CP, YP, YA, YX

H1. CHECK RTYPE: Is RTYPE....

> NAME'S PARENT OR GUARDIAN 01 *Continue*
>
> NAME HIM/HER SELF 02 *Go to H19*

PROXY FOR NAME 03 *Go to H19*

CP, YP

H2. CHECK AGE: Is (NAME)'s age.....

> \<17 01  *Continue*
>
> 17+ 02  *Go to H19*

CP

Created

H3. Now I would like to ask you about any experience you and (NAME)
might have had with the Supplemental Security Income, or SSI program
operated by the Social Security Administration.

> As you may know, SSI provides monthly payments for disabled children
> in families with limited income and resources.

Has your household ever received an SSI benefit for (NAME)?

Ahora le quiero preguntar acerca de cualquier experiencia que Ud. y
(NAME) quizás tuvieron con el programa de SSI (Supplemental Security
Income, o Seguridad de Ingreso Suplementario), que es administrado por
el Social Security Administration (Administración de Seguro Social).

> Como Ud. quizás sabe, SSI proporciona pagos mensuales para niños con
> incapacidades, en familias con recursos e ingresos limitados.

¿Alguna vez ha recibido su hogar beneficio de SSI para (NAME)?

> YES 01 *Go to H6*
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP

H4. CHECK: Does answer to H3 agree with preloaded information?

YES 01 *Go to Part I*

NO 00 *Continue*

CP (answer different from SSA information)

Created

H5. Our records show that (NAME) was receiving benefits in (INSERT MONTH
AND YEAR OF LAST RECEIPT FROM PRELOADED INFORMATION). As far as you
know, is that correct?

Nuestros registros muestran que (NAME) estaba recibiendo beneficios en
(INSERT MONTH AND YEAR OF LAST RECEIPT FROM PRELOADED INFORMATION).
Según lo que Ud. sabe, ¿es eso correcto?

> YES 01 *Continue*
>
> ![](media/image1.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP (has received SSI)

Created

H6. Did you receive an SSI benefit for (NAME) in (LAST MONTH, THIS
YEAR)?

¿Recibió Ud. beneficio de SSI para (NAME) en (LAST MONTH, THIS YEAR)?

> YES 01
>
> ![](media/image2.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP (is now receiving SSI)

Created

H7. What was the amount of the SSI benefit you received for (NAME) in
(LAST MONTH, YEAR)?

¿Cuál erá la suma del beneficio de SSI que Ud. recibió para (NAME) en
(LAST MONTH, THIS YEAR)?

\$\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT (10-2,000)

> DON'T KNOW d
>
> REFUSED r

CP (has received SSI)

Created

H8. Since January 1996, that is, since (NAME) was around (INSERT NAME'S
AGE IN 1996) was there any time when you stopped receiving SSI benefits
for (NAME) for more than one month?

IF NAME NOT BORN IN 1996 USE ALTERNATIVE WORDING: Has there ever been a
time when you stopped receiving SSI benefits for (NAME) for more than
one month?

Desde enero de 1996, o sea, desde que (NAME) tenía alrededor de (INSERT
NAME'S AGE IN 1996) años ¿hubo algún tiempo en el cual Ud. dejó de
recibir beneficios de SSI para (NAME), por más de un mes?

IF NAME NOT BORN IN 1996 USE ALTERNATIVE WORDING: ¿Hubo algún tiempo en
el cual Ud. dejó de recibir beneficios de SSI para (NAME), por más de un
mes?

> YES 01 *Go to H11*
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP (has received SSI)

Created

H9. CHECK: Does answer to H8 agree with preloaded information?

YES 01 *Go to H43*

NO 00 *Continue*

CP (has received SSI)

Created

H10. Our records show that (NAME) stopped receiving benefits in (INSERT
MONTH AND YEAR FROM PRELOADED INFORMATION) for more than a month. As far
as you know, is that correct?

> Nuestros registros muestran que (NAME) dejó de recibir beneficios en
> (INSERT
>
> MONTH AND YEAR FROM PRELOADED INFORMATION), por más de un mes. Según
> lo que Ud. sabe, ¿Es esto correcto?
>
> YES 01 *Continue*
>
> ![](media/image3.wmf)NO 00

DON'T KNOW d

> REFUSED r

![](media/image4.wmf)

CP (has lost SSI)

Created

H11. Why did you lose SSI benefits for (NAME) when this happened?

PROBE IF MORE THAN ONE TIME: I mean the last time this happened?

¿Por qué perdió Ud. beneficios de SSI para (NAME) cuando ocurrió esto?

PROBE IF MORE THAN ONE TIME: La última vez que esto ocurrió.

INTERVIEWER: IF RESPONDENT SAYS "INELIGIBLE" PROBE FOR MORE DETAIL.

> *Code all that apply*
>
> GOT A JOB 01
>
> INCOME TOO HIGH 02
>
> ASSETS TOO HIGH 03
>
> (NAME) DETERMINED MEDICALLY
>
> INELIGIBLE 04
>
> DID NOT FOLLOW PROGRAM RULES 05
>
> MARRIED/REMARRIED 06
>
> ![](media/image5.wmf)MOVED IN WITH FAMILY/OTHER PERSON 07
>
> OTHER (SPECIFY) 08

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

DON'T KNOW d

REFUSED r

CP (has lost SSI)

Created

H12. Did you appeal that decision?

¿Apeló Ud. la decisión?

YES 01  *Go to H15*

NO 00

DON'T KNOW d  *Go to H16*

REFUSED r  *Go to H16*

CP (has lost SSI)

Created

H13. Why didn't you appeal the decision?

¿Por qué no apeló la decisión?

*Code all that apply*

DID NOT WANT TO 01

DID NOT KNOW HOW 02

DID NOT KNOW COULD APPEAL 03

COULD NOT AFFORD A LAWYER 04

DID NOT HAVE A STRONG CASE 05

WORRIED WE WOULD HAVE TO REPAY

SSA FOR BENEFITS RECEIVED WHILE

CASE WAS UNDER APPEAL 06

![](media/image6.wmf) THOUGHT WE WOULD NOT WIN 07

OTHER (SPECIFY) 08

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

DON'T KNOW d

REFUSED r

CP (has lost SSI)

Created

H14. Did you consult a lawyer or legal aid group in making the decision
not to appeal?

> ¿Consultó Ud. con un abogado o un grupo de ayuda legal para tomar la
> decisión de no apelar?

YES 01

NO 00

DON'T KNOW d

REFUSED r

CP (has lost SSI)

Created

H15. Did you use the assistance of a lawyer or a legal aid group during
the appeal process?

> ¿Usó Ud. la asistencia de un abogado o de un grupo de ayuda legal
> durante el proceso de la apelacón?

YES 01

NO 00

DON'T KNOW d

REFUSED r

CP (has lost SSI)

Created

H16. What changes did your household make when your family lost SSI
benefits for (NAME), if any?

¿Qué cambios hizo su hogar cuando su familia perdió los beneficios de
SSI para (NAME), si los hubo?

*Record verbatim*

> PROBE: What did you do to get by?
>
> PROBE: ¿Qué hubo para arreglárselas?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> YES, SPECIFY 01
>
> DON'T KNOW d
>
> REFUSED r

CP (has lost SSI)

Created

H17. When you stopped receiving SSI benefits most recently, did you stop
receiving Medicaid benefits or (INSERT MEDICAID STATE NAME) benefits for
(NAME) at the same time?

> Cuando Ud. dejó de recibir beneficios de SSI lo más recientemente,
> ¿Dejó Ud. de recibir beneficios de Medicaid o beneficios de (INSERT
> MEDICAID STATE NAME) para (NAME) al mismo tiempo?

![](media/image7.wmf) YES 01

NO 00

NEVER HAD MEDICAID FOR (NAME) 03

DON'T KNOW d

REFUSED r

CP (has lost SSI)

Created

H18. Did you lose Medicaid or (INSERT MEDICAID STATE NAME) benefits for
3 months or more, or less than 3 months?

> ¿Perdió Ud. los beneficios de Medicaid o de (INSERT MEDICAID STATE
> NAME) por 3 meses o más; o por menos de 3 meses?

3 MONTHS OR MORE 01

LESS THAN 3 MONTHS 02

DON'T KNOW d

REFUSED r

YP, YA, YX

Created

H19. Now I would like to ask you about any experience (FILL "NAME AND
YOUR FAMILY" IF RTYPE=01; "YOU" IF RTYPE=02; "NAME" IF RTYPE=03) might
have had with the Supplemental Security Income, or SSI program operated
by the Social Security Administration.

> As you may know, SSI provides monthly payments to people with limited
> income and resources who are age 65 or older, blind, or disabled.
> Blind or disabled children, as well as adults, can get SSI.
>
> (FILL "HAS NAME" IF RTYPE=01, 03; "HAVE YOU" IF RTYPE=02) ever
> received an SSI benefit, either as a child or an adult?
>
> Ahora le quiero preguntar acerca de cualquier experiencia que (FILL
> "NAME Y SU FAMILIA quizás tuvieron" IF RTYPE=01; "UD. quizás TUVO" IF
> RTYPE=02; "NAME quizás TUVO" IF RTYPE=03) con el programa de SSI
> (Supplemental Security Income, o Seguridad de Ingreso Suplementario),
> que es administrado por el Social Security Administration
> (Administración de Seguro Social).
>
> Como Ud. quizás sabe, SSI proporciona pagos mensuales para personas
> con recursos e ingresos limitados que tienen 65 años o más, son ciegas
> o tienen incapacidades. Niños ciegos o incapacitados, como adultos,
> pueden recibir SSI.

¿Alguna vez ha recibido (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
un beneficio de SSI, en su niñez o cómo adulto(a)?

> YES 01 *Go to H22*
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

YP, YA, YX

H20. CHECK: Does answer to H19 agree with preloaded information?

YES 01 *Go to Part I*

NO 00 *Continue*

YP, YA, YX (answer different from SSA information)

Created

H21. Our records show that (FILL "NAME WAS" IF RTYPE=01, 03; "YOU WERE"
IF RTYPE=02) receiving benefits in (INSERT MONTH AND YEAR OF LAST
RECEIPT FROM PRELOADED INFORMATION). As far as you know, is that
correct?

> Nuestros registros muestran que (FILL "NAME" IF RTYPE=01,03; "UD." IF
> RTYPE=02) estaba recibiendo beneficios en (INSERT MONTH AND YEAR OF
> LAST RECEIPT FROM PRELOADED INFORMATION). Según lo que Ud. sabe ¿Es
> esto correcto?
>
> YES 01 *Continue*
>
> ![](media/image8.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

YP, YA, YX (has received SSI)

Created

H22. Did (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) receive an SSI
benefit in (LAST MONTH, THIS YEAR)?

¿Recibió (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) un beneficio de
SSI en (LAST MONTH, THIS YEAR)?

> YES 01 *Continue*
>
> ![](media/image9.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

YP, YA, YX (is now receiving SSI)

Created

H23. What was the amount of the SSI benefit (FILL "NAME" IF RTYPE=01,
03; "YOU" IF RTYPE=02) received in (LAST MONTH, THIS YEAR)?

¿Cuál era la suma del beneficio de SSI que (FILL "NAME" IF RTYPE=01,03;
"UD." IF RTYPE=02) recibió en (LAST MONTH, THIS YEAR)?

\$\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT (1-2000)

> DON'T KNOW d
>
> REFUSED r

YP, YA, YX

H24. CHECK AGE: Is (NAME'S) age....

18+ 01 *Continue*

\<18 02 *Go to H32*

YP, YA, YX (age 18+, has received SSI)

H25. (FILL "WAS NAME" if RTYPE=01, 03; "WERE YOU" if RTYPE=02) receiving
SSI benefits at the time of (FILL "HIS/HER" if RTYPE=01, 03; "YOUR" if
RTYPE=02) 18^th^ birthday?

> ¿Estaba (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) recibiendo
> beneficios de SSI al cumplir los 18 años?

YES 01 *Continue*

![](media/image10.wmf) NO 00

> DON'T KNOW d
>
> REFUSED r

YP, YA, YX (age 18+, receiving SSI at 18^TH^ birthday)

Created

H26. Around the time of (FILL "NAME'S" IF RTYPE=01, 03; "YOUR" IF
RTYPE=02) 18^th^ birthday, was (FILL "HIS/HER" IF RTYPE=01,03; "YOUR" IF
RTYPE=02) eligibility for SSI redetermined by the Social Security
Administration using the rules for adults?

Alrededor del tiempo que (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
cumplió los 18 años, ¿fue su elegibilidad para SSI redeterminada por la
Administración de Seguro Social (Social Security Administration), usando
las reglas para adultos?

> YES 01 *Continue*
>
> ![](media/image11.wmf)NO 00
>
> REDETERMINATION PENDING 03
>
> DON'T KNOW d
>
> REFUSED r

YP, YA, YX (age 18+, redetermined for SSI)

Created

H27. Has the Social Security made a final decision about (FILL "NAME'S"
IF RTYPE=01, 03; "YOUR" IF RTYPE=02) eligibility?

Ha tomado Social Security una decisión final acerca de (FILL "la
elegibilidad de (NAME)" IF RTYPE=01, 03; "SU elegibilidad" IF RTYPE=02)?

PROBE: By final decision, I mean did SSA notify you that (FILL "NAME'S"
IF RTYPE=01, 03; "YOUR" IF RTYPE=02) benefits would either continue or
stop, and you decided not to appeal or completed all your appeals.

PROBE: Por decisión final, quiero decir si SSA le notificó que (FILL
"lOS beneficios de (NAME)" IF RTYPE=01, 03; "SUS beneficios" IF
RTYPE=02) continuarían o serían parados, y, decidió no apelar o completó
todas sus apelaciones.

> YES 01 *Continue*
>
> ![](media/image12.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

YP, YA, YX (age 18+, redetermined for SSI)

Created

H28. What was that decision? Did (FILL "NAME" IF RTYPE=01, 03; "YOU" IF
RTYPE=02)...

> ¿Cuál fue esa decisión? ¿(FILL "NAME" IF RTYPE=01,03; "UD." IF
> RTYPE=02)...
>
> Continue to receive SSI benefits 01 *Go to H43*
>
> Stop receiving SSI benefits 02 *Go to H31*
>
> Continuó recibiendo beneficios de SSI 01 *Go to H43*
>
> Dejó de recibir beneficios de SSI 02 *Go to H31*
>
> DON'T KNOW d *Go to H43*
>
> REFUSED r *Go to H43*

YP, YA, YX (age 18+, redetermined for SSI)

Created

H29. Is the final decision pending or is it under appeal?

¿Está la decisión final pendiente, o está siendo apelada?

PENDING 01 *Go to H43*

UNDER APPEAL 02 *Continue*

DON'T KNOW d *Go to H43*

REFUSED r *Go to H43*

YP, YA, YX (age 18+, redetermined for SSI)

Created

H30. As far as you know, why did SSA make the initial decision to stop
SSI benefits for (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02)?

> Según lo que Ud. sabe, ¿por qué tomó SSA la decisión inicial de parar
> los beneficios de SSI para (FILL "NAME" IF RTYPE=01,03; "UD." IF
> RTYPE=02)?

*Code all that apply*

> INCOME TOO HIGH 01
>
> ASSETS TOO HIGH 02
>
> DETERMINED MEDICALLY INELIGIBLE 03
>
> DETERMINED ABLE TO WORK/ENGAGE
>
> IN SUBSTANTIAL GAINFUL ACTIVITY 04
>
> DID NOT FOLLOW PROGRAM RULES 05
>
> (NAME) MARRIED/REMARRIED 06
>
> ![](media/image13.wmf)(NAME) NOT IN SCHOOL/JOB TRAINING 07
>
> OTHER (SPECIFY) 08

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

DON'T KNOW d

REFUSED r

YP, YA, YX (age 18+, redetermined for SSI)

Created

H31. As far as you know, why did (FILL "NAME" IF RTYPE=01, 03; "YOU" IF
RTYPE=02) stop receiving SSI benefits?

Según lo que Ud. sabe, ¿por qué dejó (FILL "NAME" IF RTYPE=01,03; "UD."
IF RTYPE=02) de recibir beneficios de SSI?

INTERVIEWER: IF RESPONDENT SAYS "INELIGIBLE" PROBE FOR MORE DETAIL.

*Code all that apply*

> INCOME TOO HIGH 01
>
> ASSETS TOO HIGH 02
>
> DETERMINED MEDICALLY INELIGIBLE 03
>
> DETERMINED ABLE TO WORK/ENGAGE
>
> IN SUBSTANTIAL GAINFUL ACTIVITY 04
>
> DID NOT FOLLOW PROGRAM RULES 05
>
> (NAME) MARRIED/REMARRIED 06
>
> ![](media/image14.wmf)(NAME) NOT IN SCHOOL/JOB TRAINING 07
>
> OTHER (SPECIFY) 08

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

DON'T KNOW d

REFUSED r

YP, YA, YX

Created

H32. Since January 1996, that is, since (FILL "NAME WAS" IF RTYPE=01,03;
"YOU WERE" IF RTYPE=02) around (INSERT NAME'S AGE IN 1996) was there any
time when (FILL "NAME OR YOUR FAMILY" IF RTYPE=01; "YOU" IF RTYPE=02;
"NAME" IF RTYPE=03) stopped receiving SSI benefits (FILL "FOR HIM/HER"
IF RTYPE=01; ELSE BLANK) for more than one month?

> Desde enero de 1996, o sea, desde que (FILL "NAME" IF RTYPE=01,03;
> "UD." IF RTYPE=02) tenía alrededor de (INSERT NAME'S AGE IN 1996)
> años, ¿hubo algún tiempo en el cual (FILL "NAME" IF RTYPE=01,03; "UD."
> IF RTYPE=02) dejó de recibir beneficios de SSI por más de un mes?
>
> YES 01 *Go to H35*
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

YP, YA, YX

Created

H33. CHECK: Does answer to H32 agree with preloaded information?

YES 01 *Go to H43*

NO 00 *Continue*

YP, YA, YX (answer different from SSA information)

Created

H34. Our records show that (FILL "NAME" IF RTYPE=01, 03; "YOU" IF
RTYPE=02) stopped receiving benefits in (INSERT MONTH AND YEAR FROM
PRELOADED INFORMATION), for more than one month. As far as you know, is
that correct?

Nuestros registros muestran que (FILL "NAME" IF RTYPE=01,03; "UD." IF
RTYPE=02) paró de recibir beneficios en (INSERT MONTH AND YEAR FROM
PRELOADED INFORMATION), por un mes o más. Según lo que Ud. sabe, ¿es eso
correcto?

> YES 01 *Continue*
>
> ![](media/image15.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

YP, YA, YX (has lost SSI)

Created

H35. Why did (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) lose SSI
benefits when this happened?

¿Por qué perdió (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
beneficios de SSI cuando esto ocurrió?

PROBE IF MORE THAN ONE TIME: I mean the last time this happened.

PROBE: Quiero decir última vez que esto ocurrió/cuando ocurrió?

INTERVIEWER: IF RESPONDENT SAYS "INELIGIBLE" PROBE FOR MORE DETAIL.

*Code all that apply*

> PARENT'S INCOME TOO HIGH 01
>
> PARENT'S ASSETS TOO HIGH 02
>
> (NAME'S) INCOME TOO HIGH 03
>
> (NAME'S) ASSETS TOO HIGH 04
>
> (NAME) DETERMINED MEDICALLY
>
> INELIGIBLE 05
>
> DID NOT FOLLOW PROGRAM RULES 06
>
> MARRIED/REMARRIED 07
>
> ![](media/image16.wmf)MOVED IN WITH FAMILY/OTHER PERSON 08
>
> OTHER (SPECIFY) 09

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

DON'T KNOW d

REFUSED r

YP, YA, YX (has lost SSI)

Created

H36. Did (FILL "NAME OR YOUR FAMILY" IF RTYPE=01, "YOU" IF RTYPE=02,
"NAME" IF RTYPE=03) appeal that decision?

> ¿Apeló (FILL "NAME O SU FAMILIA" IF RTYPE=01; "UD." IF RTYPE=02; NAME
> IF RTYPE=03) de esa decisión?

YES 01  *Go to H39*

NO 00 *Continue*

DON'T KNOW d  *Go to H40*

REFUSED r  *Go to H40*

YP, YA, YX (has lost SSI)

Created

H37. Why didn't ("NAME OR YOUR FAMILY" IF RTYPE=01, "YOU" IF RTYPE=02,
"NAME" IF RTYPE=03) appeal the decision?

> ¿Por qué no apeló (FILL "NAME O SU FAMILIA" IF RTYPE=01; "UD." IF
> RTYPE=02; "NAME" IF RTYPE=03) la decisión?

*Code all that apply*

DID NOT WANT TO 01

DID NOT KNOW HOW 02 *Go to H40*

DID NOT KNOW COULD APPEAL 03 *Go to H40*

COULD NOT AFFORD A LAWYER 04

DID NOT HAVE A STRONG CASE 05

WORRIED WE WOULD HAVE TO REPAY

SSA FOR BENEFITS RECEIVED WHILE

CASE WAS UNDER APPEAL 06

![](media/image17.wmf) THOUGHT WE WOULD NOT WIN 07

OTHER (SPECIFY) 08

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

DON'T KNOW d

REFUSED r

YP, YA, YX (has lost SSI)

H38. Did (FILL "NAME OR YOUR FAMILY" IF RTYPE=01, "YOU" IF RTYPE=02,
"NAME" IF RTYPE=03) consult a lawyer or legal aid group in making the
decision not to appeal?

> ¿Consultó (FILL "NAME O SU FAMILIA" IF RTYPE=01; "UD." IF RTYPE=02;
> NAME IF RTYPE=03) con un abogado o un grupo de ayuda legal para tomar
> la decisión de no apelar?

![](media/image18.wmf) YES 01

NO 00

DON'T KNOW d

REFUSED r

YP, YA, YX (has lost SSI)

Created

H39. Did (FILL "NAME OR YOUR FAMILY" IF RTYPE=01, "YOU" IF RTYPE=02,
"NAME" IF RTYPE=03) use the assistance of a lawyer or a legal aid group
during the appeal process?

> ¿Usó (FILL "NAME O SU FAMILIA" IF RTYPE=01; "UD." IF RTYPE=02; "NAME"
> IF RTYPE=03) la asistencia de un abogado o de un grupo de ayuda legal
> durante el proceso de apelación?

YES 01

NO 00

DON'T KNOW d

REFUSED r

YP, YA, YX (has lost SSI)

Created

H40. What changes did (FILL "YOUR HOUSEHOLD" IF RTYPE=01, "YOU" IF
RTYPE=02, "NAME" IF RTYPE=03) make when (FILL "YOUR FAMILY" IF RTYPE=01,
"YOU" IF RTYPE=02, "HE/SHE" IF RTYPE=03) lost SSI benefits (FILL "FOR
NAME" IF RTYPE=01, ELSE BLANK), if any?

¿Qué cambios hizo (FILL "SU HOGAR" IF RTYPE=01 "UD." IF RTYPE=02; "NAME"
IF RTYPE=03) cuando perdió (FILL  "SU FAMILIA" IF RTYPE=01; "UD. " IF
RTYPE=02, "EL/ELLA » IF RTYPE=03) sus beneficios de SSI, si los hizo?

*Record verbatim*

> PROBE: What did you do to get by?
>
> PROBE: ¿Qué hizo para arreglárselas??
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> YES, SPECIFY 01
>
> DON'T KNOW d
>
> REFUSED r

YP, YA, YX (has lost SSI)

Created

H41. When (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) stopped
receiving SSI benefits most recently, did (FILL "HE/SHE" IF RTYPE=01,03;
"YOU" IF RTYPE=02) stop receiving Medicaid benefits or (INSERT MEDICAID
STATE NAME) benefits at the same time?

> Cuando (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) dejó de recibir
> beneficios de SSI lo más recientemente, ¿dejó (fill "él/ella" if
> rtype=01,03; "Ud." if rtype=02) de recibir beneficios de Medicaid o
> beneficios de (INSERT MEDICAID STATE NAME) a la mismo vez?

YES 01

![](media/image19.wmf) NO 00

(NAME) NEVER HAD MEDICAID 03

DON'T KNOW d

REFUSED r

YP, YA, YX (has lost SSI)

Created

H42. Did (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) lose Medicaid
or (INSERT MEDICAID STATE NAME) benefits for 3 months or more, or less
than 3 months?

¿Perdió (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) los beneficios
de Medicaid o de (INSERT MEDICAID STATE NAME) por 3 meses o más, o por
menos de 3 meses?

3 MONTHS OR MORE 01

LESS THAN 3 MONTHS 02

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

H43A. CHECK H6 or H22: Was (NAME) receiving an SSI benefit in (LAST
MONTH)?

YES 01 *Continue*

NO 00 *Go to Part I*

CP, YP, YA, YX (is now receiving SSI)

Created

H43B. CHECK AGE: Is (NAME'S) age...

14+ 01 *Continue*

\<14 00 *Go to H54*

CP, YP, YA, YX (age 14+, is now receiving SSI)

Created

H44. The Social Security Administration has a number of work incentives
for SSI recipients. Some can help a person with a disability go to work.
Others let disabled people keep cash or Medicaid benefits after they go
to work until they become self-supporting. (FILL "HAVE YOU" IF RTYPE=01,
02; "HAS NAME" IF RTYPE=03) ever heard of these work incentives or
discussed them with a Social Security representative?

> La Social Security Administration tiene un número de incentivos de
> trabajo para
>
> recipientes de SSI. Alguno pueden ayudar a una persona con alguna
> incapacidad, a trabajar. Otros permiten a personas incapacitadas a
> quedarse con dinero en efectivo o beneficios de Medicaid después de ir
> a trabajar, hasta que puedan mantenerse por sí mismos. ¿Alguna vez ha
> escuchado (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) de estos
> incentivos de trabajo, o los ha discutido con un representante del
> Social Security?

YES 01 *Continue*

![](media/image20.wmf) NO 00

DON'T KNOW d

REFUSED r

H45. DELETED

CP, YP, YA, YX (age 14+, is now receiving SSI)

Created

H46. Which of the following work incentive programs have ("HAVE YOU" IF
RTYPE=01, 02; "HAS NAME" IF RTYPE=03) heard of? Have ("HAVE YOU" IF
RTYPE=01, 02; "HAS NAME" IF RTYPE=03) heard of ...

¿De cuáles de los siguientes programas de incentivos ha (FILL "UD." IF
RTYPE=01,02; "NAME" IF RTYPE=03) oído hablar? ¿Ha oído hablar (FILL"UD."
IF RTYPE=01,02; "NAME" IF RTYPE=03) de ...

*Read list, Code one for each*

+---------------------------------------+-------------------------------+
|                                       | DON'T REF-                    |
|                                       |                               |
|                                       | YES NO KNOW USED              |
+---------------------------------------+-------------------------------+
| A. A plan for achieving self-support, | 01 00 d r                     |
| or PASS?                              |                               |
|                                       |                               |
| Un "Plan de Ayuda a Si Solo" o PASS   |                               |
| (plan for achieving self-support)?    |                               |
|                                       |                               |
| PROBE: A PASS can help people with    |                               |
| disabilities return to work by        |                               |
| letting them set aside money or       |                               |
| resources to help them reach a work   |                               |
| goal. The income people set aside for |                               |
| a PASS does not reduce their SSI      |                               |
| benefit amount.                       |                               |
|                                       |                               |
| PROBE: Un plan de PASS puede ayudar a |                               |
| personas con incapacidades volver a   |                               |
| trabajar, permitiéndoles guardar      |                               |
| dinero o recursos para ayudarles a    |                               |
| lograr una meta de trabajo. Los       |                               |
| ingresos que la gente guarda para un  |                               |
| plan de PASS no reduce la suma de su  |                               |
| beneficio de SSI.                     |                               |
+---------------------------------------+-------------------------------+
| B. An individual development account, | 01 00 d r                     |
| or IDA?                               |                               |
|                                       |                               |
| Una cuenta de desarrollo individual o |                               |
| IDA (individual development account)? |                               |
|                                       |                               |
| > PROBE: An IDA is a special bank     |                               |
| > account that helps people with      |                               |
| > disabilities save for their         |                               |
| > education, the purchase of a first  |                               |
| > home, or to start a business.       |                               |
| >                                     |                               |
| > PROBE: Una IDA es una cuenta de     |                               |
| > banco especial que ayuda a personas |                               |
| > con incapacidades a ahorrar para su |                               |
| > educación, la compra de su primer   |                               |
| > hogar, o para empezar un negocio.   |                               |
+---------------------------------------+-------------------------------+
|                                       | DON'T REF-                    |
|                                       |                               |
|                                       | YES NO KNOW USED              |
+---------------------------------------+-------------------------------+
| C. The general earned-income          | 01 00 d r                     |
| exclusion?                            |                               |
|                                       |                               |
| > La exclusión general de ingresos    |                               |
| >                                     |                               |
| > ganados?                            |                               |
| >                                     |                               |
| > PROBE: With this exclusion, the     |                               |
| > first \$65 of earnings and one-half |                               |
| > of earnings over \$65 are not       |                               |
| > counted when SSA figures the amount |                               |
| > of a person's SSI benefit. A        |                               |
| > maximum of \$1,620 may be excluded  |                               |
| > each year.                          |                               |
| >                                     |                               |
| > PROBE: Con esta exclusión, los      |                               |
| > primeros \$65 de ganacias y la      |                               |
| > mitad de ganacias mas altas de \$65 |                               |
| > no son contados cuando la SSA       |                               |
| > calcula la suma del beneficio de    |                               |
| > SSI para la persona.                |                               |
+---------------------------------------+-------------------------------+

+---------------------------------------+------------------------------+
|                                       | DON'T REF-                   |
|                                       |                              |
|                                       | YES NO KNOW USED             |
+---------------------------------------+------------------------------+
| D. The student earned-income          | 01 00 d r                    |
| exclusion?                            |                              |
|                                       |                              |
| La exclusión de ingresos ganados de   |                              |
| estudiantes?                          |                              |
|                                       |                              |
| PROBE: People receiving SSI who are   |                              |
| under age 22 and attending school may |                              |
| exclude up to \$400 of earned income  |                              |
| per month when SSA figures the amount |                              |
| of their SSI benefit.                 |                              |
|                                       |                              |
| > PROBE: Personas menores de 22 que   |                              |
| > reciben SSI y asisten a una         |                              |
| > institución de estudios o escuela,  |                              |
| > pueden excluir hasta \$400 de       |                              |
| > ingresos ganados por mes, cuando la |                              |
| > SSA calcula la suma de su beneficio |                              |
| > de SSI.                             |                              |
+---------------------------------------+------------------------------+
| E. The exclusion for property         | 01 00 d r                    |
| essential to self-support (PESS)?     |                              |
|                                       |                              |
| La exclusión de "Propiedad Esencial   |                              |
|                                       |                              |
| > para mantenerse a Si Solo" o PESS   |                              |
|                                       |                              |
| (property essential to self-support)? |                              |
|                                       |                              |
| > PROBE: Under this exclusion, a      |                              |
| > portion of the value of tools,      |                              |
| > equipment, or other property that   |                              |
| > people need to work is excluded     |                              |
| > when SSA figures the amount of      |                              |
| > their SSI benefit.                  |                              |
| >                                     |                              |
| > PROBE: Según esta exclusión, una    |                              |
| > porción del valor de las            |                              |
| > herramientas, aparatos, u otra      |                              |
| > propiedad que personas necesitan    |                              |
| > para trabajar es excluída cuando la |                              |
| > SSA calcula la suma de su beneficio |                              |
| > de SSI.                             |                              |
+---------------------------------------+------------------------------+

CP, YP, YA, YX (age 14+, is now receiving SSI)

Created

H47. (FILL "HAS NAME" IF RTYPE=01, 03; "HAVE YOU" IF RTYPE=02) ever used
any of these work incentives?

> ¿Alguna vez ha usado (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
> cualquiera de estos incentivos de trabajo?

YES 01 *Continue*

![](media/image21.wmf) NO 00

DON'T KNOW d

REFUSED r

CP, YP, YA, YX (age 14+, using work incentives)

Created

H48. Which ones?

¿Cuáles?

*Do not read list, code all that apply*

PLAN FOR ACHIEVING SELF-SUPPORT,

OR PASS 01

AN INDIVIDUAL DEVELOPMENT ACCOUNT,

OR IDA 02

THE GENERAL EARNED-INCOME

EXCLUSION 03

THE STUDENT EARNED-INCOME

EXCLUSION 04

THE EXCLUSION FOR PROPERTY

ESSENTIAL FOR SELF SUPPORT (PESS) 05

THE EXCLUSIONS FOR IMPAIRMENT-

RELATED WORK EXPENSES (IWRE) OR

BLIND WORK EXPENESE (BWE) 06

CONTINUED ELIGIBILITY FOR MEDICAID

AFTER CASH BENEFITS END 07

DON'T KNOW d

REFUSED r

CP, YP, YA, YX (age 14+, using work incentives)

H49. CHECK H48: Ever used IDA (H48=02)?

YES 01

NO 00 *Go to H52*

CP, YP, YA, YX (age 14+, using work incentives)

Created

H50. About how much does (FILL "NAME" IF RTYPE=01, 03; "YOU" IF
RTYPE=02) save each month in (FILL "HIS/HER" IF RTYPE=01, 03; "YOUR" IF
RTYPE=02) IDA account?

¿Más o menos cuánto ahorra (FILL "NAME" IF RTYPE=01,03; "UD." IF
RTYPE=02) cada mes, en su cuenta de IDA (cuenta de desarrollo
individual)?

\$\|\_\_\_\|,\|\_\_\_\|\_\_\_\|\_\_\_\| DOLLARS (1-5000)

DON'T KNOW d

REFUSED r

CP, YP, YA, YX (age 14+, using work incentives)

Created

H51. How does (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) intend to
use the money? Would that be for...

> ¿Cómo piensa (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) usar el
> dinero? ¿Sería eso para . .

*Read list, code all that apply*

School expenses 01

Purchasing a home 02

![](media/image22.wmf) Starting a business, or 03

Something else (SPECIFY) 04

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

Gastos de estudios o escuela 01

Comprar un hogar 02

![](media/image23.wmf) Abrir un negocio, o 03

Alguna otra cosa (SPECIFY) 04

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

DON'T KNOW d

REFUSED r

CP, YP, YA, YX (age 14+, using work incentives)

H52. CHECK: Is PASS checked "yes" in H46A?

YES 01

NO 00 *Go to H54*

CP, YP, YA, YX (age 14+, using work incentives)

Created

H53. What is the dollar amount of expenses that Social Security approved
for (FILL "NAME'S" IF RTYPE=01, 03; "YOUR" IF RTYPE=02) PASS?

¿Cuál es la suma de dólares de los gastos que Social Security aprobó
para (FILL "el plan de PASS de (NAME)" if rtype=01,03; "su plan de pass"
if rtype=02)?

\$\|\_\_\_\|,\|\_\_\_\|\_\_\_\|\_\_\_\| DOLLARS (1-5000)

DON'T KNOW d

REFUSED r

CP, YP, YA, YX (receiving SSI)

Created

H54. Now I'd like to ask about how (FILL "YOUR FAMILY USES" IF RTYPE=01;
"YOU USE" IF RTYPE=02; "NAME USES" IF RTYPE=03) (FILL "NAME'S" IF
RTYPE=01; "YOUR" IF RTYPE=02; "HIS/HER" IF RTYPE=03) SSI benefit. As you
know, (FILL "FAMILIES RECEIVING SSI BENEFITS FOR CHILDREN" IF RTYPE=01;
ELSE "PEOPLE RECEIVING SSI BENEFITS") may spend the money for any
purpose that meets (FILL "NAME'S" IF RTYPE=01 AND AGE=\<17; "THE YOUNG
PERSON'S" IF RTYPE=01 AND AGE=17+; ELSE "THEIR") needs, including food,
clothing, shelter, and utilities, as well as disability-related
services.

> Last month, did (FILL "NAME AND YOUR FAMILY" IF RTYPE=01, "YOU" IF
> RTYPE=02, "NAME" IF RTYPE=03) spend the SSI benefit (FILL "YOU" IF
> RTYPE=01, 02; "HE/SHE" IF RTYPE=03) received **mainly** on...

Ahora me gustaría hacerle hacer unas preguntas acerca de cómo usa (FILL
"SU FAMILIA" IF RTYPE=01; "UD." IF RTYPE=02; "NAME" IF RTYPE=03) su
beneficio de SSI. Como Ud. sabe, (FILL "las familias que reciben
beneficios de SSI para niños" IF RTYPE=01; ELSE "las personas que
reciben beneficios de SSI") pueden gastar el dinero en cualquier cosa
que llena (FILL "las necesidades de NAME" IF RTYPE=01 and AND AGE=\<17;
"las necesidades del /de la jóven" IF RTYPE=01 AND AGE=17+; ELSE "sus
necesidades"), incluyendo alimentos, ropa, albergue, y utilidades,
además de servicios relacionados a incapacidades.

> El mes pasado, ¿gastó (FILL "NAME Y SU FAMILIA" IF RTYPE=01; " UD. "
> IF RTYPE=02, "NAME" IF RTYPE=03) su beneficio de SSI
> **principalmente** en . . .

*Code only one answer*

> Household bills and expenses 01

Specific items and services for (NAME) 02

Both household bills and specific

![](media/image24.wmf) items or services for (NAME), or 03

Something else (SPECIFY) 04

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

Cuentas y gastos del hogar 01

Artículos y servicios específicos para

(FILL "NAME" IF RTYPE=01,03; "UD." IF

RTYPE=02) 02

Tanto para cuentas del hogar como para

artículos o![](media/image25.wmf) servicios específicos para "NAME," o
03

Alguna otra cosa? (SPECIFY) 04

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

DON'T KNOW d

REFUSED r

CP, YP, YA, YX (receiving SSI)

Created

H55. Thinking about all the extra expenses (FILL "NAME AND YOUR FAMILY"
IF RTYPE=01; "YOU" IF RTYPE=02; "NAME" IF RTYPE=03) had in order to care
for (FILL "NAME" IF RTYPE=01; "YOURSELF" IF RTYPE=02; "HIMSELF/HERSELF"
IF RTYPE=03) last month, was the SSI benefit (FILL "YOU" IF RTYPE=01,
02; "HE/SHE" IF RTYPE=03) received adequate to cover these expenses?

Pensando en todos los gastos adicionales que (FILL "NAME y su familia
tuvieron"  IF RTYPE=01; "UD. TUVO" IF RTYPE=02; "NAME TUVO" IF RTYPE=03)
para poder cuidar a, (FILL "NAME" IF RTYPE=01; FILL "sí mismo(a)" IF
RTYPE=02, 03) en el mes pasado, ¿fue el beneficio de SSI que recibió
(FILL "UD." IF RTYPE=01,02;  "EL/ELLA" IF RTYPE=03) suficientemente
adecuado para cubrir estos gastos?

YES 01  *Go to Part I*

NO 00

DON'T KNOW d  *Go to Part I*

REFUSED r  *Go to Part I*

CP, YP, YA, YX (receiving SSI)

Created

H56. Why was the benefit amount not adequate?

¿Por qué no fue adecuada la suma del beneficio?

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

> YES, SPECIFY 01
>
> DON'T KNOW d

REFUSED r