Form Context

These questions are about the energy used in your household in the last 12 months, since (current month) of last year and whether you were able to afford the home energy you need. I'm going to read you several statements that people have made about their home energy situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for (you/your household) in the last 12 months.

Source: Health and Human Services

112289-4 (I/We) worried whether (my/our) home energy bill would become overdue before (I/we) could get money to pay it

Observation ID in Form

Q1

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
I or we worried whether the home energy bill would become overdue before having money to pay it
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

I or we worried whether the home energy bill would become overdue before having money to pay it

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Observation

Example Answer List LL5890-0

AnswerCodeScoreAnswer ID
Often trueLA28397-0
Sometimes trueLA6729-3
Never trueLA28398-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112290-2 Our home energy bill became due, and (I/we) didn’t have money to pay it without somebody’s help

Observation ID in Form

Q2

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Our home energy bill became due and I or we didn't have money to pay it without somebody's help
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

Our home energy bill became due and I or we didn't have money to pay it without somebody's help

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Observation

Example Answer List LL5890-0

AnswerCodeScoreAnswer ID
Often trueLA28397-0
Sometimes trueLA6729-3
Never trueLA28398-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112291-0 (I/We) couldn’t afford to heat or cool our home to the temperature we wanted it to be, or to use our water or appliances to the extent we wanted to use them

Observation ID in Form

Q3

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
I or we couldn't afford to heat or cool our home to desired temperature or use water or appliances to the extent desired
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

I or we couldn't afford to heat or cool our home to desired temperature or use water or appliances to the extent desired

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Observation

Example Answer List LL5890-0

AnswerCodeScoreAnswer ID
Often trueLA28397-0
Sometimes trueLA6729-3
Never trueLA28398-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112288-6 (I/we) reduced our energy consumption to uncomfortable or inconvenient levels because (I was/we were) running out of money to pay our home energy bill

Observation ID in Form

Q4

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
I or we reduced our energy consumption to uncomfortable or inconvenient levels due to inability to pay bill
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

I or we reduced our energy consumption to uncomfortable or inconvenient levels due to inability to pay bill

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Observation

Example Answer List LL5890-0

AnswerCodeScoreAnswer ID
Often trueLA28397-0
Sometimes trueLA6729-3
Never trueLA28398-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112287-8 (I/we) could not use our entire home because we could not afford to heat or cool it

Observation ID in Form

Q5

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
I or we could not use our entire home because we could not afford to heat or cool it
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

I or we could not use our entire home because we could not afford to heat or cool it

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Observation

Example Answer List LL5890-0

AnswerCodeScoreAnswer ID
Often trueLA28397-0
Sometimes trueLA6729-3
Never trueLA28398-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112292-8 Did you ever leave your home for all or part of the day because there wasn’t enough money for the home energy bill, or, did you ever turn off your hot water because there wasn’t enough money for the home energy bill?

Observation ID in Form

Q6

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

respond "yes" if one or the other or both is true

Source: Health and Human Services

Fully-Specified Name

Component
Did you ever leave your home for all or part of the day or turn off your hot water because there wasn't enough money for the home energy bill
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

Did you ever leave your home for all or part of the day or turn off your hot water because there wasn't enough money for the home energy bill

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Order
Panel Type
Panel

Example Answer List LL361-7

AnswerCodeScoreAnswer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value)LA33-6
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value)LA32-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112286-0 How often did one or the other of these happen?

Observation ID in Form

Q6a

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

IF YES ABOVE, ASK

Source: Health and Human Services

Fully-Specified Name

Component
How often did one or the other of these happen
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

How often did one or the other of these happen

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Observation

Example Answer List LL7483-2

AnswerCodeScoreAnswer ID
Almost every monthLA30970-0
Some months but not every monthLA30971-8
In only 1 or 2 monthsLA37010-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112293-6 Did you ever not pay your home energy supplier because there wasn’t enough money for the home energy bill?

Observation ID in Form

Q7

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Did you ever not pay your home energy supplier because there wasn't enough money for the bill
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

Did you ever not pay your home energy supplier because there wasn't enough money for the bill

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Order
Panel Type
Panel

Example Answer List LL361-7

AnswerCodeScoreAnswer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value)LA33-6
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value)LA32-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112286-0 How often did one or the other of these happen?

Observation ID in Form

Q7a

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

IF YES ABOVE, ASK

Source: Health and Human Services

Fully-Specified Name

Component
How often did one or the other of these happen
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

How often did one or the other of these happen

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Observation

Example Answer List LL7483-2

AnswerCodeScoreAnswer ID
Almost every monthLA30970-0
Some months but not every monthLA30971-8
In only 1 or 2 monthsLA37010-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112285-2 Did you ever use your kitchen stove or oven to provide heat because there wasn’t enough money to pay your home heating bills?

Observation ID in Form

Q8

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Did you ever use your kitchen stove or oven for heat because there wasn't enough money to pay heating bills
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

Did you ever use your kitchen stove or oven for heat because there wasn't enough money to pay heating bills

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Order
Panel Type
Panel

Example Answer List LL361-7

AnswerCodeScoreAnswer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value)LA33-6
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value)LA32-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112286-0 How often did one or the other of these happen?

Observation ID in Form

Q8a

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

IF YES ABOVE, ASK

Source: Health and Human Services

Fully-Specified Name

Component
How often did one or the other of these happen
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

How often did one or the other of these happen

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Observation

Example Answer List LL7483-2

AnswerCodeScoreAnswer ID
Almost every monthLA30970-0
Some months but not every monthLA30971-8
In only 1 or 2 monthsLA37010-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112284-5 Did you ever reduce your expenses for what you consider to be basic household necessities because there was not enough money to pay for these and to pay your home energy bill?

Observation ID in Form

Q9

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Did you ever reduce your expenses for basic household necessities because there was not enough money to pay for them
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

Did you ever reduce your expenses for basic household necessities because there was not enough money to pay for them

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Order
Panel Type
Panel

Example Answer List LL361-7

AnswerCodeScoreAnswer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value)LA33-6
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value)LA32-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112286-0 How often did one or the other of these happen?

Observation ID in Form

Q9a

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

IF YES ABOVE, ASK

Source: Health and Human Services

Fully-Specified Name

Component
How often did one or the other of these happen
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

How often did one or the other of these happen

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Observation

Example Answer List LL7483-2

AnswerCodeScoreAnswer ID
Almost every monthLA30970-0
Some months but not every monthLA30971-8
In only 1 or 2 monthsLA37010-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112283-7 Did you have a supplier of your electric or home heating service threaten to disconnect your electricity or home heating fuel service, or discontinue making fuel deliveries, because you could not afford to pay a past-due home energy bill?

Observation ID in Form

Q10

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Did you have a supplier of electric or home heating service threaten to disconnect service because you could not afford to pay the bill
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

Did you have a supplier of electric or home heating service threaten to disconnect service because you could not afford to pay the bill

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Order
Panel Type
Panel

Example Answer List LL361-7

AnswerCodeScoreAnswer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value)LA33-6
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value)LA32-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112286-0 How often did one or the other of these happen?

Observation ID in Form

Q10a

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

IF YES ABOVE, ASK

Source: Health and Human Services

Fully-Specified Name

Component
How often did one or the other of these happen
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

How often did one or the other of these happen

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Observation

Example Answer List LL7483-2

AnswerCodeScoreAnswer ID
Almost every monthLA30970-0
Some months but not every monthLA30971-8
In only 1 or 2 monthsLA37010-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112282-9 Did you have a supplier of your electricity or home heating fuel disconnect or discontinue your energy supply because you were unable to pay for a past-due home energy bill?

Observation ID in Form

Q11

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Did you have your electricity or home heating fuel disconnected because you were unable to pay the home energy bill
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

Did you have your electricity or home heating fuel disconnected because you were unable to pay the home energy bill

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Order
Panel Type
Panel

Example Answer List LL361-7

AnswerCodeScoreAnswer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value)LA33-6
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value)LA32-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112286-0 How often did one or the other of these happen?

Observation ID in Form

Q11a

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

IF YES ABOVE, ASK

Source: Health and Human Services

Fully-Specified Name

Component
How often did one or the other of these happen
Property
Find
Time
12Mo
System
^Patient
Scale
Ord
Method

Long Common Name

How often did one or the other of these happen

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Observation

Example Answer List LL7483-2

AnswerCodeScoreAnswer ID
Almost every monthLA30970-0
Some months but not every monthLA30971-8
In only 1 or 2 monthsLA37010-8

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]

112281-1 The Home Energy Insecurity Scale Threshold Classification [HEIS]

Term Description

Please view Appendix E for instructions on how to assign The Home Energy Insecurity Scale Threshold Classification
https://acf.gov/sites/default/files/documents/ocs/comm_liheap_measuringoutcome.pdf
Source: Health and Human Services

Observation Required in Panel

Required

Type of Entry

Question - computer calculates response [C]

Fully-Specified Name

Component
The Home Energy Insecurity Scale Threshold Classification
Property
Imp
Time
12Mo
System
^Patient
Scale
Ord
Method
HEIS

Basic Attributes

Class
SURVEY.SDOH
Type
Surveys
First Released
Version 2.82
Last Updated
Version 2.82 (ADD)
Order vs. Observation
Observation

Example Answer List LL7481-6

AnswerCodeScoreAnswer ID
ThrivingLA37008-2
CapableLA37009-0
StableLA14122-8
VulnerableLA37007-4
In CrisisLA37006-6

Member of these Panels

LOINCLong Common Name
112280-3The Home Energy Insecurity Scale [HEIS]