NCLR Health Care Reform Storybanking Project Please use this form to collect personal stories about Latinos experiences with the local health care system. We do not ask for your name on the form, and we will protect you and your family s identities. Thank you!
Information about You Please tell us some information about you. It will help us tell your story. Age: ____ years
Sex: ___M ___F
Marital Status: ___Married ____Single, no longer married ____Single, never married
Do you have health insurance right now? ___Yes, through work ___Yes, though a state program ___No, I m uninsured If uninsured, how long have you been uninsured? ___ months/years ___Check here if you have always been uninsured Are you working right now? ___Yes, part time ___Yes, full time
___No, looking for work ___No, I don t work outside the home
Have you ever had health insurance through work? ___Yes, I currently do ___Yes, but I no longer do ___No, I have never had insurance through work If you have ever had health insurance through work, for how many months or years were you insured (total)? ___ months/years For how many years have you been working (total lifetime)? ____ years Please share with us your citizenship status: ___ U.S. citizen ___Noncitizen, Legal Permanent Resident (LPR) ___Noncitizen, other immigrant How long have you lived in the U.S.? ___ months/years If you are an LPR, how long have you had your green card? ___ months/years If you are a noncitizen who is not an LPR, how long have you held your current status? ___ months/years OPTIONAL QUESTION: Do you have legal status? ___Yes ___No
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NCLR Health Care Reform Storybanking Project Your Family s Information Please tell us some information about your Spouse/Partner and/or children. Spouse/Partner s age: ____years
Spouse/Partner s sex: ___M ___F
Does your Spouse/Partner have health insurance right now? ___Yes, through work ___Yes, though a state program ___No, he or she is uninsured Is your Spouse/Partner working right now? ___Yes, part time ___Yes, full time ___No, looking for work ___No, he or she doesn t work outside the home Has he or she ever had health insurance through work? ___Yes, currently ___Yes, but not anymore ___No, he or she has never had insurance through work Please share with us your Spouse/Partner s citizenship status: ___ U.S. citizen ___ Noncitizen, Legal Permanent Resident (LPR) ___Noncitizen, other immigrant How long has your Spouse/Partner lived in the U.S.? ___ months/years If your Spouse/Partner is an LPR, how long has he or she had a green card? ___ months/years If your Spouse/Partner is a noncitizen but not an LPR, how long has he or she held that current status? ___ months/years OPTIONAL QUESTION: Does your Spouse/Partner have legal status? ___Yes ___No Do you have any children? If so, how many? ___No ___Yes, I have ___(number) children Please list the sex, age, and citizenship of each child. For each child, please tell us: Sex: Age: Citizenship: Girl/boy Months/years old U.S. citizen, Noncitizen, Legal Permanent Resident (LPR), or Noncitizen, other immigrant? Optional: Noncitizen, no legal status Some examples: Girl, age 5 years, U.S. citizen Boy, age 12, noncitizen, no legal status Please circle any of your children who have health insurance coverage.
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NCLR Health Care Reform Storybanking Project Information about Your Health Care Please tell us about how your health care could work better for you and your family. What are some of the challenges you and your family have getting health care? For example, you might have trouble getting an appointment or taking all of your medicine if you don t have insurance.
When you go to the doctor or hospital, is it affordable? If not, why is it unaffordable? How does it affect your day-to-day life?
Do you know if there are there programs available that help you get health care? Are you able to use them? Are your children able to use them? Do you feel comfortable using these programs?
Tell Us a Story Choose one or more stories below to share, with as many details as you are willing to share. Please use another sheet of paper if you run out of space. (1) Please tell us about a time that you or your family member needed to go to the doctor, but were not able to go. Why couldn t you go? Did your health problem go away or did it get worse? How are you or your family member doing now? Did it affect other aspects of your life? Are you worried about it happening again?
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NCLR Health Care Reform Storybanking Project (2) Please tell us about a time when you or a family went to the doctor or hospital and you had to pay a lot of money for the health care. Why was it expensive? Did you have insurance? Are you still paying that bill? Did you worry about paying for rent or food? Did it affect other aspects of your life? Are you worried about it happening again?
(3) [If ever insured] Please tell us about a time when you or a family member had insurance and went to the doctor when sick or needed a checkup. How did having health insurance make a difference? Was the doctor visit any more affordable to you or your family? How did it affect your health?
Thank you for sharing your story with us. OPTIONAL: _____Please check or initial here if you are willing to be contacted by a member of the media to be interviewed about your experiences.
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