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We would like to know about what you do --are you working now, looking for work, retired, keeping house, a student, or what?
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Other (specify)
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Are you . . .
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Insurance through a current or former employer or union (of yours or another family member’s). This would include COBRA coverage.
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Insurance purchased directly from an insurance company (by you or another family member). This would include coverage purchased through an exchange or marketplace, such as HealthCare.gov [IF THE RESPONDENT IS IN A STATE WITH STATE-SPECIFIC NAMES, INSERT [or (INSERT PROGRAM NAME)]].
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Medicare, for people 65 and older, or people with certain disabilities.
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Medicaid, Medical Assistance (MA), the Children’s Health Insurance Program (CHIP), or any kind of state or government-sponsored assistance. plan based on income or a disability. You may know this type of coverage as [IF THE RESPONDENT IS IN A STATE WITH STATE-SPECIFIC NAMES INSERT PROGRAM NAME].
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TRICARE or other military health care, including VA health care.
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Indian Health Service.
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Any other type of health insurance. coverage or health coverage plan
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Does this mean you currently have no health insurance or health coverage plan? In answering this question, please exclude plans that pay for only one type of service (such as, nursing home care, accidents, family planning, or dental care) and plans that only provide extra cash when hospitalized.
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What type of health insurance do you have?
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Marital status of primary caregiver
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Relationship of primary caregiver to patient
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Other, Specify
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How far in school did she go?
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How far in school did he go?
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What is your child’s current age? Years
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What is your child’s current age? Months
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Has your child ever been held back or repeated a grade?