What best describes your employment 2 No status? Mark only ONE. Because of a physical, mental, or emotional 1 Employed full-time condition, do you have difficulty dressing or 2 Employed part-time bathing? 3 A homemaker 1 Yes 4 A full-time student 2 No 5 Retired 6 Unable to work for health Because of a physical, mental, or emotional reasons condition, do you have difficulty doing 7 Unemployed errands alone such as visiting a doctor’s 8 Other office or shopping? 1 Yes Are you of Hispanic, Latino/a, or Spanish 2 No origin? 1 Yes, of Hispanic, Latino/a, or What is your age? Spanish origin 1 18 to 24 2 No, not of Hispanic, Latino/a, or 2 25 to 34 Spanish origin If No, go to #66 3 35 to 44 4 45 to 54 Which group best describes you? 5 55 to 64 1 Mexican, Mexican American, 6 65 to 74 Chicano/a 7 75 or older 2 Puerto Rican 3 Cuban What is your sex? 4 Another Hispanic, Latino/a, or 1 Male Spanish origin 2 Female What is your race? Mark one or more. What is the highest or level of school 1 White that you have completed? 2 Black or African American 1 8th grade or less 3 American Indian or Alaska 2 Some high school, but did not Native graduate 4 Asian Indian 3 High school graduate or GED 5 Chinese 4 Some college or 2-year degree 6 Filipino 5 4-year college graduate 7 Japanese 6 More than 4-year college degree 8 Korean 9 Vietnamese 10 Other Asian 11 Native Hawaiian 12 Guamanian or Chamorro 13 Samoan 14 Other Pacific Islander
2 No Because of a physical, mental, or emotional condition, do you have difficulty dressing or bathing? 1 Yes 2 No Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? 1 Yes 2 No What is your age? 1 18 to 24 2 25 to 34 3 35 to 44 4 45 to 54 5 55 to 64 6 65 to 74 7 75 or older What is your sex? 1 Male 2 Female What is the highest or level of school that you have completed? 1 8th grade or less 2 Some high school, but did not graduate 3 High school graduate or GED 4 Some college or 2-year degree 5 4-year college graduate 6 More than 4-year college degree What best describes your employment status? Mark only ONE. 1 Employed full-time 2 Employed part-time 3 A homemaker 4 A full-time student 5 Retired 6 Unable to work for health reasons 7 Unemployed 8 Other Are you of Hispanic, Latino/a, or Spanish origin? 1 Yes, of Hispanic, Latino/a, or Spanish origin 2 No, not of Hispanic, Latino/a, or Spanish origin If No, go to #66 Which group best describes you? 1 Mexican, Mexican American, Chicano/a 2 Puerto Rican 3 Cuban 4 Another Hispanic, Latino/a, or Spanish origin What is your race? Mark one or more. 1 White 2 Black or African American 3 American Indian or Alaska Native 4 Asian Indian 5 Chinese 6 Filipino 7 Japanese 8 Korean 9 Vietnamese 10 Other Asian 11 Native Hawaiian 12 Guamanian or Chamorro 13 Samoan 14 Other Pacific Islander
CMS-2019-QHP-Survey-Questionnaire_Eng_FINAL_508.docx