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Research Survey Questionnaire: Effect of Unemployment on Health

Pro2013002733
4/25/2013

This survey is to help gather information about the effect of unemployment on physical and
mental health among New Jersey labor force. The survey will take approximately 5-10 minutes.
Thank you for your time. Your participation is greatly appreciated.
DEMOGRAPHICS:
1. Age as of your last birthday:
2. Gender (please check one):
Male
Female

3. Marital Status (please check one):


Single (Never Married)
Partner/ Common-Law
Married (Not Separated)
Divorced
Widowed
Separated
4. Highest level of education completed:
Less than High School (HS)
HS graduate or equivalent
Some College or technical training beyond HS
College graduate (4 Years)
Post-graduate or professional degree
5. Are you Hispanic, of Spanish descent, or Latino?
Yes
No
6. What best describes your race?
White/Caucasian
Black/African American
Asian
Native Hawaiian/ Pacific Islander
American Indian/Alaska Native
Other
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7. What best describes your type of unemployment:


Voluntary unemployment (quit job)
Involuntary (dismissal, company closure, laid-off, fired)
Seasonal unemployment (work available only during certain times of the year)
8. How long have you been unemployed?
Less than 6 months
6-12 months
1-2 years
2-5 years
> 5 years
9. Do you currently have a part-time job?
Yes, please describe
No
10. Prior to being unemployed, what did you consider as your main
job/occupation/profession? (example: registered nurse, personnel manager, supervisor of
order department, auto mechanic, accountant, and electrician)

11. Annual household income before unemployment: (including if applicable, income from
spouse, partner, parents and children)
< $19,999
$20,000 - 39,999
$40,000 - $59,999
$60,000 - $79,999
$80,000 - $99,999
$100,000 or more

12. Are you currently receiving income from unemployment benefits?


Yes
No

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THANK YOU VERY MUCH FOR YOUR TIME AND INPUT!

13. Since unemployment, what is your current annual household income: (including if
applicable, income from spouse, partner, parents and children)
< $19,999
$20,000 - 39,999
$40,000 - $59,999
$60,000 - $79,999
$80,000 - $99,999
$100,000 or more
14. Please tell us who is living in your household? (check all that apply)
Yourself
Spouse/Partner
Children (how many and ages)
Other: (please explain)
15. Do you currently have health insurance coverage?
Yes
No
If YES, what type of insurance?
Private insurance associated with Spouse/ Partner
COBRA/ former employer
Medicare (elderly and person with disability)
Individually purchased health insurance
Medicaid (resources for low income individuals)
Other
16. Do you currently have health insurance coverage for your child(ren)?
Yes
No
Not applicable (no dependent children)
17. Would you say that in general your overall health is:
Excellent
Very good
Good
Fair
Poor

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THANK YOU VERY MUCH FOR YOUR TIME AND INPUT!

18. Since your unemployment, have you


a. Delayed or decreased seeing a doctor/ medical professional?
b. Cut back on other expenses to be able to afford medical care?
c. Switched to generic drugs/ over the counter versus prescription
drugs?
d. Cut back on preventative care (example: cancer screening,
diabetic & blood pressure monitoring)?
e. Had difficulty meeting financial obligations (example: utilities,
rent/ mortgage, car payment, etc.)
f. Increased use of hospital emergency room for health care?

Yes
Yes
Yes

No
No
No

Yes

No

Yes

No

Yes

No

HEALTH BEHAVIOR
19. Do you exercise/ participate in physical activities? ......................... Yes

No

If yes, since being unemployed, have you made any changes in the frequency of physical
activity?
I exercise less
I exercise more
No change in physical activities/ exercise
20. Do you drink alcohol? ...................................................................... Yes No
If yes, since being unemployed, would you say you drink less, drink more or about the
same?
Drink less
Drink more
Drink about the same
21. Do you smoke cigarettes?...... Yes No
If yes, since being unemployed, would you say you smoke less, smoke more or about the
same?
Smoke less
Smoke more
Smoke about the same
22. Has financial stress caused any health problems since being unemployed?
Yes; please list/explain
No
Dont know/ not applicable

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THANK YOU VERY MUCH FOR YOUR TIME AND INPUT!

23. If you have cut back on medical


this negatively affected your health?

care

while

being

unemployed,

has

Yes; please list/explain


No
Dont know/ not applicable
24. Since your unemployment, have you
a.
b.
c.
d.
e.
f.
g.
h.
i.

Decreased your intake of fruits & vegetables?


Increased buying unhealthy food choices in place of healthy
choices due to the prices?
Decreased the purchase of produce (fresh fruits & veggies) &
increased purchase of canned foods?
Switched to store brand products vs. name brand?
Substituted home cooked meals with fast-food value menu
options (example: McDonalds dollar menu)
Skipped meals to limit spending
Decreased the number of hours of sleep at night
Felt the need to take more naps during the day due to
restlessness or tiredness?
Need sleep medication to help you fall asleep

Yes
Yes

No
No

Yes

No

Yes
Yes

No
No

Yes
Yes
Yes

No
No
No

Yes

No

MENTAL HEALTH
(Please remember that your responses are anonymous and the responses you provide cannot be
traced back to you)
25. In the past 30 days (please check all that applies)

a) How many days have you had little interest or


pleasure in doing things?
b) How many days have you felt down, depressed or
hopeless?
c) How many days have you felt tired or had little
energy?
d) How many days have you had trouble falling asleep
or staying asleep or sleeping too much?
e) How many days have you had a poor appetite or
eaten too much?
f) How many days have you felt bad about yourself or
that you were a failure or had let yourself or your
family down?
g) How many days have you had trouble concentrating
on things, such as reading the newspaper or watching
the TV?

Never

1 or 2
days

3 or 4
days

5 or more
days

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THANK YOU VERY MUCH FOR YOUR TIME AND INPUT!

26. Since being unemployed, did you begin to take medicine or receive treatment from a
doctor or other health professional for any type of mental health condition or emotional
problem?
Yes
No, did not begin and I am not taking any medication/treatment now.
No, did not begin however I was taking medication/treatment prior to
unemployment
27. Has a doctor or other healthcare provider EVER told you that you have an anxiety
disorder (including acute stress disorder, anxiety, generalized anxiety disorder, obsessivecompulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social
anxiety disorder)?
Yes; Before becoming unemployed
Yes; After becoming unemployed
No; Never
28. Since being unemployed, are you easily irritated, angry over minor incidents or hostile?
Yes
No
29. In the past 30 days, have you (please check all that applies)
NO

1 or 2 times

3 or 4times

5 or more times

a) Been in a physical fight/altercations


b) Had any feelings of anger
c) Threatened to hit or hurt another person
HEALTH KNOWLEDGE & INFORMATION

30. Are you familiar with the NJ Family Care Health Insurance Plan?
Yes
No
31. Are you aware of any free medical services where you live?
Yes, which one(s)
No
32. What is your greatest area of concern during this period of unemployment? (please use
this space to also add anything or make any suggestions on this questionnaire)

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THANK YOU VERY MUCH FOR YOUR TIME AND INPUT!