]]. [Usted/(Él/Ella)] puede parar la entrevista en cualquier momento. Si
alguna pregunta le hace sentir incómodo(a), [usted/(él/ella)] puede negarse a contestar
esa pregunta.
Si se cansa o necesita un descanso en algún momento, por favor dígame y podemos parar
o le llamaré más tarde para terminar la entrevista.
Empecemos la entrevista ahora.
CODE ONE ONLY
CONTINUE ........................................................................................................... 1
CALLBACK ........................................................................................................... 2
Callback
SUPERVISOR REVIEW ....................................................................................... 3
sup rev
REFUSED ............................................................................................................. r
ref
50
PROMOTING OPPORTUNITY DEMONSTRATION
Follow-up Survey
Login ID:
Password:
Log In (Button)
51
How to Complete the Survey Cómo completar la
encuesta
Thank you for your cooperation in completing the survey. Gracias por su cooperación al completer la
encuesta.
There are no right or wrong answers. No hay respuestas correctas ni incorrectas.
To answer a question, click the box to choose your response. Para contestar una pregunta, haga
clic en la casilla para elegir su respuesta.
• For most questions in the survey, you may answer by simply clicking a box or entering a number
in the appropriate box. La mayoría de las preguntas en la encuesta pueden ser contestadas
simplemente haciendo clic en una casilla o entrando un número en la casilla apropiada.
• For some questions, you will be asked to type a number or a brief text response. Para algunas
preguntas, se le pedirá que escriba un número o una breve respuesta de texto.
• If you are unsure how to answer a question, please give the best answer you can rather than
leaving it blank. Si no está seguro(a) de cómo responder una pregunta, por favor dé la mejor
respuesta que pueda en lugar de dejarla en blanco.
• To continue to the next page, press the "Next” button. Para continuar a la página siguiente,
presione el botón "Adelante".
• To go back to the previous page, click the "Back" link at the bottom of each page. Para volver a la
página anterior, haga clic en el enlace "Back/Volver" en la parte inferior de cada página.
• Use the buttons and links on each page to move through the survey. Clicking “Enter” or your
browser’s “Back” function may cause errors. Use los botones y enlaces en cada página para
avanzar en la encuesta. Hacer clic en "Enter" o la función "Back/Volver" de su navegador puede
causar errores.
• If you need to stop before you have finished, you may exit the survey by simply closing the tab or
your internet browser. The data you provide prior to exiting the survey will be securely stored. Si
necesita detenerse antes de terminar, puede salir de la encuesta simplemente cerrando la pestaña
o su navegador de Internet. Los datos que proporcione antes de salir de la encuesta se
almacenarán de forma segura.
• To continue the survey, log in again by clicking the link in the email you received, or using your
login ID and password found in your study packet. You will return to the point where you left off.
• If you have any questions regarding this survey, please call our study team at 1-833-832-0470.
Para continuar la encuesta, inicie sesión de nuevo haciendo clic en el enlace del correo
electrónico que recibió, o use su nombre de usuario y contraseña que se encuentran en su
paquete de estudio. Volverás al punto donde dejó.
Si tiene alguna pregunta acerca de esta encuesta, por favor llame a nuestro equipo de estudio al
1-833-832-0470.
Please click “Next” below to continue. Haga clic en "Adelante" abajo para continuar.
•
•
52
APPENDIX B
MATHEMATICA POLICY RESEARCH
ALL WEB
AA1.
Who is completing this survey?
¿Quién está completando esta encuesta?
[FULL BENEFICIARY NAME]………………………………………………………1
Someone else on behalf of [FULL BENEFICIARY NAME]/ Alguien más en nombre de [FULL
BENEFICIARY NAME] ……………………2
HARD CHECK IF AA1 = MISSING; Please provide a response in order to proceed. If you do not
wish to complete the survey, please exit your Internet browser now.
Por favor provea una respuesta para continuar. Si no desea completar la encuesta, por favor
salga de su navegador de Internet ahora.
PROGRAMMER: USE AA1 TO DETERMINE FIRST PERSON/THIRD PERSON FILLS
WEB AND IF AA1 = 2
AA2.
Please enter your full name and your relationship to [FULL BENEFICIARY NAME].
Por favor escriba su nombre completo y su relación con [FULL BENEFICIARY NAME].
FIRST NAME NOMBRE
MIDDLE INITIAL/NAME INICIAL DEL SEGUNDO NOMBRE
LAST NAME APELLIDO
RELATIONSHIP TO RESPONDENT RELACIÓN/PARENTESCO CON ENCUESTADO
SOFT CHECK: IF AA2=d, r, missing; Please try to provide an answer to this question, or proceed
to the next question.
Por favor trate de dar una respuesta a esta pregunta, o continúe a la siguiente pregunta.
ALL WEB
“30” IF Y1; “35” IF Y2
A1.
We are conducting a study for the Social Security Administration to find out more about
the experiences of people receiving Social Security Disability Benefits.
The purpose of this survey is to learn more about [your/[FIRST NAME’s] experiences over
the past year, including job experience, job training, school and other things.
53
APPENDIX B
MATHEMATICA POLICY RESEARCH
The survey takes about 30 minutes to complete. At the end of the survey, we will mail you
a check for $[30/35] to thank you for your time.
Estamos llevando a cabo un estudio para la Administración del Seguro Social para
aprender más acerca de las experiencias de las personas que están recibiendo Beneficios
del Seguro Social por Incapacidad.
El propósito de esta encuesta es aprender más acerca de las experiencias que pueden
tener personas como [usted/[FIRSTNAME]], incluyendo experiencia laboral, capacitación
en el trabajo, educación y otras cosas.
Completar la encuesta lleva unos 30 minutos. Al final de la encuesta, le enviaremos un
cheque por $[30/35] por correo para agradecerle por su tiempo.
Please click “Next” button to continue.
Por favor haga clic en el botón “Adelante” para continuar.
(NEXT button)
WEB A1=1
PROGRAMMER
CHECK BOX TO PROCEDE TEXT
A2.
[Your/[FIRST NAME]’s] participation in this study is completely voluntary. It will in no way
affect [your/[FIRST NAME]’s] current or future receipt of benefits. [You/(He/She)] can quit
the survey at any time. If any question makes [you/(him/her)] feel uncomfortable,
[you/(he/she)] can refuse to answer that question.
[Su participación/La participación de [FIRST NAME]] en este estudio es completamente
voluntaria. No afectará en ninguna forma los beneficios actuales o futuros que reciba
[usted/[FIRST NAME]]. [Usted/(Él/Ella)] puede abandonar la encuesta en cualquier
momento. Si alguna pregunta le hace sentir incómodo(a), [usted/(él/ella)] puede negarse a
contestar esa pregunta.
Please click “Next” button to continue.
Por favor haga clic en el botón “Adelante” para continuar.
CONTINUE……………………………………………………1
54
APPENDIX B
MATHEMATICA POLICY RESEARCH
SECTION B: EDUCATION AND TRAINING
RETURN TO WORK ACTIVITIES—EDUCATION AND TRAINING
ALL
B1.
The first few questions are about [your/[FIRST NAME]’s] education and training
experiences. [Are you /Is (he/she)] currently enrolled in school or taking any classes?
Las primeras preguntas son acerca de las experiencias de educación y capacitación de
[usted/FIRST NAME]. ¿Está [usted/(él/ella)] actualmente matriculado(a) en la escuela o
tomando alguna clase?
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ...................................................................................................... d
REFUSED ............................................................................................................. r
B1=1
B2.
[Are you/Is (he/she)] a full-time or part-time student?
¿Es [usted/(él/ella)] estudiante a tiempo completo o parcial?
CODE ONE ONLY
FULL-TIME TIEMPO COMPLETO ....................................................................... 1
PART-TIME TIEMPO PARCIAL ........................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
B3.
The next questions are about any training [you/[FIRST NAME]] may have had in the past 12
months.
In the past 12 months, [have you/has (he/she)] participated in any training program that
lasted at least two weeks and that was designed to help [you/him/her] find a job, improve
[your/(his/her)] job skills, or learn a new job?
Las siguientes preguntas son acerca de cualquier capacitación que [usted/[FIRST NAME]]
pueda haber recibido en los últimos 12 meses.
En los últimos 12 meses, ¿ha participado [usted/(él/ella)] en algún programa de
capacitación que durara por lo menos dos semanas y fuera designado a ayudarle a
[usted/(él/ella)] a encontrar un trabajo, mejorar sus habilidades laborales, o aprender un
nuevo trabajo?
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
55
APPENDIX B
MATHEMATICA POLICY RESEARCH
B3=1
B4.
What kind of training was that? Please include all kinds of training programs [you/[FIRST
NAME]] participated in the past 12 months.
[IF WEB: Please select all that apply.]
¿Qué tipo de capacitación fue esa? Por favor incluya todos los tipos de programas de
capacitación en el que [usted/[FIRST NAME]] participó en los últimos 12 meses.
[IF WEB: Por favor marque todas las que aplican.]
CODE ALL THAT APPLY
Vocational rehabilitation Rehabilitación vocacional. ..................................... 1
Job search assistance, job finding, orientation to the world of
work Ayuda en búsqueda de trabajo, en encontrar empleo, orientación
al mundo del trabajo .......................................................................................... 2
Vocational education apart from college (business or technical
schools, employer or union-provided training, and military training in
vocational but not military skills). Educación vocacional no
universitaria (escuelas de negocios o técnicas, capacitación
proporcionada por empleador o por gremio, y capacitación militar
vocacional, no en habilidades militares) .......................................................... 3
Non-vocational adult education not directed toward a degree (basic
education, literacy training, english as a second language). Educación
para adultos no vocacional no enfocada en un título (educación básica,
alfabetización, inglés como segundo idioma) ................................................. 4
Other (specify) Otra (especifique) ........................................................................... 99
(STRING 200)
DON’T KNOW ....................................................................................................... D
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What other kind of training was this? ¿Qué otro tipo de capacitación
fue esa?
56
APPENDIX B
MATHEMATICA POLICY RESEARCH
B3=1
[TRAINING PROGRAM IN B4] FILL FULL ANSWER CHOICE FROM B4
PROGRAMMER: REPEAT QUESTION FOR EACH TYPE OF TRAINING RECEIVED IN B4.
B5.
In the past 12 months, how many weeks or months [have you/has he/she] attended
[TRAINING PROGRAM IN B4]?
[PROBE:] Please include any time that [you/he/she] attended the training program during
the past 12 months.
En los últimos 12 meses, ¿por cuántas semanas o meses ha ido [usted/(él/ella)] a
capacitaciones de [TRAINING PROGRAM IN B4]?
[PROBE:] Por favor incluya cualquier ocación en que [usted/él/ella] asistió al programa de
capacitación en los últimos 12 meses.
INTERVIEWER:
| | |.|
(0-99.9)
RECORD NUMBER ON THIS SCREEN, THEN WEEKS OR MONTHS ON
NEXT SCREEN.
| NUMBER
WEB: DISPLAY ON SAME PAGE AFTER B5 IS ANSWERED
B5_per.
Is that weeks or months?
¿Es eso semanas o meses?
WEEKS SEMANAS............................................................................................... 1
MONTHS MESES ................................................................................................. 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: B5>52 and B5_per=1; You indicated that you have received this training for more
than 52 weeks. You can change your answer or proceed to the next question.
Usted indicó que ha recibido esta capacitación por más de 52 semanas. Puede cambiar su
respuesta o continuar a la siguiente pregunta.
SOFT CHECK: B5 >12 and B5_per=2; You indicated that you have received this training for more
than 12 months. You can change your answer or proceed to the next question.
Usted indicó que ha recibido esta capacitación por más de 12 meses. Puede cambiar su
respuesta o continuar a la siguiente pregunta.
57
APPENDIX B
MATHEMATICA POLICY RESEARCH
SECTION C: CURRENT EMPLOYMENT STATUS
ALL
FILL “IF NEEDED READ:” IF CATI
The next questions are about [your/[FIRST NAME]’s] work activities.
Las siguientes preguntas son acerca de actividades laborales [suyas/de [FIRST NAME]].
C1.
In the past 12 months, [have/has] [you/[FIRST NAME]] worked at a job, organization, or
business for pay or profit? This includes work [you/(he/she)] may do for a business that
[you own/(he/she) owns].
[IF NEEDED READ:]
By ‘working at a job for pay or profit’ we mean at a job where [you
get/(he/she) gets] paid money for the work [you do/(he/she) does].
En los últimos 12 meses, ¿ha trabajado [usted/[FIRST NAME]] en un empleo, organización,
o negocio por pago o por ganancias? Esto incluye trabajo que [usted/(él/ella)] pueda hacer
para un negocio del cual [usted/(él/ella)] es dueño(a).
[IF NEEDED READ:]
Cuando decimos ‘trabajando en un empleo por pago o por
ganancias’ queremos decir en un empleo donde le pagan dinero a
[usted/(él/ella)] por el trabajo que [usted/(él/ella)] hace].
[INTERVIEWER: IF R IS SELF-EMPLOYED, CODE RESPONSE AS YES]
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C1=d, r, missing; Please try to provide an answer to this question, or proceed to
the next question.
Por favor trate de dar una respuesta a esta pregunta, o continúe a la siguiente pregunta.
C1=0, D, R, MISSING
C2.
In the past 12 months, [have/has] [you/(he/she)] done any volunteer work for an
organization?
En los últimos 12 meses, ¿ha hecho [usted/(él/ella)] algún trabajo voluntario para una
organización?
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
58
APPENDIX B
MATHEMATICA POLICY RESEARCH
ALL
C3.
In the past 12 months, [have/has] [you/[FIRST NAME]] been looking for paid work, either
full-time or part-time work?
En los últimos 12 meses, ¿ha estado [usted/[FIRST NAME]] buscando trabajo pago, ya sea
a tiempo completo o parcial?
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C3=d, r, missing; Please try to provide an answer to this question, or proceed to
the next question.
Por favor trate de dar una respuesta a esta pregunta, o continúe a la siguiente pregunta.
IF C1=0, D, R, MISSING (NOT EMPLOYED), SKIP TO
SECTION D
59
APPENDIX B
MATHEMATICA POLICY RESEARCH
C1=1
FILL “do” IF SELF-RESPONSE; FILL “does” IF PROXY
FILL “own” IF SELF-RESPONSE; FILL “owns” IF PROXY
C4.
NBS
Modified
Now please think about all the jobs [you have/[FIRST NAME] has] had in the past 12
months. When answering these questions, please include both part-time and full-time
jobs, but only include jobs [you/(he/she)] worked at for pay or profit. This could be work
[you/(he/she)] [do/does] for a business that [you/(he/she)] [own/owns].
How many jobs for pay or profit [have/has] [you/(he/she)] had in the past 12 months?
[PROBE:] Please include any job that [you/(he/she)] worked at in the past 12 months for a
week or more. Count a job that [you/(he/she)] started, stopped and started
again as separate jobs.
Ahora por favor piense en todos los trabajos que [usted/[FIRST NAME]] ha tenido en los
últimos 12 meses. Al contestar estas preguntas, por favor incluya trabajos a tiempo
parcial y tiempo completo, pero sólo incluya empleos en los que [usted/(él/ella)] trabajó
por pago o ganancias. Esto podría ser trabajo que [usted/(él/ella)] hace para un negocio
del que [usted/(él/ella)] es dueñ(o/a).
¿Cuántos trabajos por pago o ganancias ha tenido [usted/(él/ella)] en los últimos 12
meses?
[PROBE:] Por favor incluya cualquier empleo en el que [usted/(él/ella)] trabajó por una
semana o más en los últimos 12 meses. Cuente trabajos que [usted/(él/ella)]
empezó, dejó y volvió a empezar como distintos trabajos.
|
|
| NUMBER OF JOBS
(1-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
FILL NUMBER OF JOBS FROM C4
SOFT CHECK: IF C4>20; You indicated that you have had [fill number of jobs from C4] in the
past 12 months. You can change your answer or proceed to the next question. Usted indicó que
ha tenido [fill number of jobs from C4] en los últimos 12 meses. Puede cambiar su respuesta o
continuar a la siguiente pregunta.
C1=1
C5.
[Are you/Is (he/she)] currently working at a job for pay or profit?
¿Está [usted/(él/ella)] trabajando actualmente en un empleo por pago o por ganancias?
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
60
APPENDIX B
MATHEMATICA POLICY RESEARCH
SOFT CHECK: IF C5=d, r, missing; Please try to provide an answer to this question, or proceed to
the next question.
Por favor trate de dar una respuesta a esta pregunta, o continúe a la siguiente pregunta.
C1=1
IF C5=1 and C4=1, FILL “current”; IF C5=1 AND C4>1, FILL “main”; IF C5=0, FILL “last”
IF C5=1 AND C4>1, FILL “[[Your/(His/Her)] main job is the job where [you/(he/she)] [work/works]
the most hours.”
IF C5=1, FILL “is”; IF C5=0, FILL “was”
IF C5=1, FILL “do”; IF C5=0, FILL “did”
IF C5=1, FILL “work”; IF C5=0, FILL “worked”
IF C5=1, FILL “actual.” IF C5=1 AND C4>1, FILL “principal” AND “, IF C5=0, FILL “último”
IF C4>1, FILL “Su trabajo principal es el empleo en donde trabaja más horas.”
IF C5=1, FILL “es”. IF C5=0, FILL “era”
IF C5=1, FILL “hacen”. IF C5=0, FILL “hicieron”
IF C5=1, FILL “trabaja”. IF C5=0, FILL “trabajó”
C6.
CPS/MTO
Modified
The next questions are about [your/(his/her)] [current/main/last] job. [[Your/(His/Her)] main
job is the job where [you/(he/she)] [work/works] the most hours.] What kind of business or
industry [is/was] this? That is, what [do/did] they make or do where [you/(he/she)]
[work/worked]?
Las siguientes preguntas son acerca del trabajo [actual/principal/último] [suyo/de (él/ella)].
[Su trabajo principal es el empleo en donde [usted/(él/ella)] trabaja más horas.] ¿Qué tipo
de negocio o industria [es/era] esta? Es decir, ¿qué [hacen/hicieron] donde [usted/(él/ella)]
[trabaja/trabajó]?
RECORD VERBATIM
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C6=d, r, missing; Please try to provide an answer to this question, or proceed to
the next question.
Por favor trate de dar una respuesta a esta pregunta, o continúe a la siguiente pregunta.
61
APPENDIX B
MATHEMATICA POLICY RESEARCH
C1=1
IF C5=1 AND SELF RESPONSE, FILL “do”; IF C5=1 AND PROXY, FILL “does”; IF C5=0, FILL “did”
IF C5=1, FILL “hace”. IF C5=0, FILL “hizo”
IF C5=1, FILL “es”. IF C5=0, FILL “era”
FILL “PROBE:” IF CATI
Language in probe is conditional on gender or respondent. Males should have “programador,
mecanógrafo, cajero. Females should have programadora, mecanógrafa, cajera
C7.
CPS/MTO
Modified
What kind of work [do/does/did] [you/(he/she)] do? That is, what [is/was] [your/(his/her)]
occupation? For example, programmer, janitor, cashier.
RECORD VERBATIM
[PROBE:] Different kinds of work can include duties such as: typing, keeping account
books, filing, selling cars, operating printing press, or laying brick.
¿Qué tipo de trabajo [hace/hizo] [usted/(él/ella)]? Es decir, ¿cuál [es/era] su ocupación?
Por ejemplo, programador(a), mecanograf(o/a), cajer(o/a).
RECORD VERBATIM
[PROBE:] Diferentes tipos de trabajo pueden incluir tareas como mecanografía, llevar
libros contables, archivar, vender autos, operar una impresora, o colocar
ladrillos.
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C7=d, r, missing; Please try to provide an answer to this question, or proceed to
the next question.
Por favor trate de dar una respuesta a esta pregunta, o continúe a la siguiente pregunta.
C1=1
FILL “Were” IF SELF RESPONSE AND C5=0; FILL “Are” IF SELF RESPONSE AND C5=1; FILL
“Was” IF PROXY AND C5=0; FILL “Is” IF PROXY AND C5=1.
FILL “work” IF SELF RESPONSE AND C5=1; FILL “works" IF PROXY AND C5=1; FILL “worked” IF
C5=0
FILL “own” IF SELF RESPONSE AND C5=1; FILL “owns" IF PROXY AND C5=1; FILL “owned” IF
C5=0
FILL “fue” IF C5=0; FILL “es” IF C5=1
TRABAJADOR(A) IS GENDER SPECIFIC. IF MALE RESPONDENT THEN SAY TRABAJADOR. IF
FEMALE THEN SAY TRABAJADORA.
IF C5=1, FILL “trabaja”. IF C5=0, FILL “trabajó”
FILL “si” IF PROXY; FILL “uste” IF SELF RESPONSE
FILL “misma” IF PROXY; FILL “mismo” IF SELF RESPONSE
FILL “PROBE:” IF CATI
62
APPENDIX B
C8.
MATHEMATICA POLICY RESEARCH
[Are/Were/Is/Was] [you/(he/she)] self-employed at this job?
[PROBE:] Self-employed means that [you/(he/she)] [work/worked/works] for
[you/(him/her)]self or [own/owned/owns] [your(his/her)] own business.
NBS
¿[Es/fue] [usted/(él/ella)] trabajador(a) por cuenta propia en este trabajo?
[PROBE:] Trabajador por cuenta propia quiere decir que [usted/(él/ella)] [trabaja/trabajó]
para [usted/si] [mismo/misma] o [es/fue] dueño(a) de su propio negocio.
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C8=d, r, missing; Please try to provide an answer to this question, or proceed to
the next question.
Por favor trate de dar una respuesta a esta pregunta, o continúe a la siguiente pregunta.
C1=1
FILL [PROBE:] IF CATI
C9.
New
[Is/Was] this job a temporary or seasonal job?
[PROBE:] A Temporary job is one in which a person is hired to meet the short-term
and/or project needs of an employer. Temporary help has come to be used
across a broad range of skills and occupations to substitute for employees on
leave, on vacation, or in emergencies, or to provide supplemental support
where there are temporary skills shortages or specific projects or peak load
needs.
[PROBE:] A seasonal job is one in which a person is hired to support existing staff
during a busy season—such as holiday help or summer work.
¿[Es/fue] este un trabajo temporal o estacional?
[PROBE:] Un trabajo temporal es uno en el que una persona es contratada para
satisfacer las necesidades a corto plazo y/o de proyecto de un empleador. La
ayuda temporal ha llegado a ser utilizada en una amplia gama de habilidades y
ocupaciones para sustituir a empleados con licencias, de vacaciones, o
durante emergencias, o para proporcionar apoyo suplementario cuando hay
escasez temporal de habilidades o proyectos específicos o necesidades de
carga máxima.
[PROBE:] Un trabajo estacional es uno en el que una persona es contratada para apoyar
personal existente durante una época ocupada – como ayuda durante las
fiestas o trabajo de verano.
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
63
APPENDIX B
MATHEMATICA POLICY RESEARCH
C1=1
IF C5=1 AND SELF RESPONSE, FILL “do”; IF C5=1 AND PROXY, FILL “does”; IF C5=0, FILL “did”
IF C5=1, FILL “trabaja”. IF C5=0, FILL “trabajó”
C10.
How many hours per week [do/did/does] [you(he/she)] typically work at this job?
¿Cuántas horas por semana [trabaja/trabajó] [usted/(él/ella)] típicamente en este trabajo?
| | |
(0-99)
HOURS PER WEEK/ HORAS POR SEMANA
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C10>40; You indicated that you worked more than 40 hours a week at this
job. You can change your answer or proceed to the next question. Usted indicó que trabajó
más de 40 horas por semana en este trabajo. Puede cambiar su respuesta o continuar a la
siguiente pregunta.
C1=1
IF C5=1 AND SELF RESPONSE, FILL “do”; IF C5=1 AND PROXY, FILL “does”; IF C5=0, FILL “did”
IF C5=1, FILL “gana”. IF C5=0, FILL “ganó”
FILL “PROBE:” IF CATI
C11.
How much [do/does/did] [you/(he/she)] typically earn, before taxes or other deductions, on
this job? Please include tips and bonuses.
[PROBE:] Your best estimate is fine.
¿Cuánto [gana/ganó] [usted/(él/ella)] típicamente antes de impuestos u otras deducciones,
en este trabajo? Por favor incluya propinas y bonos.
[PROBE:] Su mejor estimación está bien.
$|
|
| |,| | |
($0-999,999.99)
|.|
|
|
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF C11=d, r, missing; Please try to provide an answer to this question, or proceed
to the next question.
Por favor trate de dar una respuesta a esta pregunta, o continúe a la siguiente pregunta.
64
APPENDIX B
MATHEMATICA POLICY RESEARCH
C1=1
FILL “were” IF SELF RESPONSE AND C5=0; FILL “are” IF SELF RESPONSE AND C5=1; FILL “was”
IF PROXY AND C5=0; FILL “is” IF PROXY AND C5=1.
IF C5=1, FILL “pagan”. IF C5=0, FILL “pagaron”
FILL “fue” IF C5=0; FILL “es” IF C5=1
FILL RESPONSE FROM C11
C12.
[Is/Was] that hourly, daily, weekly, bi-weekly, twice a month, monthly, or annually?
¿[Es/fue] eso por hora, día, semana, quincenal, dos veces por mes, mensualmente, o
anualmente?
[PROBE:] Your response from the previous question is [FILL C11].
Su respuesta a la pregunta anterior es [FILL C11].
CODE ONE ONLY
HOURLY HORA .................................................................................................... 1
DAILY DIA ............................................................................................................. 2
WEEKLY SEMANA ............................................................................................... 3
BI-WEEKLY QUINCENAL..................................................................................... 4
TWICE A MONTH DOS VECES POR MES ......................................................... 5
MONTHLY MENSUALMENT ................................................................................ 6
ANNUALLY ANUALMENT .................................................................................... 7
OTHER (SPECIFY) ............................................................................................... 8
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
FILL C11 RESPONSE. IF C12=1, FILL “HOURLY”, IF C12=2, FILL “DAILY”.
SOFT CHECK: IF C11>$1000 and C12=1 or 2; You answered [FILL C11 RESPONSE]
[hourly/daily]. You can change your answer or proceed to the next question. Usted contestó
[FILL C11 RESPONSE] por [hora/día]. Puede cambiar su respuesta o continuar a la siguiente
pregunta.
65
APPENDIX B
MATHEMATICA POLICY RESEARCH
C1=1
IF C5=1, FILL “current”; IF C5=1 AND C4>1, FILL “main”; IF C5=0, FILL “last”
IF C5=1, FILL “offers”; IF C5=0 FILL “offered”
IF C5=1, FILL “Does”; IF C5=0 FILL “Did”
IF SELF RESPONSE, FILL “are”; IF PROXY, FILL “is”
IF IF SELF RESPONSE AND C5=1, FILL “are”; IF PROXY AND C5=1, FILL “is”; IF SELF RESPONSE
AND C5=0, FILL “were”; IF PROXY AND C5=0, FILL “was”
IF C5=1, FILL “actual.” IF C5=1 AND C4>1, FILL “principal” AND “, IF C5=0, FILL “último”
IF C5=1, FILL ofrece, if C5=0, FILL ofrecía
C13.
NBS
Modified
Here are benefits some employers offer their employees. Please indicate if [your/(his/her)]
[current/main/last] employer [offers/offered] [you(him/her)] any of these benefits.
Please answer ‘yes’ if [you/(he/she)] [were/was] eligible for the benefit even if
[you/(he/she)] did not receive it.
[Did/Does] [your/(his/her)] employer offer [you/(him/her)] …
Los siguientes son beneficios que algunos empleadores ofrecen a sus empleados. Por
favor dígame si el empleador [principal/actual/último] [suyo/de (él/ella)] le [ofrece/ofrecía]
a [usted/(él/ella)] alguno de estos beneficios.
Por favor responda ‘sí’ si [usted/(él/ella] [es/era] elegible para el beneficio incluso si
[usted/(él/ella] aún no lo recibió.
¿Le [ofrece/ofrecía] su empleador a [usted/(él/ella)]…
CODE ONE PER ROW
YES
NO
DON’T
KNOW
REFUSED
a. Health care insurance? (Such as medical and/or
hospital)
Seguro de cuidado de salud? (como médico y/o de
hospital)
1
0
d
r
b. Dental benefits?
Beneficios dentales?
1
0
d
r
c. Sick days with pay?
Días libres por enfermedad pagos?
1
0
d
r
d. Paid vacation?
Vacaciones pagas?
1
0
d
r
e. Free or low-cost childcare?
Cuidado de niños gratis o de bajo costo?
1
0
d
r
1
0
d
r
g. Long-term disability benefits?
Beneficios por incapacidad a largo plazo?
1
0
d
r
h. Pension or retirement benefits?
Beneficios de pensión o jubilación?
1
0
d
r
f.
Transportation, a transportation allowance, or
transportation discounts?
Transporte, un subsidio de transporte, o descuentos
para transporte?
66
APPENDIX B
MATHEMATICA POLICY RESEARCH
CODE ONE PER ROW
YES
NO
DON’T
KNOW
REFUSED
i.
Short-term disability benefits?
Beneficios por incapacidad a corto plazo?
1
0
d
r
j.
Flexible health or dependent care spending accounts?
Cuentas flexibles para gastos de salud o
dependientes?
1
0
d
r
C1=1
IF C5=1, FILL “current”; IF C5=1 AND C4>1, FILL “main”; IF C5=0, FILL “last”
IF C5=1, FILL “Has”; IF C5=0, FILL “Did”
IF C5=1, FILL “made”; IF C5=0, FILL “make”
IF SELF RESPONSE AND C5=1, FILL “have”; IF PROXY AND C5=1, FILL “has”; IF C5=0, FILL “had”
IF C5=1, FILL “Ha hecho” IF C5=0, FILL “Hizo”
IF C5=1, FILL “actual.” IF C5=1 AND C4>1, FILL “principal” AND “, IF C5=0, FILL “último”
IF C5=1, FILL “debe” IF C5=0, FILL “debía”
C14.
[Has/Did] [your/[FIRST NAME]’s] [main/current/last] employer [made/make] any
accommodations because of [your/(his/her)] physical or mental condition. For example,
provided [you/(him/her)] with any special equipment or assistive technology or kept
[your/(his/her)] job available to [you/(him/her)], even though [you/(he/she)] [have/has/had]
to go out on disability from time to time.
¿[Ha hecho/Hizo] algún arreglo el [principal/actual/último] empleador [suyo/de [FIRST
NAME]] debido a alguna condición física o mental [suya/ de (él/ella)]? Por ejemplo,
proporcionarle a [usted/(él/ella)] algún equipo especial o tecnología asistida o mantener el
trabajo disponible para [usted/ (él/ella)], a pesar de que [usted/ (él/ella)] [debe/debía/debió]
salir por incapacidad de vez en cuando.
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
67
APPENDIX B
MATHEMATICA POLICY RESEARCH
C1=1
were IF SELF RESPONSE and IF C5=0; are IF SELF RESPONSE and IF C5=1; was IF SELF
RESPONSE and IF C5=0
IF C5=1, FILL “current”; IF C5=1 AND C4>1, FILL “main”; IF C5=0, FILL “last”
IF SELF RESPONSE, FILL “have”; IF PROXY, FILL “has”
IF C5=1, FILL “actual.” IF C5=1 AND C4>1, FILL “principal” AND “, IF C5=0, FILL “último”
IF SELF RESPONSE, FILL “su [principal/actual/último] trabajo”; IF PROXY, FILL “el
[principal/actual/último trabajo] de (él/ella)”
FILL está IF SELF RESPONSE and IF C5=0; FILL estaba IF SELF RESPONSE and IF C5=1
C15.
Taking all things into account, how satisfied [are/is/were/was] [you/[FIRST NAME]] with
[your/(his/her)] [main/current/last] job? (CATI ONLY: Would you say [you/(he/she)]
[are/is/were/was]:)
Tomando todo en consideración, ¿qué tan satisfecho(a) [está/estaba] [usted/[FIRST
NAME]] con [su [principal/actual/último] trabajo/el [principal/actual/último trabajo] de
(él/ella)]? (CATI ONLY:¿Diría que [usted/(él/ella)] [está/estaba]:)
CODE ONE ONLY
Very satisfied Muy satisfecho(a) ....................................................................... 1
Somewhat satisfied Algo satisfecho(a) ............................................................ 2
Not very satisfiedNo muy satisfecho(a)............................................................ 3
Not at all satisfied Para nada satisfecho(a) ...................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
68
APPENDIX B
MATHEMATICA POLICY RESEARCH
C5=1 (CURRENTLY WORKING)
CATI: DISPLAY ONE ROW PER SCREEN
WEB: DISPLAY GRID
C16.
The next questions are about any expenses [you/[FIRST NAME]] may have had for
services or other support related to [your/(his/her)] condition that [you need/(he/she)
needs] in order to work.
In the past month, did [you/[FIRST NAME]] have any of the following expenses related to
[your/(his/her)] condition that help [you/(him/her)] to work?
[PROBE:] Please think about any expenses [you/[FIRST NAME]] paid out of pocket.
Las siguientes preguntas son sobre cualquier gasto que [usted / [FIRST NAME]] haya
tenido para servicios u otro apoyo relacionado con su condición que [usted / (él / ella)]
necesita para poder trabajar.
En el último mes, ¿tuvo [usted / [FIRST NAME]] alguno de los siguientes gastos
relacionados con su condición que le ayuda a [usted/(él /ella)] a trabajar?
[PROBE:] Por favor piense en cualquier gasto que [usted / [FIRST NAME]] haya pagado de
su bolsillo.
CODE ONE PER ROW
YES
NO
DK
R
a. Transportation costs, such as vehicle modifications or
paratransit Costos de transporte, como modificaciones
de vehículos o paratránsito
1
0
d
r
b. Attendant care costs, such as services performed to help
prepare for work Costos de cuidado de asistente, como
servicios realizados para ayudar a prepararse para el
trabajo
1
0
d
r
c. Medical exam or prescription drug costs Costos de
exámenes medicos o medicamentos recetados
1
0
d
r
d. Physical device costs, such as wheelchairs, dialysis
equipment, or pacemakers Costos de dispositivo físico,
como sillas de ruedas, equipos de diálisis o
marcapasos
1
0
d
r
e. Residential modification costs, such as exterior ramps,
railings, pathways, or enlarging a doorway doorway
Costos de modificación residencial, como rampas
exteriores, barandas, senderos o ampliación de una
puerta
1
0
d
r
f. Other costs Otros costos
1
0
d
r
IF C16A, C16B, C16C, C16D, C16E, OR C16F = 1
REPEAT FOR EACH YES AT C16
69
APPENDIX B
C17.
MATHEMATICA POLICY RESEARCH
In the past month, how much did [you/[FIRST NAME]] spend on expenses for
[FILL SERVICE FROM C16]?
En el ultimo mes, ¿cuánto gastó [usted/[FIRST NAME]] en gastos para [FILL SERVICE
FROM C16]?
$|
|,| | | |.|
(0-9,999.99)
|
| AMOUNT MONTO
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
GO TO C17 FOR NEXT EXPENSE OR D1 IF NO OTHER EXPENSES
IF CANNOT PROVIDE AN AMOUNT AT C17, ASK FOR EACH
C18.
Was it …¿Fue …
Less than $100? Menos de $100? ..................................................................... 1
Between $100 and $199? Entre $100 y $199? .................................................. 2
Between $200 and $299? Entre $200 y $299?...........................................3
$300 or more? $300 o más?.......................................................................4
Don’t know No sabe ............................................................................................ d
REFUSED……………………………………………………………………………….r
70
APPENDIX B
MATHEMATICA POLICY RESEARCH
SECTION D: UNDERSTANDING AND ATTITUDES TOWARDS WORK AND WORK
INCENTIVES
ALL
IF C1=0, FILL “GETTING A JOB,” “obtener un trabajo,” ELSE DO NOT FILL
IF SELF RESPONSE, FILL “sus objetivos personales”; IF PROXY, FILL “los objetivos personales
de (él/ella)”
D1.
Do [your/(his/her)] personal goals include [getting a job,] moving up in a job or learning
new job skills?
¿Incluyen [sus objetivos personales/los objetivos personales de (él/ella)] [obtener un
trabajo,] avanzar en un trabajo o aprender nuevas habilidades laborales?
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ...................................................................................................... d
REFUSED ............................................................................................................. r
ALL
IF C1=0, FILL “SOMEDAY WORKING AND” “trabajar algún día y” ELSE DO NOT FILL
IF SELF RESPONSE, FILL “sus objetivos personales”; IF PROXY, FILL “los objetivos personales
de (él/ella)”
D2.
Do [your/(his/her)] personal goals include [someday working and] earning enough to stop
receiving Social Security disability benefits?
¿Incluyen [sus objetivos personales/los objetivos personales de (él/ella)] [trabajar algún
día y] ganar lo suficiente para dejar de recibir beneficios del Seguro Social por
Incapacidad?
YES SÍ ................................................................................................................... 1
NO ......................................................................................................................... 0
NOT CURRENTLY RECEIVING SSDI BENEFITS NO RECIBE
BENEFICIOS SSDI EN ESTE MOMENTO........................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
AWARENESS OF FEATURES OF POD PROGRAM
RANDOM ASSIGNMENT = 1 OR 2 (OR SAMPGROUP = T)
D3.
Before today, had [you/(he/she)] ever heard of the Promoting Opportunity Demonstration,
or the POD program?
Antes de hoy, ¿alguna vez había oído hablar [usted/(él/ella)] de la Demostración
Promoviendo Oportunidades, o del programa POD?
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
71
APPENDIX B
MATHEMATICA POLICY RESEARCH
ALL
IF TREATMENT, FILL “This refers to the rules SSA uses for those enrolled in POD.” IF
CONTROL, FILL “This refers to the current Social Security Disability Insurance (SSDI) rules.”
IF TREATMENT, FILL “POD”. IF CONTROL FILL, “CURRENT SSDI RULES” “reglas actuales de
SSDI”
IF TREATMENT, FILL “Esto se refiere a las reglas que usa SSA para aquellos registrados en
POD.” IF CONTROL, FILL “Esto se refiere a las reglas actuales del Seguro Social por
Incapacidad (SSDI, por sus siglas en inglés).”
IF SELF RESPONSE, FILL “sus beneficios”; IF PROXY, FILL “los beneficios de (él/ella)”
IF SELF RESPONSE, FILL “sus ingresos”; IF PROXY, FILL “los ingresos de (él/ella)”
WEB: DISPLAY “DON’T KNOW” ANSWER
D4.
The next questions are about [your/(his/her)] understanding of the rules SSA uses to
calculate [your/(his/her)] benefit check.
[This refers to the rules SSA uses for those enrolled in POD./This refers to the current
Social Security Disability Insurance (SSDI) rules.]
Under [POD/Current SSDI rules], [do/does] [you/(he/she)] have a Trial Work Period where
[your/(his/her)] benefits remain unchanged regardless of [your/(his/her)] earnings?
Las siguientes preguntas son acerca de [su comprensión/la comprensión de (él/ella)] de
las reglas que usa SSA para calcular su cheque de beneficios.
[Esto se refiere a las reglas que usa SSA para aquellos registrados en POD. Esto se refiere
a las reglas actuales del Seguro Social por Incapacidad (SSDI, por sus siglas en inglés).]
Bajo [POD/reglas actuales de SSDI], ¿tiene [usted/(él/ella)] un Período de Prueba Laboral
cuando [sus beneficios/los beneficios de (él/ella)] permanecen sin cambios sin importar
[sus ingresos/los ingresos de (él/ella)]?
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW NO SABE ..................................................................................... d
REFUSED ............................................................................................................. r
72
APPENDIX B
MATHEMATICA POLICY RESEARCH
RANDOM ASSIGNMENT = 3 (OR SAMPGROUP = C)
IF CATI FILL “PROBE:”
IF SELF RESPONSE, FILL “sus beneficios”; IF PROXY, FILL “los beneficios de (él/ella)”
WEB: DISPLAY “DON’T KNOW” ANSWER
D5.
Under current SSDI rules, are [your/(his/her)] benefits reduced at any time if
[your/(his/her)] earnings are above SSA’s definition of substantial gainful activity (SGA)?
[PROBE:] The SGA amount is about $1,200 a month for a person who is not blind or
$2,000 a month for a person who is blind.
Bajo las reglas actuales de SSDI, ¿disminuyen en algún momento [sus beneficios/ los
beneficios de (él/ella)] si [sus ingresos/los ingresos de (él/ella)] están por encima de la
definición de SSA de actividad lucrativa sustancial (SGA, por sus siglas en inglés)?
[PROBE:] El monto mensual de SGA para una persona que no es ciega es unos $1,200, o
$2,000 al mes para una persona ciega.
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW NO SABE ..................................................................................... d
REFUSED ............................................................................................................. r
RANDOM ASSIGNMENT = 1 OR 2 (OR SAMPGROUP = T)
IF SELF RESPONSE, FILL “sus beneficios”; IF PROXY, FILL “los beneficios de (él/ella)”
D6.
Under POD, are [your/(his/her)] benefits reduced at any time if [your/(his/her)] monthly
earnings are above a level that SSA set for POD??
[PROBE:] The monthly earnings level that SSA set for POD is the higher of the following:
(1) $850 in 2018 called the POD earnings threshold, or (2) your total monthly
itemized Impairment-Related Work Expenses (IRWEs) if that amount is greater
than $850.
Bajo las reglas de POD, ¿disminuyen en algún momento [sus beneficios/ los beneficios
de (él/ella)] si [sus ingresos/los ingresos de (él/ella)] están por encima del nivel que hace
SSA por POD?
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
Don’t know No sabe .............................................................................................. d
REFUSED ............................................................................................................. r
73
APPENDIX B
MATHEMATICA POLICY RESEARCH
ALL
IF TREATMENT, FILL “the POD rules that apply to you”; IF CONTROL FILL, “current SSDI rules”
IF TREATMENT, FILL “las reglas de POD que aplican a usted” IF CONTROL, FILL “las reglas
actuales de SSDI”
IF SELF RESPONSE, FILL “sus beneficios”; IF PROXY, FILL “los beneficios de (él/ella)”
IF SELF RESPONSE, FILL “sus ingresos”; IF PROXY, FILL “los ingresos de (él/ella)”
D7.
Under [the POD rules / current SSDI rules], do [your/(his/her)] benefits ever terminate if
[your/(his/her)] earnings are too high?
Bajo [las reglas de POD /las reglas actuales de SSDI], ¿alguna vez terminan [sus
beneficios/los beneficios de (él/ella)] si [sus ingresos/los ingresos de (él/ella)] son muy
altos?
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW NO SABE ..................................................................................... d
REFUSED ............................................................................................................. r
RANDOM ASSIGNMENT = 1 OR 2 (OR SAMPGROUP = T)
D8.
How satisfied [are/is] [you/(he/she)] with the POD offset and rules? (CATI ONLY: Are
you…)
¿Qué tan satisfecho(a) está [usted/(él/ella)] con las compensaciones y reglas de POD?
(CATI ONLY: ¿Está usted…)
Very satisfied Muy satisfecho(a)…………………………………………….
1
Somewhat satisfied Algo satisfecho(a) ............................................................ 2
Not very satisfiedNo muy satisfecho(a)............................................................ 3
Not at all satisfied Para nada satisfecho(a) ...................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
RANDOM ASSIGNMENT = 1 OR 2 (OR SAMPGROUP = T)
D9.
How satisfied [are/is] [you/(he/she)] with the POD services [you have/(he/she) has]
received? For example, benefits counseling. (CATI ONLY: [Are/Is] [you/(he/she)]…)
¿Qué tan satisfecho(a) está [usted/(él/ella)] con los servicios que ha recibido de POD? Por
ejemplo, el asesoramiento de beneficios. (CATI ONLY:¿Está [usted/(él/ella)]…)
Very satisfied Muy satisfecho(a) ....................................................................... 1
Somewhat satisfied Algo satisfecho(a) ............................................................ 2
Not very satisfied No muy satisfecho(a)........................................................... 3
Not at all satisfied Para nada satisfecho(a) ...................................................... 4
Haven’t received any POD services No ha recibido ningún servicio
POD....................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
74
APPENDIX B
MATHEMATICA POLICY RESEARCH
T1 OR T2 AND WITHDREW FROM OFFSET
D10.
I understand that [you/[FIRST NAME]] no longer use(s) the POD benefit offset. Why did
[you/[FIRST NAME]] choose to withdraw from POD?
Entiendo que [usted/[FIRST NAME]] ya no usa el beneficio de compensación POD. ¿Por
qué eligió [usted/[FIRST NAME]] salir de POD?
Benefits went down with POD Los beneficios disminuyeron con POD ........ 1
New POD rules were confusing Las nuevas reglas POD eran confusas ...... 2
Benefit payment issue Problemas con pago de beneficios ........................... 3
Didn’t like benefit counseling services No le gustaron los servicios de
consejería ............................................................................................................ 4
Reporting earnings too often Reporte de ganancias muy seguido ............... 5
Other (specify) Otro (especifique) ..................................................................... 99
___________________________________________________ (string 500)
Didn’t withdraw from POD No salió de POD ................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SECTION E: INCOME
ALL
FILL PREVIOUS MONTH, CURRENT YEAR
E_intro.
The following questions are about income that [you/[FIRST NAME]] personally received last
month, that is, in [INSERT LAST MONTH, THIS YEAR]. This includes income and benefits from
different programs. When answering these questions, please include only [your/(his/her)] own
earnings and benefits, and don’t include earnings or benefits that other family members may have
received.
Las siguientes preguntas son acerca de ingreso que [usted/[FIRST NAME]] recibió personalmente
el mes pasado, es decir en [INSERT LAST MONTH, THIS YEAR]. Esto incluye ingreso y beneficios
de diferentes programas. Al contestar estas preguntas, por favor incluya solamente los ingresos y
beneficios [suyos/de (él/ella)], y no incluya ingresos ni beneficios que puedan haber recibido
otros miembros de la familia.
[IF WEB: Please click “Next” button to continue.
Por favor haga clic en el botón “Adelante” para continuar.]
ALL
CATI: DISPLAY ONE ROW PER SCREEN
WEB: DISPLAY GRID
E1.
Last month, did [you/(she/he)] receive any income from…
El mes pasado, ¿recibió [usted/(él/ella)] algún ingreso de…
75
APPENDIX B
MATHEMATICA POLICY RESEARCH
CODE ONE PER ROW
a. Veterans’ benefits?
Beneficios para Veteranos?
b. Public assistance or welfare payments?
Asistencia pública o pagos de asistencia social?
c. Workers’ compensation?
Compensación de trabajadores?
d. Employer-provided or other private disability insurance for
[you/(him/her)]?
Seguro proporcionado por empleador u otro seguro
privado por incapacidad para [usted/(él/ella)]?
e. Unemployment benefits?
Beneficios por desempleo?
f. Private pensions or government employee pensions?
Pensiones privadas o de empleados públicos?
g. Disability insurance for a disabled adult child?
Seguro por incapacidad para un niño adulto
discapacitado?
h. Other sources on a regular basis but not from jobs or
Social Security?
Otras fuentes de forma regular, pero no de trabajos o
del Seguro Social?
________________ (STRING 100)
i. Other sources not on a regular basis? (SPECIFY)
Otras fuentes pero no de forma regular?
(ESPECIFIQUE)
________________ (STRING 100)
YES
NO
DON’T
KNOW
REFUSED
1
0
d
r
1
0
d
r
1
0
d
r
1
0
d
r
1
0
d
r
1
0
d
r
1
0
d
r
1
0
d
r
1
0
d
r
IF OTHER SPECIFY: What other sources of income were received? ¿Qué otras fuentes
de ingreso fueron recibidas?
________________ (STRING 100)
E1A, E1B, E1C, E1D, E1E, E1F, E1G, E1H, OR E1I=1. IF E1J=1, SKIP.
FILL WITH INCOME SOURCE FROM E1 (FOR E1I, FILL VERBATIM RESPONSE)
E2[1] SHOULD CORRELATE TO E1A; E2[2] SHOULD CORRELATE TO E1B , ETC.
E2.
How much income did [you/(she/he)] receive last month from [SOURCE FROM E1]?
¿Cuánto ingreso recibió [usted/(él/ella)] el mes pasado de [SOURCE FROM E1]?
INTERVIEWER:
$|
ROUND TO NEAREST DOLLAR
|,| | | |.|
(0-9,999.99)
|
| AMOUNT MONTO
SKIP TO E4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
76
APPENDIX B
MATHEMATICA POLICY RESEARCH
GO TO E2 FOR NEXT INCOME SOURCE OR E4 IF NO OTHER SOURCES OF INCOME
IF CANNOT PROVIDE AN AMOUNT AT E2, ASK FOR EACH
WEB: DISPLAY IF E2=d, r, missing
E3.
About how much was it…
¿Fue aproximadamente …
Less than $150 Menos de $150 .......................................................................... 1
$150 to less than $300 A menos de $300 ......................................................... 2
$300 to less than $500 A menos de $500 ......................................................... 3
$500 or more $500 o más ................................................................................... 4
Don’t know No sabe ............................................................................................ d
REFUSED ............................................................................................................. r
ALL
IF PROXY: del hogar de él IF SAMPMEMBSEX = MALE; del hogar de ella IF SAMPMEMBSEX =
FEMALE; del hogar de él o ella IF SAMPMEMBSEX = UNKNOW;
su hogar IF SELF RESPONSE
FILL “IF NECESSARY:” IF CATI
E4.
Did [you/(she/he)] or any member of [your/(his/her)] household receive SNAP benefits or
food stamps last month?
[IF NECESSARY:] SNAP stands for the Supplemental Nutrition Assistance Program.
¿Recibió [usted/(él/ella)] u cualquier otro miembro de [su hogar/del hogar de (él/ella)]
beneficios SNAP o estampillas para alimentos el mes pasado?
[IF NECESSARY:] SNAP quiere decir Programa de Asistencia Nutricional Suplementaria.
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
E4=1
E5.
What was the dollar value of the SNAP benefit (Supplemental Nutrition Assistance
Program) or food stamps [you/(she/he)] received last month?
¿Cuál fue el valor en dólares del beneficio SNAP (Programa de Asistencia Nutricional
Suplementaria) o de estampillas de alimentos que recibió [usted/(él/ella)] el mes pasado?
INTERVIEWER: ROUND TO NEAREST DOLLAR
$|
|,| | | |.|
(0-9,999.99)
|
| AMOUNT
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
77
APPENDIX B
MATHEMATICA POLICY RESEARCH
ALL
IF SELF RESPONSE, FILL “Do”; IF PROXY, FILL “Does”
E6.1.
HOPE VI,
MTO E9.
[Do/Does] [you/(she/he)] currently receive any governmental housing assistance in paying
rent, such as through public housing or Section 8 or a Housing Choice Voucher?
¿Recibe [usted/(él/ella)] actualmente algún tipo de asistencia gubernamental para la
vivienda en pagos de alquiler, como por medio de vivienda pública o Sección 8 o un
Cupón de Opción de Vivienda?
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
ALL
E6.
Did [you/(she/he)] or any member of [your/his/her] household receive assistance from any
other government source? For example: energy assistance or child care assistance.
¿Recibió [usted/(él/ella)] o cualquier miembro de su hogar asistencia de alguna otra fuente
gubernamental? Por ejemplo: asistencia con energía o para el cuidado de niños.
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
E6=1
E7.
What type of other assistance did [you/(she/he)] receive?
¿Qué otro tipo de asistencia recibió [usted/(él/ella)]?
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
78
APPENDIX B
MATHEMATICA POLICY RESEARCH
E6=1
FILL “PROBE:” IF CATI
FILL RESPONSE FROM E7
E8.
How much income did [you/(she/he)] receive last month from this other assistance?
INTERVIEWER: INCLUDE INCOME FROM ALL OTHER SOURCES LISTED IN E7
[PROBE:] Other assistance received: [FILL VERBATIM FROM E7]
¿Cuánto ingreso recibió [usted/(él/ella)] el mes pasado de esta otra asistencia?
INTERVIEWER: INCLUDE INCOME FROM ALL OTHER SOURCES LISTED IN E7
[PROBE:] Otra asistencia recibida: [FILL VERBATIM FROM E7]
INTERVIEWER: ROUND TO NEAREST DOLLAR
$|
|
|,| | | |.|
(0-99,999.99 )
|
| AMOUNT
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
FILL “del hogar de [FIRST NAME]” IF PROXY; “de su hogar” , IF SELF RESPONSE
Fill [LAST CALENDAR YEAR]
The next question is about the income of all members in [your/[FIRST NAME]’s] household.
E10.
Effects of
Housing
Choice
Vouchers on
Welfare
Families
What was the total combined income of all members of this household during [LAST
CALENDAR YEAR]? Please include money from jobs, work on the side, welfare, SSDI, help
from [your/(his/her)] family and friends, and any other money income received by
[you/(him/her)] or any other household member.
Your best estimate is fine.
La siguiente pregunta es acerca del ingreso de todos los miembros [de su hogar/del hogar de
[FIRST NAME]].
¿Cuál fue el ingreso total combinado de todos los miembros del hogar durante [LAST
CALENDAR YEAR]? Por favor incluya dinero de trabajos, trabajo extra, asistencia social,
SSDI, ayuda de su familia y amigos, y cualquier otro ingreso monetario recibido por
[usted/(él/ella)] o cualquier otro miembro del hogar.
Su mejor estimación está bien.
$|
|
|
|,| | |
($0-999,999)
| AMOUNT
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
79
APPENDIX B
MATHEMATICA POLICY RESEARCH
SOFT CHECK: IF E10=d, r, missing; Please try to provide an answer to this question, or proceed
to the next question.
Por favor trate de dar una respuesta a esta pregunta, o continúe a la siguiente pregunta.
E10=D
FILL “del hogar de [FIRSTNAME]” IF PROXY; “de su hogar” , IF SELF RESPONSE
FILL [LAST CALENDAR YEAR]
E11.
What was the total combined income of all members of [your/[FIRST NAME]’S] household
during [LAST CALENDAR YEAR]?
¿Cuál fue el ingreso total combinado de todos los miembros [de su hogar/del hogar de
[FIRST NAME]] durante [LAST CALENDAR YEAR]?
CODE ONE ONLY
Less than $10,000 Menos de $10,000................................................................ 1
$10,000 to less than $20,000 $10,000 a menos de $20,000 ............................. 2
$20,000 to less than $30,000 $20,000 a menos de $30,000 ............................. 3
$30,000 to less than $40,000 $30,000 a menos de $40,000 ............................. 4
$40,000 to less than $50,000 $40,000 a menos de $50,000 ............................. 5
$50,000 or more $50,000 o más ......................................................................... 6
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
80
APPENDIX B
MATHEMATICA POLICY RESEARCH
SECTION F: HEALTH AND FUNCTIONAL STATUS
ALL
FILL “de [FIRSTNAME]” IF PROXY; “suya” IF SELF RESPONSE
F_intro.
The next few questions ask about [your/[FIRST NAME]’s] health and how well [you/(he/she)]
[are/is] able to do [your/(his/her)] usual activities.
Las siguientes preguntas son acerca de la salud [suya/ de [FIRST NAME]] y qué tan bien puede
[usted/(él/ella)] hacer sus actividades usuales.
[IF WEB: Please click “Next” button to continue.
Por favor haga clic en el botón “Adelante” para continuar.]
ALL
F1.
In general, how would you rate [your/(his/her)] health?
En general, ¿cómo diría que es [su salud / la salud de (él/ella)]?
CODE ONE ONLY
Excellent Excelente............................................................................................. 1
Very good Muy buena ......................................................................................... 2
Good Buena ......................................................................................................... 3
Fair Regular ......................................................................................................... 4
Poor Mala ............................................................................................................. 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
F2.
Does [your/(his/her)] health now limit [you/(him/her)] in moderate activities such as
moving a table, pushing a vacuum cleaner, bowling, or playing golf?
¿Le limita a [usted/(él/ella)] su salud ahora en actividades moderadas como mover una
mesa, empujar una aspiradora, jugar a los bolos, o jugar al golf?
CODE ONE ONLY
A lot Mucho .......................................................................................................... 1
A little Un poco .................................................................................................... 2
Not at all Para nada ............................................................................................. 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
81
APPENDIX B
MATHEMATICA POLICY RESEARCH
ALL
F3.
Does [your/(his/her)] health now limit [you/(him/her)] in climbing several flights of stairs?
¿Le limita a [usted/(él/ ella)] su salud ahora al subir varios pisos por escaleras?
CODE ONE ONLY
A lot Mucho .......................................................................................................... 1
A little Un poco .................................................................................................... 2
Not at all Para nada ............................................................................................. 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
IF PROXY: la salud física de él IF SAMPMEMBSEX = MALE; la salud física de ella IF
SAMPMEMBSEX = FEMALE;
su salud física IF SELF RESPONSE
F4.
The next two questions ask about [your/[FIRST NAME]’S] physical health and
[your/(his/her)] daily activities. During the past 4 weeks, how much of the time
[have/has] [you/(he/she)]accomplished less than [you/(he/she)] would have liked
to as a result of [your/(his/her)] physical health?
Las siguientes dos preguntas son acerca [su salud física / la salud física de
[FIRST NAME]] y sus actividades diarias. Durante las últimas 4 semanas, ¿por
cuánto tiempo ha [usted/(él/ella)] logrado menos de lo que le hubiera gustado
como resultado de [su salud física/ la salud física de (él/ella)]?
CODE ONE ONLY
All of the time Todo el tiempo ............................................................................ 1
Most of the time La mayor parte del tiempo..................................................... 2
Some of the time Parte del tiempo .................................................................... 3
A little of the time Poco tiempo ......................................................................... 4
None of the time Nunca ...................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
82
APPENDIX B
MATHEMATICA POLICY RESEARCH
ALL
IF PROXY, FILL “was”; IF SELF RESPONSE, FILL “were”
IF PROXY, FILL “does”; IF SELF RESPONSE, FILL “do”
F5.
During the past 4 weeks, how much of the time [were/was] [you/(he/she)] limited in the
kind of work or other regular daily activities [you/(he/she)] [do/does] as a result of
[your/(his/her)] physical health?
Durante las últimas 4 semanas, ¿por cuánto tiempo estuvo [usted/(él/ella)] limitado(a) en
el tipo de trabajo u otras actividades diarias que hace [usted/(él/ella)] como resultado de
su salud física?
CODE ONE ONLY
All of the time Todo el tiempo ............................................................................ 1
Most of the time La mayor parte del tiempo..................................................... 2
Some of the time Parte del tiempo .................................................................... 3
A little of the time Poco tiempo ......................................................................... 4
None of the time Nunca ...................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
F6.
During the past 4 weeks, how much of the time [have/has] [you/(he/she)]
accomplished less than [you/(he/she)] would have liked to as a result of any
emotional problems, such as feeling depressed or anxious?
Durante las últimas 4 semanas, ¿por cuánto tiempo ha logrado [usted/(él/ella)]
menos de lo que le hubiera gustado como resultado de algún problema
emocional, como sentirse deprimido(a) o ansioso(a)?
CODE ONE ONLY
All of the time Todo el tiempo ............................................................................ 1
Most of the time La mayor parte del tiempo..................................................... 2
Some of the time Parte del tiempo .................................................................... 3
A little of the time Poco tiempo ......................................................................... 4
None of the time Nunca ...................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
83
APPENDIX B
MATHEMATICA POLICY RESEARCH
ALL
F7.
During the past 4 weeks, how much of the time did [you/(he/she)] not do work or other
activities as carefully as usual as a result of any emotional problems, such as feeling
depressed or anxious?
Durante las últimas 4 semanas, ¿por cuánto tiempo [usted/(él/ella)] no trabajó ni hizo otras
actividades tan cuidadosamente como de costumbre como resultado de algún problema
emocional, como sentirse deprimido(a) o ansioso(a)?
CODE ONE ONLY
All of the time Todo el tiempo ............................................................................ 1
Most of the time La mayor parte del tiempo..................................................... 2
Some of the time Parte del tiempo .................................................................... 3
A little of the time Poco tiempo ......................................................................... 4
None of the time Nunca ...................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
IF SELF RESPONSE, FILL “su trabajo normal”; IF PROXY, FILL “el trabajo normal de (él/ella)”
F8.
During the past 4 weeks, how much did pain interfere with [your/(his/her)] normal work,
including both work outside the home and housework?
Durante las últimas 4 semanas, ¿cuánto ha interferido el dolor con [su trabajo normal/el
trabajo normal de (él/ella)], incluyendo trabajo fuera de casa y trabajo doméstico?
CODE ONE ONLY
All of the time Todo el tiempo ............................................................................ 1
Most of the time La mayor parte del tiempo..................................................... 2
Some of the time Parte del tiempo .................................................................... 3
A little of the time Poco tiempo ......................................................................... 4
None of the time Nunca ...................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
84
APPENDIX B
MATHEMATICA POLICY RESEARCH
ALL
IF SELF RESPONSE FILL “feel”; IF PROXY FILL “feels”
F9.
These next questions are about how [you/(he/she)] [feel/feels] and how things have
been with [you/(him/her)] during the past 4 weeks. For each question, please provide
an answer that comes closest to the way [you/(he/she)] [have/has] been feeling.
During the past 4 weeks, how much of the time [have/has]
[you/(he/she)] felt calm and peaceful?
Las siguientes preguntas son acerca de cómo se siente [usted/(él/ella)] y cómo han
estado las cosas durante las últimas 4 semanas. Para cada pregunta, por favor
provea la respuesta que más se acerca a cómo se ha estado sintiendo
[usted/(él/ella)].
Durante las últimas 4 semanas, ¿por cuánto tiempo se ha sentido [usted/(él/ella)]
calmado(a) y en paz?
CODE ONE ONLY
All of the time Todo el tiempo ............................................................................ 1
Most of the time La mayor parte del tiempo..................................................... 2
Some of the time Parte del tiempo .................................................................... 3
A little of the time Poco tiempo ......................................................................... 4
None of the time Nunca ...................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
F10.
During the past 4 weeks, how much of the time did [you/(he/she)] have
a lot of energy?
Durante las últimas 4 semanas, ¿por cuánto tiempo ha tenido
[usted/(él/ella)] mucha energía?
CODE ONE ONLY
All of the time Todo el tiempo ............................................................................ 1
Most of the time La mayor parte del tiempo..................................................... 2
Some of the time Parte del tiempo .................................................................... 3
A little of the time Poco tiempo ......................................................................... 4
None of the time Nunca ...................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
85
APPENDIX B
MATHEMATICA POLICY RESEARCH
ALL
F11.
During the past 4 weeks, how much of the time [have/has] [you/(he/she)] felt
downhearted and depressed?
Durante las últimas 4 semanas, ¿cuánto tiempo se ha sentido [usted/(él/ella)]
desanimado(a) y deprimido(a)?
CODE ONE ONLY
All of the time Todo el tiempo ............................................................................ 1
Most of the time La mayor parte del tiempo..................................................... 2
Some of the time Parte del tiempo .................................................................... 3
A little of the time Poco tiempo ......................................................................... 4
None of the time Nunca ...................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL
IF SELF RESPONSE, FILL “su salud física o problemas emocionales con sus actividades
sociales”; IF PROXY, FILL “la salud física o problemas emocionales con las actividades sociales
de (él/ella)”
F12.
During the past 4 weeks, how much of the time has [your/(his/her)]
physical health or emotional problems interfered with [your/(his/her)]
social activities, like visiting with friends or relatives?
Durante las últimas 4 semanas, ¿por cuánto tiempo han interferido [su salud física o
problemas emocionales con sus actividades sociales/la salud física o problemas
emocionales con las actividades sociales de (él/ella)], como visitar a amigos o parientes?
CODE ONE ONLY
All of the time Todo el tiempo ............................................................................ 1
Most of the time La mayor parte del tiempo..................................................... 2
Some of the time Parte del tiempo .................................................................... 3
A little of the time Poco tiempo ......................................................................... 4
None of the time Nunca ...................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
86
APPENDIX B
MATHEMATICA POLICY RESEARCH
ALL
FILL CURRENT MONTH AND LAST YEAR (MONTH, YEAR).
Now think about the past 12 months, that is since [CURRENT MONTH; LAST YEAR].
F13.
During the past 12 months, [have/has] [you/[FIRST NAME]] stayed overnight in a hospital?
Ahora piense en los últimos 12 meses, es decir desde [CURRENT MONTH; LAST YEAR].
Durante los últimos 12 meses, ¿ha [usted/[FIRST NAME]] pasado la noche en un hospital?
HCC
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
87
APPENDIX B
MATHEMATICA POLICY RESEARCH
SECTION G: HEALTH INSURANCE
ALL
The next question is about different types of health insurance coverage [you/[FIRST NAME]] might
have.
La siguiente pregunta es acerca de los diferentes tipos de cobertura de seguro de salud que
[usted/[FIRST NAME]] podría tener.
[IF WEB: Please click “Next” button to continue.
Por favor haga clic en el botón “Next/Siguiente” para continuar.]
ALL
FILL “do” IF SELF-RESPONSE; FILL “does” IF PROXY
FILL “pay” IF SELF-RESPONSE; FILL “pays” IF PROXY
FILL “PROBE” CATI ONLY
FILL “PROBE: “Is this a plan...” CATI ONLY
FILL MEDICAID NAME BY SAMPMEMB STATE:
POD STATE
STATE MEDICAID NAME(S)
Alabama
Alabama Medicaid
California
Medi-Cal
Connecticut
Connecticut Medicaid, CT Medicaid, or HUSKY Health
Maryland
Maryland Medicaid or Maryland Medical Assistance Program
Michigan
Michigan Medicaid or Michigan Department of Health and Human Service
Nebraska
Nebraska Medicaid
Texas
Texas Medicaid or State of Texas Access Reform (STAR+PLUS)
Vermont
Vermont Medicaid or Vermont Health Access Plan (DVHA)
SPANISH:
Alabama
California
Connecticut
Maryland
Michigan
Nebraska
Texas
inglés)
Vermont
Alabama Medicaid
Medi-Cal
Connecticut Medicaid, CT Medicaid, o HUSKY Health
Maryland Medicaid o Maryland Medical Assistance Program
Michigan Medicaid o Departamento de Salud y Servicios Humanos de Michigan
Nebraska Medicaid
Texas Medicaid o State of Texas Access Reform (STAR+PLUS por sus siglas en
Vermont Medicaid o Vermont Health Access Plan (DVHA por sus siglas en inglés)
88
APPENDIX B
G1.
MATHEMATICA POLICY RESEARCH
What kinds of health coverage [do/does] [you/(he/she)] have?
[IF WEB: Please select all that apply.]
[PROBE: Any other kind?]
[PROBE: ] Medicare is health insurance coverage provided nationally to certain disabled
people under age 65, including Social Security Disability Insurance
beneficiaries that have been receiving benefits for more than 24 months.
INTERVIEWER: IF RESPONDENT SAYS “OBAMACARE” “AFFORDABLE CARE ACT” OR
HEALTH INSURANCE NAME LIKE “BLUE CROSS” OR AETNA PROBE:
[PROBE: “Is this a plan [you/(he/she)] [pay/pays] for on [your/(his/her)] own? (IF YES,
CODE AS PRIVATE INSURANCE PAID BY SELF/FAMILY). (IF NO), “Is this
provided through Medicaid?” (IF YES, CODE AS MEDICAID)]
[PROBE:] Medicaid is state medical assistance program that serves low-income people
and Social Security Income recipients with disabilities.
[PROBE: ] TRICARE is a managed health care program for active duty and retired
members of the uniformed services, their families and survivors. CHAMPUS is
a health care program for dependents of active or retired military personnel.
CHAMP-VA is health insurance for dependents or survivors of disabled
veterans
¿Qué tipos de cobertura de salud tiene [usted/(él/ella)]?
[IF WEB: Por favor marque todas las que aplican.]
[PROBE:] ¿Algún otro tipo?
[PROBE: ] Medicare es una cobertura de seguro de salud provista a nivel nacional a cierto
tipo de personas incapacitadas menores de 65, incluyendo a beneficiarios del
Seguro Social por Incapacidad que han estado recibiendo beneficios por más
de 24 meses.
INTERVIEWER: IF RESPONDENT SAYS “OBAMACARE” “AFFORDABLE CARE ACT” OR
HEALTH INSURANCE NAME LIKE “BLUE CROSS” OR AETNA PROBE:
[PROBE: ] ¿Es este un plan que [usted/(él/ella)] paga por [usted/(él/ella)] mismo(a)? (IF
YES, CODE AS PRIVATE INSURANCE PAID BY SELF/FAMILY). (IF NO), ¿Es
provisto por Medicaid? (IF YES, CODE AS MEDICAID)
[PROBE:] Medicaid es un programa de asistencia médica estatal para personas de bajos
ingresos y beneficiarios del Seguro Social con incapacidades.
[PROBE:] TRICARE es un programa administrado de atención médica para miembros
activos y retirados de los servicios uniformados, sus familias y sobrevivientes.
CHAMPUS es un programa de cuidado de salud para dependientes de personal
militar activo o retirado. CHAMP-VA es un seguro de salud para dependientes
o sobrevivientes de veteranos incapacitados.
CODE ALL THAT APPLY
Medicare ............................................................................................................... 1
Medicaid/[State Medicaid Name] ....................................................................... 2
Champus/Champ-Va, Tricare, VA, Other Military Champus/Champ-Va,
Tricare, VA, Otro programa militar .................................................................... 3
Indian Health Service Servicio de Salud Indígena ........................................... 4
State Program Programa estatal ...................................................................... 6
Private Insurance Through Own Employer Seguro privado del
empleador ............................................................................................................ 7
Private Insurance Through Spouse/ Partner/ Parent Seguro privado del
esposo/pareja/padres ......................................................................................... 8
Private Insurance Paid By Self/Family Seguro privado pago por sí
mismo/familia ...................................................................................................... 9
89
APPENDIX B
MATHEMATICA POLICY RESEARCH
Private Disability Insurance Paid By Self/Family Seguro privado por
incapacidad pago por sí mismo/familia ............................................................ 10
Other Plan (Specify) Otro plan ............................................................................ 99
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What other kind of health coverage is that? :¿Qué otro tipo de
cobertura de salud es esa?
90
APPENDIX B
MATHEMATICA POLICY RESEARCH
SECTION H: RESPONDENT CONTACT INFORMATION
H_intro.
This section will confirm some information about [you/[FIRST NAM]E]. This information will
ensure that [your/(his/her)] incentive payment is sent to the correct address.
Esta sección confirmará alguna información acerca de [usted/[FIRST NAME]]. Esta información
asegurará que el pago incentivo [suyo/de (él/ella)] es enviado a la dirección correcta.
[IF WEB: Please click “Next” button to continue.
Por favor haga clic en el botón “Adelante” para continuar.]
ALL
H1.
Is [your/(his/her)] full name [FULLNAME]?
¿Es [su nombre/ el nombre de (él/ella)] [FULLNAME]?
YES, ALL CORRECT SÍ, TODO CORRECTO ..................................................... 1
NO, NAME NOT CORRECT NO, EL NOMBRE NO ES CORRECTO ................. 0
REFUSED ............................................................................................................. r
H1=0
H2.
Could you please spell [your/(his/her)] name?
¿Podría deletrearme [su nombre/el nombre de (él/ella)]?
___________________________________________________ (STRING 50)
FIRST NAME NOMBRE
___________________________________________________ (STRING 50)
MIDDLE INITIAL/NAME INICIAL DEL SEGUNDO NOMBRE
___________________________________________________ (STRING 50)
LAST NAME APELLIDO
___________________________________________________ (STRING 25)
SUFFIX SUFIJO
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
91
APPENDIX B
MATHEMATICA POLICY RESEARCH
ALL
FILL STREET ADDRESS, CITY, STATE, ZIP
H3.
Our records show that [your/(his/her)] current address is [FILL FROM PRELOADS]. Is this
correct?
Nuestros registros muestran que la dirección [suya/de (él/ella)] es (FILL FROM
PRELOADS). ¿Es correcta?
YES, ADDRESS IS CORRECT SÍ, LA DIRECCIÓN ES CORRECTA ................. 1
NO, ADDRESS NOT CORRECT NO, LA DIRECCIÓN NO ES CORRECTA ...... 0
REFUSED ............................................................................................................. r
H3=0
H4.
What is [your/(his/her)] current address?
¿Cuál es la dirección actual [suya/de (él/ella)]?
___________________________________________________ (STRING 100)
STREET 1 CALLE 1
___________________________________________________ (STRING 100)
STREET 2 CALLE 2
___________________________________________________ (STRING 100)
STREET 3 CALLE 3
___________________________________________________ (STRING 100)
CITY CIUDAD
___________________________________________________ (STRING 50)
STATE ESTADO
___________________________________________________ (STRING 50)
ZIP CÓDIGO
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
92
APPENDIX B
MATHEMATICA POLICY RESEARCH
ALL
FILL PHONE NUMBER
H5.
Is this [your/(his/her)] home telephone number?
¿Es este el número de teléfono [suyo/de (él/ella)] en casa?
[AREA CODE/PHONE NUMBER]
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
H5=0
H6.
What is [your/(his/her)] home phone number, starting with area code?
[IF WEB: The phone number should be 10 numeric digits, no spaces, dashes, parentheses
or other punctuation.]
¿Cuál es el número de teléfono [suyo/de (él/ella)] en casa, empezando con el código de
área?
[IF WEB: El número de teléfono debe tener 10 dígitos, sin espacios, guiones, paréntesis u
otros signos de puntuación.]
|
| | |-| | | |-| | | | |
(201-989)
(200-999)
(0000-9999)
NO HOME NUMBER NO TIENE ......................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF OUTSIDE RANGE; This looks like an invalid phone number. Can you provide
the phone number again? Este parece un número de teléfono inválido. ¿Puede darme el
número de nuevo?
ALL
FILL “do” IF SELF-RESPONSE; FILL “does” IF PROXY
H7.
[Do/Does] [you/(he/she)] have a cell phone number?
¿Tiene [usted/(él/ella)] un número de teléfono celular?
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
93
APPENDIX B
MATHEMATICA POLICY RESEARCH
H7=1
H8.
What is [your/(his/her)] cell phone number, starting with area code?
[IF WEB: The phone number should be 10 numeric digits, no spaces, dashes, parentheses
or other punctuation.]
¿Cuál es el número de teléfono celular [suyo/de (él/ella)], empezando con el código de
área?
[IF WEB: El número de teléfono debe tener 10 dígitos, sin espacios, guiones, paréntesis u
otros signos de puntuación.]
|
| | |-| | | |-|
(201-989)
(200-999)
| | | |
(0000-9999)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF OUTSIDE RANGE; This looks like an invalid phone number. Can you provide
the phone number again? Este parece un número de teléfono inválido. ¿Puede darme el
número de nuevo?
Y1 SURVEY AND H8≠NULL
H9.
When we contact [you/(him/her)] for the next survey in about a year, may we send
[you/(him/her)] a text message on [your/(his/her)] cell phone? Depending on
[your/(his/her)] service plan, standard text message rates may apply.
Cuando le contactemos a [usted/(él/ella)] para la próxima encuesta en aproximadamente
un año, ¿podemos enviarle a [usted/(él/ella)] un mensaje de texto a su teléfono celular?
Puede que apliquen cargos por mensaje de texto dependiendo del plan de servicio,
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
IF HAVE EMAIL ADDRESS ON FILE
FILL EMAIL ADDRESS FROM PRELOAD
H10.
[Your/[FIRST NAME]’s] email address is [EMAIL ADDRESS]. Is this still the best email
address to reach [you/(her/him)] at?
Tenemos la dirección de correo electrónico [suya/ de [FIRST NAME]] es [EMAIL
ADDRESS]. ¿Sigue siendo ésta la mejor dirección de correo electrónico para contactarle a
[usted/(él/ella)]?
YES SÍ .................................................................................................................. 1
NO ......................................................................................................................... 0
DON’T KNOW ..................................................................................................... d
REFUSED ............................................................................................................. r
94
APPENDIX B
MATHEMATICA POLICY RESEARCH
IF DO NOT HAVE EMAIL ADDRESS ON FILE OR H10=0 OR D
H11.
What is [your/(his/her)] email address?
¿Cuál es la dirección de correo electrónico [suya/de (él/ella)]?
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
THIS SECTION FOR 12-MONTH FOLLOW UP SURVEY RESPONDENTS ONLY.
24-MONTH SURVEY RESPONDENTS, SKIP TO “END”
ALL 12 MONTH SURVEY RESPONDENTS
H12.
Please think about the name, address, and telephone number of 2 persons who will always
know how to reach [you/[FIRST NAME]]. This will be used when it is time to contact
[you/(him/her)] for the next survey. All information collected will be kept private, and will
only be used if we cannot reach [you/(him/her)].
Please provide the name of someone who lives with [you/[FIRST NAME]] and will always
know how to contact [you/(him/her)].
[IF WEB: The phone number should be 10 numeric digits, no spaces, dashes, parentheses
or other punctuation.]
Por favor piense en el nombre, dirección, y número de teléfono de 2 personas que siempre
sabrán como contactarle a [usted/[FIRST NAME]]. Esto se usará cuando sea el momento
de contactarle a [usted/(él/ella)] para la siguiente encuesta. Toda la información recogida
se mantendrá privada, y solamente será usada si no podemos contactarle a
[usted/(él/ella)].
Por favor provea el nombre de alguien que vive con [usted/[FIRST NAME]] y siempre sabrá
como contactarle a [usted/(él/ella)].
[IF WEB: El número de teléfono debe tener 10 dígitos, sin espacios, guiones, paréntesis u
otros signos de puntuación.]
95
APPENDIX B
MATHEMATICA POLICY RESEARCH
PERSON 1:
PERSONA 1:
FIRST NAME NOMBRE
MIDDLE INITIAL/NAME INICIAL DEL SEGUNDO NOMBRE
LAST NAME APELLIDO
RELATIONSHIP TO RESPONDENT RELACIÓN/PARENTESCO CON ENCUESTADO
ADDRESS 1 DIRECCIÓN 1
ADDRESS 2 DIRECCIÓN 2
CITY CIUDAD
STATE/TERRITORY ESTADO/TERRITORIO
| | | | | |-| | | | |
ZIP CODE (+ 4 IF NEEDED) CÓDIGO POSTAL (+4 DE SER NECESARIO)
| | | |-| | | |-|
TELÉFONO - CASA
(200-999)
(100-999)
| | | |-| | | |-|
DE TELÉFONO - CELULAR
(200-999)
(100-999)
| | | |-| | | |-|
TELÉFONO - OTRO
(200-999)
(100-999)
|
|
|
| PHONE NUMBER - HOME NÚMERO DE
(0000-9999)
|
|
|
| PHONE NUMBER – CELLULAR NÚMERO
(0000-9999)
|
|
|
| PHONE NUMBER – OTHER NÚMERO DE
(0000-9999)
EMAIL CORREO ELECTRÓNICO
LIVES ALONE .......................................................................................... 1
DON’T KNOW .......................................................................................... d
REFUSED ................................................................................................ r
SOFT CHECK: IF OUTSIDE RANGE; This looks like an invalid phone number. Can you provide
the phone number again? Este parece un número de teléfono inválido. ¿Puede darme el
número de nuevo?
96
APPENDIX B
MATHEMATICA POLICY RESEARCH
ALL
H13.
Please provide the name of someone who does not live with [you/[FIRST NAME]] and will
always know how to contact [you/(him/her)].
What is the full name of the second person?
[IF WEB: The phone number should be 10 numeric digits, no spaces, dashes, parentheses
or other punctuation.]
Por favor provea el nombre de alguien que no vive con [usted/[FIRST NAME]] y siempre
sabrá como contactarle a [usted/(él/ella)].
¿Cuál es el nombre completo de la segunda persona?
[IF WEB: El número de teléfono debe tener 10 dígitos, sin espacios, guiones, paréntesis u
otros signos de puntuación.]
FIRST NAME NOMBRE
MIDDLE INITIAL/NAME INICIAL DEL SEGUNDO NOMBRE
LAST NAME APELLIDO
RELATIONSHIP TO RESPONDENT RELACIÓN/PARENTESCO CON ENCUESTADO
ADDRESS 1 DIRECCIÓN 1
ADDRESS 2 DIRECCIÓN 2
CITY CIUDAD
STATE/TERRITORY ESTADO/TERRITORIO
| | | | | |-| | | | |
ZIP CODE (+ 4 IF NEEDED) CÓDIGO POSTAL (+4 DE SER NECESARIO)
| | | |-| | | |-|
TELÉFONO - CASA
(200-999)
(100-999)
| | | |-| | | |-|
DE TELÉFONO - CELULAR
(200-999)
(100-999)
| | | |-| | | |-|
TELÉFONO - OTRO
(200-999)
(100-999)
|
|
|
| PHONE NUMBER - HOME NÚMERO DE
(0000-9999)
|
|
|
| PHONE NUMBER – CELLULAR NÚMERO
(0000-9999)
|
|
|
| PHONE NUMBER – OTHER NÚMERO DE
(0000-9999)
EMAIL CORREO ELECTRÓNICO
DON’T KNOW .......................................................................................... d
REFUSED ................................................................................................ r
97
APPENDIX B
MATHEMATICA POLICY RESEARCH
SOFT CHECK: IF OUTSIDE RANGE; This looks like an invalid phone number. Can you provide
the phone number again? Este parece un número de teléfono inválido. ¿Puede darme el
número de nuevo?
ALL
IF CATI, FILL “20” IF Y1; FILL “25” IF Y2; IF WEB, FILL “30” IF Y1; FILL “35” IF Y2
END.
Thank you very much for your time today. [You/[FIRST NAME]] can expect to receive
[your/his/her] $[20/25/30/35] check within 4 weeks.
IF WEB: Your answers have been submitted. You can safely close your browser.
Muchas gracias por su tiempo hoy. [Usted/[FIRST NAME]] puede esperar recibir su cheque
por $[20/25/30/35] dentro de las próximas 4 semanas.
IF WEB: Sus respuestas han sido enviadas. Puede cerrar su navegador de forma
segura.
98
| File Type | application/pdf |
| File Title | POD Follow up |
| Subject | CATI |
| Author | MATHEMATICA |
| File Modified | 2019-01-09 |
| File Created | 2019-01-09 |