USARA'S Health Care Survey Question Title * 1. Do you identify as someone who has had a drug or alcohol problem? Yes No Question Title * 2. Do you consider yourself in recovery from drug and/or alcohol addiction? Yes No Question Title * 3. Do you have a mental health disorder (anxiety, depression, bi-polar, etc)? Yes No Question Title * 4. What is your gender? Female Male Other (please specify) Question Title * 5. What is your age? 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 or older Question Title * 6. What race and ethnicity do you identify with? (check all that apply) Asian Black or African American Hispanic/Latino Native American Pacific Islander White Other (please specify) Question Title * 7. What is your Utah zipcode? Question Title * 8. Are you a Vet? Yes No Question Title * 9. What is the highest level of education you have completed? Did not attend school 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade 8th grade 9th grade 10th grade 11th grade Graduated from high school 1 year of college 2 years of college 3 years of college Graduated from college Some graduate school Completed graduate school Question Title * 10. Are you married? Yes No Question Title * 11. How many children in household? Question Title * 12. What is your approximate average household income? less than or equal to $11,490 more than $11,490, but less than or equal to $15,510 more than $15,510, but less than or equal to $19,530 more than $19,530, but less than or equal to $23,550 more than $23,550, but less than or equal to $31,590 Other (please specify) Question Title * 13. Employment status (Check all that apply) Part-time Full-time Unemployed Student Disability/Social Security Income Question Title * 14. Do you have health care insurance? Yes No (skip 14 and 15) Unsure Question Title * 15. What is your current health care insurance? Private insurance COBRA Medicaid Medicare CHIP Other (please specify) Question Title * 16. Who provides your health insurance? Employer Education Institution Individual Insurance Family Policy Medicaid Medicare Question Title * 17. What is your current means of medical care? (check all that apply) Primary Care Doctor InstaCare Clinic Hospital/Emergency Room Other (please specify) Question Title * 18. How many times in the last 5 years have you been to the emergency room? 0 1-3 4-6 7-9 Over 10 Question Title * 19. Have you applied for help on the Health Insurance Marketplace? Yes No Question Title * 20. If you answered yes to the previous question, did you qualify for a tax subsidy? Yes No Unsure Question Title * 21. Are you interested in learning more about health care coverage options? Yes No Unsure Question Title * 22. Have you ever lost your health insurance? Loss of job Due to incarceration Could not pay premium No Other (please specify) Question Title * 23. Have you been denied health care coverage? Yes* No Unsure* *Please describe Question Title * 24. Have you received treatment for a substance use disorder? Yes No Question Title * 25. How was your treatment funded? (check all that apply) Public Funding Private Insurance Self Pay Medicade Medicare Question Title * 26. How many times have you been treated for a substance use disorder? Question Title * 27. Were you court ordered to treatment for substance use? Yes No Question Title * 28. If you answered yes to the previous question, approximately how long did you wait to receive treatment? Days Weeks Months Question Title * 29. Have you ever been prescribed medication to treat a substance use disorder? Yes No Question Title * 30. Have you ever been prescribed medication to treat a mental health disorder? Yes No Question Title * 31. Have you been prescribed medication for a medical condition other than a substance use or mental health disorder? Yes No Question Title * 32. How do you pay for your medication? Private Insurance Self Pay Charity Funds Medicaid Medicare Employer Cafeteria Plan Unable to Pay for Medication Other (please specify) Question Title * 33. Do you know what the "Mental Health Parity and Addiction Equity Act" is? Yes No Question Title * 34. How would having health care coverage effect your life? Question Title * 35. If you do not have health care coverage what is your greatest concern? Question Title * 36. I give my permission that answers used in this survey may be used for USARA's Storybanking Project to increase awareness about health care coverage in Utah. Agree Disagree Thank you for your time! Results of this survey can be found on www.myusara.com on September 1, 2014. Done
