Page 168 - QAP Manual 2020

NCI™ ADULT IN-PERSON SURVEY (IPS) 2020-21

Pre-Survey Background Section I Section II Surveyor
Form Info Feedback

Background Information

This section should be completed along with the Pre-Survey Form by the appropriate agency staff
member, such as a case manager/service coordinator, according to state-specific protocols. For some
items, either the individual receiving services, a residential staff person, or a family member may
inform the response to the questions.

IMPORTANT: Background Information (BI) items that are highlighted represent critical items for data
analysis purposes. Please make every effort to provide this information so that your state’s data can be
fully analyzed.

Questions that can be asked during the face-to-face survey are marked with a meeting symbol:

Personal

BI-1 Zip Code (where person resides) _______________________

Please note that the zip code will not be stored. When entered into the online data entry system, it will
be converted into a rural/urban designation and the area median income.

BI-2 Date of Birth: (mm/yyyy) ______/_______
BI-3 Gender

□ 1. Male
□ 2. Female
□ 3. Other

BI-4 What is this person’s race and ethnicity? Check ONE or MORE boxes to indicate what this
person considers themselves to be:

□ 1. American Indian or Alaska Native
□ 2. Asian (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or Other Asian)
□ 3. Black or African-American
□ 4. Pacific Islander (Native Hawaiian, Guamanian or Chamorro, Samoan, or Other Pacific

Islander)
□ 5. White
□ 6. Hispanic/Latino (Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, or Other
Spanish/Hispanic/Latino)
□ 7. Other race not listed
□ 99. Don’t know

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