Socio Economic Status (SES)

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SSPGF Suicide Prevention Grant Program
Page 1

SES Measure
Record ID

__________________________________

First Name:

__________________________________

Last Name

__________________________________

What is your current employment status?

Employed
Disabled

Unemployed
Retired

If employed, is it full-time or part-time?

Full-time

Part-time

Are you currently unemployed?

Yes

If unemployed, when did you lose your job

No

__________________________________

How long have you been receiving unemployment benefits?
Less than 6 weeks

6 - 14 weeks

15 - 26 weeks

How much are your weekly unemployment benefits?

Greater than 26 weeks

__________________________________

Are you receiving any other temporary financial
assistance?

Yes

No

Pending

Have you ever received financial counseling services?

Yes

No

Pending

Have you had difficulty covering medical, food, and
housing expenses?

Yes

No

Are you experiencing any stress over your financial
situation? (financial stress)

Yes

No

07/08/2021 2:20pm

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Total Household Income (Last 12 months)

Less than $5,000
$5,000 to $7,499
$7,500 to $9,999
$10,000 to $12,499
$12,500 to $14,999
$15,000 to
$19,999
$20,000 to $24,999
$25,000 to $29,999
$30,000 to
$34,999
$35,000 to $39,999
$40,000 to $49,999
$50,000 to
$59,999
$60,000 to $74,999
$75,000 to $99,999
$100,000 to
$149,999
$150,000 or more

Has your income been reduced?

Yes

How much as your income been reduced? (annual
estimate)

Less than $5,000
$5,000 to $7,499
$7,500 to $9,999
$10,000 to $12,499
$12,500 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000 to $29,999
$30,000 to $34,999
$35,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 or more

Are you enrolled in VA healthcare?

Yes

No

Pending

Do you have Health Care insurance?

Yes

No

Pending

Type of Health Care Insurance

Other

Are you currently receiving VA Compensation (Service
Connected Disability) or a Pension?

07/08/2021 2:20pm

No

No health insurance
Insurance through
a current or former employer or union (of
yours or another family member)
Insurance purchased directly from an
insurance company (by you or another family
member)
Insurance purchased on the
Affordable Care Act Healthcare Exchange (also
known as Obamacare)
Medicare, for
people 65 and older, or people with certain
disabilities
Medical Assistance, or any kind
of government-assistance plan for those with
low incomes or a disability
VA (including those who have ever used or
enrolled for VA health care)
TRICARE, TRICARE for Life or other military
health care
Indian Health Service
Other

__________________________________
Yes

No

Pending

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What is your current living situation?
Live alone
Veteran

Live with spouse

Live with another person

Which of the following best describes the area you
live in?

Highest grade level completed or degree achieved?

07/08/2021 2:20pm

Live with parents

Urban
Rural

Live with another

Suburban

Less than high school
High school diploma / GED
Some college credit, but less than one year
of college credit
One or more years of
college credit, no degree
Associate's degree (for example, AA, AS)
Bachelor's degree (for example, BA, BS)
Master's degree (for example, MA, MS,
MEng, MEd, MSW, MBA)
Professional degree beyond a bachelor's
degree (for example, MD, DDS, DVM, LLB, JD)
Doctorate degree (for example, PhD, EdD)

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