Questionnaire Text

Questionnaire form view entire document:  text  image
16. Is this person currently covered by any of the following types of health insurance or health coverage plans?
Mark "Yes" or "No" for each type of coverage in items a - h.

c) Medicare, for people 65 and older, or people with certain disabilities
[] Yes
[] No
d) Medicaid, Medical Assistance, or any kind of government- assistance plan for those with low incomes or a disability
[] Yes
[] No
e) TRICARE or other military health care
[] Yes
[] No
f) VA (including those who have ever used or enrolled for VA health care)
[] Yes
[] No
g) Indian Health Service
[] Yes
[] No
Questionnaire instructions view entire document:  text  image
Answer person questions 7 through 17 for all persons on pages 2, 3, and 4.

Questions 7-48 are a continuation of the questions for each person. (Questions 1-6 appear on pages 2, 3, and 4 of the questionnaire.)

Answer person question 24 if this person is female and is 15-50 years old.