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.

d) Medicaid, Medical Assistance, or any kind of government- assistance plan for those with low incomes or a disability

[] 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.)

24. Mark the "Yes" box if the person has given birth to at least one child born alive in the past 12 months, even if the child died or no longer lives with the mother. Do not consider miscarriages, or stillborn children, or any adopted, foster, or stepchildren.