A
world-wide survey of beneficiaries eligible for health care coverage
through the military health system
TRICARE
Select Survey of Beneficiaries
RCS:
DD-HA(A) 1942
SURVEY
STARTS HERE
As
an eligible TRICARE beneficiary, please
complete this survey even if you did not receive your health care
from a military facility.
Please
recognize that some specific questions about TRICARE benefits may
not apply to you, depending on your entitlement and particular
TRICARE program.
This
survey is about the health care of the person whose name appears on
the cover letter. The survey should be completed by that person. If
you are not the addressee, please give this survey to that person.
1.
Are you the person whose name appears on the cover letter? Yes
4
Go to Question 2 on the next page No
4
Please
give this questionnaire to the person addressed on the cover
letter.
745-01 01 DKT
Providing
information in this survey is voluntary. There is no penalty nor
will your benefits be affected if you choose not to respond,
although maximum participation is encouraged so that the data will
be complete and representative.
The
survey was written so that answers should not require you to provide
any personally identifiable information (PII), but please be assured
that any PII provided will be treated as confidential. Your
responses are collected via a secure system which does not collect
any information that could be used to determine your identity.
Answering
the questions is voluntary; you may stop the survey at any time.
Answer
all
the questions by filling in the circle to the left of your answer.
You are sometimes told to skip over some questions in this survey.
When this happens you will see an arrow with a note that tells you
what question to answer next, like this: Yes
4
Go to Question 12 No
Please
return the completed questionnaire in the enclosed postage-paid
envelope within seven
days.
If the envelope is missing, please send to:
Office
of the Assistant Secretary of Defense (Health Affairs) DHA,
Analytics and Evaluation Division c/o
DataStat, Inc. 3975
Research Park Dr. Ann
Arbor, MI 48108
SURVEY
INSTRUCTIONS
OMB
CONTROL NUMBER: XXXX-XXXX OMB
EXPIRATION DATE: XX/XX/XXXX AGENCY
DISCLOSURE NOTICE The
public reporting burden for this collection of information, [Insert
OMB
Control Number],
is estimated to average 15 minutes per response, including the time
for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding the
burden estimate or burden reduction suggestions to the Department of
Defense, Washington Headquarters Services, at
whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil.
Respondents should be aware that notwithstanding any other provision
of law, no person shall be subject to any penalty for failing to
comply with a collection of information if it does not display a
currently valid OMB control number.
March
2024
PRIVACY
ADVISORY
currently covered?
MARK
ALL THAT APPLY.
Military
Health Plans
TRICARE Prime (including most Active Duty, TRICARE Prime Remote and TRICARE Overseas)
TRICARE Select (previously known as TRICARE Extra or Standard (CHAMPUS))
TRICARE Plus
TRICARE for Life
TRICARE Supplemental Insurance
TRICARE Reserve Select
TRICARE Retired Reserve
TRICARE Young Adult Prime
TRICARE Young Adult Select
Continued Health Care Benefit Program (CHCBP) (a COBRA-like premium-based health care program)
Other Health Plans
Medicare
Federal Employees Health Benefit Program (FEHBP)
Medicaid or other state health insurance
A civilian HMO (such as Kaiser)
Other civilian health insurance (such as Blue Cross)
The Veterans Administration (VA)
Government health insurance from a country other than the US
Not sure
3. Which health plan did you use for all or most of your health care in the last 12 months?
MARK
ONLY ONE.
Military
Health Plans
TRICARE Prime (including most Active Duty, TRICARE Prime Remote and TRICARE Overseas)
TRICARE Select (previously known as TRICARE Extra or Standard (CHAMPUS))
TRICARE Plus
TRICARE Reserve Select
TRICARE Retired Reserve
TRICARE Young Adult
Continued Health Care Benefit Program (CHCBP) (a COBRA-like premium-based health care program)
Other Health Plans
Medicare
Federal Employees Health Benefit Program (FEHBP)
Medicaid or other state health insurance
A civilian HMO (such as Kaiser)
Other civilian health insurance (such as Blue Cross)
Uniformed Services Family Health Plan (USFHP)
The Veterans Administration (VA)
Government health insurance from a country other than the US
Not sure 4 Go to Question 5
Did not use any health plan in the last 12 months 4 Go to Question 5
For the remainder of this questionnaire, the term health plan refers to the plan you indicated in Question 3.
4. How many months or years in a row have you been in this health plan?
Less than 6 months
6 up to 12 months
12 up to 24 months
2 up to 5 years
5 up to 10 years
10 or more years
5. Are you covered by the same health plan beginning January 1, 2024 as the one you selected in Question 3?
Yes
No
Don't know
also have the opportunity to obtain other civilian health insurance through their job or a family member's job, through COBRA, or through retirement coverage from a previous job, or from some other group. COBRA lets beneficiaries pay to keep their coverage temporarily when they leave their job.
Do you have the opportunity to obtain civilian health insurance coverage for yourself through some civilian group?
Yes
No 4 Go to Question 10
7. What options do you have for obtaining civilian coverage?
MARK ALL THAT APPLY.
Through my current employer
Through COBRA from my previous employer
Through retirement coverage from my previous employer
Through a family member's current employer
Through COBRA from a family member's previous employer
Through retirement coverage from a family member's previous employer
Through another organization
Through a government program
Insurance sold by insurance health exchanges (healthcare.gov)
Don't Know
8. Are you now covered by a civilian health insurance policy?
Yes
No 4 Go to Question 10
9. Are you alone covered or are you and others in
your household covered by the civilian health insurance policy?
I alone am covered
I and at least one other person in my household are covered
10. Have you used TRICARE for any health care (not including for prescription drugs) in the past 12 months?
Yes 4 Go to Question 12
No
11.
Why haven't you used TRICARE?
MARK
ALL THAT APPLY.
I have a greater choice of doctors with my civilian plan
My personal doctor is not available to me through TRICARE
My TRICARE regular doctor is no longer available to me
My TRICARE specialist is no longer available to me
My preferred doctors do not accept TRICARE
I prefer civilian hospitals
There are no military facilities near me
I have to travel too far to see my TRICARE doctor
I get better customer service with civilian plans
TRICARE benefits are poor compared to my civilian plan
It is easier for me to get care through my civilian plan
I do not want to pay the premium for TRICARE
I pay less for civilian care than I would for TRICARE
I have not needed health care
Another reason
TRICARE SELECT ENROLLMENT
12. Are you a retired member of a uniformed service or the spouse or child of a retired member who was covered by TRICARE Select in 2023?
Yes
No 4 Go to Question 17
13. Have you, your spouse, or parent arranged to pay a monthly enrollment fee for TRICARE Select?
Yes 4 Go to Question 15
No
Don't Know 4 Go to Question 15
14. What is the main reason you don't pay a monthly enrollment fee for TRICARE Select?
MARK ONLY ONE.
I was not aware that fees must be paid for Tricare Select
Did not know how to set up payments
I thought TRICARE was responsible for setting up payments
I expected the requirement to be waived or delayed
I dropped my TRICARE Select coverage
My
enrollment fee is paid on an annual or
quarterly basis 4
Go to Question 16
Don't Know
Yes
No
16. Where did you get information about arranging to pay TRICARE Select premiums?
MARK ALL THAT APPLY.
The TRICARE website
Friends or colleagues
Military or retiree news media
My TRICARE regional contractor
My benefits counselor
Civilian news media
A service members' professional organization
Other
YOUR PERSONAL DOCTOR
17. A personal doctor is the one you would see if you need a checkup, want advice about a health problem, or get sick or hurt. Do you have a personal doctor?
Yes
No 4 Go to Question 25
18. In the last 12 months, how often did your personal doctor listen carefully to you?
Never
Sometimes
Usually
Always
I had no visits in the last 12 months.
19. In the last 12 months, how often did your personal doctor explain things in a way that was easy to understand?
Never
Sometimes
Usually
Always
I had no visits in the last 12 months.
20. In the last 12 months, how often did your
personal doctor show respect for what you had to say?
Never
Sometimes
Usually
Always
I had no visits in the last 12 months.
21. In the last 12 months, how often did your personal doctor spend enough time with you?
Never
Sometimes
Usually
Always
I had no visits in the last 12 months.
22. Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you use to rate your personal doctor?
Worst Best
possible possible
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
I don't have a personal doctor.
23. How long does it take you to travel to your personal doctor?
Less than 15 minutes
15 to 30 minutes
31 minutes to 60 minutes (1 hour)
61 minutes to 90 minutes
91 minutes to 120 minutes (2 hours)
More than 120 minutes (2 hours)
24. Did you have the same personal doctor before you joined this health plan?
Yes 4 Go to Question 26
No
25. Since you joined your health plan, how much of a problem, if any, was it to get a personal doctor you are happy with?
A big problem
A small problem
Not a problem
26. Where is your personal doctor located? MARK ONLY ONE.
A military facility - This includes: Military clinic, Military hospital, PRIMUS clinic, NAVCARE clinic 4 Go to Question 28
A civilian facility - This includes: Doctor's office, Clinic, Hospital, Civilian TRICARE contractor
Uniformed Services Family Health Plan facility (USFHP)
Veterans Affairs (VA) clinic or hospital
I do not have a personal doctor
27. In the last 12 months, did you try to find a
personal doctor who was located at a military treatment facility?
Yes
No 4 Go to Question 30
A big problem
A small problem
Not a problem 4 Go to Question 30
29. What is the biggest problem you encountered trying to find a personal doctor at a military treatment facility?
MARK ONLY ONE.
The military facilities near me have downsized or closed
The wait for an appointment at the military treatment facilities near me is too long
The waiting rooms at the military facilities near me are crowded or uncomfortable
The staff at the military treatment facilities near me are not helpful or courteous
I have had problems communicating with doctor(s) at the military treatment facilities
Another reason
30. Is your personal doctor a civilian?
Yes
No 4 Go to Question 35
I
do not have a personal doctor or
nurse 4
Go to Question 35
31. The TRICARE civilian provider network is made up of the doctors, clinics, hospitals and other health care providers who are part of DoD's preferred provider pool.
Is your personal doctor part of the TRICARE civilian provider network?
Yes
No
Don't Know
32. What is the specialty of your personal doctor? MARK ONLY ONE.
Family Medicine or General Practitioner
Internist
Pediatrician
OB-GYN
Geriatrician or Geriatric Nurse
Preventive Medicine
Nurse Practitioner or Physician's Assistant
Other Specialty
33. In the last 12 months, how much of a problem was it to find a personal doctor who would accept TRICARE?
A big problem
A small problem
Not a problem 4 Go to Question 35
34. What problems did you encounter in finding a personal doctor who would accept TRICARE?
MARK ALL THAT APPLY.
Travel distance too long
Problems communicating with doctor
Doctor(s) not taking any new patients
Doctor(s) not taking new TRICARE patients
Doctor(s) not accepting TRICARE payments
Could not find the specialty I wanted
Did not like doctor(s)
Wait for an appointment was too long
Could not find information about doctors
Other
GETTING
HEALTH CARE
FROM A SPECIALIST
When you answer the next questions, do not include dental visits or care you got when you stayed overnight in a hospital.
35. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care.
In the last 12 months, did you make any appointments to see a specialist?
Yes
No 4 Go to Question 37
36. In the last 12 months, how often did you get an appointment to see a specialist as soon as you needed?
Never
Sometimes
Usually
Always
I didn't need a specialist in the last 12 months.
37. How many specialists have you seen in the last 12 months?
None 4 Go to Question 46
1 specialist
2
3
4
5 or more specialists
Worst Best
possible possible
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
I didn't see a specialist in the last 12 months.
39. How long does it take you to travel to the specialist you saw most in the past 12 months?
Less than 15 minutes
15 to 30 minutes
31 minutes to 60 minutes (1 hour)
61 minutes to 90 minutes
91 minutes to 120 minutes (2 hours)
More than 120 minutes (2 hours)
40. In the last 12 months, did you see a civilian specialist?
Yes
No 4 Go to Question 46
41. In the last 12 months, was the civilian specialist you saw most the same doctor as your personal doctor?
Yes
No
42. In the last 12 months, was the civilian specialist you saw most part of the TRICARE civilian provider network?
Yes
No
Don't know
43. In the last 12 months, what was the specialty of the civilian specialist you saw most?
MARK ONLY ONE.
Surgeon
Cardiologist (heart doctor)
Allergist
Dermatologist (skin doctor)
Rheumatologist (specialist of the joints)
Endocrinologist (thyroid, hormone and diabetes specialist)
Urologist (specialist of the urinary tract and male reproductive system)
Oncologist (cancer specialist)
Orthopedist (specialist of the bones, muscles and their connected tissues)
Ear, nose and throat specialist
Obstetrician/Gynecologist
Ophthalmologist
Other
please do not include personally identifying information
44. In the last 12 months, how much of a problem
was it to find a doctor with this specialty who would accept TRICARE?
A big problem
A small problem
Not a problem 4 Go to Question 46
45. What problems did you encounter in finding a specialist who would accept TRICARE?
MARK ALL THAT APPLY.
Travel distance too long
Problems communicating with doctor
Doctor(s) not taking any new patients
Doctor(s) not taking new TRICARE patients
Doctor(s) not accepting TRICARE payments
Could not find the specialty I wanted
Did not like doctor(s)
Wait for an appointment was too long
Could not find information about doctors
Other
CALLING DOCTORS' OFFICES
46. In the last 12 months, did you call a doctor's office or clinic during regular office hours to get help or advice for yourself?
Yes
No 4 Go to Question 48
47. In the last 12 months, when you called during regular office hours, how often did you get the help or advice you needed?
Never
Sometimes
Usually
Always
THE LAST 12 MONTHS
These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits.
48. In the last 12 months, did you have an illness, injury, or condition that needed care right away in
a clinic, emergency room, or doctor's office?
Yes
No 4 Go to Question 51
49. In the last 12 months, when you needed care right away, how often did you get care as soon as you needed?
Never
Sometimes
Usually
Always
I
didn't need care right away for an illness,
injury or
condition in the last 12 months.
50. In the last 12 months, when you needed care right away for an illness, injury, or condition, how long did you usually have to wait between trying to get care and actually seeing a provider?
Same day
1 day
2 days
3 days
4-7 days
8-14 days
15 days or longer
I
didn't need care right away for an illness,
injury or
condition in the last 12 months.
51. In the last 12 months, did you make any appointments for a check-up or routine care at a doctor's office or clinic?
Yes
No 4 Go to Question 54
52. In the last 12 months, how often did you get an appointment for a check-up or routine care at a doctor's office or clinic as soon as you needed?
Never
Sometimes
Usually
Always
I had no appointments in the last 12 months.
53. In the last 12 months, not counting the times you needed health care right away, how many days did you usually have to wait between making an appointment and actually seeing a provider?
Same day
1 day
2-3 days
4-7 days
8-14 days
15-30 days
31 days or longer
I had no appointments in the last 12 months.
54. In the last 12 months, how many times did you go to an emergency room to get care for yourself?
None
1 time
2
3
4
5 to 9
10 or more times
55. In the last 12 months, not counting the times you went to an emergency room, how many times did you go to a doctor's office or clinic to get health care for yourself?
None
1 time
2
3
4
5 to 9
10 or more times
Telehealth is phone call or video conference that links you to a provider at another location in order to assess, treat, and provide care to you remotely. When you answer the next questions, do not include dental visits.
56. In the last 12 months, did you have a telehealth appointment?
Yes
No 4 Go to Question 63
57. What type of telehealth appointment(s) did you have?
MARK ALL THAT APPLY.
Phone call
Video conference
MARK ALL THAT APPLY.
Primary care doctor
Nurse Practitioner or Physician Assistant
Specialist (Such as heart, allergy, OB-GYN, and skin doctors)
Mental health provider (Counselor, psychologist, psychiatrist)
Other doctor or provider
Don't know
Please indicate how much you agree or disagree with the following statements.
59. Thinking about your most recent telehealth appointment, the provider...
|
Strongly agree |
Agree |
Disagree |
Strongly Disagree |
|
0 |
0 |
0 |
0 |
|
0 |
0 |
0 |
0 |
|
0 |
0 |
0 |
0 |
|
0 |
0 |
0 |
0 |
60. Thinking about your most recent telehealth appointment...
|
Strongly agree |
Agree |
Disagree |
Strongly Disagree |
|
0 |
0 |
0 |
0 |
|
0 |
0 |
0 |
0 |
|
0 |
0 |
0 |
0 |
61. Using any number from 0 to 10, where 0 is the worst care possible and 10 is the best care possible, what number would you use to rate the care you received via telehealth in the last 12 months?
Worst Best
possible possible
0 |
0 |
0 |
|
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
2 |
|
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
Worst Best
possible possible
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
I had no visits in the last 12 months.
63. In the last 12 months, how often was it easy to
get the care, tests, or treatment you needed?
Never
Sometimes
Usually
Always
I didn't need care, tests, or treatment in the last 12 months.
64. In the last 12 months, where did you go most often for your health care?
MARK ONLY ONE.
A military facility - This includes: Military clinic, Military hospital, PRIMUS clinic, NAVCARE clinic
A civilian facility - This includes: Doctor's office, Clinic, Hospital, Civilian TRICARE contractor
Uniformed Services Family Health Plan facility (USFHP)
Veterans Affairs (VA) clinic or hospital
I went to none of the listed types of facilities in the last 12 months.
TREATMENT OR COUNSELING
65. In the last 12 months, did you need any treatment or counseling for a personal or family problem?
Yes
No 4 Go to Question 80
66. In the last 12 months, what type of provider did you want to see most for this treatment or counseling?
MARK ONLY ONE.
Psychologist
Psychiatrist
Psychotherapist
Social worker
Mental health counselor
Marriage or family therapist
Your personal doctor or nurse
Other
please do not include personally identifying information
Don't know
67. In the last 12 months, did you receive treatment or counseling for a personal or family problem?
Yes
No 4 Go to Question 71
68. In the last 12 months, did you receive this treatment or counseling from a civilian provider?
Yes
No 4 Go to Question 70
69. In the last 12 months, did you receive this treatment or counseling from a provider in TRICARE's civilian network?
Yes
No
Don't know
70. In the last 12 months, what type of provider did you see most often for this treatment or counseling?
MARK ONLY ONE.
Psychologist
Psychiatrist
Psychotherapist
Social worker
Mental health counselor
Marriage or family therapist
Your personal doctor or nurse
Other
please do not include personally identifying information
Don't know
71. In the last 12 months, how much of a problem, if any, was it to get the treatment or counseling you needed through your health plan?
A big problem
A small problem
Not a problem 4 Go to Question 73
72. In the last 12 months, what problems did you
encounter in finding treatment or counseling?
MARK ALL THAT APPLY.
Travel distance too long
Problems communicating with doctor
Doctor(s) or counselor(s) not taking new patients
Doctor(s) or counselor(s) not taking new TRICARE patients
Doctor(s) or counselor(s) not accepting TRICARE payments
Could not find the specialty I wanted
Did not like doctor(s) or counselor(s)
Wait for an appointment was too long
Could not find information about doctors or counselors
Other
Yes
No 4 Go to Question 75
74. In the last 12 months, when you needed treatment or counseling right away, how often did you see someone as soon as you wanted?
Never
Sometimes
Usually
Always
75. In the last 12 months, did you need approval for any treatment or counseling?
Yes
No 4 Go to Question 77
76. In the last 12 months, how much of a problem, if any, were delays in treatment or counseling while you waited for approval?
A big problem
A small problem
Not a problem
77. In the last 12 months, did you call customer service to get information or help about treatment or counseling?
Yes
No 4 Go to Question 79
78. In the last 12 months, how often did your health plan's customer service give you the information or help you needed?
Never
Sometimes
Usually
Always
79. Using any number from 0 to 10, where 0 is the worst treatment or counseling possible and 10 is the best treatment or counseling possible, what number would you use to rate all your treatment or counseling in the last 12 months?
Worst Best
possible possible
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
I didn't receive treatment or counseling in the last 12 months.
80. Would you say that in general your mental or
emotional health is excellent, very good, good, fair, or poor?
Excellent
Very good
Good
Fair
Poor
YOUR HEALTH PLAN
The next question asks about your experience with your health plan. By your health plan, we mean the health plan you marked in Question 3.
Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your health plan?
Worst Best
possible possible
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
Even if you do not use TRICARE Select, we'd like to know what you like and dislike about these plans compared to civilian plans.
What do you like about TRICARE Select (including Standard/Extra, TRICARE Reserve Select, or TRICARE Retired Reserve)?
MARK ALL THAT APPLY.
I have a better choice of doctors with TRICARE than with a civilian plan
My preferred personal doctor is only available to me through TRICARE
I want to be sure I can always use military health care
I get better customer service with TRICARE than with civilian plans
It is easier to get care through TRICARE than a civilian plan
The premium for TRICARE is lower than the premium for civilian coverage
Copays or cost-shares cost less through TRICARE than a civilian plan
Deductibles cost less through TRICARE than a civilian plan
Civilian benefits are poor compared to TRICARE
Other:
I have a better choice of doctors with a civilian plan than with TRICARE
My preferred personal doctor is not available to me through TRICARE
I worry about losing access to civilian coverage
I get better customer service with civilian plans than with TRICARE
It is easier to get care through a civilian plan than TRICARE
The premium for TRICARE is too high
Copays or cost-shares cost more through TRICARE than a civilian plan
Deductibles cost more through TRICARE than a civilian plan
TRICARE benefits are poor compared to a civilian plan
Other:
please do not include personally identifying information
84. Using any number from 0 to 10, where 0 is not at all likely and 10 is extremely likely, how likely is it that you would recommend your healthcare plan to a friend or family member?
Not at Extremely
all likely likely
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
PREVENTIVE CARE
Preventive care is medical care you receive that is intended to maintain your good health or prevent a future medical problem. A physical or blood pressure screening are examples of preventive care.
85. When did you last have a blood pressure reading?
Less than 12 months ago
1 to 2 years ago
More than 2 years ago
86. Do you know if your blood pressure is too high?
Yes, it is too high
No, it is not too high
Don't know
87. Have you ever smoked at least 100 cigarettes in your entire life?
Yes
No 4 Go to Question 90
Don't know 4 Go to Question 90
88. Do you now smoke cigarettes or use tobacco every day, some days, or not at all?
Every day
Some days
Not at all 4 Go to Question 91
Don't know 4 Go to Question 91
89. In the last 12 months, how often were you
advised to quit smoking or using tobacco by a doctor or other health provider in your plan?
Never
Sometimes
Usually
Always
90. When did you last have a cholesterol screening, that is, a test to determine the level of cholesterol in your blood?
Less than 12 months ago
1 to 2 years ago
More than 2 but less than 5 years ago
5 or more years ago
Never had a cholesterol screening
91. When did you last have a flu shot?
Less than 12 months ago
1-2 years ago
More than 2 years ago
Never had a flu shot
92. Are you male or female?
Male 4 Go to Question 95
Female
93. If you are over 40 years of age, when was the last time your breasts were checked by mammography?
Within the last 12 months
1 to 2 years ago
More than 2 but less than 5 years ago
5 or more years ago
Never had a mammogram
I am under 40 years of age
ABOUT YOU
94. Would you say that in general your health is excellent, very good, good, fair or poor?
Excellent
Very good
Good
Fair
Poor
95. Are you limited in any way in any activities because of any impairment or health problem?
Yes
No
96. What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
97. What is your race and/or ethnicity?
Select all that apply and enter additional details in the spaces below.
American
Indian or Alaska Native –
Enter,
for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian
Reservation of Montana, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.
Asian – Provide details below.
m
Chinese m
Asian Indian m
Filipino
Enter, for example, Pakistani, Hmong, Afghan, etc.
m Vietnamese m Korean m Japanese
Black or African American – Provide details below.
m
African American m
Jamaican m
Haitian
Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc.
m Nigerian m Ethiopian m Somali
12
Hispanic or Latino – Provide details below.
m
Mexican m
Puerto Rican m
Salvadoran
Enter, for example, Colombian, Honduran, Spaniard, etc.
m Cuban m Dominican m Guatemalan
Middle Eastern or North African – Provide details below.
m
Lebanese m
Iranian m
Egyptian
Enter, for example, Moroccan, Yemeni, Kurdish, etc.
m Syrian m Iraqi m Israeli
Native Hawaiian or Pacific Islander – Provide details below.
m
Native Hawaiian m
Samoan m
Chamorro
Enter, for example, Chuukese, Palauan, Tahitian, etc.
m Tongan m Fijian m Marshallese
White – Provide details below.
m
English m
German m
Irish
Enter, for example, French, Swedish, Norwegian, etc.
m Italian m Polish m Scottish
98. What is your age now?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
99.
Which of the following income ranges is closest
to your
family's (2023) total income from all
sources? Your best
estimate would be fine.
Less than $10,000
$10,000 to $24,999
$25,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000 and above
Don't Know
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Jennifer Peterson |
File Modified | 0000-00-00 |
File Created | 2024-08-02 |