Participation Questionnaire

Mathematica Policy Research, Inc.


This instrument was developed for the Cash and Counseling Demonstration. This project was conducted by the University of Maryland under contract #HHS-100-95-0046 for the Department of Health and Human Services (HHS) Office of Disability, Aging and Long-Term Care Policy, as well as additional funding from the Robert Wood Johnson Foundation. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Pamela Doty.


NOTE: This is a recreation of this form. See the PDF version for a scanned version of the actual form.

DECIDING ABOUT CONSUMER DIRECTED CARE

In order to improve the Medicaid project, Consumer Directed Care, we would like to know more about who is interested in applying to the project and why, and who is not interested in applying and why not.

INSTRUCTIONS

Thank you for taking the time to complete this form. Directions for filling it out are provided with each question. Because not all questions will apply to everyone, you may be asked to skip certain questions.

  • Part A of this form is for people who decided to apply to the project. Part B is for people who decided NOT to apply. Parts C and D are for everyone.

  • Follow all "SKIP" instructions AFTER marking a box. If no "SKIP" instruction is provided, you should continue to the NEXT question.

  • Either a pen or pencil may be used.

  • When answering questions that require marking a box, please use an "X".

  • If you need to change an answer, please make sure that your old answer is either completely erased or clearly crossed out.

Thanks again for your help, we really apprciate it.

 

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number of this information is 0990-0223. The time requred to complete this information collection is estimated to average 5 minutes, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the information collection. Approval expires 10/31/2001.

 

PART A - If decided TO APPLY to the Consumer Directed Care project

Part A is only for people who decided to apply to the project. If you decided not to apply, start with question B1.

A1. Who made the decision to apply to the Consumer Directed Care project? Mark (X) one or more.

01 _____ Person who would receive the monthly budget (if randomly selected)
02 _____ Someone who will be managing the monthly budget as a representative of the person receiving it
03 _____ Other family members and friends

A2. What were the main reasons for deciding to apply? Mark (X) one or more reasons.

01 _____ Have more control over who to hire
02 _____ Get better or more care
03 _____ Get care at more convenient times
04 _____ Purchase community services not covered under Medicaid
05 _____ Purchase equipment or supplies
06 _____ Purchase home or care modifications
07 _____ Get help from consultants or bookkeeping service
08 _____ Pay personal care workers more or provide (more) benefits
09 _____ Pay family members or friends
10 _____ None of the above

SKIP TO C1

 

PART B - If decided NOT to apply.

B1. Who made the decision not to apply to the project? Mark (X) one or more.

01 _____ Person who would have been receiving the monthly budget (if randomly selected)
02 _____ Someone who would have been managing the monthly budget as a representative of the person receiving it
03 _____ Other family members and friends

B2. What were the main reasons for deciding not to apply? Mark (X) one or more reasons.

01 _____ Do not want to hire and possibly fire workers
02 _____ Concern about quality of care or personal safety if hire workers
03 _____ Do not want to file payroll taxes for workers or track project expenses
04 _____ Do not think budget would be enough to pay for all needed care
05 _____ Satisfied with current care arrangements
06 _____ Afraid change might upset family or friends
07 _____ Do not think providing a budget is a good idea
08 _____ Do not like random selection, or do not like that participation is guaranteed for only two years
09 _____ Afraid family or friends might misuse budget
10 _____ None of the above

 

Continue with Section C

PART C - FOR EVERYONE: About the Person MANAGING the Monthly Budget

Please answer the questions in Section C about the person who will be, or would have been, MANAGING the monthly budget. This could be a person randomly selected to receive the budget or someone else managing the budget as his or her representative.

C1. Did someone explain the Consumer Directed Care project in person or over the telephone to the person who will be, or would have been, MANAGING the monthly budget? Mark (X) only one.

01 _____ In person
02 _____ Over the telephone, not in-person
03 _____ In person AND over the telephone
04 _____ Neither SKIP TO C2
08 _____ Don't know SKIP TO C2

C1a. How useful did this perso find the explanations in deciding whether or not to apply? Mark (X) only one.

01 _____ Very useful
02 _____ Somewhat useful
03 _____ Not useful

C2. Did this person receive materials explaining the project, like a brochure or other information in the mail? Mark (X) only one.

01 _____ Yes, received materials
02 _____ No, did not receive materials SKIP TO C3

C2a. How useful did he or she find those materials in deciding whether or not to apply to the Consumer Directed Care project? Mark (X) only one.

01 _____ Very useful
02 _____ Somewhat useful
03 _____ Not useful

C3. Has this person EVER supervised another person as part of paid or volunteer work? Mark (X) only one.

01 _____ Yes
02 _____ No

Continue with Section D

 

PART D - FOR EVERYONE: About the Person RECEIVING the Monthly Budget

Please answer the questions in Section D about the person who will be, or would have been, RECEIVING the monthly budget, if randomly selected. Please do NOT answer about a representative who is, or would have been, managing the monthly budget for someone else.

D1. What is this person's age? (The person who will be, or would have been, RECEIVING the monthly budget if randomly selected.) Please write in age.

Age in years (at last birthday): |_____|_____|

D2. What is this person's sex? Mark (X) only one.

1 _____ Male
2 _____ Female

D3. Is this person of Hispanic or Latino origin, such as Mexican, Puerto Rican, Cuban, or other Spanish background? Mark (X) only one.

1 _____ Yes
2 _____ No

D4. What is this person's race? Mark (X) one or more races.

1 _____ White
2 _____ Black or African American
3 _____ American Indian or Alaska Native
4 _____ Asian
5 _____ Native Hawaiian or other Pacific Islander
6 _____ Some other race. Please write in _________________________

D5. In what county and state does this person live? Please write in county and state names.

County name _________________________
State name _________________________

D6. How long has this person been receiving home and community-based Medicaid services? Mark (X) only one.

0 _____ Have not yet begun receiving services
1 _____ Less than three months
2 _____ Three months to a year
3 _____ More than a year
8 _____ Don't know

 

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