Current POD Year 1 and 2 Follow-up Surveys

OMB Control No.: 0960-XXXX
Expiration Date: XX/XX/20XX

PROMOTING OPPORTUNITY
DEMONSTRATION
12- and 24-Month Follow-up Survey Instrument

June 6, 2017

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.

1

CONTENTS

Section

Page

A.

RESPONDENT SCREENER AND INTRODUCTION .....................................................1

B.

EDUCATION AND TRAINING .......................................................................................3

C.

EMPLOYMENT AND EARNINGS ..................................................................................5

D.

EMPLOYMENT GOALS AND SSDI / POD UNDERSTANDING ................................... 11

E.

INCOME ......................................................................................................................15

F.

HEALTH AND FUNCTIONAL STATUS ........................................................................19

G.

HEALTH INSURANCE .................................................................................................24

H.

RESPONDENT CONTACT INFORMATION ................................................................25

2

APPENDIX B

MATHEMATICA POLICY RESEARCH

SECTION A: RESPONDENT SCREENER AND INTRODUCTION
ALL
A1.
SampMemb

IF CONTROL GROUP: 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 the experiences that people like you
may have, including job experience, job training, school and other things.
The survey takes about 30 minutes to complete. At the end of the interview, we will mail
you a check for $[25] to thank you for your time. You should receive it within 2 weeks.
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

A1=1
A2.

[Your/(His/Her)/Your] participation in this study is completely voluntary. It will in no way
affect [your/(his/her)/BENEFICIARY’s] current or future receipt of benefits.
[You/(He/She)/You] can stop the interview at any time. If any question makes
[you/(him/her)/you] feel uncomfortable, [you/(he/she)/you] 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.
CODE ONE ONLY
CONTINUE ........................................................................................................... 1
CALLBACK ........................................................................................................... 2

Callback

SUPERVISOR REVIEW ....................................................................................... 3

sup rev

REFUSED ............................................................................................................. r

ref

B.3

APPENDIX B

MATHEMATICA POLICY RESEARCH

SECTION B: EDUCATION AND TRAINING

The first few questions are about [your/BENEFICIARY’s] education and training experiences.
RETURN TO WORK ACTIVITIES—EDUCATION AND TRAINING
ALL
B1.

[Are you /Is he/she] currently enrolled in school or taking any classes?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B1=1
B2.

[Are you/is he/she] a full-time or part-time student?
CODE ONE ONLY
FULL-TIME ............................................................................................................ 1
PART-TIME ........................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL
Fill RADATE as Month Day, Year.
B3.

Now I would like to ask you about any [other] training [you/(BENEFICIARY] 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?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.4

APPENDIX B

MATHEMATICA POLICY RESEARCH

B3=1
B4.

What kind of training was that?
CODE ONE ONLY
VOCATIONAL REHABILITATION ....................................................................... 1
JOB SEARCH ASSISTANCE, JOB FINDING, ORIENTATION TO THE
WORLD OF WORK............................................................................................... 2
VOCATIONAL EDUCATION APART FROM COLLEGE (BUSINESS OR
TECHNICAL SCHOOLS, EMPLOYER OR UNION-PROVIDED TRAINING,
AND MILITARY TRAINING IN VOCATIONAL BUT NOT MILITARY SKILLS
OR JTPA) .............................................................................................................. 3
NON-VOCATIONAL ADULT EDUCATION NOT DIRECTED TOWARD A
DEGREE (BASIC EDUCATION, LITERACY TRAINING, ENGLISH AS A
SECOND LANGUAGE)......................................................................................... 4
OTHER (SPECIFY) ............................................................................................... 99
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

IF OTHER SPECIFY (99): What other kind of training was this?

B3=1
B5.

In the past 12 months, how many months [have you/has he/she] gone to [TRAINING
PROGRAM IN B4]?
PROBE:

Over the course of the year, during how many weeks did you attend at least
some training?

PROBE:

If you did not go for a full month, can you tell me how many weeks you went to
a training?

INTERVIEWER:
| | |.|
(0-99.9)

B5_per.

RECORD NUMBER ON THIS SCREEN, THEN WEEKS OR MONTHS ON
NEXT SCREEN.

| NUMBER OF MONTHS

IF NEEDED: Is that weeks or months?

WEEKS ................................................................................................................. 1
MONTHS ............................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.5

APPENDIX B

MATHEMATICA POLICY RESEARCH

SECTION C: CURRENT EMPLOYMENT STATUS
ALL
The next questions are about [your/BENEFICIARY’s] work activities.
C1.

In the past 12 months, [have you /has (NAME)] worked at a job, organization, or business
for pay or profit? This includes work you may do for a business that you own.
IF NEEDED READ:

By ‘working at a job for pay or profit’ we mean at a job where you
get paid money for the work you do.

[INTERVIEWER: IF R IS SELF-EMPLOYED, CODE RESPONSE AS YES]
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
C1=0, D, R
C2.

In the past 12 months, [have you/has he/she] done any volunteer work for an
organization?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

C1=0
C3.

In the past 12 months, [have you/has BENEFICIARY] been looking for work?
IF NEEDED READ:

By looking for work, I mean looking for a job, either full-time or parttime, for which [you/(s)/he] will be paid.

YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

IF C1=0, D, R (NOT EMPLOYED), SKIP TO SECTION D

B.6

APPENDIX B

MATHEMATICA POLICY RESEARCH

C1=1
C4.
NBS
Modified

Now please think about all the jobs [[you/he/she] [have/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
do/he/she does] for a business that [you own/he/she owns].
How many jobs for pay or profit [have you/has he/she] had in the past 12 months?
PROBE:

Please include any job that you worked at in the past 12 months for a week or
more. Count a job that you started, stopped and started again as separate jobs.

| | | NUMBER OF JOBS
(1-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
C1=1
C5.

[Are you/Is (s)he] currently working at a job for pay or profit?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

C1=1
IF C5=1, FILL “CURRENT.” IF C5=1 AND C4>1, FILL “MAIN” AND “Your main job is the job where
you work the most hours”. IF C5=0, FILL LAST
C6.
CPS/MTO
Modified

Now I have a few questions about [your/his/her] [current/main/last] job. [IF MORE THAN
ONE JOB [C4>1] READ: [[Your/His/Her] main job is the job where [you work/(s)/he works]
the most hours]. What kind of business or industry is/was this? That is, what do/did they
make or do where [you work/worked /he/she works/worked]?
RECORD VERBATIM
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.7

APPENDIX B

MATHEMATICA POLICY RESEARCH

C1=1
C7.
CPS/MTO
Modified

What kind of work [do/did you/does/did he/she] do? That is, what is/was [your/his/her]
occupation? For example, programmer, typist, 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.

___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

C1=1
C8.

[Are/Were you/ Is/Was he/she] self-employed at this job?
PROBE:

NBS

Self-employed means that [you work/worked /he/she works/worked] for
[yourself/himself/herself] or [own/owned your/ owns/owned his/her] own
business.

YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
C1=1
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.

YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.8

APPENDIX B

MATHEMATICA POLICY RESEARCH

C1=1
C10.

How many hours per week [do/did you/does/did he/she] typically work at this job?
| | |
(0-99)

HOURS PER WEEK

DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
C1=1
C11.

How much [do/did you/does/did he/she] typically earn, before taxes or other deductions,
on this job? Please include tips and bonuses.
PROBE:
$|

|

Your best estimate is fine.

| |,| | |
($0-999,999.99)

|.|

|

|

DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

C1=1
C12.

How [are/were you is/was he/she] typically paid? Is/Was it hourly, daily, weekly, bi-weekly,
twice a month, monthly, or annually?
CODE ONE ONLY
HOURLY ............................................................................................................... 1
DAILY .................................................................................................................... 2
WEEKLY ............................................................................................................... 3
BI-WEEKLY ........................................................................................................... 4
TWICE A MONTH ................................................................................................. 5
MONTHLY ............................................................................................................. 6
ANNUALLY ........................................................................................................... 7
OTHER (SPECIFY) ............................................................................................... 8
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.9

APPENDIX B

MATHEMATICA POLICY RESEARCH

C1=1
C13.
NBS
Modified

I am going to read a list of benefits that some employers offer their employees. Please tell
me whether or not [your/his/her] [main/current/last] employer [offers/offered] [you/him/her]
any of these benefits.
Does [your/his/her] employer offer [you/him/her] …
IF NECESSARY READ: Please answer ‘yes’ if [you are/(s)/he is] eligible for the benefit
even if [you haven’t/(s)/he hasn’t] started to receive it yet.
CODE ONE PER ROW
YES

NO

DON’T
KNOW

REFUSED

a. Health care insurance? (IF NECESSARY: medical
and/or hospital) .........................................................

1

0

d

r

b. Dental benefits? ........................................................

1

0

d

r

c.

Sick days with pay? ..................................................

1

0

d

r

d. Paid vacation?...........................................................

1

0

d

r

e. Free or low-cost childcare? .......................................

1

0

d

r

Transportation, a transportation allowance, or
transportation discounts? ..........................................

1

0

d

r

g. Long-term disability benefits? ...................................

1

0

d

r

h. Pension or retirement benefits? ................................

1

0

d

r

i.

Short-term disability benefits?...................................

1

0

d

r

j.

Flexible health or dependent care spending
accounts? ..................................................................

1

0

d

r

f.

B.10

APPENDIX B

MATHEMATICA POLICY RESEARCH

C1=1
C14.

Has [your/BENEFICIARY’s] [main/current/last] employer made 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 have /(s)he has] to go out on disability from
time to time.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

C1=1
C15.

Taking all things into account, how satisfied (are/were) you with your [main/current/last]
job? Would you say you [are/were]:
CODE ONE ONLY
Very satisfied, ...................................................................................................... 1
Somewhat satisfied,............................................................................................ 2
Not very satisfied, or........................................................................................... 3
Not at all satisfied? ............................................................................................. 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.11

APPENDIX B

MATHEMATICA POLICY RESEARCH

SECTION D: UNDERSTANDING AND ATTITUDES TOWARDS WORK AND WORK
INCENTIVES
ALL
IF C1=0, FILL “GETTING A JOB,” ELSE DO NOT FILL
D1.

Do your personal goals include [getting a job,] moving up in a job or learning new job
skills?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL
IF C1=0, FILL “SOMEDAY WORKING AND” ELSE DO NOT FILL
D2.

Do your personal goals include [someday working and] earning enough to stop receiving
Social Security disability benefits?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
NOT CURRENTLY RECEIVING SSDI BENEFITS .............................................. 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

AWARENESS OF FEATURES OF POD PROGRAM
T1 AND T2 – TREATMENT CASES ONLY
D3.

Before today, had you ever heard of the Promoting Opportunity Demonstration, or the
POD program?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.12

APPENDIX B

MATHEMATICA POLICY RESEARCH

ALL
D4.

The next questions are about your understanding of the rules SSA uses to calculate your
benefit check.
[For Ts: This refers to the rules SSA uses for those enrolled in POD.]
[For Cs: This refers to the current Social Security Disability Insurance (SSDI) rules.]
Under [Ts: POD/ Cs: Current SSDI rules], do you have a Trial Work Period where your
benefits remain unchanged regardless of your earnings?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

CONTROL SUBJECTS ONLY
D5.

Under current SSDI rules, are your benefits reduced at any time if your earnings are above
SSA’s definition of substantial gainful activity?
PROBE:

In 2017, the SGA amount is $1,170 a month for a person who is not blind or
$1,950 a month for a person who is blind.

YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

T1 AND T2 – TREATMENT SUBJECTS ONLY
D6.

Under POD, how do earnings affect your benefits?
PROBE:

In 2017, the SGA amount is $1,170 a month for a person who is not blind or
$1,950 a month for a person who is blind.

BENEFITS REDUCED BY $1 FOR EVERY $2 IN EARNINGS ABOVE A
CERTAIN AMT ...................................................................................................... 1
REDUCED TO ZERO FOR EARNINGS ABOVE A CERTAIN AMOUNT ............ 2
NEVER REDUCED FOR ANY EARNINGS AMOUNT ......................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.13

APPENDIX B

MATHEMATICA POLICY RESEARCH

ALL
D7.

Under [Ts: the POD rules that apply to you/ Cs: current SSDI rules], do your benefits ever
terminate if your earnings are too high?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

T1 AND T2 TREATMENT SUBJECTS ONLY
D8.

How satisfied are you with the POD offset and rules? Are you…
Very satisfied, ...................................................................................................... 1
Somewhat satisfied,............................................................................................ 2
Not very satisfied, or........................................................................................... 3
Not at all satisfied? ............................................................................................. 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

T1 AND T2 TREATMENT SUBJECTS ONLY
D9.

How satisfied are you with the POD services you have received? Are you…
Very satisfied, ...................................................................................................... 1
Somewhat satisfied,............................................................................................ 2
Not very satisfied, or........................................................................................... 3
Not at all satisfied? ............................................................................................. 4
HAVEN’T RECEIVED ANY POD SERVICES ....................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.14

APPENDIX B

MATHEMATICA POLICY RESEARCH

T1 AND T2 AND WITHDREW FROM OFFSET
D10.

I understand that [you/BENEFICIARY] no longer use(s) the POD benefit offset. Why did
[you/BENEFICIARY] choose to withdraw from POD?
BENEFITS WENT DOWN WITH POD ................................................................. 1
NEW POD RULES WERE CONFUSING ............................................................. 2
BENEFIT PAYMENT ISSUE ................................................................................. 3
DIDN’T LIKE BENEFIT COUNSELING SERVICES ............................................. 4
REPORTING EARNINGS TOO OFTEN ............................................................... 5
OTHER (SPECIFY) ............................................................................................... 99
___________________________________________________ (STRING 500)
DIDN’T WITHDRAW FROM POD ........................................................................ 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.15

APPENDIX B

MATHEMATICA POLICY RESEARCH

SECTION E: INCOME
I’m going to ask you about the income [you/BENEFICIARY] 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 think only about [your/his/her] own earnings
and benefits, and don’t include earnings or benefits that other family members may have received.
ALL
E1.

Last month did [you/(s)/he] receive any income from…
INTERVIEWER:

READ EACH SOURCE. IF BENEFICIARY VOLUNTEERS ‘I ONLY GET
SSDI OR SOCIAL SECURITY,’ CONFIRM A “NO” RESPONSE FOR A-I,
THEN ENTER “1” FOR E2J.
CODE ONE PER ROW
YES

NO

DON’T
KNOW

REFUSED

a. Veterans’ benefits? ...........................................................

1

0

d

r

b. Public assistance or welfare payments? ..........................

1

0

d

r

c.

Workers’ compensation? ..................................................

1

0

d

r

d. Private disability insurance? .............................................

1

0

d

r

e. Unemployment benefits? ..................................................

1

0

d

r

f.

Private pensions or government employee pensions? ....

1

0

d

r

g. Disability insurance for a disabled adult child? ................

1

0

d

r

h. Other sources on a regular basis but not from jobs or
Social Security? ................................................................

1

0

d

r

i.

Other sources not on a regular basis? (SPECIFY) ..........
________________ (STRING 100)

1

0

d

r

j.

IF VOLUNTEERED BY RESPONDENT: SSDI ONLY .....

1

0

d

r

INTERVIEWER: IF NOT VOLUNTEERED, ENTER “0”.
IF OTHER SPECIFY (99): What other sources of income were received?

B.16

APPENDIX B

MATHEMATICA POLICY RESEARCH

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/(s)/he] receive last month from [SOURCE FROM E1]?
INTERVIEWER:
$|

|,|

|

|

ROUND TO NEAREST DOLLAR
|.|

|

| AMOUNT

SKIP TO E4

(0-9,999.99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

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
E3.

Was it…
Less than $150, ................................................................................................... 1
$150 to less than $300, ....................................................................................... 2
$300 to less than $500, or .................................................................................. 3
$500 or more? ...................................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL
E4.

Did [you/(s)/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.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.17

APPENDIX B

MATHEMATICA POLICY RESEARCH

E4=1
E5.

What was the dollar value of the SNAP benefit (Supplemental Nutrition Assistance
Program) or food stamps [you/(s)/he] received last month?
INTERVIEWER: ROUND TO NEAREST DOLLAR
$|

|,| | | |.|
(0-9,999.99)

|

| AMOUNT

DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL
E6.

Did [you/(s)/he] or any member of [your/his/her] household receive assistance from any
other government source? For example: energy assistance or child care assistance.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

E6=1
E7.

What type of other assistance did [you/(s)/he] receive?
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

E6 NE D OR R
E8.

How much income did [you/(s)/he] receive last month from this other assistance?
(INCLUDE INCOME FROM ALL OTHER SOURCES LISTED IN E6)
PROBE:

Other assistance received: [FILL VERBATIM FROM E6]

INTERVIEWER: ROUND TO NEAREST DOLLAR
$|

|

|,| | | |.|
(0-99,999.99 )

|

| AMOUNT

DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.18

APPENDIX B

MATHEMATICA POLICY RESEARCH

ALL
E9.
HOPE VI,
MTO

[Do you/Does (s)/he] currently receive any governmental housing assistance in paying
rent, such as through public housing or Section 8 or a Housing Choice Voucher?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL
Now I’d like you to think about the income of all members in [your/BENEFICIARY’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, SSI, 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.

$|

|

|

|,| | |
($0-999,999)

| AMOUNT

DON’T KNOW ....................................................................................................... d

E10=D
E11.

Would you say the total combined income of all members of [your/BENEFICIARY’S]
household during [CALENDAR YEAR] was…
CODE ONE ONLY
Less than $10,000, .............................................................................................. 1
$10,000 to less than $20,000, ............................................................................. 2
$20,000 to less than $30,000, ............................................................................. 3
$30,000 to less than $40,000, ............................................................................. 4
$40,000 to less than $50,000, or ........................................................................ 5
$50,000 or more?................................................................................................. 6
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.19

APPENDIX B

MATHEMATICA POLICY RESEARCH

SECTION F: HEALTH AND FUNCTIONAL STATUS
The next few questions ask about [your/BENEFICIARY’s] health and how well [you are/(s)/he is]
able to do [your/his/her] usual activities.
ALL
F1.

In general, would you say [your/(his/her)] health is . . .
CODE ONE ONLY
Excellent, ............................................................................................................. 1
Very good, ............................................................................................................ 2
Good, .................................................................................................................... 3
Fair, or .................................................................................................................. 4
Poor? .................................................................................................................... 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? Does it limit [you/him/her]…
CODE ONE ONLY
A lot, ..................................................................................................................... 1
A little, or .............................................................................................................. 2
Not at all? ............................................................................................................. 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL
F3.

Does [your/his/her] health now limit [you/him/her] in climbing several flights of stairs?
Does it limit [you/him/her]…
CODE ONE ONLY
A lot, ..................................................................................................................... 1
A little, or .............................................................................................................. 2
Not at all? ............................................................................................................. 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.20

APPENDIX B

MATHEMATICA POLICY RESEARCH

ALL
F4.

The next two questions ask about your physical health and your daily activities.
During the past 4 weeks, how much of the time have you accomplished less
than you would have liked to as a result of your physical health? Would you
say…
CODE ONE ONLY
All of the time, ..................................................................................................... 1
Most of the time,.................................................................................................. 2
Some of the time, ................................................................................................ 3
A little of the time, or .......................................................................................... 4
None of the time? ................................................................................................ 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL
F5.

During the past 4 weeks, how much of the time [were you/was (s)/he] limited in the kind of
work or other regular daily activities [you do/(s)/he does] as a result of [your/his/her]
physical health? Would you say…
CODE ONE ONLY
All of the time, ..................................................................................................... 1
Most of the time,.................................................................................................. 2
Some of the time, ................................................................................................ 3
A little of the time, or .......................................................................................... 4
None of the time? ................................................................................................ 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL
F6.

During the past 4 weeks, how much of the time have you accomplished less than
you would have liked to as a result of any emotional problems, such as feeling
depressed or anxious? Would you say…
CODE ONE ONLY
All of the time, ..................................................................................................... 1
Most of the time,.................................................................................................. 2
Some of the time, ................................................................................................ 3
A little of the time, or .......................................................................................... 4
None of the time? ................................................................................................ 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL

B.21

APPENDIX B

F7.

MATHEMATICA POLICY RESEARCH

During the past 4 weeks, how much of the time did you not do work or other activities as
carefully as usual as a result of any emotional problems, such as feeling depressed or
anxious? Would you say…
CODE ONE ONLY
All of the time, ..................................................................................................... 1
Most of the time,.................................................................................................. 2
Some of the time, ................................................................................................ 3
A little of the time, or .......................................................................................... 4
None of the time? ................................................................................................ 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL
F8.

During the past 4 weeks, how much did pain interfere with your normal work, including
both work outside the home and housework? Did it interfere…
CODE ONE ONLY
Not at all, .............................................................................................................. 1
A little bit, ............................................................................................................. 2
Moderately, .......................................................................................................... 3
Quite a bit, or ....................................................................................................... 4
Extremely? ........................................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL
F9.

These next questions are about how you feel and how things have been with you
during the past 4 weeks. For each question, please give me the one answer that
comes closest to the way you have been feeling.
During the past 4 weeks, how much of the time have you felt calm and
peaceful? Would you say…
CODE ONE ONLY
All of the time, ..................................................................................................... 1
Most of the time,.................................................................................................. 2
Some of the time, ................................................................................................ 3
A little of the time, or .......................................................................................... 4
None of the time? ................................................................................................ 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL

B.22

APPENDIX B

F10.

MATHEMATICA POLICY RESEARCH

During the past 4 weeks, how much of the time did you have a lot of
energy? Would you say…
CODE ONE ONLY
All of the time, ..................................................................................................... 1
Most of the time,.................................................................................................. 2
Some of the time, ................................................................................................ 3
A little of the time, or .......................................................................................... 4
None of the time? ................................................................................................ 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL
F11.

During the past 4 weeks, how much of the time have you felt downhearted and
depressed? Would you say…
CODE ONE ONLY
All of the time, ..................................................................................................... 1
Most of the time,.................................................................................................. 2
Some of the time, ................................................................................................ 3
A little of the time, or .......................................................................................... 4
None of the time? ................................................................................................ 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL
F12.

During the past 4 weeks, how much of the time has your physical
health or emotional problems interfered with your social activities, like
visiting with friends or relatives? Would you say…
CODE ONE ONLY
All of the time, ..................................................................................................... 1
Most of the time,.................................................................................................. 2
Some of the time, ................................................................................................ 3
A little of the time, or .......................................................................................... 4
None of the time? ................................................................................................ 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.23

APPENDIX B

MATHEMATICA POLICY RESEARCH

ALL
FILL INTERVIEW MONTH AND LAST YEAR (MONTH, YEAR).
Now I’d like you to think about the past 12 months, that is since [INTERVIEW DATE LAST YEAR].
F13.
HCC

During the past 12 months, [have you/has BENEFICIARY] stayed overnight in a hospital?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.24

APPENDIX B

MATHEMATICA POLICY RESEARCH

SECTION G: HEALTH INSURANCE
The next question is about different types of health insurance coverage [you/BENEFICIARY] might
have.
ALL
G1.

What kinds of health coverage [do you/does (s)/he] have?
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” OR “AFFORDABLE CARE ACT”
PROBE:
PROBE:

“Is this a plan [you pay/(s)he 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
CODE ALL THAT APPLY

MEDICARE ........................................................................................................... 1
MEDICAID/[STATE MEDICAID NAME] ................................................................ 2
CHAMPUS/CHAMP-VA, TRICARE, VA, OTHER MILITARY ............................... 3
INDIAN HEALTH SERVICE .................................................................................. 4

STATE PROGRAM ............................................................................................... 6
PRIVATE INSURANCE THROUGH OWN EMPLOYER ...................................... 7
PRIVATE INSURANCE THROUGH SPOUSE/ PARTNER/ PARENT ................. 8
PRIVATE INSURANCE PAID BY SELF/FAMILY ................................................. 9
PRIVATE DISABILITY INSURANCE PAID BY SELF/FAMILY............................. 10
OTHER PLAN (SPECIFY) .................................................................................... 99
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What other kind of health coverage is that?

B.25

APPENDIX B

MATHEMATICA POLICY RESEARCH

SECTION H: RESPONDENT CONTACT INFORMATION
We are almost done. I’d like to confirm some information about [you/BENEFICIARY]. This
information will ensure that [your/his/her] incentive payment is sent to the correct address.
ALL
Fill [VARIABLES FOR NAME?]
H1.

I have [your/his/her] name listed as [READ AND CONFIRM SPELLING OF NAME, FIRST
MIDDLE LAST SUFFIX]. Is that correct?
YES, ALL CORRECT ............................................................................................ 1
NO, NAME NOT CORRECT ................................................................................. 0
REFUSED ............................................................................................................. r

H1=0
H2.

Could you please tell me how to spell [your/his/her] name?
___________________________________________________ (STRING 50)
FIRST NAME
___________________________________________________ (STRING 50)
MIDDLE INITIAL/NAME
___________________________________________________ (STRING 50)
LAST NAME
___________________________________________________ (STRING 25)
SUFFIX
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL
H3.

Our records show that [your/his/her] current address is (FILL FROM PRELOADS). Is this
correct?
YES, ADDRESS IS CORRECT ............................................................................ 1
NO, ADDRESS NOT CORRECT .......................................................................... 0
REFUSED ............................................................................................................. r

B.26

APPENDIX B

MATHEMATICA POLICY RESEARCH

H3=0
H4.

What is [your/his/her] current address?
___________________________________________________
STREET 1
___________________________________________________
STREET 2
___________________________________________________
STREET 3
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL
H5.

I called [you/him/her] at [AREA CODE/PHONE NUMBER]. Is this [your/his/her] home
telephone number?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

H5=0
H6.

What is [your/(his/her)] home phone number, starting with area code?
|

| | |-| | | |-| | | | |
201-989)
(200-999)
(0000-9999)

NO HOME NUMBER ............................................................................................ 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

ALL
H7.

[Do you/Does (s)/he] have a cell phone number?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.27

APPENDIX B

MATHEMATICA POLICY RESEARCH

H7=1
H8.

What is [your/his/her] cell phone number, starting with area code?
|

| | |-| | | |-|
(201-989)
(200-999)

| | | |
(0000-9999)

DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF OUTSIDE RANGE; I’m sorry, it looks like I entered an invalid phone number.
Can you please repeat the number for me?
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.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

IF HAVE EMAIL ADDRESS ON FILE
H10.

We have [your/BENEFICIARY’s] email address as [EMAIL ADDRESS]. Is this still the best
email address to reach [you/her/him] at?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

IF DO NOT HAVE EMAIL ADDRESS ON FILE OR H10=0 OR D
H11.

What is [your/his/her] email address?
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r

B.28

APPENDIX B

MATHEMATICA POLICY RESEARCH

THIS SECTION FOR 12-MONTH FOLLOW UP SURVEY RESPONDENTS ONLY.
24-MONTH SURVEY RESPONDENTS, SKIP TO “END”
ALL 12 MONTH SURVEY RESPONDENTS
H12.

I would like to ask you for the name, address, and telephone number of 2 persons who will
always know how to reach [you/BENEFICIARY]. This will be used when it is time to contact
[you/him/her] for the next interview. 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/BENEFICIARY] and will always
know how to contact [you/him/her].
PERSON 1:
FIRST NAME
MIDDLE INITIAL/NAME
LAST NAME
RELATIONSHIP TO RESPONDENT
ADDRESS 1
ADDRESS 2
CITY
STATE/TERRITORY
| | | | | |-| | |
ZIP CODE (+ 4 IF NEEDED)

|

|

| | | |-| | | |-|
(200-999)
(100-999)

| | | | PHONE NUMBER - HOME
(0000-9999)

| | | |-| | | |-|
(200-999)
(100-999)

| | | | PHONE NUMBER – CELLULAR
(0000-9999)

| | | |-| | | |-|
(200-999)
(100-999)

| | | | PHONE NUMBER - OTHER
(0000-9999)

EMAIL
DON’T KNOW .......................................................................................... d
REFUSED ................................................................................................ r

B.29

APPENDIX B

MATHEMATICA POLICY RESEARCH

ALL
H13.

Please provide the name of someone who does not live with [you/BENEFICIARY] and will
always know how to contact [you/him/her].
What is the full name of the second person?
FIRST NAME
MIDDLE INITIAL/NAME
LAST NAME
RELATIONSHIP TO RESPONDENT
ADDRESS 1
ADDRESS 2
CITY
STATE/TERRITORY
| | | | | |-| | |
ZIP CODE (+ 4 IF NEEDED)

|

|

| | | |-| | | |-|
(200-999)
(100-999)

| | | | PHONE NUMBER - HOME
(0000-9999)

| | | |-| | | |-|
(200-999)
(100-999)

| | | | PHONE NUMBER – CELLULAR
(0000-9999)

| | | |-| | | |-|
(200-999)
(100-999)

| | | | PHONE NUMBER - OTHER
(0000-9999)

EMAIL
DON’T KNOW .......................................................................................... d
REFUSED ................................................................................................ r

ALL
END.

Thank you very much for your time today. [You/BENEFICIARY] can expect to receive
[your/his/her] $[25] check within 2 weeks.

B.30