NJCAT3

circa 2015

NJCAT3 Question

Date Of Interview

Consumer Name (Respondent Name)

Q1a) Who will be filling out the information in this survey?

Q1_Cons) Consumer Current Street Address:

Q1_Cons) Consumer City:

Q1_Cons) Consumer State:

Q1_Cons) Consumer Zip:

Consumer DOB

Panel DOB

Verify DOB

Q1_Resp) Respondent First Name:

Q1_Resp) Respondent Last Name:

Q1_Resp) Respondent Phone Number(Please use xxx-xxx-xxxx format):

Q1_Resp) Respondent Cell/Alternate Number(Please use xxx-xxx-xxxx format):

Q1_Resp) Respondent Email Address(eg abcdef@ghijcom):

Q1_Resp) Respondent Street Address:

Q1_Resp) Respondent City:

Q1_Resp) Respondent State:

Q1 Resp) Respondent Zip:

Q2) Are you the primary caregiver for [name]? The primary caregiver is the person who is principally responsible for the care and well-being of [name]

Q3a) Does [name] currently live with you?

Q3b) What best describes [names]’s current living arrangement?

Q3b_TEXT) What best describes [names]’s current living arrangement?(Please specify)- TEXT

Q4) What is your relationship to [name]?

Q4_TEXT) What is your relationship to [name]? (Please specify)-TEXT

Q5) Respondents (your) gender

Q6) Who is [name]’s guardian for medical and legal decisions at this time?

Q6_TEXT) Who is [name]’s guardian for medical and legal decisions at this time? (Please specify) -TEXT

Q7) Who is likely to be [name]’s guardian for medical and legal decisions 5 years from now?

Q7_TEXT) Who is likely to be [name]’s guardian for medical and legal decisions 5 years from now? - (Please specify) TEXT

Q8) How old is [name]?

Q9a) What is [name]s gender?

Q9b_1) Consumer race/ethnicity- Hispanic, Latino, or Spanish Origin

Q9b_2) Consumer race/ethnicity- Black or African-American

Q9b_3) Consumer race/ethnicity- White

Q9b_4) Consumer race/ethnicity- Asian

Q9b_5) Consumer race/ethnicity- American Indian or Alaska Native

Q9b_6) Consumer race/ethnicity- Native Hawaiian or Pacific Islander

Q9b_7) Consumer race/ethnicity- Some other group (Please specify)

Q9b_7_TEXT) Consumer race/ethnicity- (Please specify) TEXT

Q9c) Does [name] have a valid drivers license?

Q9d) Does [name] have access to a motor vehicle and drive himself/herself as a means of regular transportation?

Q10_1) Consumer conditions- Autism spectrum disorder

Q10_2) Consumer conditions- Cerebral palsy

Q10_3) Consumer conditions- Spina bifida

Q10_4) Consumer conditions- Down’s syndrome

Q10_5) Consumer conditions- An intellectual or cognitive disability (formerly known as mental retardation)

Q10_6) Consumer conditions- Prader-Willi syndrome

Q10_7) Consumer conditions- Any physical disabilities (including, but not limited to, any physical disability on this list)

Q10_8) Consumer conditions- A mental health problem with a psychiatric diagnosis (other than an intellectual or cognitive disability, pervasive developmental disorder, or autism spectrum disorder)

Q10_9) Consumer conditions- Traumatic brain injury including acquired non-degenerative brain injury

Q10_10) Consumer conditions- Epilepsy or a seizure disorder

Q10_1a) Would you describe [name]s autism or autism spectrum disorder as mild, moderate, or severe?

Q10_8a) You indicated that [name] has a mental health problem with a psychiatric diagnosis  Please specify the diagnosis in the space below

Q10_10a) You indicated that [name] has epilepsy or a seizure disorder When was the last time that [name] had a seizure?

Q10_10b) Does [name] currently require CONSTANT SUPERVISION at all times during waking and/or sleeping hours in order to prevent injury due to an uncontrolled seizure disorder?

Q11) Does [name] experience any hearing loss that cannot be corrected by hearing aids?

Q12) Which answer best describes [name]s hearing in the last month?

Q13) Does [name] experience any visual problems that cannot be corrected with glasses or contacts?

Q14) Which answer best describes [name]s vision in the last month?

Q15_1) Past month, level of ability to do- Rolling from back to stomach

Q15_2) Past month, level of ability to do- Pulling himself/herself to standing from a sitting position

Q15_3) Past month, level of ability to do- Going up stairs in any house or building

Q15_4) Past month, level of ability to do- Going down stairs in any house or building

Q15_5) Past month, level of ability to do- Picking up small objects, such as a Cheerio

Q15_6) Past month, level of ability to do- Transferring an object from hand to hand

Q15_7) Past month, level of ability to do- Crawling, creeping, or scooting, such as getting something from under a bed or chair

Q15_8) Past month, level of ability to do- Sitting without support for at least 5 minutes, such as on a piano bench or stool without a back

Q16) Does [name] walk independently without difficulty, without using a corrective device, and/or without receiving assistance?

Q17) Which best describes [name]s typical level of walking mobility?

Q18) Does [name] use a wheelchair or electric scooter?

Q19a) Currently uses- Non-motorized wheelchair

Q19b) Currently uses- Motorized wheelchair

Q19c) Currently uses- Electric scooter

Q20) Which best describes [name]’s ability to transfer himself/herself in or out of the wheelchair or scooter?

Q21) Which best describes [name]’s ability to move a wheelchair from place to place?

Q22A_1) Associating Time with Events and Actions- Remembers events that happened a month or more ago

Q22A_2) Associating Time with Events and Actions- Knows daily routine, such as what occurs in the morning, afternoon, and evening

Q22A_3) Associating Time with Events and Actions- Associates events with time in past, present, or future, such as knowing the difference between yesterday, today, and tomorrow

Q22_2a) Associating Time with Events and Actions- Associates regular events with a specific hour, such as knowing 6:00 PM is time for dinner

Q22A_3a) Associating Time with Events and Actions-Tells time to nearest 5 min,knowing difference between 5 min before/after 6 PM, or understands the difference between 5 min and 10 min from now

Q22B_1) Spatial/Perceptual Abilities- Knows difference between red, blue, green, and yellow

Q22B_2) Spatial/Perceptual Abilities- Knows difference between big and small

Q22B_3) Spatial/Perceptual Abilities- Knows difference between a circle, square, and triangle

Q22B_4) Spatial/Perceptual Abilities- Finds way around the home by himself/herself

Q22C_1) Number Awareness- Uses numbers, even if inaccurately

Q22C_2) Number Awareness- Counts to 10 without help

Q22C_2a) Number Awareness- Does simple addition without use of a calculator or computer

Q22C_2b) Number Awareness- Does simple subtraction without use of a calculator or computer

Q22D_1) Writing Skills- Prints or writes single letters without a model or tracing

Q22D_1a) Writing Skills- Prints or writes own first name without a model or tracing

Q22D_1b) Writing Skills- Prints or writes single words, other than his/her name, without a model or tracing

Q22D_1ba) Writing Skills- Prints or writes simple sentences without a model or tracing

Q22E_1) Reading and Sign Skills- Recognizes his/her own first and last name when it is written

Q22E_2) Reading and Sign Skills- Reads and understands simple words

Q22E_2a) Reading and Sign Skills- Reads and understands simple sentences

Q22E_2aa) Reading and Sign Skills- Reads and understands a simple story

Q23A_1) Expressive Verbal Communication- Uses at least a few simple words, signs, or picture symbols

Q23A_1a) Expressive Verbal Communication- Uses 10 or more simple words or signs in his/her entire vocabulary

Q23A_1aa) Expressive Verbal Communication- Asks simple questions using words or signs

Q23A_1ab) Expressive Verbal Communication- Uses complete sentences when carrying on a conversation

Q23A_1ac) Expressive Verbal Communication- Tells a simple story, such as about a television show

Q23B_1) Clarity of Speech- Clearly says “Yes” or “No” to a simple question

Q23B_2) Clarity of Speech- Speech is readily understood by strangers

Q23B_2a) Clarity of Speech-Speech is understood by those who know [name] well

Q23B_1a) Clarity of Speech- Is English [name]s primary language?

Q23B_1aa) Clarity of Speech- What is [name]s primary language? (Please specify in the box below)

Q23C_1) Receptive Verbal Communication- Does [name] respond to his/her name when it is spoken or signed?

Q23C_2) Receptive Verbal Communication- Does [name] understand the meaning of “Yes” and “No”?

Q23C_2a) Receptive Verbal Communication- Does [name] understand a one-step direction, such as "Look at me"?

Q23C_2aa) Receptive Verbal Communication- Does [name] understand a two-step direction, such as “Turn your head and look at me”?

Q23C_2ab) Receptive Verbal Communication- Does [name] understand a joke or story?

Q24a) Does [name] make direct eye contact when you or others are talking to him/her -- or does he/she tend to look away?

Q24b) Can you tell by [name]’s facial expression how he/she is feeling -- or is it difficult to tell what he/she is feeling?

Q24c) Does [name] primarily prefer spending time with other people -- or would he/she rather be alone?

Q24d) Is [name] comfortable being part of a group -- or does he/she find it uncomfortable to be a part of a group?

Q24e) Does [name] show enjoyment/sadness about what he/she is doing -- or does [name] keep feelings of enjoyment/sadness to himself/herself (ie, you can’t tell if he/she is happy or sad)?

Q24f) Does [name] like to do things with others -- or would he/she rather do things alone?

Q24g) Does [name] easily take turns -- or is taking turns difficult for him/her?

Q24h) Does [name] notice when others are upset or feeling bad -- or is it difficult for him/her to tell if others are upset or feeling bad?

Q24i) Does [name] tend to use the same words or sounds over and over -- or does his/her use of different words or sounds vary by subject matter?

Q24j) Does [name] like to do one activity over and over -- or does he/she like a variety of activities?

Q24k) Does [name] have special rituals or repetitive behaviors that have to be expressed a number of times -- or does he/she not have special rituals or repetitive behaviors?

Q25_1) Everyday Activities- How to spend time during weekdays

Q25_2) Everyday Activities- How to spend time on weekends

Q25_3) Everyday Activities- How to spend his/her own money

Q25_4) Everyday Activities- When to spend time with friends or others (other than family)

Q25_5) Everyday Activities- When to go out of or leave the house for leisure

Q25_6) Everyday Activities- Whether to have someone over to the home

Q25_7) Everyday Activities- Whether to go for a visit to someones home with or without someone else

Q25_8) Everyday Activities- Whether to go to the movies with or without someone else

Q25_9) Everyday Activities- Whether to go to a library, museum, or other public building with or without someone else

Q25_10) Everyday Activities- Whether to go to a beach or park with or without someone else

Q26A_1) Basic Self-Care Needs- Feeding himself/herself

Q26A_2) Basic Self-Care Needs- Drinking from a glass or cup

Q26A_3) Basic Self-Care Needs- Chewing and swallowing bite-size food

Q26A_4) Basic Self-Care Needs- Toileting with regards to bladder

Q26A_5) Basic Self-Care Needs- Toileting with regards to bowels

Q26A_6) Basic Self-Care Needs- Physically dressing himself/herself

Q26A_7) Basic Self-Care Needs- Moving around in familiar settings, such as home

Q26A_8) Basic Self-Care Needs- Washing hands

Q26A_9) Basic Self-Care Needs- Washing face

Q26A_10) Basic Self-Care Needs- Brushing or combing hair

Q26A_11) Basic Self-Care Needs- Wiping or blowing nose with tissue

Q26A_12) Basic Self-Care Needs- Adjusting water temperature for washing hands or bathing

Q26A_13) Basic Self-Care Needs- Tying laces or fastening Velcro on own shoes

Q26A_14) Basic Self-Care Needs- Drying entire body after bathing

Q26B_1) Being Independent- Making his/her bed

Q26B_2) Being Independent- Cleaning his/her room

Q26B_3) Being Independent- Doing his/her laundry

Q26B_4) Being Independent- Caring for his/her own clothes, such as folding them or putting them away

Q26C_1) Household Activities- Using public transportation for a simple direct trip other than ACCESS link or other medical transports

Q26C_2) Household Activities- Choosing food when shopping for a simple meal

Q26C_3) Household Activities- Preparing foods that do not require cooking, such as making a sandwich or bowl of cereal

Q26C_4) Household Activities- Using the stove

Q26C_5) Household Activities- Using the microwave

Q26C_6) Household Activities- Washing dishes or using a dishwasher

Q26C_7) Household Activities- Ordering food in public

Q26C_8) Household Activities- Choosing items he/she wants to buy

Q26C_9) Household Activities- Using money, such as handing it to a cashier

Q26C_9a) Household Activities- Making small routine purchases

Q26C_9b) Household Activities- Making or counting change

Q27A_1) Behaviors Dangerous to Self- Runs away or wanders off without you knowing

Q27A_2) Behaviors Dangerous to Self- Repeatedly gets out of bed at night other than for going to the bathroom

Q27A_3) Behaviors Dangerous to Self- Eats or mouths inedible objects

Q27A_3a) How often does [name] eat or mouth inedible objects?

Q27A_3b) Has [name] ever been hospitalized due to this behavior?- eat or mouth inedible objects

Q27A_3c) Did this behavior occur while [name] was being supervised?- eat or mouth inedible objects

Q27A_4) Behaviors Dangerous to Self- Scratches own body to the point of causing harm

Q27A_5) Behaviors Dangerous to Self- Hits his/her own body

Q27A_6) Behaviors Dangerous to Self- Hits his/her own face or head

Q27A_7) Behaviors Dangerous to Self- Bangs his/her head

Q27A_8) Behaviors Dangerous to Self- Bites self

Q27A_8a) How often does [name] bite himself/herself?

Q27A_8b) Has [name] ever been hospitalized due to this behavior?- bite himself/herself

Q27A_8c) Did this behavior occur while [name] was being supervised?- bite himself/herself

Q27B_1) Behaviors Dangerous to Others- Verbally threatens others

Q27B_2) Behaviors Dangerous to Others- Physically threatens others

Q27B_3) Behaviors Dangerous to Others- Hits or punches others

Q27B_4) Behaviors Dangerous to Others- Kicks others

Q27B_5) Behaviors Dangerous to Others- Uses objects to harm others

Q27B_5a) How often does [name] use objects to harm others?

Q27B_5b) Has [name] ever been hospitalized due to this behavior?- use objects to harm others

Q27B_5c) Did this behavior occur while [name] was being supervised?- use objects to harm others

Q27B_6) Behaviors Dangerous to Others- Bites others

Q27B_6a) How often does [name] bite others?

Q27B_6b) Has [name] ever been hospitalized due to this behavior?- bite others

Q27B_6c) Did this behavior occur while [name] was being supervised?- bite others

Q27B_7) Behaviors Dangerous to Others- Grabs or scratches others

Q27B_8) Behaviors Dangerous to Others- Head-butts others

Q27B_8a) How often does [name] head-butt others?

Q27B_8b) Has [name] ever been hospitalized due to this behavior?- head-butt others

Q27B_8c) Did this behavior occur while [name] was being supervised- head-butt others?

Q27B_9) Behaviors Dangerous to Others- Pulls hair of others

Q27B_10) Behaviors Dangerous to Others- Chokes or attempts to choke others

Q27B_10a) How often does [name] choke or attempt to choke others?

Q27B_10b) Has [name] ever been hospitalized due to this behavior?- choke or attempt to choke others

Q27B_10c) Did this behavior occur while [name] was being supervised?- choke or attempt to choke others

Q27B_11) Behaviors Dangerous to Others- Aggression toward personal property (ie, breaks or harms objects)

Q27C_1) Inappropriate or Rule-Violating Behaviors- Has tantrums or outbursts

Q27C_2) Inappropriate or Rule-Violating Behaviors- Displays repetitive behavior, such as body rocking or hand flapping

Q27C_3) Inappropriate or Rule-Violating Behaviors- Smears feces

Q27C_4) Inappropriate or Rule-Violating Behaviors- Makes noises, curses, or other inappropriate vocalizations

Q27C_5) Inappropriate or Rule-Violating Behaviors- Disrupts activities of others

Q27C_6) Inappropriate or Rule-Violating Behaviors- Defies known directions or rules

Q27C_7) Inappropriate or Rule-Violating Behaviors- Takes off clothes in public

Q27C_8) Inappropriate or Rule-Violating Behaviors- Masturbates in public

Q27C_9) Inappropriate or Rule-Violating Behaviors- Sexually touches others without their consent

Q27C_10) Inappropriate or Rule-Violating Behaviors- Displays sexually predatory behavior (For example, forcing himself/herself on others in a sexual manner)

Q27D_1) Other Special Behaviors- Has [name] been a target or victim of inappropriate behavior by others?

Q27E_1) In last 6 months, occurred as a result of any behavior problem- Has it required one-on-one supervision due to behavioral issues?

Q27E_2) In last 6 months, occurred as a result of any behavior problem- Have any specific behavioral modification/support procedures actually been used?

Q27E_3) In last 6 months, occurred as a result of any behavior problem- Has [name]’s environment been carefully structured due to behaviors?

Q27E_4) In last 6 months, occurred as a result of any behavior problem- Has physical intervention sometimes been required?

Q27E_5) In last 6 months, occurred as a result of any behavior problem- Was a supervised time-out needed to an area within or outside the room?

Q27E_6) In last 6 months, occurred as a result of any behavior problem- Were any medications increased or used as needed (prn) to reduce/control behaviors?

Q28_1) Currently has any of the following diagnosed conditions or illnessess- Respiratory or Breathing Conditions, such as asthma, emphysema, or cystic fibrosis

Q28_2) Currently has any of the following diagnosed conditions or illnessess- Heart or Circulatory Conditions,such as heart disease, high blood pressure, anemia, or other blood disorders

Q28_3) Currently has any of the following diagnosed conditions or illnessess- Digestive Conditions, such as ulcers, colitis, liver/bowel disorders, or tube feeding

Q28_4) Currently has any of the following diagnosed conditions or illnessess- Swallowing Conditions, such as difficulty swallowing, gastric reflux, or aspiration

Q28_5) Currently has any of the following diagnosed conditions or illnessess- Bladder or Kidney Conditions

Q28_6) Currently has any of the following diagnosed conditions or illnessess- Conditions of the Nervous System, such as multiple sclerosis, organic brain syndrome, Parkinsons disease, or seizures

Q28_7) Currently has any of the following diagnosed conditions or illnessess- Hormone or Endocrine Conditions,such as diabetes, thyroid problems, or hormone replacement therapy

Q28_8) Currently has any of the following diagnosed conditions or illnessess- Chronic Conditions related to Skin, Hair, or Nails, such as thick toenails, eczema, psoriasis, or dermatitis

Q28_9) Currently has any of the following diagnosed conditions or illnessess- Musculoskeletal Conditions, such as muscular difficulties with the arms and/or legs, arthritis, osteoporosis, or cerebral palsy

Q28_10) Currently has any of the following diagnosed conditions or illnessess- Allergies, such as those to foods, medications, or seasonal

Q28_11) Currently has any of the following diagnosed conditions or illnessess- Other Conditions (Please specify)

Q28_11_TEXT) Currently has any of the following diagnosed conditions or illnessess- Other Conditions (Please specify)-TEXT

Q29_1) Past 3 months, health services used- Been to an emergency clinic or emergency room in a hospital

Q29_2) Past 3 months, health services used- Stayed overnight in a hospital

Q29_3) Past 3 months, health services used- Seen a podiatrist (ie, a specialist for the feet)

Q29_4) Past 3 months, health services used- Seen a psychiatrist

Q29_5) Past 3 months, health services used- Seen a psychologist for counseling or behavior management

Q29_6) Past 3 months, health services used- Seen any other behavior specialist (such as a behavioral analyst)

Q29_7) Past 3 months, health services used- Received physical therapy

Q29_8) Past 3 months, health services used- Received speech therapy

Q29_9) Past 3 months, health services used- Received occupational therapy

Q30_1) Past 3 months, special medical treatments or services- Use of special bowel equipment or enemas

Q30_2) Past 3 months, special medical treatments or services- Catheterization

Q30_3) Past 3 months, special medical treatments or services- Suctioning at least once a day to remove internal fluids

Q30_4) Past 3 months, special medical treatments or services- Special breathing or respiratory care, such as the use of an inhaler or nebulizer

Q30_5) Past 3 months, special medical treatments or services- Turning or positioning to protect skin integrity

Q30_6) Past 3 months, special medical treatments or services- Dressing and wound care

Q30_7) Past 3 months, special medical treatments or services- Dialysis or use of a kidney machine

Q30_8) Past 3 months, special medical treatments or services- Any medication via injection by others or intravenously at home other than insulin via an auto-injector (which is similar to an epi pen or flex pen)

Q30_8a) Past 3 months, special medical treatments or services- Insulin administered with an auto-injector (which is similar to a flex pen or epi pen)

Q30_9) Past 3 months, special medical treatments or services- Is [name] tube fed?

Q30_9a) Past 3 months, special medical treatments or services- Does [name] eat any food by mouth?

Q30_10a) Past 3 months, special medical treatments or services- Has [name] used adaptive eating equipment, such as a plate guard and special utensils (not a feeding tube)?

Q30_10b) Past 3 months, special medical treatments or services- Has [name] required assistance due to choking incident(s), such as requiring food to be cleared from the mouth with hand or the Heimlich Maneuver?

Q30_10c) Past 3 months, special medical treatments or services- Is [name] physically fed by others?

Q30_10d) Past 3 months, special medical treatments or services- Does [name] require special food preparation, such as pureed or chopped?

Q30_10e) Past 3 months, special medical treatments or services- Does [name] have any special dietary foods or restrictions, such as low salt?

Q30_11) Past 3 months, special medical treatments or services- Were any increases in fluids required?

Q31_1) Past 3 months, adaptive or special equipment used- Glasses or other visual aids

Q31_2) Past 3 months, adaptive or special equipment used- Walker

Q31_3) Past 3 months, adaptive or special equipment used- Crutches or cane

Q31_4) Past 3 months, adaptive or special equipment used- Brace or splint

Q31_5) Past 3 months, adaptive or special equipment used- Hearing aid

Q31_6) Past 3 months, adaptive or special equipment used- Picture symbols or any other communication device

Q31_7) Past 3 months, adaptive or special equipment used- A helmet not used for biking or horseback riding

Q31_8) Past 3 months, adaptive or special equipment used- Prescribed orthotics or orthopedic shoes

Q31_9) Past 3 months, adaptive or special equipment used- Special bed or bed modifications, such as side rails, special mattress, elevated bed, or hospital bed

Q31_10) Past 3 months, adaptive or special equipment used- Other(Please specify)

Q31_10_TEXT) Past 3 months, adaptive or special equipment used- Other (Please specify)-TEXT

Q32) Did [name] ever attend any type of public or private school, including a special school for persons with disabilities?

Q33) Is [name] currently enrolled in a high school or some other special school for persons with disabilities?

Q34) Is [name] participating in any school-sponsored work activities like a work-study job, internships, or a school-based business?

Q35) Is [name] paid for this work?

Q36_1) [name] will do after leaving school- Get a job for pay (making at least minimum wage)

Q36_2) [name] will do after leaving school- College or junior college

Q36_3) [name] will do after leaving school- Vocational training or technical school

Q36_4) [name] will do after leaving school- Day program

Q36_5) [name] will do after leaving school- Other(Please specify)

Q36_5_TEXT) [name] will do after leaving school- (Please specify)-TEXT

Q37) Current Employment- Does [name] currently have a paid job?

Q38) Current Employment- About how many hours per week did [name] work at this paid job in the past 2 weeks?

Q39) Current Employment- About how much per hour was [name] paid? (If you are unsure of the exact amount, please enter your best estimate)

Q40) Current Employment- Does [name] have a job coach or someone special from an agency who helps him/her him/her at this paid job?

Q41) Past Employment- Has [name] had a paid job in the past 2 years?

Q42) Past Employment- About how many hours per week on average did [name]work for pay?

Q43) Past Employment- About how much per hour was [name] paid? (If you are unsure of the exact amount, please enter your best estimate)

Q44) Past Employment- Did [name] have a job coach or someone special from an agency who helped him/her on this paid job?

Q45) Future Employment- Was [name] actively looking and trying to get a paid job in the past 2 weeks?

Q46) Future Employment- How likely do you think it is that [name] will have a paid job next year?

Q47) Future Employment- If [name] had a paid job next year, about how much do you think [name] would make per hour?

Q48) Have you had any contact with anyone who works for the Division of Vocational Rehabilitation (DVR) within the last two years?

Q49) How helpful were the services or information provided by DVR?

Q50) Caregiver Characteristics- How many years of schooling have you had a chance to complete?

Q51) Caregiver Characteristics- Are you currently employed?

Q52) Caregiver Characteristics- Is this employment inside or outside of your home?

Q53) Caregiver Characteristics- On average, how many hours per week do you work for pay?

Q54) Caregiver Characteristics- In total, how many persons under 18 currently live in your home?

Q55) Caregiver Characteristics- In total, how many persons 18 or older currently live in your home, including you and [name]?

Q56) Caregiver Characteristics- Are you currently the primary caregiver for anyone else inside or outside of your home who needs special care, such as a disabled child, elderly parent, disabled spouse, etc?

Q57) Caregiver Characteristics- Does this individual live with you?

Q58_1) Caregiver Characteristics- race/ethnicity- Hispanic, Latino, or Spanish Origin

Q58_2) Caregiver Characteristics- race/ethnicity- Black or African-American

Q58_3) Caregiver Characteristics- race/ethnicity- White

Q58_4) Caregiver Characteristics- race/ethnicity- Asian

Q58_5) Caregiver Characteristics- race/ethnicity- American Indian or Alaska Native

Q58_6) Caregiver Characteristics- race/ethnicity- Native Hawaiian or Pacific Islander

Q58_7) Caregiver Characteristics- race/ethnicity- Some other group

Q58_7_TEXT) Respondent race/ethnicity- (Please specify) TEXT

Q59) Caregiver Characteristics- How old were you on your last birthday?

Q60_1) Currently received by respondent or consumer- SSI (Supplemental Security Income)

Q60_2) Currently received by respondent or consumer- Medicaid or New Jersey Family Care

Q60_3) Currently received by respondent or consumer- Social Security: Retirement, Disability, or Survivor

Q60_4) Currently received by respondent or consumer- Medicare

Q60_5) Currently received by respondent or consumer- Food stamps

Q60_6) Currently received by respondent or consumer- Unemployment

Q60_7) Currently received by respondent or consumer- Any other form of state or local public assistance, other than those mentioned above (Please specify)

Q60_7_TEXT) Currently received by respondent or consumer- Any other form of state or local public assistance, other than those mentioned above (Please specify)-TEXT

Q61_1) Information sources to complete this evaluation- Medical records/ISP (Individualized Service Plan)

Q61_2) Information sources to complete this evaluation- Legal guardian

Q61_3) Information sources to complete this evaluation- Family member

Q61_4) Information sources to complete this evaluation- [name]

Q61_5) Information sources to complete this evaluation- Other professionals

Q61_6) Information sources to complete this evaluation- Own knowledge of [name]

Q61_7) Information sources to complete this evaluation- Other (Please specify)

Q61_7_TEXT) Information sources to complete this evaluation- Other(Please specify)-TEXT