Survey Text

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2021

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2020

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2019

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2018
Survey form view entire document:  text  image
AC270 (AC1191)
BLAISE NAME: AffrdCareDN
Question Text:
In the last 12 months, was there any time when [[you/[PERSON]]/anyone in the household] needed dental care, but did not get it because [[you/he/she]/they] couldn?t afford it?
Responses:

 

YES 1
NO 2 AC290 (AC1193)
REFUSED RF AC290 (AC1193)
DON'T KNOW DK AC290 (AC1193)
Programmer Instructions: 
If coded ?1? (YES) and a MULTI-PERSON RU, continue with AC280.
If coded ?1? (YES) and a SINGLE-PERSON RU, automatically code person at AC280, and go to AC290.
Display Instructions: 
Display ?[you/[PERSON]]? if SINGLE-PERSON RU. Otherwise, display ?anyone in the household?.
AC280 (AC1192)
BLAISE NAME: AffrdWhoDN
Question Text:
Who was that?
PROBE: Did anyone else need dental care but did not get it because they couldn?t afford it?
ENTER ALL THAT APPLY.
Responses:

 

[FIRST NAME [MIDDLE NAME] LAST NAME]1 1
[FIRST NAME [MIDDLE NAME] LAST NAME]2 2
[FIRST NAME [MIDDLE NAME] LAST NAME]3 3
[FIRST NAME [MIDDLE NAME] LAST NAME]4 4
[FIRST NAME [MIDDLE NAME] LAST NAME]N 5
Programmer Instructions: Go to AC290.
Display Instructions: Roster 2 - no add/edit/delete
Roster definition:
This item displays RU members roster for selection. Display RU member?s first, middle, and last name (Person.FullName).
Roster filter:
No filter; display all.