Form CMS-10458 SHOP Screener

SHOP Tracking Survey
INTRO: Thank you for participating in our market research study, which is about health insurance and
the healthcare law. Your opinions are very important to us. We will start by asking you a series of
questions to see if you qualify for our study. Once you have completed the preliminary questions, if you
qualify, you will be taken through the remainder of the survey, which is estimated to take about 15
minutes of your time. We thank you in advance for your interest in our study.

Screener
NOTE: Target audience = small business employers/health insurance decision makers at companies that
employ fewer than 50 employees. Split (2-25) and large (26-49) and those who do and do not currently
offer health insurance.
SBO2. Including yourself, how many full time or full time equivalent employees does your company
have?
1
2-9
10-25
26-49
50+
DK/REF

1
2
3
4
5
-1

[TERMINATE]
[SMALL QUOTA]
[SMALL QUOTA]
[LARGE QUOTA]
[TERMINATE]
[TERMINATE]

SBO1. Are you the person who makes health insurance decisions for your business or company?
Yes
No
DK/REF

1
2 [ASK FOR PERSON WHO DOES]
-1 [TERMINATE]

INBO1. Do you currently offer health insurance for the employees in your business or company?
Yes - all
Yes - some
No
DK/REF

1
2
3
-1

[INSURED QUOTA – GO TO ING3A]
[INSURED QUOTA – GO TO ING3A]
[UNINSURED QUOTA – GO TO ING3B]
[TERMINATE]