CP, YP, YA, YX

O1a. That concludes this interview. In case I need to contact you again
to verify some information; what is your name, address and the best
telephone number with which to reach you?

> Esto concluye esta entrevista. En caso que tenga que comunicarme con
> Ud.
>
> Para verificar alguna información. ¿Cuál es su nombre y apellido,
> dirección, y el
>
> mejor número de teléfono para' ponerme en contacto con Ud.?
>
> NAME:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> STREET ADDRESS:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> CITY/STATE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ZIP
> CODE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> TELEPHONE NUMBER: (\|\_\_\_\|\_\_\_\|\_\_\_\|)
> \|\_\_\_\|\_\_\_\|\_\_\_\| - \|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|
>
> AREA CODE
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

O1b. What is the name and address of the person to whom we should send
the \$10.00 (FILL "CHECK" IF INCENTIVE TYPE=01; FILL " DEBIT CARD" IF
INCENTIVE TYPE=02; FILL " PHONE CARD" IF INCENTIVE TYPE=03)?

> ¿Cuál es el nombre y apellido, y la dirección de la persona a quien
> debemos
>
> enviar (FILL "el cheque por \$10.00" IF INCENTIVE TYPE=01; FILL "LA
>
> TARJETA DE DÉBITO DE \$10.00" IF INCENTIVE TYPE=02; FILL "LA

TARJETA TELEFÓNICA DE \$10.00"  IF INCENTIVE TYPE=03)?

> NAME:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> STREET ADDRESS:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> CITY/STATE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ZIP
> CODE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> TELEPHONE NUMBER: (\|\_\_\_\|\_\_\_\|\_\_\_\|)
> \|\_\_\_\|\_\_\_\|\_\_\_\| - \|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|
>
> AREA CODE
>
> DON'T KNOW d

REFUSED r

CP, YP, YA, YX

O1C. (SKIP TO O2 IF INCENTIVE TYPE=02 OR 03) And would you like the
check

made out to you or someone else?

> (SKIP TO O2 IF INCENTIVE TYPE=02 OR 03) Y quiere que extendamos el
> cheque a su favor o a favor de alguien más?
>
> Make check out to NAME Below 01 *Go to O2*
>
> make check out to different
>
> person 02
>
> DON'T KNOW d

REFUSED r

> NAME:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

CP, YP, YA, YX

O1d. What is that person's address and telephone number?

> ¿Cuál es la dirección y el número de teléfono de esa persona?

STREET ADDRESS:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> CITY/STATE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ZIP
> CODE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> TELEPHONE NUMBER: (\|\_\_\_\|\_\_\_\|\_\_\_\|)
> \|\_\_\_\|\_\_\_\|\_\_\_\| - \|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|
>
> AREA CODE
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

O2. Finally, in about two years the Social Security Administration may
wish to contact you again to follow-up with (FILL "NAME'S" IF
RTYPE=01,03; "YOUR" IF RTYPE=02) health and other circumstances. In case
we have trouble reaching you, what is the name, address and phone number
of two close relatives or friends who are likely to know (FILL "NAME'S"
IF RTYPE=01,03; "YOUR" IF RTYPE=02) location in the future?

Finalmente, en unos dos años la Administración del Seguro Social (Social
Security Administration) quizás quierá comunicarse con Ud. para un
seguimiento de (FILL "LA SALUD DE NAME" IF RTYPE=01,03; "SU SALUD" IF
RTYPE=02) y otras circunstancias. En caso de que tengamos dificultad en
contactarlo(a) ¿cuáles son los nombres, direcciones, y números de
teléfono de dos parientes cercanos o amigos íntimos que probablemente
sepán dónde se encontrará (FILL "NAME" IF RTYPE=01,03; "UD." IF
RTYPE=02) en el futuro?

> NAME:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

STREET ADDRESS:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> CITY/STATE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ZIP
> CODE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> TELEPHONE NUMBER: (\|\_\_\_\|\_\_\_\|\_\_\_\|)
> \|\_\_\_\|\_\_\_\|\_\_\_\| - \|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|
>
> AREA CODE

NO CONTACT PERSON 01

> DON'T KNOW d
>
> REFUSED r
>
> How is that person related to (FILL "NAME" IF RTYPE=01,03; "YOU" IF
>
> RTYPE=02), if at all?
>
> ¿Cuál es el parentesco de esa persona con (FILL "NAME" IF RTYPE=01,03;
> "YOU" IF RTYPE=02) si es que lo hay?

MOTHER (BIOLOGICAL OR ADOPTIVE) 02

FATHER (BIOLOGICAL OR ADOPTIVE) 03

STEP-PARENT OF (NAME) 04

FOSTER PARENT OF (NAME) 05

UNMARRIED PARTNER OF PARENT 06

GRANDPARENT OF (NAME) 07

BROTHER/SISTER (NATURAL/STEP) OF

(NAME) 08

AUNT/UNCLE OF (NAME) 09

(NAME'S) SPOUSE 10

OTHER RELATIVE OF (NAME)

(SPECIFY IN QUESTION) 15

NOT RELATED (SPECIFY IN QUESTION) 16

STAFF AT RESIDENCE 17

> DON'T KNOW d
>
> REFUSED r
>
> NAME:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> STREET ADDRESS:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> CITY/STATE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ZIP
> CODE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> TELEPHONE NUMBER: (\|\_\_\_\|\_\_\_\|\_\_\_\|)
> \|\_\_\_\|\_\_\_\|\_\_\_\| - \|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|
>
> AREA CODE
>
> NO CONTACT PERSON 01
>
> DON'T KNOW d
>
> REFUSED r
>
> How is that person related to (FILL "NAME" IF RTYPE=01, 03; "YOU" IF
>
> RTYPE=02), if at all?
>
> ¿Cuál es el parentesco de esa persona con (FILL "NAME" IF RTYPE=01,03;
> "UD." IF RTYPE=02) si es que lo hay?

MOTHER (BIOLOGICAL OR ADOPTIVE) 02

FATHER (BIOLOGICAL OR ADOPTIVE) 03

STEP-PARENT OF (NAME) 04

FOSTER PARENT OF (NAME) 05

UNMARRIED PARTNER OF PARENT 06

GRANDPARENT OF (NAME) 07

BROTHER/SISTER (NATURAL/STEP) OF

(NAME) 08

AUNT/UNCLE OF (NAME) 09

(NAME'S) SPOUSE 10

OTHER RELATIVE OF (NAME)

(SPECIFY IN QUESTION) 15

NOT RELATED (SPECIFY IN QUESTION) 16

STAFF AT RESIDENCE 17

> DON'T KNOW d
>
> REFUSED r
>
> **THANK YOU VERY MUCH!**
>
> **MUCHAS GRACIAS!**
>
> ***Record stop time.***

**INTERVIEWER OBSERVATIONS: (DO NOT READ)**

CP, YP, YA, YX

O3. Who was the respondent to this interview?

*Code only one*

> PARENT/GUARDIAN OF (NAME) 01 *Go to O7*
>
> NAME HIMSELF/HERSELF 02 *Continue*
>
> PROXY FOR NAME 03 *Go to O5*

CP, YP, YA, YX

O4. Was the respondent assisted by anyone during this interview? That
is, did anyone help the respondent in interpreting the questions or
giving answers?

> YES 01 *Continue*
>
> NO 02 *Go to O7*

CP, YP, YA, YX

O5. How is the assistant/proxy related to (NAME)?

> *If more than one assistant or proxy, indicate the relationship of the
> one you consider to be the main assistant or proxy.*

MOTHER (BIOLOGICAL OR ADOPTIVE) 02

FATHER (BIOLOGICAL OR ADOPTIVE) 03

STEP-PARENT OF (NAME) 04

FOSTER PARENT OF (NAME) 05

UNMARRIED PARTNER OF PARENT 06

GRANDPARENT OF (NAME) 07

BROTHER/SISTER (NATURAL/STEP) OF

(NAME) 08

AUNT/UNCLE OF (NAME) 09

(NAME'S) SPOUSE 10

(NAME'S) CHILD 11

FOSTER CHILD LIVING WITH FAMILY 12

HOUSEMATE/ROOMATE/FRIEND 13

ROOMATE/BOARDER 14

OTHER RELATIVE OF (NAME)

(SPECIFY IN QUESTION) 15

OTHER NON-RELATIVE

(SPECIFY IN QUESTION) 16

STAFF AT RESIDENCE 17

> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

O6. Why was an assistant/proxy needed?

> *Code all that apply*
>
> (NAME) DIDN'T KNOW HOW TO ANSWER
>
> SOME QUESTIONS 01
>
> (NAME) HOSPITALIZED 02
>
> (NAME) INSTITUTIONALIZED 03
>
> (NAME) HAS HEARING PROBLEM 04
>
> (NAME) HAS SPEECH PROBLEM 05
>
> (NAME) HAS LANGUAGE PROBLEM 06
>
> (NAME) HAS POOR MEMORY OR
>
> CONFUSION 07
>
> (NAME) HAS OTHER MENTAL CONDITION 08
>
> (NAME) HAS PHYSICAL ILLNESS OR
>
> DISABILITY 09

![](media/image1.wmf) OTHER NON-HEALTH RELATED

REASON (SPECIFY) 10
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> DON'T KNOW d

CP, YP, YA, YX

O7. Do you feel the respondent was intellectually capable of responding?

> YES 01
>
> NO 00
>
> DON'T KNOW d

CP, YP, YA, YX

O8. Do you feel the respondent's answers were reasonably accurate?

> YES 01
>
> NO 00
>
> DON'T KNOW d

CP, YP, YA, YX

O9. Do you feel the respondent understood the questions?

> YES 01
>
> NO 00

DON'T KNOW d

CP, YP, YA, YX

O10. How tiring did the interview seem to be for the respondent?

> VERY TIRING 01
>
> A LITTLE TIRING 00
>
> NOT TIRING d

CP, YP, YA, YX

O11. Did the respondent have difficult hearing you during the interview?

> YES 01
>
> NO 00 *End Interview*
>
> DON'T KNOW d *End Interview*

CP, YP, YA, YX

O12. Do you feel the respondent's hearing difficulty affected the
interview?

> YES 01
>
> NO 00
>
> DON'T KNOW d