F1. CHECK RTYPE: Is RTYPE...

> NAME'S PARENT OR GUARDIAN 01 *Continue*
>
> NAME HIMSELF/HERSELF 02  *Go to F3*

PROXY FOR NAME 03  *Go to F3*

CP, YP

ICHP

F2. Have you (FILL "or your spouse" IF B2=01; FILL "or your partner" IF
B2=02) ever participated in any parent support or parent training groups
for children with disabilities?

¿Ha participado Ud. (FILL "o su esposo(a)" IF B2=01; FILL "o su
parejo(a)" IF B2=02) alguna vez en cualquier grupo de apoyo o grupo de
entrenamiento de padres para niños con incapacidades?

YES 01

NO 00

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

ICHP/NHIS-D (modified)

F3. Now I'm going to ask you about some of the services that (FILL "NAME
RECEIVES" IF RTYPE=01, 03; "YOU RECEIVE" IF RTYPE=02), (FILL "HIS/HER"
IF RTYPE=01, 03; "YOUR" IF RTYPE=02) need for services, and some
out-of-pocket expenses that (FILL "YOU AND YOUR FAMILY" IF RTYPE=01, 02;
"NAME AND HIS/HER FAMILY" IF RTYPE=03) may have had for these services.

During the past 12 months, did (FILL "NAME" IF RTYPE=01, 03; "YOU" IF
RTYPE=02) **receive** any **physical, occupational, or speech**
**therapy**?

Ahora le voy a hacer unas preguntas acerca de algunos de los servicios
que (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) recibe, de sus
necesidades de servicios, y de algunos de los gastos que (FILL "UD." IF
RTYPE=01, 02; "NAME" IF RTYPE=01,03) y su familia quizás han tenido que
pagar de sus propios bolsillos por estos servicios.

Durante los últimos 12 meses, ¿**recibió** (FILL "NAME" IF RTYPE=01,03;
"UD." IF RTYPE=02) cualquier **terapia física, ocupacional, o del
habla**?

> YES 01  *Go to F6*
>
> NO 00

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

ICHP/NHIS-D (modified)

F4. During the past 12 months, did (FILL "NAME" IF RTYPE=01, 03; "YOU"
IF RTYPE=02) **need** any **physical, occupational, or speech**
**therapy**?

> Durante los últimos 12 meses, ¿**necesitó** (FILL "NAME" IF
> RTYPE=01,03; "UD." IF RTYPE=02) cualquier **terapia física,
> ocupacional, o del habla**?
>
> YES 01  *Continue*
>
> ![](media/image1.wmf) NO 00

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

ICHP/NHIS-D (modified)

F5. Why did (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) not receive
any **physical, occupational, or speech therapy**?

¿Por qué no recibió (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
ningún **terapia física, ocupacional, o del habla**?

![](media/image2.wmf) *Do not read list, code all that apply*

(NAME) DIDN'T NEED THE SERVICE 01

PROVIDER THINKS NO LONGER NEEDED 02

TOO EXPENSIVE/CAN'T AFFORD IT 03

INSURANCE OR MEDICAID DOESN'T

COVER IT/NO INSURANCE 04

DON'T KNOW WHERE/HOW TO

GET SERVICE 05

ON WAITING LIST 06

SERVICE NOT AVAILABLE 07

DON'T LIKE PROVIDER 08

TRANSPORTATION PROBLEMS 09

![](media/image3.wmf) COULDN'T TAKE TIME OFF WORK 10

OTHER (SPECIFY) 11

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

ICHP/NHIS-D (modified)

F6. Who paid for the **physical, occupational, or speech therapy** that
(FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) received?

¿Quién pagó por la **terapia física, ocupacional, o del habla, que**
(FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) recibió?

PROBE: For example, (FILL "YOUR FAMILY" IF RTYPE=01; "YOU OR YOUR
FAMILY" IF RTYPE=02; "NAME OR HIS/HER FAMILY" IF RTYPE=03), insurance or
Medicaid, the school system, or something else?

PROBE: Por ejemplo, ¿fue (FILL "SU FAMILIA." IF RTYPE=01; " UD O SU
FAMILIA" IF RTYPE=02; NAME O SU FAMILIA IF RTYPE=03), su seguro o
Medicaid, el sistema de escuelas, o alguna otra cosa?

*Do not read list, code all that apply*

(NAME) 01

(NAME'S) FAMILY LIVING IN SAME

HOUSEHOLD 02

(NAME'S) FAMILY **NOT** LIVING IN SAME

HOUSEHOLD 03

INSURANCE/MEDICAID 04

SCHOOL SYSTEM/SPECIAL EDUCATION 05

TITLE 5 PROGRAM 06

EARLY INTERVENTION 07

> ![](media/image4.wmf) NO ONE/FREE 08 *Go to F8*

OTHER (SPECIFY) 09

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

ICHP/NHIS-D (modified)

F7. In the past 12 months, about how much did (FILL "YOU AND YOUR
FAMILY" IF RTYPE=01, 02; "NAME AND HIS/HER FAMILY" IF RTYPE=03) pay for
**physical, occupational, or speech therapy,** if any? Do not count any
money that has been or will be reimbursed by insurance or from any other
source but include any insurance copayments (FILL "YOU AND YOUR FAMILY"
IF RTYPE=01, 02; "NAME AND HIS/HER FAMILY" if RTYPE=03) may have paid.

En los últimos 12 meses, ¿más o menos cuánto pagaron (FILL "UD."  IF
RTYPE=01, 02; "NAME" IF RTYPE=03) y su familia por **terapia física,
ocupacional, o del habla**, si pagaron algo? Por favor no cuente ningún
dinero que ya ha sido o que será reembolsado por el seguro o por
cualquier otra fuente, pero sí incluya cualquier co-pago (copayment) del
seguro que (FILL "UD." IF RTYPE=01, 02; "NAME" IF RTYPE=03) y su familia
quizás pagaron.

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT PAID (0-99,999)

ENTIRE AMOUNT 01

AMOUNT PER WEEK 02

DON'T KNOW d

REFUSED r

F8. CHECK AGE: Is NAME's age...

\<18 01 *Continue*

18+ 02 *Go to F25*

CP, YP (if age \<18)

F9. During the past 12 months, did (NAME) **receive** any
**respiratory** **therapy**?

Durante los últimos 12 meses, ¿**recibió** (NAME) alguna **terapia**

**respiratoria**?

> YES 01  *Go to F12*
>
> NO 00

DON'T KNOW d

REFUSED r

CP, YP (if age \<18)

F10. During the past 12 months, did (NAME) **need** any **respiratory
therapy**?

Durante los últimos 12 meses, ¿**necesitó** (NAME) alguna **terapia
respiratoria**?

> YES 01
>
> ![](media/image5.wmf) NO 00

DON'T KNOW d

REFUSED .r

CP, YP (if age \<18)

F11. Why did (NAME) not receive any **respiratory therapy**?

¿Por qué no recibió (NAME) ninguna **terapia respiratoria**?

*Do not read list, code all that apply*

![](media/image6.wmf)

(NAME) DIDN'T NEED THE SERVICE 01

PROVIDER THINKS NO LONGER NEEDED 02

TOO EXPENSIVE/CAN'T AFFORD IT 03

INSURANCE OR MEDICAID DOESN'T

COVER IT/NO INSURANCE 04

DON'T KNOW WHERE/HOW TO

GET SERVICE 05

ON WAITING LIST 06

SERVICE NOT AVAILABLE 07

DON'T LIKE PROVIDER 08

TRANSPORTATION PROBLEMS 09

![](media/image7.wmf) COULDN'T TAKE TIME OFF WORK 10

OTHER (SPECIFY) 11

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP (if age \<18)

F12. Who paid for the **respiratory therapy** that (NAME) received?

¿Quién pagó por la **terapia respiratoria** que (NAME) recibió?

> PROBE: For example, your family, insurance or Medicaid, the school
> system, or something else?

PROBE: Por ejemplo, ¿fue su familia, su seguro o Medicaid, el sistema de
escuelas, o alguna otra cosa?

*Do not read list, code all that apply*

(NAME) 01

(NAME'S) FAMILY LIVING IN SAME

HOUSEHOLD 02

(NAME'S) FAMILY **NOT** LIVING IN SAME

HOUSEHOLD 03

INSURANCE/MEDICAID 04

SCHOOL SYSTEM/SPECIAL EDUCATION 05

TITLE 5 PROGRAM 06

EARLY INTERVENTION 07

> ![](media/image8.wmf) NO ONE/FREE 08 *Go to F14*

OTHER (SPECIFY) 09

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP (if age \<18)

ICHP/NHIS-D (modified)

F13. In the past 12 months, about how much did your family pay for
**respiratory** **therapy**, if any? Do not count any money that has
been or will be reimbursed by insurance or from any other source but
include any insurance copayments your family may have paid.

En los últimos 12 meses, ¿más o menos cuánto pagó su familia por
**terapia respiratoria**, si pagó algo? Por favor no cuente ningún
dinero que ya ha sido o que será reembolsado por el seguro o por
cualquier otra fuente, pero sí incluya cualquier co-pago (copayment) del
seguro que su familia quizás haya pagado.

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT PAID BY FAMILY (0-99,999)

ENTIRE AMOUNT 01

AMOUNT PER WEEK 02

DON'T KNOW d

REFUSED r

CP

F14. During the past 12 months, did (NAME) **receive** any
**recreational therapy**?

> Durante los últimos 12 meses, ¿**recibió** (NAME) cualquier **terapia
> de** **recreación**?

PROBE: Recreational therapy provides activities adapted for children
with disabilities such as wheelchair sports and community outings, and
special play activities.

PROBE: Terapia de recreación proporciona actividades ajustadas para
niños con incapacidades, tales como deportes en sillas de rueda y
excursiones comunitarias, y activides especiales de juego.

> YES 01*Go to F17*
>
> NO 00

DON'T KNOW .d

REFUSED .r

CP, YP (if age \<18)

F15. During the past 12 months, did (NAME) **need** any **recreational
therapy**?

Durante los últimos 12 meses, ¿**necesitó** (NAME) alguna **terapia de**
**recreación**?

> YES 01
>
> ![](media/image9.wmf) NO 00

DON'T KNOW d

REFUSED .r

CP, YP (if age \<18)

F16 Why did (NAME) not receive any **recreational therapy**?

¿Por qué no recibió (NAME) ninguna **terapia de** **recreación**?

*Do not read list, code all that apply*

![](media/image10.wmf)

(NAME) DIDN'T NEED THE SERVICE 01

PROVIDER THINKS NO LONGER NEEDED 02

TOO EXPENSIVE/CAN'T AFFORD IT 03

INSURANCE OR MEDICAID DOESN'T

COVER IT/NO INSURANCE 04

DON'T KNOW WHERE/HOW TO

GET SERVICE 05

ON WAITING LIST 06

SERVICE NOT AVAILABLE 07

DON'T LIKE PROVIDER 08

TRANSPORTATION PROBLEMS 09

![](media/image11.wmf) COULDN'T TAKE TIME OFF WORK 10

OTHER (SPECIFY) 11

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP (if age \<18)

F17 Who paid for the **recreational therapy** that (NAME) received?

¿Quién pagó por la **terapia de recreación** que (NAME) recibió?

PROBE: For example, your family, insurance or Medicaid, the school
system, or something else?

PROBE: Por ejemplo, ¿fue su familia, su seguro o Medicaid, el sistema de
escuelas, o alguna otra cosa?

*Do not read list, code all that apply*

(NAME) 01

(NAME'S) FAMILY LIVING IN SAME

HOUSEHOLD 02

(NAME'S) FAMILY **NOT** LIVING IN SAME

HOUSEHOLD 03

INSURANCE/MEDICAID 04

SCHOOL SYSTEM/SPECIAL EDUCATION 05

TITLE 5 PROGRAM 06

EARLY INTERVENTION 07

> ![](media/image12.wmf) NO ONE/FREE 08 *Go to F19*

OTHER (SPECIFY) 09

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP (if age \<18)

F18. In the past 12 months, about how much did your family pay for
**recreational therapy,** if any? Do not count any money that has been
or will be reimbursed by insurance or from any other source but include
any insurance copayments your family may have paid.

En los últimos 12 meses, ¿más o menos cuánto pagó su familia por
**terapia de recreación**, si pagó algo? Por favor no cuente ningún
dinero que ya ha sido o que será reembolsado por el seguro o por
cualquier otra fuente, pero sí incluya cualquier co-pago (copayment) del
seguro que su familia quizás haya pagado.

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT PAID BY FAMILY (0-99,999)

ENTIRE AMOUNT 01

AMOUNT PER WEEK 02

DON'T KNOW d

REFUSED r

CP, YP (if age \<18)

F19. During the past 12 months, did (NAME) **receive** any **audiology
services?** This includes testing for hearing loss, auditory training or
rehabilitation, and fitting for hearing aids or other devices.

Durante los últimos 12 meses, ¿**recibió** (NAME) cualquier **servicio
de audiología**? Esto incluye exámenes de pérdida del (sentido de) oído,
entrenamiento o rehabilitación auditiva, y pruebas para poder usar
aparatos para sordos y otro equipo.

> YES 01  *Go to F22*
>
> NO 00

DON'T KNOW d

REFUSED r

CP, YP (if age \<18)

F20. During the past 12 months, did (NAME) **need** any **audiology
services**?

Durante los últimos 12 meses, ¿**necesitó** (NAME) algún **servicio de
audiología**?

> YES 01
>
> ![](media/image13.wmf) NO 00

DON'T KNOW d

REFUSED r

CP, YP (if age \<18)

F21. Why did (NAME) not receive any **audiology services**?

¿**Por qué no recibió** (NAME) ningunos **servicios de audiología**?

*Do not read list, code all that apply*

![](media/image14.wmf) (NAME) DIDN'T NEED THE SERVICE 01

PROVIDER THINKS NO LONGER NEEDED 02

TOO EXPENSIVE/CAN'T AFFORD IT 03

INSURANCE OR MEDICAID DOESN'T

COVER IT/NO INSURANCE 04

DON'T KNOW WHERE/HOW TO

GET SERVICE 05

ON WAITING LIST 06

SERVICE NOT AVAILABLE 07

DON'T LIKE PROVIDER 08

TRANSPORTATION PROBLEMS 09

![](media/image15.wmf) COULDN'T TAKE TIME OFF WORK 10

OTHER (SPECIFY) 11

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP (if age \<18)

F22. Who paid for the **audiology services** that (NAME) received?

¿Quién pagó por los **servicios de audiología** que (NAME) recibió

PROBE: For example, your family, insurance or Medicaid, the school
system, or something else?

PROBE: Por ejemplo, ¿fue su familia, su seguro o Medicaid, el sistema de
escuelas, o alguna otra cosa?

Do not read list, code all that apply

(NAME) 01

(NAME'S) FAMILY LIVING IN SAME

HOUSEHOLD 02

(NAME'S) FAMILY **NOT** LIVING IN SAME

HOUSEHOLD 03

INSURANCE/MEDICAID 04

SCHOOL SYSTEM/SPECIAL EDUCATION 05

TITLE 5 PROGRAM 06

EARLY INTERVENTION 07

![](media/image16.wmf) NO ONE/FREE 08 *Go to F24*

OTHER (SPECIFY) 09

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP (if age \<18)

F23. In the past 12 months, about how much did your family pay for
**audiology** **services,** if any? Do not count any money that has been
or will be reimbursed by insurance or from any other source but include
any insurance copayments your family may have paid.

En los últimos 12 meses, ¿más o menos cuánto pagó su familia por
**servicios de audiología**, si pagó algo? Por favor no cuente ningún
dinero que ya ha sido o que será reembolsado por el seguro o por
cualquier otra fuente, pero sí incluya cualquier co-pago (copayment) del
seguro que su familia quizás haya pagado.

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT PAID BY FAMILY (0-99,999)

ENTIRE AMOUNT 01

AMOUNT PER WEEK 02

DON'T KNOW d

REFUSED r

F24. CHECK AGE: Is NAME'S age...

\<18 01 *Go to F31*

18+ 02 *Continue*

YP, YA, YX (if age 18+)

F25. During the past 12 months, did (FILL "NAME" IF RTYPE=01, 03; "YOU"
IF RTYPE=02) **receive** any **other type of therapy**, such as
respiratory or recreational therapy?

Durante los últimos 12 meses, ¿**recibió** (FILL "NAME" IF RTYPE=01,03;
"UD." IF RTYPE=02) cualquier **otro tipo de terapia**, tales como
terapia respiratoria, o de recreación?

PROBE: Do not include therapy for mental health or substance abuse.

PROBE: No incluya terapia por salud mental o por abuso de sustancias.

> YES 01
>
> ![](media/image17.wmf) NO 00

DON'T KNOW d

REFUSED r

YP, YA, YX (if age 18+)

F26. What type of therapy was that?

¿Qué tipo de terapia era?

*Read list, code all that apply:*

Respiratory Therapy 01

![](media/image18.wmf) Recreational Therapy 02

Other (SPECIFY) 03

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Terapia Respiratoria 01

![](media/image19.wmf) Terapia de recreación 02

Otra (¿Cuál?) 03

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

YP, YA, YX (if age 18+)

F27. During the past 12 months, did (FILL "NAME" IF RTYPE=01, 03; "YOU"
IF RTYPE=02) **need** any **other type of therapy**?

Durante los últimos 12 meses, ¿**necesitó** (FILL "NAME" IF RTYPE=01,03;
"UD." IF RTYPE=02) cualquier **otro tipo de terapia**?

> YES 01  *Continue*
>
> ![](media/image20.wmf) NO 00

DON'T KNOW d

REFUSED r

YP, YA, YX (if age 18+)

F28. Why did (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) not
receive any **other type of therapy**?

¿Por qué no recibió (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
ningún **otro tipo de terapia**?

![](media/image21.wmf) *Do not read list, code all that apply*

(NAME) DIDN'T NEED THE SERVICE 01

PROVIDER THINKS NO LONGER NEEDED 02

TOO EXPENSIVE/CAN'T AFFORD IT 03

INSURANCE OR MEDICAID DOESN'T

COVER IT/NO INSURANCE 04

DON'T KNOW WHERE/HOW TO

GET SERVICE 05

ON WAITING LIST 06

SERVICE NOT AVAILABLE 07

DON'T LIKE PROVIDER 08

TRANSPORTATION PROBLEMS 09

![](media/image22.wmf) COULDN'T TAKE TIME OFF WORK 10

OTHER (SPECIFY) 11

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

YP, YA, YX (if age 18+)

F29. Who paid for the (FILL "RESPIRATORY THERAPY" IF F26=01;
"RECREATIONAL THERAPY" IF F26=02; "OTHER TYPE OF THERAPY" IF F26=03;
"RESPIRATORY AND RECREATIONAL THERAPY" IF F26=01 AND 02; "RESPIRATORY
THERAPY AND OTHER THERAPY" IF F26=01 AND 03; "RECREATIONAL AND OTHER
THERAPY" IF F26=02 AND 03; "RESPIRATORY, RECREATIONAL AND OTHER TYPE OF
THERAPY" IF F26=01,02, AND 03) that (FILL "NAME" IF RTYPE=01, 03; "YOU"
IF RTYPE=02) received?

¿Quién pagó por la (FILL "Terapia Respiratoria" IF F26=01; "TERAPIA
RECREACIóN" IF F26=02; "OTRA TIPO DE TERAPIA" IF F26=03; "Terapia
Respiratoria Y TERAPIA RECREACIóN" IF F26=01 AND 02; "Terapia
Respiratoria Y OTRO TIPO DE TERAPIA" IF F26=01 AND 03; "TERAPIA
RECREACIóN Y OTRO TIPO DE TERAPIA" IF F26=02 AND 03; "TERAPIA
RESPIRATORIA, TERAPIA DE RECREACIóN Y OTRO TIPO DE TERAPIA" IF
F26=01,02, AND 03) que (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
recibió?

PROBE: For example, (FILL "YOUR FAMILY" IF RTYPE=01, "YOU OR YOUR
FAMILY" IF RTYPE=02; "NAME OR HIS/HER FAMILY" IF RTYPE=03), insurance or
Medicaid, the school system, or something else?

PROBE: Por ejemplo, ¿fue (FILL "SU FAMILIA" IF RTYPE=01, UD. O SU
FAMILIA IF RTYPE=02; "NAME O SU FAMILIA " IF RTYPE=03), su seguro o
Medicaid, el sistema de escuelas, o alguna otra cosa?

*Do not read list, code all that apply*

(NAME) 01

(NAME'S) FAMILY LIVING IN SAME

HOUSEHOLD 02

(NAME'S) FAMILY **NOT** LIVING IN SAME

HOUSEHOLD 03

INSURANCE/MEDICAID 04

SCHOOL SYSTEM/SPECIAL EDUCATION 05

TITLE 5 PROGRAM 06

EARLY INTERVENTION 07

> ![](media/image23.wmf) NO ONE/FREE 08 *Go to F31*

OTHER (SPECIFY) 09

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

YP, YA, YX (if age 18+)

F30. In the past 12 months, about how much did (FILL "YOU AND YOUR
FAMILY" IF RTYPE=01, 02; "NAME AND HIS/HER FAMILY" IF RTYPE=03) pay for
(FILL "RESPIRATORY THERAPY" IF F26=01; "RECREATIONAL THERAPY" IF F26=02;
"OTHER TYPE OF THERAPY" IF F26=03; "RESPIRATORY AND RECREATIONAL
THERAPY" IF F26=01 AND 02; "RESPIRATORY THERAPY AND OTHER THERAPY" IF
F26=01 AND 03; "RECREATIONAL AND OTHER THERAPY" IF F26=02 AND 03;
"RESPIRATORY, RECREATIONAL AND OTHER TYPE OF THERAPY" IF F26=01,02, AND
03) if any? Do not count any money that has been or will be reimbursed
by insurance or from any other source but include any insurance
copayments (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) and (FILL
"YOUR" IF RTYPE=01,02; "HIS/HER" IF RTYPE=03) family may have paid.

En los últimos 12 meses, ¿más o menos cuánto pagaron (FILL "UD." IF
RTYPE=01, 02; "NAME" IF RTYPE=03) y su familia por (FILL "Terapia
Respiratoria" IF F26=01; "TERAPIA RECREACIóN" IF F26=02; "OTRA TIPO DE
TERAPIA" IF F26=03; "Terapia Respiratoria Y TERAPIA RECREACIóN" IF
F26=01 AND 02; "Terapia Respiratoria Y OTRO TIPO DE TERAPIA" IF F26=01
AND 03; "TERAPIA RECREACIóN Y OTRO TIPO DE TERAPIA" IF F26=02 AND 03;
"TERAPIA RESPIRATORIA, TERAPIA DE RECREACIóN Y OTRO TIPO DE TERAPIA" IF
F26=01,02, AND 03), si pagaron algo? Por favor no cuente ningún dinero
que ya ha sido o que será reembolsado por el seguro o por cualquier otra
fuente, pero sí incluya cualquier co-pago (copayment) del seguro que
(FILL "UD." IF RTYPE=01, 02; "NAME" IF RTYPE=03) y su familia quizás
pagaron.

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT PAID (0-99,999)

ENTIRE AMOUNT 01

AMOUNT PER WEEK 02

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

F31. During the past 12 months, did (FILL "NAME" IF RTYPE=01, 03; "YOU"
IF RTYPE=02) **receive** any special **transportation** **services** to
travel to and from medical appointments or other places?

Durante los últimos 12 meses, ¿**recibió** (FILL "NAME" IF RTYPE=01,03;
"UD." IF RTYPE=02) algún **servicio** especial **de transporte** para ir
y regresar a citas médicas u otros lugares?

> YES 01  *Go to F34*
>
> NO 00

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

F32. During the past 12 months, did (FILL "NAME" IF RTYPE=01, 03; "YOU"
IF RTYPE=02) **need** any special **transportation services**?

Durante los últimos 12 meses, ¿**necesitó** (FILL "NAME" IF RTYPE=01,03;
"UD." IF RTYPE=02) algún **servicio** especial **de transporte**?

> YES 01  *Continue*
>
> ![](media/image24.wmf) NO 00

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

F33. Why did (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) not
receive any special **transportation services**?

¿Por qué no recibió (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
ningunos **servicios** especiales **de transporte**?

*Do not read list, code all that apply*

![](media/image25.wmf)

(NAME) DIDN'T NEED THE SERVICE 01

PROVIDER THINKS NO LONGER NEEDED 02

TOO EXPENSIVE/CAN'T AFFORD IT 03

INSURANCE OR MEDICAID DOESN'T

COVER IT/NO INSURANCE 04

DON'T KNOW WHERE/HOW TO

GET SERVICE 05

ON WAITING LIST 06

SERVICE NOT AVAILABLE 07

DON'T LIKE PROVIDER 08

TRANSPORTATION PROBLEMS 09

![](media/image26.wmf) COULDN'T TAKE TIME OFF WORK 10

OTHER (SPECIFY) 11

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

F34. Who paid for the special **transportation services** that (FILL
"NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) received?

¿Quién pagó por los **servicios** especiales **de transporte**, que
(FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) recibió?

PROBE: For example, (FILL "YOUR FAMILY" IF RTYPE=01, "YOU OR YOUR
FAMILY" IF RTYPE=02; "NAME OR HIS/HER FAMILY" IF RTYPE=03), insurance or
Medicaid, the school system, or something else?

PROBE: Por ejemplo, ¿fue (FILL "SU FAMILIA" IF RTYPE=01, "UD. O SU
FAMILIA" IF RTYPE=02; "NAME O SU FAMILIA " IF RTYPE=03), su seguro o
Medicaid, el sistema de escuelas, o alguna otra cosa?

(NAME) 01

(NAME'S) FAMILY LIVING IN SAME

HOUSEHOLD 02

(NAME'S) FAMILY **NOT** LIVING IN SAME

HOUSEHOLD 03

INSURANCE/MEDICAID 04

SCHOOL SYSTEM/SPECIAL EDUCATION 05

TITLE 5 PROGRAM 06

EARLY INTERVENTION 07

> ![](media/image27.wmf) NO ONE/FREE 08 *Go to F36*

OTHER (SPECIFY) 09

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

F35. In the past 12 months, about how much did (FILL "YOU AND YOUR
FAMILY" IF RTYPE=01,02; "NAME AND HIS/HER FAMILY" IF RTYPE=03) family
pay for special **transportation services,** if any? Do not count any
money that has been or will be reimbursed by insurance or from any other
source but include any insurance copayments that (FILL "NAME" IF
RTYPE=01, 03; "YOU" IF RTYPE=02) and (FILL "YOUR" IF RTYPE=01, 02;
"HIS/HER" IF RTYPE=03) family may have paid.

En los últimos 12 meses, ¿más o menos cuánto pagaron (FILL "UD." IF
RTYPE=01,02; "NAME" IF RTYPE=03) y su familia por **servicios de
transporte** especiales, si pagaron algo? Por favor no cuente ningún
dinero que ya ha sido o que será reembolsado por el seguro o por
cualquier otra fuente, pero sí incluya cualquier co-pago (copayment) del
seguro que (FILL "UD." IF RTYPE=01,02; "NAME" IF RTYPE=03) y su familia
quizás pagaron.

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT PAID (0-99,999)

ENTIRE AMOUNT 01

AMOUNT PER WEEK 02

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

F36. CHECK AGE: Is NAME's age...

> \<18 01 *Go to F48*
>
> 18+ 02 *Continue*

YP, YA, YX

F37. CHECK A10 or A87b: Is (NAME) living in a residential facility or
nursing home

(A10 or A87b=4 or 8)?

YES 01 *Go to F60*

NO 00 *Continue*

YP, YA, YX (if age 18+, not in group/nursing home)

F38. During the past 12 months, did (FILL "NAME" IF RTYPE=01, 03; "YOU"
IF RTYPE=02) **receive** any services from a **personal care
attendant**, other than a family member or friend?

Durante los últimos 12 meses, ¿**recibió** (FILL "NAME" IF RTYPE=01,03;
"UD." IF RTYPE=02) servicios de un(a) **asistente de cuidado personal**
(**personal care attendant**), además de un miembro de la familia o una
amistad?

PROBE: A personal care attendant is someone people hire to help them in
daily tasks such as bathing, dressing, and eating that they cannot do
because of a disability or health condition.

PROBE IF A9, A10, A87b=06: This does not include personal care

assistance that (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02)

received from staff at school as a part of the cost of attending that
school.

PROBE: Un asistente de cuidado personal es alguien que es empleado(a)
por gente, para ayudar en tareas diarias tales como bañarse, vestirse y
comer, que no pueden hacer por causa de un incapacidad o condición de
salud.

PROBE IF A9, A10, OR A87b=06: Esto no incluye asistencia de cuidado

personal que ("NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02) recibió de

empleados en la escuela como parte del costo de asistir a esa escuela.

> YES 01  *Go to F41*
>
> NO 00

DON'T KNOW d

REFUSED r

YP, YA, YX (if age 18+, not in group/nursing home)

F39. During the past 12 months, did (FILL "NAME" IF RTYPE=01, 03; "YOU"
IF RTYPE=02) **need** any services from a **personal care attendant**?

Durante los últimos 12 meses, ¿**necesitó** (FILL "NAME" IF RTYPE=01,03;
"UD." IF RTYPE=02) algun servicio de un(a) **asistente de cuidado
personal**?

> YES 01
>
> ![](media/image28.wmf) NO 00

DON'T KNOW d

REFUSED r

YP, YA, YX (if age 18+, not in group/nursing home)

F40. Why did (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) not
receive any services from a **personal care attendant**?

¿Por qué no recibió (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
ningunos servicios de un(a) **asistente de cuidado personal**?

*Do not read list, code all that apply*

![](media/image29.wmf) (NAME) DIDN'T NEED THE SERVICE 01

PROVIDER THINKS NO LONGER NEEDED 02

TOO EXPENSIVE/CAN'T AFFORD IT 03

INSURANCE OR MEDICAID DOESN'T

COVER IT/NO INSURANCE 04

DON'T KNOW WHERE/HOW TO

GET SERVICE 05

ON WAITING LIST 06

SERVICE NOT AVAILABLE 07

DON'T LIKE PROVIDER 08

TRANSPORTATION PROBLEMS 09

![](media/image30.wmf) COULDN'T TAKE TIME OFF WORK 10

OTHER (SPECIFY) 11

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

YP, YA, YX (if age 18+, not in group/nursing home)

F41. Who paid for the services from a **personal care attendant** that
(FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) received?

¿Quién pagó por los servicios de un(a) **asistente de cuidado
personal**, que (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) recibió?

PROBE: For example, (FILL "YOUR FAMILY" IF RTYPE=01, "YOU OR YOUR
FAMILY" IF RTYPE=02; "NAME OR HIS/HER FAMILY" IF RTYPE=03), insurance or
Medicaid, the school system, or something else?

PROBE: Por ejemplo, ¿fue (FILL "SU FAMILIA" IF RTYPE=01, UD. O SU
FAMILIA IF RTYPE=02; "NAME O SU FAMILIA " IF RTYPE=03), su seguro o
Medicaid, el sistema de escuelas, o alguna otra cosa?

*Do not read list, code all that apply*

(NAME) 01

(NAME'S) FAMILY LIVING IN SAME

HOUSEHOLD 02

(NAME'S) FAMILY **NOT** LIVING IN SAME

HOUSEHOLD 03

INSURANCE/MEDICAID 04

SCHOOL SYSTEM/SPECIAL EDUCATION 05

TITLE 5 PROGRAM 06

EARLY INTERVENTION 07

> ![](media/image31.wmf) NO ONE/FREE 08 *Go to F43*

OTHER (SPECIFY) 09

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

YP, YA, YX (if age 18+, not in group/nursing home)

F42. In the past 12 months, about how much did (FILL "YOU AND YOUR
FAMILY" IF RTYPE=01, 02; "NAME AND HIS/HER FAMILY" IF RTYPE=03) family
pay for services from a **personal care attendant**, if any? Do not
count any money that has been or will be reimbursed by insurance or from
any other source but include any insurance copayments that (FILL "NAME"
IF RTYPE=01, 03; "YOU" IF RTYPE=02) and (FILL "HIS/HER" IF RTYPE=01,03;
"YOUR" IF RTYPE=02) family may have paid.

En los últimos 12 meses, ¿más o menos cuánto pagaron (FILL  "UD. " IF
RTYPE=01, 02 ; "NAME" IF RTYPE=03) y su familia por servicios de un(a)
**asistente de cuidado personal**, si pagaron algo? Por favor no cuente
ningún dinero que ya ha sido o que será reembolsado por el seguro o por
cualquier otra fuente, pero sí incluya cualquier co-pago (copayment) del
seguro que (FILL "UD." IF RTYPE=01,02; "NAME" IF RTYPE=03) y su familia
quizás pagaron.

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT PAID (0- 99,999)

ENTIRE AMOUNT 01

AMOUNT PER WEEK 02

DON'T KNOW d

REFUSED r

YP, YA, YX (if age 18+, not in group/nursing home)

F43. During the past 12 months, did (FILL "NAME" IF RTYPE=01, 03; "YOU"
IF RTYPE=02) **receive** any services from **an adult day care center or
day activity center**?

Durante los últimos 12 meses, ¿**recibió** (FILL "NAME" IF RTYPE=01,03;
"UD." IF RTYPE=02) cualquier servicio de **un centro de cuidado diurno
de adultos (adult day care) o un centro de actividades diurnas (day
activity)**?

PROBE: Adult day care is for people who are not fully able to care for
themselves and require some help or supervision during the day at a
place other than their home.

PROBE: Cuidado diurno de adultos (Adult day care) es para personas que
no pueden cuidarse completamente sólos, y necesitan algo de ayuda o
supervisión durante el día, en un lugar fuera de su hogar.

> YES 01  *Go to F46*
>
> NO 00

DON'T KNOW d

REFUSED r

YP, YA, YX (if age 18+, not in group/nursing home)

F44. During the past 12 months, did (FILL "NAME" IF RTYPE=01, 03; "YOU"
IF RTYPE=02) **need** any services from **an adult day care center or
day activity center**?

Durante los últimos 12 meses, ¿**necesitó** (FILL "NAME" IF RTYPE=01,03;
"UD." IF RTYPE=02) cualquier servicio de **un centro de cuidado diurno
de adultos (adult day care) o un centro de actividades diurnas (day
activity)**?

> YES 01  *Continue*
>
> ![](media/image32.wmf) NO 00

DON'T KNOW d

REFUSED r

YP, YA, YX (if age 18+, not in group/nursing home)

F45. Why did (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) not
receive any services from an **adult day care center** **or** **day
activity center**?

¿Por qué no recibió (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
servicios de **un centro de cuidado diurno de adultos (adult day care) o
un centro de actividades diurnas (day activity)**?

*Do not read list, code all that apply*

![](media/image33.wmf) (NAME) DIDN'T NEED THE SERVICE 01

PROVIDER THINKS NO LONGER NEEDED 02

TOO EXPENSIVE/CAN'T AFFORD IT 03

INSURANCE OR MEDICAID DOESN'T

COVER IT/NO INSURANCE 04

DON'T KNOW WHERE/HOW TO

GET SERVICE 05

ON WAITING LIST 06

SERVICE NOT AVAILABLE 07

DON'T LIKE PROVIDER 08

TRANSPORTATION PROBLEMS 09

![](media/image34.wmf) COULDN'T TAKE TIME OFF WORK 10

OTHER (SPECIFY) 11

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

YP, YA, YX (if age 18+, not in group/nursing home)

F46. Who paid for the services from an **adult day care center or day
activity center** that (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02)
received?

> ¿Quién pagó por los servicios de **un centro de cuidado diurno de
> adultos (adult day care) o un centro de actividades diurnas (day
> activity)**, que (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
> recibió?

PROBE: For example, (FILL "YOUR FAMILY" IF RTYPE=01, "YOU OR YOUR
FAMILY" IF RTYPE=02; "NAME OR HIS/HER FAMILY" IF RTYPE=03), insurance or
Medicaid, the school system, or something else?

> PROBE: Por ejemplo, ¿fue (FILL "SU FAMILIA" IF RTYPE=01, UD. O SU
> FAMILIA IF RTYPE=02; "NAME O SU FAMILIA " IF RTYPE=03), su seguro o
> Medicaid, el sistema de escuelas, o alguna otra cosa*?*

*Do not read list, code all that apply*

(NAME) 01

(NAME'S) FAMILY LIVING IN SAME

HOUSEHOLD 02

(NAME'S) FAMILY **NOT** LIVING IN SAME

HOUSEHOLD 03

INSURANCE/MEDICAID 04

SCHOOL SYSTEM/SPECIAL EDUCATION 05

TITLE 5 PROGRAM 06

EARLY INTERVENTION 07

> ![](media/image35.wmf) NO ONE/FREE 08 *Go to F48*

OTHER (SPECIFY) 09

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

YP, YA, YX (if age 18+, not in group/nursing home)

F47. In the past 12 months, about how much did (FILL "YOU AND YOUR
FAMILY" IF RTYPE=01, 02; "NAME AND HIS/HER FAMILY" IF RTYPE=03) pay for
services from an **adult day care center or day activity center**, if
any? Do not count any money that has been or will be reimbursed by
insurance or from any other source but include any insurance copayments
(FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) and (FILL "HIS/HER" IF
RTYPE=01,03; "YOUR" IF RTYPE=02) family may have paid.

En los últimos 12 meses, ¿más o menos cuánto pagaron (FILL "UD." IF
RTYPE=01,02; "NAME" IF RTYPE=03) y su familia por servicios de un
**centro de cuidado diurno de adultos o un centro de actividades
diurnas**, si pagaron algo? Por favor no cuente ningún dinero que ya ha
sido o que será reembolsado por el seguro o por cualquier otra fuente,
pero sí incluya cualquier co-pago (copayment) del seguro que (FILL "UD."
IF RTYPE=01,02; "NAME" IF RTYPE=03) y su familia quizás pagaron.

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT PAID (0-99,999)

ENTIRE AMOUNT 01

AMOUNT PER WEEK 02

DON'T KNOW d

REFUSED r

F48. CHECK RTYPE: Is RTYPE...

> NAME'S PARENT OR GUARDIAN 01  *Continue*
>
> NAME HIM/HER SELF 02 *Go to F60*

PROXY FOR NAME 03 *Go to F60*

CP, YP

F49. During the past 12 months, did your family receive any **respite
care**? Respite care is a service provided to families so the family
caregivers can go on vacation or take a break. It can be provided by a
person or organization at your home or somewhere else.

Durante los últimos 12 meses, ¿recibió su familia algún **relevo de
descanso del cuidador (respite care)**? **Relevo de descanso del
cuidador** es un servicio proporcionado a familias para que los
cuidadores (caregivers) en la familia puedan disfrutar de vacaciones o
tener un descanso. El servicio puede ser proporcionado por una persona o
una organización, y puede ser en su hogar o en otro lugar.

> YES 01  *Go to F52*
>
> NO 00

DON'T KNOW d

REFUSED r

CP, YP

F50. During the past 12 months, did your family **need** any **respite
care** services?

Durante los últimos 12 meses, ¿**necesitó** su familia algún servicio de
**relevo de descanso del cuidador**?

> YES 01  *Continue*
>
> ![](media/image36.wmf) NO 00

DON'T KNOW d

REFUSED r

CP, YP

F51. Why did your family not receive any **respite care** services?

¿Por qué no recibió su familia ningunos servicios de **relevo de
descanso del cuidador**?

![](media/image37.wmf)

FAMILY DIDN'T NEED THE SERVICE 01

(NAME) WON'T ACCEPT RESPITE CARE 02

TOO EXPENSIVE/CAN'T AFFORD IT 03

INSURANCE OR MEDICAID DOESN'T

COVER IT/NO INSURANCE 04

DON'T KNOW WHERE/HOW TO

GET SERVICE 05

ON WAITING LIST 06

SERVICE NOT AVAILABLE 07

DON'T LIKE PROVIDER 08

TRANSPORTATION PROBLEMS 09

![](media/image38.wmf) COULDN'T TAKE TIME OFF WORK 10

OTHER (SPECIFY) 11

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP

F52. Who paid for the **respite care** services that your family
received?

¿Quién pagó por los servicios de **relevo de descanso del cuidador** que
su familia recibió?

PROBE: For example, your family, insurance or Medicaid, or something
else?

PROBE: Por ejemplo, ¿fue su familia, su seguro o Medicaid, o alguna otra
cosa?

*Do not read list, code all that apply*

(NAME) 01

(NAME'S) FAMILY LIVING IN SAME

HOUSEHOLD 02

(NAME'S) FAMILY **NOT** LIVING IN SAME

HOUSEHOLD 03

INSURANCE/MEDICAID 04

SCHOOL SYSTEM/SPECIAL EDUCATION 05

TITLE 5 PROGRAM 06

EARLY INTERVENTION 07

> ![](media/image39.wmf) NO ONE/FREE 08 *Go to F55*

OTHER (SPECIFY) 09

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP

ICHP/NHIS-D (modified)

F53. In the past 12 months, about how much did your family pay for
**respite care** services, if any? Do not count any money that has been
or will be reimbursed by insurance or from any other source but include
any insurance copayments your family may have paid.

En los últimos 12 meses, ¿más o menos cuánto pagó su familia por
**relevo de descanso del cuidador (respite care)**, si pagó algo? Por
favor no cuente ningún dinero que ya ha sido o que será reembolsado por
el seguro o por cualquier otra fuente, pero sí incluya cualquier co-pago
(copayment) del seguro que su familia quizás pagó.

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT PAID (0-99,999)

ENTIRE AMOUNT 01

AMOUNT PER WEEK 02

DON'T KNOW d

REFUSED r

F54. Deleted

CP, YP

F55. During the past 12 months, did you or other family members
**receive** **any mental health care or counseling** because of (NAME's)
health?

Durante los últimos 12 meses, ¿**recibió** Ud. o recibieron otros
miembros de la familia algún **servicio de consejo o salud mental** por
causa del estado de salud de (NAME)?

> YES 01  *Go to F58*
>
> NO 00

DON'T KNOW d

REFUSED r

CP, YP

F56. During the past 12 months, did you or other family members **need**
any **mental health care or counseling** because of (NAME's) health?

> Durante los últimos 12 meses, ¿**necesitaba** Ud. o necesitaban otros
> miembros de la familia algún **servicio de consejo** **o salud
> mental** por causa del estado de salud de (NAME)?
>
> YES 01

![](media/image40.wmf) NO 00

DON'T KNOW d

REFUSED r

CP, YP

F57. Why did you or other family members not receive any **mental health
care or counseling?**

¿Por qué no recibió Ud. o no recibieron otros miembros de la familia
**servicios de consejo** **o salud mental?**

*Do not read list, code all that apply*

![](media/image41.wmf) DIDN'T NEED THE SERVICE 01

PROVIDER THINKS NO LONGER NEEDED 02

TOO EXPENSIVE/CAN'T AFFORD IT 03

INSURANCE OR MEDICAID DOESN'T

COVER IT/NO INSURANCE 04

DON'T KNOW WHERE/HOW TO

GET SERVICE 05

ON WAITING LIST 06

SERVICE NOT AVAILABLE 07

DON'T LIKE PROVIDER 08

TRANSPORTATION PROBLEMS 09

![](media/image42.wmf) COULDN'T TAKE TIME OFF WORK 10

OTHER (SPECIFY) 11

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP

F58. Who paid for the **mental health care or counseling** you or your
family members received?

¿Quién pagó por los **servicios de consejería** **o salud mental** que
Ud. u otros miembros de la familia recibieron?

PROBE: For example, your family, your insurance or Medicaid, or
something else?

PROBE: Por ejemplo, ¿fue su familia, su seguro o Medicaid, o alguna otra
cosa?

*Do not read list, code all that apply*

(NAME) 01

(NAME'S) FAMILY LIVING IN SAME

HOUSEHOLD 02

(NAME'S) FAMILY **NOT** LIVING IN SAME

HOUSEHOLD 03

INSURANCE/MEDICAID 04

SCHOOL SYSTEM/SPECIAL EDUCATION 05

TITLE 5 PROGRAM 06

EARLY INTERVENTION 07

> ![](media/image43.wmf) NO ONE/FREE 08 *Go to F60*

OTHER (SPECIFY) 09

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP

F59. In the past 12 months, about how much did your family pay for
**mental health care** **or counseling**, if any? Do not count any money
that has been or will be reimbursed by insurance or from any other
source but include any insurance copayments your family may have paid.

En los últimos 12 meses, ¿más o menos cuánto pagó su familia por
**servicios de consejo** **o salud mental**, si pagó algo? Por favor no
cuente ningún dinero que ya ha sido o que será reembolsado por el seguro
o por cualquier otra fuente, pero sí incluya cualquier co-pago
(copayment) del seguro que su familia quizás pagó.

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT PAID BY FAMILY (0-99,999)

ENTIRE AMOUNT 01

AMOUNT PER WEEK 02

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

Created

F60. In the past 12 months, (FILL "HAS NAME" If RTYPE=01, 03; "HAVE YOU"
IF RTYPE=02) received any **other services** that we haven't yet talked
about?

> En los últimos 12 meses, ¿recibió (FILL "NAME" IF RTYPE=01,03; "UD."
> IF RTYPE=02) algún **otro servicio** del cual aún no hemos hablado?

YES 01

![](media/image44.wmf) NO 00

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

Created

F61. What services are these?

¿Qué servicios son?

*Do not read list, code all that apply*

DOCTOR VISITS 01

HOSPITAL CARE 02

MENTAL HEALTH COUNSELING 03

PERSONAL ATTENDANT OR HOME CARE

SERVICES 04

SPECIAL EDUCATION 05

SKILLED NURSING (RN/LPN) SERVICES 06

SOCIAL WORK SERVICES 07

TRAINING IN SELF-CARE OR HOMEMAKING 08

TRAINING IN SOCIAL SKILLS 09

![](media/image45.wmf) OTHER THERAPY SERVICES 10

OTHER (SPECIFY) 11

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

F62. Who paid for these **other services** that (FILL "NAME" IF
RTYPE=01, 03; "YOU" IF RTYPE=02) received?

> ¿Quién pagó por estos **otros servicios** que (FILL "NAME" IF
> RTYPE=01,03; "UD." IF RTYPE=02) recibió?

PROBE: For example, (FILL "YOUR FAMILY" IF RTYPE=01, "YOU OR YOUR
FAMILY" IF RTYPE=02; "NAME OR HIS/HER FAMILY" IF RTYPE=03), insurance or
Medicaid, the school system, or something else?

PROBE: Por ejemplo, ¿fue (FILL "SU FAMILIA" IF RTYPE=01, UD. O SU
FAMILIA IF RTYPE=02; "NAME O SU FAMILIA " IF RTYPE=03), su seguro o
Medicaid, el sistema de escuelas, o alguna otra cosa?

*Do not read list, code all that apply*

(NAME) 01

(NAME'S) FAMILY LIVING IN SAME

HOUSEHOLD 02

(NAME'S) FAMILY **NOT** LIVING IN SAME

HOUSEHOLD 03

INSURANCE/MEDICAID 04

SCHOOL SYSTEM/SPECIAL EDUCATION 05

TITLE 5 PROGRAM 06

EARLY INTERVENTION 07

> ![](media/image46.wmf) NO ONE/FREE 08 *Go to F64*

OTHER (SPECIFY) 09

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

F63. In the past 12 months, about how much did (FILL "YOU AND YOUR
FAMILY" IF RTYPE=01, 02; "NAME AND HIS/HER FAMILY" IF RTYPE=03) pay for
these **other services**, if any? Do not count any money that has been
or will be reimbursed by insurance or from any other source but include
any insurance copayments (FILL "NAME" IF RTYPE=01, 03; "YOU" IF
RTYPE=02) and (FILL "YOUR" IF RTYPE=01,02; "HIS/HER" IF RTYPE=03) family
may have paid.

> En los últimos 12 meses, ¿más o menos cuánto pagaron (FILL "UD." IF
> RTYPE=01, 02; "NAME" IF RTYPE=03) y su familia por estos **otros
> servicios**, si pagaron algo? Por favor no cuente ningún dinero que ya
> ha sido o que será reembolsado por el seguro o por cualquier otra
> fuente, pero sí incluya cualquier co-pago (copayment) del seguro que
> (FILL "UD." IF RTYPE=01, 02; "NAME" IF RTYPE=03) y su familia quizás
> pagaron.

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT PAID BY FAMILY (0-99,999)

ENTIRE AMOUNT 01

AMOUNT PER WEEK 02

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

Created

F64. Are there any services that (FILL "NAME" IF RTYPE=01, 03; "YOU" IF
RTYPE=02) now **need(s)** but (FILL "IS" IF RTYPE=01, 03; "ARE" IF
RTYPE=02) not receiving that we haven't yet talked about?

¿Hay algún otro servicio que (FILL "NAME" IF RTYPE=01,03; "UD." IF
RTYPE=02) **necesita** ahora, pero no está recibiendo, y del cuál ya no
hemos hablado?

YES 01 *Continue*

![](media/image47.wmf) NO 00

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CP, YP, YA, YX

Created

F65. What are these services?

¿Cuáles son estos servicios?

*Do not read list, code all that apply*

DOCTOR VISITS 01

HOSPITAL CARE 02

MENTAL HEALTH COUNSELING 03

SPECIAL EDUCATION 04

VISITING NURSE (RN/LPN) SERVICES 05

SOCIAL WORK SERVICES 06

TRAINING IN SELF-CARE OR

HOMEMAKING 07

TRAINING IN SOCIAL SKILLS 08

![](media/image48.wmf) OTHER THERAPY SERVICES 09

OTHER (SPECIFY) 10

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

F66. Why (FILL "IS NAME" IF RTYPE=01, 03; "ARE YOU" IF RTYPE=02) not
receiving (THIS SERVICE/THESE SERVICES)?

¿Por qué no está (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
recibiendo (este servicio/estos servicios)?

*Do not read list, code all that apply*

(NAME) DIDN'T NEED THE SERVICE 01

PROVIDER THINKS NO LONGER NEEDED 02

TOO EXPENSIVE/CAN'T AFFORD IT 03

INSURANCE OR MEDICAID DOESN'T

COVER IT/NO INSURANCE 04

DON'T KNOW WHERE/HOW TO

GET SERVICE 05

ON WAITING LIST 06

SERVICE NOT AVAILABLE 07

DON'T LIKE PROVIDER 08

TRANSPORTATION PROBLEMS 09

![](media/image49.wmf) COULDN'T TAKE TIME OFF WORK 10

OTHER (SPECIFY) 11

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

ICHP (modified)

F67. Next, I'm going to ask you about specific items (FILL "NAME" IF
RTYPE=01, 03; "YOU" IF RTYPE=02) may have used last month, that is in
(FILL LAST MONTH), and how much (FILL "YOU AND YOUR FAMILY" IF RTYPE=01,
02; "NAME AND HIS/HER FAMILY" IF RTYPE=03) paid for these items
out-of-pocket. Out-of-pocket expenses are those that (FILL "YOU AND YOUR
FAMILY" IF RTYPE=01, 02; "NAME AND HIS/HER FAMILY" IF RTYPE=03) paid
that were not covered by insurance or paid by a program.

Ahora, le voy a preguntar de cosas específicas que (FILL "NAME" IF
RTYPE=01,03; "UD." IF RTYPE=02) quizás usó el mes pasado, o sea en (FILL
LAST MONTH), y de cuánto han pagado (FILL "UD." IF RTYPE=01,02; "NAME"
IF RTYPE=03) y su familia de sus propio bolsillo por estas cosas. Pagos
de su propio bolsillo son los que (FILL "UD." IF RTYPE=01,02; "NAME" IF
RTYPE=03) y su familia pagan por sí mismos, y que no eran cubiertos por
el seguro, o pagados por algún programa.

+--------------------------+--------------------+---------------------+
| Question                 | Answer             | (Ask if yes) How    |
|                          |                    | much did (FILL "YOU |
|                          |                    | AND YOUR FAMILY" IF |
|                          |                    | RTYPE=01,02; "NAME  |
|                          |                    | AND HIS/HER FAMILY" |
|                          |                    | IF RTYPE=03) pay    |
|                          |                    | out-of-pocket for   |
|                          |                    | (INSERT ITEM) in    |
|                          |                    | (LAST MONTH)?       |
|                          |                    |                     |
|                          |                    | ¿Cuánto pagaron     |
|                          |                    | (FILL "UD." IF      |
|                          |                    | RTYPE=01,02; "NAME" |
|                          |                    | IF RTYPE=03) y su   |
|                          |                    | familia de su       |
|                          |                    | propio bolsillo por |
|                          |                    | (INSERT ITEM) en    |
|                          |                    | (LAST MONTH)?       |
+==========================+====================+=====================+
| A.  In (LAST MONTH) did  | > YES 01           | \$\_                |
|     (FILL "NAME" IF      | >                  | \_\_\_\_\_\_\_\_.00 |
|     RTYPE=01, 03; "YOU"  | > NO 00            | AMOUNT (0-9,999)    |
|     IF RTYPE=02) use any | >                  |                     |
|     medications for      | > DON'T KNOW d     | OR:                 |
|     (FILL "HIS/HER" IF   | >                  |                     |
|     RTYPE=01,03; YOUR"   | > REFUSED r        | \$                  |
|     IF RTYPE=02) health  |                    | \_\_\_\_\_\_\_\_.00 |
|     care needs?          |                    | per week            |
|                          |                    |                     |
| > ¿En (LAST MONTH) usó   |                    | (0-9,999)           |
| > (FILL "NAME" IF        |                    |                     |
| > RTYPE=01,03; "UD." IF  |                    |                     |
| > RTYPE=02) cualquier    |                    |                     |
| > medicina para sus      |                    |                     |
| > necesidades (de        |                    |                     |
| > servicio) de salud?    |                    |                     |
+--------------------------+--------------------+---------------------+
| B.  In (LAST MONTH) did  | > YES 01           | \$\_                |
|     (FILL "NAME" IF      | >                  | \_\_\_\_\_\_\_\_.00 |
|     RTYPE=01, 03; "YOU"  | > NO 00            | AMOUNT (0-9,999)    |
|     IF RTYPE=02) use a   | >                  |                     |
|     special diet (IF AGE | > DON'T KNOW d     | OR:                 |
|     \<18, FILL "OR       | >                  |                     |
|     FORMULA") for (FILL  | > REFUSED r        | \$                  |
|     "HIS/HER" IF         |                    | \_\_\_\_\_\_\_\_.00 |
|     RTYPE=01,03; "YOUR"  |                    | per week            |
|     IF RTYPE=02) health  |                    |                     |
|     care needs?          |                    | (0-9,999)           |
|                          |                    |                     |
| > ¿En (LAST MONTH) usó   |                    |                     |
| > (FILL "NAME" IF        |                    |                     |
| > RTYPE=01,03; "UD." IF  |                    |                     |
| > RTYPE=02) una dieta    |                    |                     |
| > (IF AGE \<18, FILL "o  |                    |                     |
| > formula") especial     |                    |                     |
| > para sus necesidades   |                    |                     |
| > de salud?              |                    |                     |
+--------------------------+--------------------+---------------------+
| C.  In (LAST MONTH) did  | > YES 01           | \$\_                |
|     (FILL "NAME" IF      | >                  | \_\_\_\_\_\_\_\_.00 |
|     RTYPE=01, 03; "YOU"  | > NO 00            | AMOUNT (0-9,999)    |
|     IF RTYPE=02) use any | >                  |                     |
|     medical supplies     | > DON'T KNOW d     | OR:                 |
|     such as distilled    | >                  |                     |
|     water, bandages, or  | > REFUSED r        | \$                  |
|     syringes?            |                    | \_\_\_\_\_\_\_\_.00 |
|                          |                    | per week            |
| > ¿En (LAST MONTH) usó   |                    |                     |
| > (FILL "NAME" IF        |                    | (0-9,999)           |
| > RTYPE=01,03; "UD." IF  |                    |                     |
| > RTYPE=02) algunas      |                    |                     |
| > provisiones médicas    |                    |                     |
| > tales como agua        |                    |                     |
| > destilada, vendas, o   |                    |                     |
| > jeringas?              |                    |                     |
+--------------------------+--------------------+---------------------+
| D.  In (LAST MONTH) did  | > YES 01           | \$\_                |
|     (FILL "NAME" IF      | >                  | \_\_\_\_\_\_\_\_.00 |
|     RTYPE=01, 03; "YOU"  | > NO 00            | AMOUNT (0-9,999)    |
|     IF RTYPE=02) use any | >                  |                     |
|     special clothing or  | > DON'T KNOW d     | OR:                 |
|     (IF AGE \<18 FILL    | >                  |                     |
|     "DIAPERS THAT A      | > REFUSED r        | \$                  |
|     CHILD HIS/HER AGE    |                    | \_\_\_\_\_\_\_\_.00 |
|     WOULD NOT NORMALLY   |                    | per week            |
|     USE"; IF AGE 18+     |                    |                     |
|     FILL "INCONTINENCE   |                    | (0-9,999)           |
|     CARE PRODUCTS")?     |                    |                     |
|                          |                    |                     |
| > En (LAST MONTH) usó    |                    |                     |
| > (FILL "NAME" IF        |                    |                     |
| > RTYPE=01,03; "UD." IF  |                    |                     |
| > RTYPE=02) ropa         |                    |                     |
| > especial o (IF AGE     |                    |                     |
| > \<18 FILL "pañales que |                    |                     |
| > normalmente no son     |                    |                     |
| > usados por niños de la |                    |                     |
| > misma edad que         |                    |                     |
| > (él/ella); IF AGE 18+  |                    |                     |
| > FILL "productos para   |                    |                     |
| > incontinencia?"        |                    |                     |
+--------------------------+--------------------+---------------------+
| E. CHECK RTYPE: Is       |                    |                     |
| RTYPE...                 |                    |                     |
|                          |                    |                     |
| NAME'S PARENT OR         |                    |                     |
| GUARDIAN 01 Continue    |                    |                     |
|                          |                    |                     |
| NAME HIMSELF/HERSELF 02 |                    |                     |
| Continue                 |                    |                     |
|                          |                    |                     |
| PROXY FOR NAME 00 Go to |                    |                     |
| F67i                     |                    |                     |
+--------------------------+--------------------+---------------------+
| F. In (LAST MONTH) did   | > YES 01           | \$\_                |
| (FILL "YOU AND YO        | >                  | \_\_\_\_\_\_\_\_.00 |
| FAMILY" IF RTYPE=01, 02; | > NO 00            | AMOUNT (0-9,999)    |
| "NAME AND HIS/HER        | >                  |                     |
| FAMILY" IF RTYPE=03)     | > NO INSURANCE 03  | OR:                 |
| have higher health       | >                  |                     |
| insurance premiums       | > DON'T KNOW d     | \$                  |
| because (FILL "NAME HAS" | >                  | \_\_\_\_\_\_\_\_.00 |
| IF RTYPE=01, 03; "YOU    | > REFUSED r        | per week            |
| HAVE" IF RTYPE=02)       |                    |                     |
| special health care      |                    | (0-9,999)           |
| needs?                   |                    |                     |
|                          |                    |                     |
| > ¿En (LAST MONTH)       |                    |                     |
| > tuvieron (FILL "UD."   |                    |                     |
| > IF RTYPE=01, 02;       |                    |                     |
| > "NAME" IF RTYPE=03) y  |                    |                     |
| > su familia premias más |                    |                     |
| > altas de seguro de     |                    |                     |
| > salud porque (FILL     |                    |                     |
| > "NAME" IF RTYPE=01,03; |                    |                     |
| > "UD." IF RTYPE=02)     |                    |                     |
| > tiene necesidades      |                    |                     |
| > especiales de          |                    |                     |
| > servicios de salud?    |                    |                     |
+--------------------------+--------------------+---------------------+
| CP, YP, YA               | > YES 01           | \$\_                |
|                          | >                  | \_\_\_\_\_\_\_\_.00 |
| G. In (LAST MONTH) did   | > NO 00            | AMOUNT (0-9,999)    |
| (FILL "YOU AND YOUR      | >                  |                     |
| FAMILY" IF RTYPE=01, 02; | > DON'T KNOW d     | OR:                 |
| "NAME AND HIS/HER        | >                  |                     |
| FAMILY" IF RTYPE=03)     | > REFUSED r        | \$                  |
| have any extra charges   |                    | \_\_\_\_\_\_\_\_.00 |
| on your phone bill       |                    | per week            |
| related to (FILL         |                    |                     |
| "NAME'S" IF RTYPE=01,    |                    | (0-9,999)           |
| 03; "YOUR" IF RTYPE=02)  |                    |                     |
| special health care      |                    |                     |
| needs?                   |                    |                     |
|                          |                    |                     |
| > ¿En (LAST MONTH)       |                    |                     |
| > tuvieron (FILL "UD."   |                    |                     |
| > IF RTYPE=01,02; IF     |                    |                     |
| > RTYPE=03) y su familia |                    |                     |
| > cargos adicionales en  |                    |                     |
| > su cuenta de teléfono  |                    |                     |
| > relacionados a (FILL   |                    |                     |
| > "LAS NECESIDADES       |                    |                     |
| > ESPECIALES DE SALUD DE |                    |                     |
| > NAME" IF RTYPE=01,03;  |                    |                     |
| > "SUS NECESIDADES       |                    |                     |
| > ESPECIALES DE SALUD"   |                    |                     |
| > IF RTYPE=02)?          |                    |                     |
+--------------------------+--------------------+---------------------+
| CP, YP, YA               | > YES 01           | \$\_                |
|                          | >                  | \_\_\_\_\_\_\_\_.00 |
| H. In (LAST MONTH) did   | > NO 00            | AMOUNT (0-9,999)    |
| (FILL "YOU AND YOUR      | >                  |                     |
| FAMILY" IF RTYPE=01, 02; | > DON'T KNOW d     | OR:                 |
| "NAME AND HIS/HER        | >                  |                     |
| FAMILY" IF RTYPE=03)     | > REFUSED r        | \$                  |
| have any extra charges   |                    | \_\_\_\_\_\_\_\_.00 |
| on your electric or      |                    | per week            |
| utility bills related to |                    |                     |
| (FILL "NAME'S" IF        |                    | (0-9,999)           |
| RTYPE=01, 03; "YOUR" IF  |                    |                     |
| RTYPE=02) special health |                    |                     |
| care needs?              |                    |                     |
|                          |                    |                     |
| > ¿En (LAST MONTH)       |                    |                     |
| > tuvieron (FILL "UD."   |                    |                     |
| > IF RTYPE=01,02; "NAME" |                    |                     |
| > IF RTYPE=03) y su      |                    |                     |
| > familia cargos         |                    |                     |
| > adicionales en su      |                    |                     |
| > cuenta de electricidad |                    |                     |
| > o de utilidades        |                    |                     |
| > relacionados a (FILL   |                    |                     |
| > "LAS NECESIDADES       |                    |                     |
| > ESPECIALES DE SALUD DE |                    |                     |
| > (NAME)" IF             |                    |                     |
| > RTYPE=01,03; "SUS      |                    |                     |
| > NECESIDADES ESPECIALES |                    |                     |
| > DE SALUD" IF           |                    |                     |
| > RTYPE=02)?             |                    |                     |
+--------------------------+--------------------+---------------------+
| CP, YP, YA, YX           | > ![](             | \$\_                |
|                          | media/image50.wmf) | \_\_\_\_\_\_\_\_.00 |
| I. In (LAST MONTH) did   |                    | AMOUNT              |
| (FILL "YOU AND YOUR      | OTHER (SPECIFY) 06 |                     |
| FAMILY" IF RTYPE=01, 02; |                    | (0-9,999)           |
| "NAME AND HIS/HER        | \_                 |                     |
| FAMILY" IF RTYPE=03) buy | \_\_\_\_\_\_\_\_\_ | OR:                 |
| any other items or have  | \_\_\_\_\_\_\_\_\_ |                     |
| any other out-of-pocket  |                    | \$                  |
| expenses related to      | > DON'T KNOW d     | \_\_\_\_\_\_\_\_.00 |
| (FILL "NAME'S" IF        | >                  | per week            |
| RTYPE=01, 03; "YOUR" IF  | > REFUSED r        |                     |
| RTYPE=02) special health |                    | (0-9,999)           |
| care needs?              |                    |                     |
|                          |                    |                     |
| > ¿En (LAST MONTH)       |                    |                     |
| > compraron (FILL "UD."  |                    |                     |
| > IF RTYPE=01,02; "NAME" |                    |                     |
| > IF RTYPE=03) y su      |                    |                     |
| > familia cualquier otra |                    |                     |
| > cosa o tuvieron otros  |                    |                     |
| > gastos de sus propios  |                    |                     |
| > bolsillos relacionados |                    |                     |
| > a (FILL; "LAS          |                    |                     |
| > NECESIDADES ESPECIALES |                    |                     |
| > DE SALUD DE (NAME)" IF |                    |                     |
| > RTYPE=01,03; "SUS      |                    |                     |
| > NECESIDADES ESPECIALES |                    |                     |
| > DE SALUD" IF           |                    |                     |
| > RTYPE=02)?             |                    |                     |
+--------------------------+--------------------+---------------------+

CP, YP, YA, YX

Created

F68. Are there any other health care items that (FILL "NAME" IF
RTYPE=01, 03; "YOU" IF RTYPE=02) **need(s)** now but (FILL "IS" IF
RTYPE=01, 03; "ARE" IF RTYPE=02) not receiving?

¿Hay otros artículos para el cuidado de salud que (FILL "NAME" IF
RTYPE=01,03; "UD." IF RTYPE=02) **necesita** ahora pero no está
recibiendo?

PROBE: Please don't include items or services we've already talked
about.

PROBE: Por favor no incluya artículos o servicios de las que ya hemos
hablado.

YES 01

![](media/image51.wmf) NO 00

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

Created

F69. What items are these?

¿Qué artículos son?

*Do not read,* c*ode all that apply*

EDUCATION SERVICES SUCH AS

TUTORING, BOOKS ON TAPE, SENSORY

INTEGRATION 01

MEDICAL DEVICES SUCH AS

WHEELCHAIRS, CANES, OR CRUTCHES 02

EYEGLASSES 03

HEARING AID 04

![](media/image52.wmf) HOSPITAL BED 05

OTHER (SPECIFY) 06

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

Created

F70. (FILL "HAVE YOU AND YOUR FAMILY" IF RTYPE=01, 02; "HAS NAME AND
HIS/HER FAMILY" IF RTYPE=03) ever purchased any durable medical
equipment or devices for (FILL "HIM/HER" IF RTYPE=01,03; "YOU" IF
RTYPE=02) such as a wheelchair, hospital bed, leg braces, or prosthetic
devices?

> ¿Alguna vez ha comprado (FILL "UD." IF RTYPE=01,02 "NAME" IF
> RTYPE=03;) y su familia cualquier tipo de equipo médico duradero para
> (FILL "él/ella" IF RTYPE=01,03; "UD." IF RTYPE=02), tal como una silla
> de ruedas o una cama de hospital, abrazaderas (braces) para las
> piernas, o aparatos prostéticos?

PROBE: Prosthetic devices include such things as artificial limbs,
artificial heart valves, or ear implants.

PROBE: Aparatos prostéticos incluyen cosas tales como brazos o piernas
artificiales, válvulas artificiales para el corazón, o implantes en las
orejas.

YES 01

![](media/image53.wmf) NO 00

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CP, YP, YA, YX

Created

F71. Thinking about just the past 12 months, how much did (FILL "YOU AND
YOUR FAMILY" IF RTYPE=01, 02; "NAME AND HIS/HER FAMILY" IF RTYPE=03) pay
out-of-pocket for durable medical equipment or devices?

Pensando sólo de los últimos 12 meses, ¿cuánto pagó su familia, de su
propio bolsillo, por equipo médico duradero o por aparatos?

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT PAID (0-99,999)

ENTIRE AMOUNT 01

AMOUNT PER WEEK 02

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

Created

F72. How much (FILL "HAVE YOU AND YOUR FAMILY" IF RTYPE=01, 02; "HAS
NAME AND HIS/HER FAMILY" IF RTYPE=03) **ever** paid out-of-pocket for
durable medical equipment or devices for (FILL "HIM/HER" IF RTYPE=01,03;
"YOU" IF RTYPE=02)? Your best estimate is fine.

¿Cuánto han pagado **en total** (FILL "UD." IF RTYPE=01,02; "NAME" IF
RTYPE=03) y su familia de sus propio bolsillos por equipo médico
duradero o aparatos para (FILL "él/ella" IF RTYPE=01,03; "UD." IF
RTYPE=02)? Por favor dénos su mejor cálculo.

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT PAID (0-99,999)

ENTIRE AMOUNT 01

AMOUNT PER WEEK 02

DON'T KNOW d

REFUSED r