M002
|
|
Do you have any impairment or health problem that limits the kind or amount of paid work you could do? |
M003
|
|
What health condition causes this impairment or problem? |
M004
|
|
Is this a temporary condition that will last for less than three months? |
M005
|
|
Have you had this condition before? |
M006
|
|
Does any impairment or health problem limit the kind or amount of work you can do around the house? |
M007
|
|
Are you limited in any way in activities because of an impairment or problem? |
M008
|
|
Does this limitation keep you from working altogether? |
M011
|
|
Are you able to work full-time or can you work only part-time? |
M013
|
|
Are you now able to do the same kind of work you did before your health limitation began? |
M014
|
|
In what year did the impairment or health problem begin to interfere with your work? YEAR____________ |
M015
|
|
What month was that? |
M018
|
|
Do you expect this condition to improve enough within the next few years so that it will no |
M020
|
|
Was the impairment or health problem you just mentioned the result of an accident or injury? |
M021
|
|
Did the accident or injury occur at work, at home, or somewhere else? |
M023
|
|
Was this impairment or health problem in any way caused by the nature of your work? |
M024
|
|
Were you employed at the time your health began to limit your ability to work? |
M026
|
|
Which company or organization did you work for at that time? |
M027
|
|
What was the name of that company or organization? NAME OF COMPANY____________________ |
W200_1
|
|
Before your health began to limit your ability to work, were you working for someone else, were you self-employed, or what? |
W202_1
|
|
What kind of business or industry did you work in ? that is, what did they make or do at the place where you worked? BUSINESS_____________ |
W201_1
|
|
What sort of work did you do on that job? TYPE OF WORK___________ |
W203_1
|
|
About how many employees work for that company or organization at all locations? NUMBER___________ |
W204_1
|
|
Is it fewer than 5, 5 to 14, 15 to 24, 25 to 99, 100 to 499, or 500 or more? |
W205_1
|
|
What were you earning, before deductions, when you [left that employer/stopped working for that business]? $ _________ |
W206_1
|
|
[INSTR: PROBE IF NECESSARY:Was that per hour, week, month, or year?] PER: |
W208_1
|
|
[BANNER: Employer When Impairment Began] How many hours a week did you usually work for that [employer/business]? HOURS___________ |
W209_1
|
|
Counting paid vacations as weeks of work, how many weeks per year did you usually work for this [employer/business]? WEEKS_____________ |
W210_1
|
|
[BANNER: Employer When Impairment Began] Were you covered by a union or employee-association contract? |
M028
|
|
At the time your health started to limit your ability to work, did your employer do anything special to help you out so that you could stay at work? |
W211_1
|
|
[BANNER: Employer When Impairment Began: Accommodations] Did your employer get someone to help you? |
W214_1
|
|
[BANNER: Employer When Impairment Began: Accommodations] Did your employer shorten your work days? |
W217_1
|
|
[BANNER: Employer When Impairment Began: Accommodations] Did your employer allow you to change the time you came to and left work? |
W220_1
|
|
(Did your employer) allow you more breaks and rest periods? |
W223_1
|
|
Did your employer arrange for special transportation? |
W226_1
|
|
Did your employer change(d) the job to something you could do? |
W227_1
|
|
Did your employer help(ed) you learn new job skills? |
W228_1
|
|
Did your employer get you special equipment for the job? |
W229_1
|
|
Did your employer assist you in receiving rehabilitative services from an external provider? |
W230_1
|
|
Did your employer do any other things to help you out? |
W231_1
|
|
What other things? __________________DK |
M029
|
|
Does your employer currently do anything special to make it easier for you to stay at work? |
W211_2
|
|
Does your employer get someone to help you? |
W214_2
|
|
Does your employer shorten your work days? |
W217_2
|
|
Does your employer allow you to change the time you come to and leave work? |
W220_2
|
|
Does your employer allow you more breaks and rest periods? |
W223_2
|
|
Does your employer arrange for special transportation? |
W226_2
|
|
Has your employer changed the job to something you can do? |
W227_2
|
|
Has your employer helped you learn new job skills? |
W228_2
|
|
Does your employer get you special equipment for the job? |
W229_2
|
|
Does your employer assist you in receiving rehabilitative services from an external provider? |
W230_2
|
|
Does your employer do any other things to help you out? |
W231_2
|
|
What other things? ______________ |
M030
|
|
Which program was this: the Social Security Disability or the Supplemental Security Income program, or both? |
W238_1
|
|
Are you still receiving benefits from [Social Security Disability/ Social Security]? |
W256_1
|
|
Why are you no longer receiving those benefits? Did your household resources increase, did you return to work, are you not working but able to work, or what? |
W239_1
|
|
How much did you receive (from the [Social Security Disability/Social Security] program last month? $______________ .00 |
W242_1
|
|
(Thinking about the amount you received from the [Social Security Disability/Social Security] program last month:) Did it amount to a total of less than $____ per month, more than $____ per month, or what? |
W244_1
|
|
In what year did the benefits stop? YEAR___________ |
W243_1
|
|
What month was that? |
W256_2
|
|
Why are you no longer receiving those benefits? |
W257_2S
|
|
Did your household resources increase, did you return to work, are you not working but able to work, or what? |
W239_2
|
|
How much did you receive from the Supplemental Security Income program the last month you received this benefit? $ ____________ .00 |
W242_2
|
|
Thinking about the amount you received from the Supplemental Security Income program last month: Did it amount to a total of less than $____ per month, more than $____ per month, or what? |
W244_2
|
|
In what year did the benefits stop? YEAR_____________ |
W243_2
|
|
What month was that? |
M031
|
|
Which program was this: the Social Security Disability or the Supplemental Security Income program, or both? |
M032
|
|
Was your SSDI application approved? |
W234_3
|
|
In what year did you start receiving Social Security Disability benefits? YEAR______________ |
W233_3
|
|
What month was that? |
W235_3
|
|
Were you offered rehabilitative services? |
W237_3
|
|
In what year were you offered rehabilitative services? YEAR____________ |
W236_3
|
|
What month was that? |
W238_3
|
|
Are you still receiving benefits from Social Security Disability? |
W256_3
|
|
Why are you no longer receiving those benefits? |
W239_3
|
|
How much did you receive from the Social Security Disability program the last month you received this benefit? $ ___________ .00 |
W242_3
|
|
Thinking about the amount you received from the Social Security Disability program last month: Did it amount to a total of less than $____ per month, more than $____ per month, or what? |
W244_3
|
|
In what year did the benefits stop? YEAR___________ |
W243_3
|
|
What month was that? |
W245_1
|
|
Did you appeal or apply again later? |
W247_1
|
|
In what year did you last appeal or apply for benefits? YEAR___________ |
W246_1
|
|
What month was that? |
W248_1
|
|
Was your application eventually accepted, rejected, or is it still being considered? |
W234_4
|
|
In what year did you start receiving Social Security Disability benefits? YEAR________ |
W233_4
|
|
What month was that? |
W235_4
|
|
Were you offered rehabilitative services? |
W237_4
|
|
In what year were you offered rehabilitative services? YEAR____________ |
W236_4
|
|
What month was that? |
W238_4
|
|
Are you still receiving benefits from Social Security Disability? |
W256_4
|
|
Why are you no longer receiving those benefits? |
W239_4
|
|
How much did you receive from the Social Security Disability program the last month you received this benefit? $ ___________ .00 |
W242_4
|
|
Thinking about the amount you received from the Social Security Disability program last month: Did it amount to a total of less than $____ per month, more than $____ per month, or what? |
W244_4
|
|
In what year did the benefits stop? YEAR_________ |
W243_4
|
|
What month was that? |
M033
|
|
Was your SSI application approved? |
W234_5
|
|
In what year did you start receiving Supplemental Security Income benefits? YEAR___________ |
W233_5
|
|
What month was that? |
W238_5
|
|
Are you still receiving benefits from Supplemental Security Income? |
W256_5
|
|
Why are you no longer receiving those benefits? |
W239_5
|
|
How much did you receive from the Supplemental Security Income program the last month you received this benefit? $ ___________ .00 |
W242_5
|
|
Thinking about the amount you received from the Supplemental Security Income program last month: Did it amount to a total of less than $____ per month, more than $____ per month, or what? |
W244_5
|
|
In what year did the benefits stop? YEAR_________ |
W243_5
|
|
What month was that? |
W245_2
|
|
Did you appeal or apply again later? |
W247_2
|
|
In what year did you last appeal or apply for benefits? YEAR__________ |
W246_2
|
|
What month was that? |
W248_2
|
|
Was your application eventually accepted, rejected, or is it still being considered? |
W234_6
|
|
In what year did you start receiving Supplemental Security Income benefits? YEAR___________ |
W233_6
|
|
What month was that? |
W238_6
|
|
Are you still receiving benefits from Supplemental Security Income? |
W256_6
|
|
Why are you no longer receiving those benefits? |
W239_6
|
|
How much did you receive from the Supplemental Security Income program the last month you received this benefit? $ ________ .00 |
W242_6
|
|
Thinking about the amount you received from the Supplemental Security Income program last month: Did it amount to a total of less than $____ per month, more than $____ per month, or what? |
W244_6
|
|
In what year did the benefits stop? YEAR_________ |
W243_6
|
|
What month was that? |
W238_7
|
|
Are you still receiving benefits from the Veterans Administration? |
W239_7
|
|
How much did you receive from the Veterans Administration program the last month you received this benefit? $__________ .00 |
W242_7
|
|
Thinking about the amount you received from the Veterans Administration program last month: Did it amount to a total of less than $____ per month, more than $____ per month, or what? |
W244_7
|
|
In what year did the benefits stop? YEAR__________ |
W243_7
|
|
What month was that? |
M034
|
|
Was your application approved? |
W232_8
|
|
What disability rating did you receive? __________%DK |
W234_8
|
|
In what year did you start receiving Veterans Administration benefits? YEAR_________ |
W233_8
|
|
What month was that? |
W238_8
|
|
Are you still receiving benefits from the Veterans Administration? |
W239_8
|
|
How much did you receive from the Veterans Administration program the last month you received this benefit? $ __________ .00 |
W242_8
|
|
(Thinking about the amount you received from the Veterans Administration program last month:) Did it amount to a total of less than $____ per month, more than $____ per month, or what? |
W244_8
|
|
In what year did the benefits stop? YEAR_________ |
W243_8
|
|
What month was that? |
W238_9
|
|
Are you still receiving benefits from Workers' Compensation? |
W239_9
|
|
How much did you receive from the Workers' Compensation program the last month you received this benefit? $ _______ .00 |
W242_9
|
|
(Thinking about the amount you received from the Workers' Compensation program last month:) Did it amount to less than $____ per month, more than $____ per month, or what? |
W244_9
|
|
In what year did the benefits stop? YEAR_________ |
W243_9
|
|
What month was that? |
M035
|
|
According to our records, in R's LAST IW MONTH, YEAR you had applied for benefits from Workers' Compensation. Was your application approved? |
W234_10
|
|
In what year did you start receiving Workers' Compensation benefits? YEAR___________ |
W233_10
|
|
What month was that? |
W238_10
|
|
Are you still receiving benefits from Workers' Compensation? |
W239_10
|
|
How much did you receive from the Workers' Compensation program the last month you received this benefit? $ ____________ .00 |
W242_10
|
|
Thinking about the amount you received from the Workers' Compensation program last month: Did it amount to less than $____ per month, more than $____ per month, or what? |
W244_10
|
|
In what year did the benefits stop? YEAR___________ |
W243_10
|
|
What month was that? |
M036
|
|
Since R's LAST IW MONTH, YEAR, have you applied for disability benefits from any (other) government program? |
M037
|
|
Which programs did you apply to? |
M058
|
|
Did you apply to Social Security Disability or the Supplemental Security Income program, or both? |
W250_1
|
|
In what year did you first apply for disability benefits from the Social Security disability program? YEAR________ |
W249_1
|
|
What month was that? |
W252_1
|
|
In what year did you first apply for benefits from the Social Security disability program since that time? YEAR__________ |
W251_1
|
|
What month was that? |
M040
|
|
Was your application accepted, rejected, or is it still being considered? |
W245_3
|
|
Did you appeal or apply again later? |
W247_3
|
|
In what year did you last appeal or apply for benefits? YEAR_________ |
W246_3
|
|
What month was that? |
W248_3
|
|
Was your application eventually accepted, rejected, or is it still being considered? |
W234_11
|
|
In what year did you start receiving Social Security Disability benefits? YEAR__________ |
W233_11
|
|
What month was that? |
W235_11
|
|
Were you offered rehabilitative services? |
W237_11
|
|
In what year were you offered rehabilitative services? YEAR_________ |
W236_11
|
|
What month was that? |
W238_11
|
|
Are you still receiving benefits from Social Security Disability? |
W256_11
|
|
Why are you no longer receiving those benefits? |
W239_11
|
|
How much did you receive from the Social Security Disability program the last month you received this benefit? $ __________ .00 |
W242_11
|
|
Did it amount to a total of less than $____ per month, more than $____ per month, or what? |
W244_11
|
|
In what year did the benefits stop? YEAR_________ |
W243_11
|
|
What month was that? |
W250_2
|
|
Not including those disability benefits we have already discussed, In what year did you first apply for disability benefits from the Supplemental Security Income disability program? YEAR________ |
W249_2
|
|
What month was that? |
W252_2
|
|
In what year did you first apply for benefits from the Supplemental Security Income disability program since that time? YEAR_________ |
W251_2
|
|
What month was that? |
M041
|
|
Was your application accepted, rejected, or is it still being considered? |
W245_4
|
|
Did you appeal or apply again later? |
W247_4
|
|
In what year did you last appeal or apply for benefits? YEAR_________ |
W246_4
|
|
What month was that? |
W248_4
|
|
Was your application eventually accepted, rejected, or is it still being considered? |
W234_12
|
|
In what year did you start receiving Supplemental Security Income benefits? YEAR__________ |
W233_12
|
|
What month was that? |
W238_12
|
|
Are you still receiving benefits from Supplemental Security Income? |
W256_12
|
|
Why are you no longer receiving those benefits? |
W239_12
|
|
How much did you receive from the Supplemental Security Income program the last month you received this benefit? $ _________ .00 |
W242_12
|
|
Thinking about the amount you received from the Supplemental Security Income program last month: Did it amount to a total of less than $____ per month, more than $____ per month, or what? |
W244_12
|
|
In what year did the benefits stop? YEAR_________ |
W243_12
|
|
What month was that? |
W250_3
|
|
Not including those disability benefits we have already discussed, In what year did you first apply for disability benefits from the Veterans Administration disability program? YEAR_________ |
W249_3
|
|
What month was that? |
W252_3
|
|
In what year did you first apply for benefits from the Veterans Administration disability program since that time? YEAR_________ |
W251_3
|
|
What month was that? |
M042
|
|
Was your application accepted, rejected, or is it still being considered? |
W245_5
|
|
Did you appeal or apply again later? |
W247_5
|
|
In what year did you last appeal or apply for benefits? YEAR__________ |
W246_5
|
|
What month was that? |
W248_5
|
|
Was your application eventually accepted, rejected, or is it still being considered? |
W232_13
|
|
What disability rating did you receive? __________%DK |
W234_13
|
|
In what year did you start receiving Veterans Administration benefits? YEAR_______ |
W233_13
|
|
What month was that? |
W238_13
|
|
Are you still receiving benefits from the Veterans Administration? |
W239_13
|
|
How much did you receive from the Veterans Administration program the last month you received this benefit? $ _________ .00 |
W242_13
|
|
Thinking about the amount you received from the Veterans Administration program last month: Did it amount to a total of less than $____ per month, more than $____ per month, or what? |
W244_13
|
|
In what year did the benefits stop? YEAR_________ |
W243_13
|
|
What month was that? |
W250_4
|
|
Not including those disability benefits we have already discussed, In what year did you first apply for disability benefits from the Workers' Compensation disability program? YEAR__________ |
W249_4
|
|
What month was that? |
W252_4
|
|
We are interested in your first application since R's LAST IW MONTH, YEAR. In what year did you first apply for benefits from the Workers' Compensation disability program since that time? YEAR_________ |
W251_4
|
|
What month was that? |
M043
|
|
Was your application accepted, rejected, or is it still being considered? |
W245_6
|
|
Did you appeal or apply again later? |
W247_6
|
|
In what year did you last appeal or apply for benefits? YEAR_________ |
W246_6
|
|
What month was that? |
W248_6
|
|
Was your application eventually accepted, rejected, or is it still being considered? |
M046
|
|
[INSTR: PROBE IF NECESSARY REFERRING TO WORKERS' COMPENSATION:What percentage did you receive?] [What percentage did you receive?[INSTR: ENTER WHOLE NUMBERS ONLY, 1-100.] __________%DK |
M047
|
|
[INSTR: PROBE IF NECESSARY REFERRING TO WORKERS' COMPENSATION:For how many years?] 0-50 YEARS |
M048
|
|
[INSTR: PROBE IF NECESSARY REFERRING TO WORKERS' COMPENSATION:What percentage did you receive?] |
M049
|
|
For how many years? YEARS_________ |
W234_14
|
|
In what year did you start receiving Workers' Compensation benefits? YEAR________ |
W233_14
|
|
What month was that? |
W238_14
|
|
Are you still receiving benefits from Workers' Compensation? |
W239_14
|
|
How much did you receive from the Workers' Compensation program the last month you received this benefit? $_________ .00 |
W242_14
|
|
Thinking about the amount you received from the Workers' Compensation program last month: Did it amount to less than $____ per month, more than $____ per month, or what? |
W244_14
|
|
In what year did the benefits stop? YEAR_________ |
W243_14
|
|
What month was that? |
W250_5
|
|
Not including those disability benefits we have already discussed, In what year did you first apply for disability benefits from the public welfare or other government disability program? YEAR________ |
W249_5
|
|
What month was that? |
W252_5
|
|
In what year did you first apply for benefits from the public welfare or other government disability program since that time? YEAR________ |
W251_5
|
|
What month was that? |
M050
|
|
Was your application accepted, rejected, or is it still being considered? |
W245_7
|
|
Did you appeal or apply again later? |
W247_7
|
|
In what year did you last appeal or apply for benefits? YEAR__________ |
W246_7
|
|
What month was that? |
W248_7
|
|
Was your application eventually accepted, rejected, or is it still being considered? |
W234_15
|
|
In what year did you start receiving benefits from this public welfare or other government program? YEAR__________ |
W233_15
|
|
What month was that? |
W238_15
|
|
Are you still receiving benefits from the public welfare or other government program? |
W239_15
|
|
How much did you receive from the public welfare or other government program the last month you received this benefit? $ ________ .00 |
W242_15
|
|
Thinking about the amount you received from the public welfare or other government program last month: Did it amount to less than $____ per month, more than $____ per month, or what? |
W244_15
|
|
In what year did the benefits stop? YEAR_________ |
W243_15
|
|
What month was that? |
M051
|
|
Since R's LAST IW MONTH, YEAR, have you had any injuries at work that required special medical attention or treatment or interfered with your work activities? |
M052
|
|
How many times have you been injured on the job since R's LAST IW MONTH, YEAR? NUMBER OF TIMES__________ |
M053On
|
|
what date did your (most recent) injury happen? MONTH: |
M054
|
|
DAY_______ |
M055
|
|
YEAR________ |
M056M1
|
|
ASSIST INSTR: HOW OFTEN DID R RECEIVE ASSISTANCE WITH ANSWERS IN SECTION M1 -- RE-IW DISABILITY? |