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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