All 30 items in reading order, with their exact response options, the scoring rules where the instrument defines one, and the source of every question.
What is your living situation today?
Why it may help after benefit loss: Lost food or medical support can force tradeoffs with rent, utilities, and safe shelter. Unstable housing also makes notices and proof harder to receive and retain.
Think about the place you live. Do you have problems with any of the following? CHOOSE ALL THAT APPLY
Why it may help after benefit loss: Lost food or medical support can force tradeoffs with rent, utilities, and safe shelter. Unstable housing also makes notices and proof harder to receive and retain.
Some people have made the following statements about their food situation. Please answer whether the statements were OFTEN, SOMETIMES, or NEVER true for you and your household in the last 12 months.
Within the past 12 months, you worried that your food would run out before you got money to buy more.
Why it may help after benefit loss: These are the most direct signals that a SNAP reduction or loss is already changing what the household can eat or afford.
Within the past 12 months, the food you bought just didn't last and you didn't have money to get more.
Why it may help after benefit loss: These are the most direct signals that a SNAP reduction or loss is already changing what the household can eat or afford.
In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?
Why it may help after benefit loss: Transportation can determine whether a client reaches a renewal appointment, provider, workforce activity, food source, or referred service.
In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?
Why it may help after benefit loss: A benefit loss can shift scarce income toward food or health costs and expose an existing shutoff risk.
Because violence and abuse happens to a lot of people and affects their health we are asking the following questions.
How often does anyone, including family and friends, physically hurt you?
Why it may help after benefit loss: The complete CMS core includes these questions, and financial or housing disruption can increase danger or constrain a person's options.
How often does anyone, including family and friends, insult or talk down to you?
Why it may help after benefit loss: The complete CMS core includes these questions, and financial or housing disruption can increase danger or constrain a person's options.
How often does anyone, including family and friends, threaten you with harm?
Why it may help after benefit loss: The complete CMS core includes these questions, and financial or housing disruption can increase danger or constrain a person's options.
How often does anyone, including family and friends, scream or curse at you?
Why it may help after benefit loss: The complete CMS core includes these questions, and financial or housing disruption can increase danger or constrain a person's options.
How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Would you say it is:
Why it may help after benefit loss: This question can reveal the broader tradeoffs created or intensified by lost food or health coverage, including rent, care, heating, and other basics.
Do you want help finding or keeping work or a job?
Why it may help after benefit loss: For clients who want it, employment help may support income stability or connect them with an approved activity pathway.
If for any reason you need help with day-to-day activities such as bathing, preparing meals, shopping, managing finances, etc., do you get the help you need?
Why it may help after benefit loss: A person managing a renewal or service transition alone may need practical help with meals, shopping, finances, communications, or follow-through.
How often do you feel lonely or isolated from those around you?
Why it may help after benefit loss: A person managing a renewal or service transition alone may need practical help with meals, shopping, finances, communications, or follow-through.
Do you speak a language other than English at home?
Why it may help after benefit loss: A notice, proof request, or referral that cannot be understood is unlikely to produce a timely response.
Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED or equivalent.
Why it may help after benefit loss: Training or education may be a client-chosen route toward employment, income, or an approved activity, depending on current program rules.
In the last 30 days, other than the activities you did for work, on average, how many days per week did you engage in moderate exercise (like walking fast, running, jogging, dancing, swimming, biking, or other similar activities)?
Why it may help after benefit loss: These questions add useful health context but are less directly connected to stabilizing a SNAP or Medicaid transition than the earlier groups.
On average, how many minutes did you usually spend exercising at this level on one of those days?
Why it may help after benefit loss: These questions add useful health context but are less directly connected to stabilizing a SNAP or Medicaid transition than the earlier groups.
The next questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances are prescribed by a doctor (like pain medications), but only count those if you have taken them for reasons or in doses other than prescribed. One question is about illicit or illegal drug use, but we only ask in order to identify community services that may be available to help you.
How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits.
Why it may help after benefit loss: Loss of health coverage can interrupt treatment or increase the urgency of connecting someone to care.
How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)?
Why it may help after benefit loss: Loss of health coverage can interrupt treatment or increase the urgency of connecting someone to care.
How many times in the past year have you used prescription drugs for non-medical reasons?
Why it may help after benefit loss: Loss of health coverage can interrupt treatment or increase the urgency of connecting someone to care.
How many times in the past year have you used illegal drugs?
Items AHC-19 through AHC-22 may create 42 CFR Part 2 protected records depending on who administers them and where the responses are stored. Resolve this before these items are fielded.
Why it may help after benefit loss: Loss of health coverage can interrupt treatment or increase the urgency of connecting someone to care.
Over the past 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things?
Why it may help after benefit loss: Coverage uncertainty, interrupted treatment, food insecurity, and administrative burden can worsen distress. These questions help identify continuity and clinical follow-up needs.
Feeling down, depressed, or hopeless?
PHQ-2 is the first two items of PHQ-9 and does not include the suicidal ideation item. A defined escalation pathway must exist before this item is fielded.
Why it may help after benefit loss: Coverage uncertainty, interrupted treatment, food insecurity, and administrative burden can worsen distress. These questions help identify continuity and clinical follow-up needs.
Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his or her mind is troubled all the time. Do you feel this kind of stress these days?
Why it may help after benefit loss: Coverage uncertainty, interrupted treatment, food insecurity, and administrative burden can worsen distress. These questions help identify continuity and clinical follow-up needs.
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
Why it may help after benefit loss: Difficulty concentrating, remembering, deciding, or completing errands can make notices, portals, proof gathering, and appointments harder to manage.
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?
Why it may help after benefit loss: Difficulty concentrating, remembering, deciding, or completing errands can make notices, portals, proof gathering, and appointments harder to manage.
During the past 12 months, did you or anyone in the family have to quit a job, not take a job, or greatly change your job because of problems with child care for this child?
Why it may help after benefit loss: Child care can determine whether a parent can work, train, attend appointments, or complete a benefits process.
Do you need child care for your child? If yes, would you like help finding it?
Why it may help after benefit loss: Child care can determine whether a parent can work, train, attend appointments, or complete a benefits process.
Would you like help with any of the needs you told us about today?
Why it may help after benefit loss: A positive needs screen does not mean the person wants DCHS to act. This proposed local item separates identified need from requested assistance.
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