Persons using assistive technology may not be able to fully access information in this file. For assistance, e-mail niddk-cr@imsweb.com. Include the Web site and filename in your message. QW RETURN TO WORK FORM: ADULTS NIDDK Liver Transplantation Database LTD_ID:_________________________________ ID Many patients after liver transplantation are not able to work or to take care of their household. These questions are meant to record your work experience. 1. What was your work activity or employment status PRIOR TO YOUR BECOMING ILL WITH LIVER DISEASE? (check one) __ 1. Employed full-time PEMPL (EMPL) __ 2. Employed part-time __ 3. Employed, but temporarily laid off __ 4. Unemployed, looking for work __ 5. Unemployed, not looking for work __ 6. Unemployed, unable to work because of health __ 7. Homemaker __ 8. Student full-time __ 9. Student part-time __ 10. Retired __ 11. Other, specify:____________________________________________ PEMPS 2. Have you worked for pay at any time SINCE YOUR FIRST TRANSPLANT? (check one) EPAY (YNQOL) __ Yes __ No 3. Which of the following factors prevented your return to work? (check all that apply) RHOM __ 1. Homemaker and prefer to remain one RSCH __ 2. In school RLAC __ 3. Lack necessary schooling, training or experience (YNQOL) RRET __ 4. Retired RDONT __ 5. Don't want to work RUNAB __ 6. Unable to find work RDISS __ 7. Dissatisfied with previous work RJOB __ 8. Jobs available, but don?t pay enough RFAM __ 9. Family responsibilities RDISC __ 10. Job discrimination RLMED __ 11. Loss of Medicaid benefits RLDIS __ 12. Loss of Disability benefits RLINS __ 13. Loss of other insurance benefits RHLTH __ 14. Problems with my health RANX __ 15. Anxiety RDEP __ 16. Depression ROTH __ 17. Other, specify:___________________________________________ ROTHS 4. Which of the factors checked above is the most important one that prevented your return to work? Write factor number here: ______ RPREV 5. After your FIRST liver transplant, how many months was it until you started to work? ______ months WMON 6. Are you currently working for pay? (check one) CPAY (YNQOL) ___ Yes ___ No 7. What is your current occupation? Specify:_______________________________________________________ OCCUP 8. Check the category that best describes your occupation (check one): OCCP (OCCP) __ 1. Managerial and professional specialty occupations (includes executive, administrative, and managerial occupations; professional specialty occupations) __ 2. Technical, sales, and administrative support occupations (includes technicians and related support occupations; sales occupations; administrative support occupations, including clerical) __ 3. Service occupations (includes private household occupations; protective service occupations; other service occupations) __ 4. Agriculture, farming, forestry, and fishing occupations __ 5. Precision production, craft, and repair occupations __ 6. Operators, fabricators, and laborers (includes machine operators, assemblers, and inspectors; transportation and material moving occupations; handlers, equipment cleaners, helpers, and laborers) __ 7. Other, specify: ___________________________________________ OCCPS 9. Are you working (check one): FPT (FPT) __ 1. Full-time __ 2. Part-time 10. If employed full- or part-time PRIOR TO YOUR BECOMING ILL WITH LIVER DISEASE, did you return to work for your previous employer? (check one) __ Yes RETRN (YNRETR) __ No __ Did not work full or part-time prior to becoming ill 11. Are you (check one): NEMPL (EMPL) __ 1. Employed full-time __ 2. Employed part-time __ 3. Employed, but temporarily laid off __ 4. Unemployed, looking for work __ 5. Unemployed, not looking for work __ 6. Unemployed, unable to work because of health __ 7. Homemaker __ 8. Student full-time __ 9. Student part-time __ 10. Retired __ 11. Other, specify:____________________________________________ NEMPS 12. Which of the following factors caused you to stop working? (check all that apply) SHOM __ 1. Homemaker and prefer to remain one SSCH __ 2. In school SLAC __ 3. Lack necessary schooling, training or experience (YNQOL) SRET __ 4. Retired SDONT __ 5. Do't want to work SUNAB __ 6. Unable to find work SDISS __ 7. Dissatisfied with previous work SJOB __ 8. Jobs available, but don't pay enough SFAM __ 9. Family responsibilities SDISC __ 10. Job discrimination SLMED __ 11. Loss of Medicaid benefits SLDIS __ 12. Loss of Disability benefits SLINS __ 13. Loss of other insurance benefits SHLTH __ 14. Problems with my health SANX __ 15. Anxiety SDEP __ 16. Depression SOTH __ 17. Other, specify:___________________________________________ SOTHS 13. Which of the factors checked above is the most important one that caused you to stop working? Write factor number here: ____ STOP 14. Do you intend to return to work? (check one) INTND (YNUNC) __ Yes __ No __ Uncertain 15. What health insurance do you have at the present time? (check all that apply) MCAID __ 1. Medicaid MCARE __ 2. Medicare (YNQOL) TCC __ 3. TRICARE-CHAMPUS INEMP __ 4. Insurance provided by employer INSP __ 5. Insurance provided by spouse?s employer NOINS __ 6. No insurance IOTH __ 7. Other, specify:____________________________________________ IOTHS 16. THIS FORM WAS FILLED OUT BY (check one): FFOBY (FFOBY) __ 1. Patient alone __ 2. Patient with assistance __ 3. Other, relationship to the patient_____________________________ NKR 17. TODAY'S DATE _____/_____/_____ EVALM EVALD EVALY Month Day Year COMM YN COM1 TEXT COM2 TEXT COM3 TEXT COM4 TEXT COM5 TEXT COM6 TEXT COM7 TEXT COM8 TEXT COM9 TEXT COM10 TEXT THANK YOU FOR SPENDING THE TIME TO FILL OUT THIS FORM. ******************************************************************************** QW NIDDK Liver Transplantation Database RETURN TO WORK FORM: ADULTS 06/30/1999 Version 2.0 FOR DATA CENTER USE ONLY METHOD OF DATA COLLECTION (check one) __1. Patient (Mail-in) DCMTH (DCMTH) __ 2. Phone Interview __ 3. Both If 2 or 3, specify questions completed by phone: __________________________ BYPH __________________________ __________________________ COMPLETION LOG LTD_ID:__________________ ID Follow-up Year:_________ Data Collector ID _______--__________ DCID DATE Form Received and Complete _____/_____/_____ DCCM DCCD DCCY Data Entry _____/_____/_____ Sysid __________ SYSID Verification _____/_____/_____ Cleaned _____/_____/_____ Transfer _____/_____/_____ MM DD YY