DSS RE-ENROLLMENT SURVEY, OCTOBER 2003, DRAFT 10
May I speak with Mr. or
Ms. ____________? Hello, my name is
___________.
I am calling from UNC
Wilmington to ask some questions about re-enrollment in the Health
Choice/Health Check insurance program for your children. This is part of a research project to
determine how to improve the re-enrollment process for parents and guardians of
children in these programs. All of your
responses will be confidential and the survey will only take about 10 minutes. Your participation in this research
is entirely voluntary. You may refuse
to participate or you may stop participating at any time without penalty or
loss of benefits.
New
Screener Questions
·
Are
you aware that your children were not re-enrolled in the Health Choice/Health Check insurance program?
If yes: Go to question 1.
If no, I did re-enroll them. Give them contact info to check status, and end survey.
If no: Do you want to re-enroll them?
If yes, give contact info, and end survey.
If no, go to question 1.
1. What were your reasons for not re-enrolling your children? (Circle all that apply.)
Write/Summarize Response:
___________________________________________________
____________________________________________________________________________________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Now I would like to ask a few questions about your child with the most recent
birthday.
2. Has this child been to see a doctor or nurse in the
past 12 months?
1. Yes (go to
questions 2a-c)
2. No (go to
question 3)
8. Don’t Know (go to question 3)
9. No Answer
2a.
How many times? _____
2b.
Were any of these visits for routine
care when
your child was not sick or injured?
1. Yes
2. No
8. Don’t Know
9. No Answer
2c.
How satisfied were you with the
treatment your child received? Were you
very satisfied, somewhat satisfied, or not satisfied?
1. Not Satisfied
2. Somewhat Satisfied
3. Very Satisfied
8. Don’t Know
9. No Answer
3. Was
obtaining transportation to the doctor or nurse a problem in the last year?
1. Yes
2. No
8. Don’t
Know
9. No Answer
4. Has your child with the
most recent birthday taken any prescription medication in the last twelve
months?
1. Yes (go
to question 5a and 5b)
2. No (go to
question 6)
8. Don’t
Know (go to question 6)
9. No Answer
(go to question 6)
4a. How much money did you spend last month for
prescriptions for your youngest child? $_____
4b. Does
your child need to stay on this medication permanently?
1. Yes
2. No
8. Don’t
Know
9. No Answer
5. Did you
take your child to the eye doctor in the last 12 months?
1. Yes
2. No
8. Don’t
Know
9. No Answer
6. Did you
take your child to the dentist in the last 12 months?
1. Yes
2. No
8. Don’t
Know
9. No Answer
7. Now that you do not have Medicaid or Health
Choice insurance, where will you go if
your child with the most recent birthday has a cold or a sore throat in the next month? ________________________
8.
Where will you take your child for a routine physical in the next
month?_____________________________
Now I am going to ask some demographic questions
about your child with the most recent birthday.
9. Is
your child’s current health excellent, good, fair, or poor?
1. Poor
2. Fair
3. Good
4. Excellent
8. Don’t Know
9. No Answer
10.
What age is your child? _____
years
11.
Is your child male or female?
1. Male
2. Female
12. Is your youngest child White, African American,
Hispanic American, Asian American, Native American, or some other race:
(Interviewer: Circle all that apply)
1.
White
2.
African American
3.
Hispanic American
4.
Asian American
5.
American Indian
6.
Other:___________________________
8.
Don’t Know
9. No Answer
Now I am going to ask some demographic questions
about you.
13. What is your age? ______ years
14.
Are you male or female?
1.
Male
2.
Female
15.
Are you White, African American,
Hispanic American, Asian American, Native American, or some other race:
(Interviewer: Circle all that apply)
1.
White
2.
African American
3.
Hispanic American
4.
Asian American
5.
American Indian
6.
Other:___________________________
8.
Don’t Know
9.
No Answer
16.
What is the highest degree or level of school that you have completed? Is it
less than high school degree; a high school degree; some college but no degree;
Associate’s or Junior college degree; a Bachelor’s degree; or a graduate
degree?
1. Less than
high school degree
2. High
school degree
3. Some
college, No degree
4.
Associate/Junior college degree
5.
Bachelor’s degree
6. Graduate
degree
8.
Don’t Know
9.
No Answer
17.
Are you currently married, widowed, divorced, separated, or never married?
1.
Married
2.
Widowed
3.
Divorced
4.
Separated
5.
Never Married
8. Don’t Know
9. No Answer
18.
In general, is your current health
excellent, good, fair, or poor?
1. Poor
2. Fair
3. Good
4. Excellent
8. Don’t Know
9. No Answer
19. How many people, including yourself, normally live in your household? ______
20. How many of these
people are under 18 years of age? ______
21. Do you have anything else you would like to
add about the Health Choice/Health Check programs? (Write response below.)
That is the end of our
survey. Thank you for completing the survey. Your answers will remain
confidential and only be used to determine ways to improve the Medicaid and
Health Choice Programs.