Download:
pdf |
pdfClosing (CL) Section
Beta
Subsection 1:
MPC Authorization Forms (Round 1 through Round 5)
BOX_01
IF:
AT LEAST ONE PERSON-PROVIDER-PAIR ELIGIBLE (SEE SAMPLING BOXES BELOW) FOR
AUTHORIZATION FORM COLLECTION FOR THE CURRENT ROUND, OR
AT LEAST ONE PERSON-PROVIDER-PAIR ELIGIBLE FOR AUTHORIZATION FORM
COLLECTION DURING THE PREVIOUS ROUND AND CL04 WAS CODED '3' (LEFT WITH R),
'4' (MAILED TO R), '5' (REFUSED), OR '91' (OTHER) FOR THIS PERSON-PROVIDERPAIR IN PREVIOUS ROUND, CONTINUE WITH CL01
OTHERWISE, GO TO BOX_02
NOTE: RECEIPT CONTROL WILL UPDATE CAPI INTER-ROUND, USING THE CODE
STRUCTURE AT CL04. UPDATES CAN BE EITHER POSITIVE OR NEGATIVE. THIS
MEANS THAT INTER-ROUND AN AUTHORIZATION FORM'S STATUS CAN EITHER GET
UPDATED TO A HIGHER STATUS CODE (FROM UNSIGNED TO SIGNED) OR TO A LOWER
STATUS CODE (FROM SIGNED TO UNSIGNED -- I.E., IT WAS NOT SIGNED BY THE
RIGHT PERSON). SEE MAPPING SPECIFICATIONS FOR EXACT UPDATES TO STATUS
CODES.
NOTE: DUE TO LEGISLATION THAT WENT INTO EFFECT IN APRIL 2003, MEPS
CHANGED TO NEW HIPAA-COMPLIANT AUTHORIZATION FORMS.
SAMPLING BOX (FOR ROUND 1):
PERSON-PROVIDER-PAIRS ELIGIBLE FOR MPC AUTHORIZATION FORM COLLECTION:
NOTE:
PERSON IS A KEY, ELIGIBLE RU MEMBER (AT TIME OF EVENT).
ROUND 1: PERSON-PROVIDER-PAIRS ELIGIBLE FOR AUTHORIZATION FORM COLLECTION
ARE THOSE ASSOCIATED WITH A HOSPITAL-BASED EVENT (HS, ER, AND OP EVENTS)
DURING THE CURRENT REFERENCE PERIOD.
ONE AUTHORIZATION FORM IS CREATED FOR EACH PERSON-PROVIDER-PAIR IN WHICH
THE PROVIDER IS ASSOCIATED WITH AN HS, ER, OR OP EVENT DURING THE EVENT
ROSTER OR EVENT DRIVER SECTION.
SAMPLING BOX (FOR ROUNDS 2-5):
PERSON-PROVIDER-PAIRS ELIGIBLE FOR MPC AUTHORIZATION FORM COLLECTION:
NOTE:
PERSON IS A KEY, ELIGIBLE RU MEMBER (AT TIME OF EVENT).
ROUNDS 2-5: PERSON-PROVIDER-PAIRS ELIGIBLE FOR AUTHORIZATION FORM
COLLECTION ARE THOSE ASSOCIATED WITH A HOSPITAL-BASED EVENT (HS, ER, AND
OP EVENTS) DURING THE CURRENT REFERENCE PERIOD.
ADDITIONAL PAIRS ELIGIBLE FOR AUTHORIZATION FORM COLLECTION ARE THOSE
ASSOCIATED WITH A HOME HEALTH EVENT (HH EVENT), WHERE THE PROVIDER IS
FLAGGED AS AN ‘AGENCY’, AND CARE WAS PROVIDED TO PERSON DURING THE ROUND
1, ROUND 2, ROUND 3, ROUND 4, OR ROUND 5 REFERENCE PERIODS.
OTHER PAIRS ELIGIBLE FOR AUTHORIZATION FORM COLLECTION ARE THOSE
ASSOCIATED WITH A MEDICAL PROVIDER VISIT EVENT (MV EVENT) WHERE CARE WAS
PROVIDED TO PERSON DURING THE ROUND 1, ROUND 2, ROUND 3, ROUND 4, OR ROUND
5 REFERENCE PERIODS, WHERE THE RU IS SELECTED FOR THE MPC SAMPLE, AS
DEFINED BELOW, AND EITHER:
- A MEDICAL DOCTOR WAS SEEN DURING THE VISIT (MV03 = 1)
- MEDICAL DOCTORS WORK AT THE SAME LOCATION AS THE PROVIDER SEEN (MV06 = 1)
1
Closing (CL) Section
Beta
FINAL PAIRS ELIGIBLE FOR AUTHORIZATION FORM COLLECTION ARE THOSE
ASSOCIATED WITH AN INSTITUTIONAL CARE EVENT (IC EVENTS), WHERE CARE WAS
PROVIDED TO PERSON DURING THE ROUND 1, ROUND 2, ROUND 3, ROUND 4 OR ROUND
5 REFERENCE PERIODS.
WHEN DETERMINING IF THE MV EVENTS FOR AN RU REQUIRE AUTHORIZATION FORMS,
AN RU IS SELECTED FOR THE MPC SAMPLE AT THE TIME OF THE ROUND 1 INTERVIEW
USING THE FOLLOWING RATES:
- 100% OF RUs WITH AT LEAST ONE RU MEMBER COVERED BY MEDICAID OR GOV’T
HOSPITAL (PHYSICIAN) INSURANCE AT ANY TIME DURING THE REFERENCE PERIOD
- 100% OF THE REMAINING RUs (THAT IS, RUs WITH NO RU MEMBER COVERED BY
MEDICAID OR GOV’T-HOSPITAL/PHYSICIAN INSURANCE AT ANY TIME DURING
THE REFERENCE PERIOD) WITH AT LEAST ONE RU MEMBER WITH HMO COVERAGE
AT ANY TIME DURING THE REFERENCE PERIOD. HMO COVERAGE IS DEFINED AS:
IF AT LEAST ONE PRIVATE INSURANCE PLAN IN RU MEETS THE FOLLOWING
CONDITIONS:
- FLAGGED AS ‘PROVIDING HOSPITAL/PHYSICIAN BENEFITS’ (EXCLUDE INSURERS
WHERE HOSPITAL/PHYSICIAN BENEFITS ARE PROVIDED SOLELY THROUGH MEDIGAP)
- ESTABLISHMENT OR INSURER IS FLAGGED AS ‘HMO’ OR INSURER IS AN HMO
(MC01 IS CODED ‘1’ (YES)) OR INSURER REQUIRES PERSONS TO SIGN UP WITH
PRIMARY PHYSICIAN (MC02 IS CODED ‘1’ (YES))
- 100% OF THE REMAINING RUs (THAT IS, RUs WITH NO RU MEMBER COVERED BY
MEDICAID OR GOV’T-HOSPITAL/PHYSICIAN INSURANCE AND HMO COVERAGE AT
ANY TIME DURING THE REFERENCE PERIOD).
NOTE: IF THE SAME PROVIDER IS ASSOCIATED MORE THAN ONCE WITH A PARTICULAR
PERSON, ONLY ONE AUTHORIZATION FORM IS CREATED FOR THAT PAIR. IF THE SAME
PROVIDER IS ASSOCIATED WITH MORE THAN ONE PERSON, AN AUTHORIZATION FORM IS
CREATED FOR EACH UNIQUE PERSON-PROVIDER-PAIR.
NOTE: IF THE PERSON-PROVIDER-PAIR IS OUTSTANDING FROM A PREVIOUS ROUND
AND THERE IS A NEW ELIGIBLE EVENT FOR THIS PAIR IN THE CURRENT ROUND, THE
PAIR WILL NOT BE TREATED AS IF IT IS OUTSTANDING. THAT IS, THE DISPLAYS
FOR PREVIOUS ROUND STATUS WILL NOT BE SHOWN, ETC.
2
Closing (CL) Section
Beta
CL01
Help Enabled
Comment Enabled
Jump Back Enabled
Variable Name
PPID.PPIDID
Label
PPID ID KEY: PERSID + PROVID + ROUND
Size
20
PPID.PPIDRURN
PPID.CREATEQ
ROUND STAMP: RU LETTER + ROUND NUMBER
CREATION STAMP
2
2
PPID.RNDFLG
PPID.EVPVNUM
REQUIRED COLLECTION OR PREPRINTED FORMS
ID NUMBER OF LAST ELIGIBLE EVPV FOR PERS
2
4
PPID.FORMSTAT
STATUS OF MPS PERMISSION FORMS
2
PPID.NEXTRND
PPID.PFIDN01
NEXT ROUND RECORD EXISTS FOR CURRENT ONE
MPS PF TRACING ID NUMBERS PER RND
2
8
PPID.PFIDN02
MPS PF TRACING ID NUMBERS PER RND
8
PPID.PFIDN03
PPID.PFIDN04
MPS PF TRACING ID NUMBERS PER RND
MPS PF TRACING ID NUMBERS PER RND
8
8
PPID.PFIDN05
PPID.PFSTAT01
MPS PF TRACING ID NUMBERS PER RND
MPS PF TRACING STATUSES PER RND - CONT
8
2
PPID.PFSTAT02
MPS PF TRACING STATUSES PER RND - CONT
2
PPID.PFSTAT03
PPID.PFSTAT04
MPS PF TRACING STATUSES PER RND - CONT
MPS PF TRACING STATUSES PER RND - CONT
2
2
PPID.PFSTAT05
MPS PF TRACING STATUSES PER RND - CONT
2
PPID.PPIDEVNT
PPID.PREVRND
FIRST EVENT FROM WHICH P.F. REC IS CREAT
PREV RND RECORD EXISTS FOR CURRENT ONE
2
2
PPID.RURNDCOL
EVPV.MPSFLAG
RU + RND WHERE PF IS REQUESTED
MPS PERMISSION FORM FLAG
2
2
EVPV.PROVLINK
EVENT PROVIDER LINKED TO MPS PF PROV ID
4
PROV.PROVCATG
TYPE OF PROVIDER FOR MPS STUDY
2
{[As I mentioned during the last interview], it/It} is important for us to get
accurate names and addresses for medical providers so that we can contact
them for more information about the services they provide. To do this, we
must have written authorization from the family members receiving these
services. I would like to get authorization from the following people:
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[HAND RESPONDENT THE AUTHORIZATION FORM BOOKLET.]
[These materials explain more about why we contact medical providers and
answer questions people sometimes ask about this part of the study. Please
take a minute to review this information while I prepare the forms.]
3
Closing (CL) Section
Beta
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
DISPLAY INSTRUCTIONS:
DISPLAY ‘[As I mentioned during the last interview], it’ IF
NOT ROUND 1 AND AT LEAST ONE PERSON-PROVIDER-PAIR WAS ELIGIBLE
FOR MPC AUTHORIZATION FORM COLLECTION DURING THE PREVIOUS
ROUND. OTHERWISE, DISPLAY ‘It’.
PROGRAMMER NOTES:
DISPLAY EACH UNIQUE ELIGIBLE PERSON NAME ONLY ONCE.
ROUTING INSTRUCTION:
CONTINUE WITH LOOP_01
Roster Details
Title:
RU_ESTB_PERS_PAIRS_1
Col #
Header
Instructions
NAME
Display RU member's first, middle, and last names
PERS.FULLNAME
1
Roster Definition:
Display the RU_Person_Establishment_Pairs_Roster for display
of RU members only.
Roster Behavior:
1. Display only.
2. Select, add, delete disallowed.
Roster Filter:
Display only those persons who meet the following condition(s):
- Person is eligible for MPC authorization form collection for
the current round (see BOX_01 sampling specifications) or
- Person was associated with a person-provider-pair eligible
for authorization form collection in previous round, and
- CL04 was coded '3' (LEFT WITH R), ‘4’ (MAILED TO R), ‘5’
(REFUSED), OR ‘91’ (OTHER) for this person-provider-pair in
previous round
4
Closing (CL) Section
Beta
LOOP_01
FOR EACH ELEMENT ON THE RU-PERSON-PROVIDER-PAIRS-ROSTER, ASK CL03 END_LP01
LOOP DEFINITION: LOOP_01 PRESENTS EACH UNIQUE PERSON-PROVIDER-PAIR
ELIGIBLE FOR AUTHORIZATION FORM COLLECTION (THIS INCLUDES NEW AND
OUTSTANDING FORMS) FOR THE INTERVIEWER TO COMPLETE THE AUTHORIZATION
FORM. THIS LOOP CYCLES ON RU-PERSON-PROVIDER-PAIRS WITH AN EVENT-PROVIDERPAIR THAT MEET THE FOLLOWING CONDITION(S):
- PAIR IS ELIGIBLE FOR AUTHORIZATION FORM COLLECTION FOR THE CURRENT ROUND
(SEE BOX_01 SAMPLING
SPECIFICATIONS) OR
- PAIR WAS ELIGIBLE FOR AUTHORIZATION FORM COLLECTION IN PREVIOUS ROUND,
AND CL04 WAS CODED '3' (LEFT WITH R),
‘4’ (MAILED TO R), ‘5’ (REFUSED), OR ‘91’ (OTHER) FOR THIS PAIR IN THE
PREVIOUS
ROUND
PROGRAMMER NOTE:
LOOP ONLY ONE TIME FOR EACH UNIQUE PERSON-PROVIDER-PAIR.
5
Closing (CL) Section
Beta
CL03
Help Enabled (CL03Help)
Comment Enabled
Jump Back Enabled
INTERVIEWER: {COMPLETE AUTHORIZATION FORM/LOCATE
APPROPRIATE PREPRINTED MPC AUTHORIZATION FORM (COMPLETE
NEW ONE IF FORM CANNOT BE LOCATED)} FOR THE FOLLOWING
PERSON-PROVIDER-PAIR:
PID: [PID-3]
PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PROVIDER ID: [ProvID-4]
PROVIDER NAME: [Provider Full Name-65]
PROVIDER ADDRESS: [Street Address from Provider Directory]
[City Name], [ST] [Zip Code] [Telephone]
{AF STATUS FROM PREVIOUS ROUND: {DISPLAY PREVIOUS ROUND
STATUS - 40}}
SIGNATURE DATE ON MPC AF MUST BE ON OR AFTER: {MM/DD/YYYY}
{IF A MPC AF FOR THIS PAIR HAS ALREADY BEEN SIGNED ON OR
AFTER THE ABOVE DATE, DO NOT CREATE A NEW MPC AF.}
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
HELP AVAILABLE FOR MORE INFORMATION ON MPC AUTHORIZATION
FORMS.
6
Closing (CL) Section
Beta
DISPLAY INSTRUCTIONS:
DISPLAY ‘COMPLETE AUTHORIZATION FORM ...’ IF PAIR CREATED AND
ELIGIBLE DURING CURRENT ROUND. OTHERWISE, DISPLAY ‘LOCATE ...
LOCATED)’.
DISPLAY ‘AF STATUS ... -40}’ IF CURRENT PERSON-PROVIDER-PAIR
IS OUTSTANDING FROM THE PREVIOUS ROUND AND NO ELIGIBLE EVENT
WAS CREATED FOR THIS PAIR IN THE CURRENT ROUND.
FOR ‘DISPLAY PREVIOUS...-40’, DISPLAY THE CATEGORY ENTRY
ASSOCIATED WITH THE PREVIOUS ROUND (OR RECEIPT CONTROL
UPDATED) CL04 OUTSTANDING STATUS. THAT IS, IF CL04 WAS CODED
‘3’, DISPLAY ‘LEFT WITH R’; IF CL04 WAS CODED ‘4’, DISPLAY
‘MAILED TO R’; IF CL04 WAS CODED ‘5’, DISPLAY ‘REFUSED’; AND
IF CL04 WAS CODED ‘91’, DISPLAY THE FIRST 40 CHARACTERS FROM
THE OTHER SPECIFY ENTRY FIELD (OR THE RECEIPT CONTROL UPDATE
TEXT GENERATED FOR THE ‘91’ CODE).
DISPLAY THE INTERVIEW DATE OF THE MOST RECENT ROUND’S
INTERVIEW FOR WHICH PAIR IS/WAS ELIGIBLE FOR AUTHORIZATION
FORM COLLECTION FOR ‘MM/DD/YYYY’.
DISPLAY ‘IF MPC AF FOR ... NEW MPC AF.’ IF CURRENT PERSONPROVIDER-PAIR WAS ELIGIBLE FOR MPC IN PREVIOUS ROUND AND FORM
WAS NOT SIGNED IN THE PREVIOUS ROUND.
END_LP01
CYCLE ON NEXT PAIR ON THE RU-PERSON-PROVIDER-PAIRS-ROSTER THAT MEETS THE
CONDITIONS STATED IN THE LOOP DEFINITION.
IF NO OTHER PAIRS MEET THE STATED CONDITIONS, END LOOP_01 AND CONTINUE
WITH LOOP_02
LOOP_02
FOR EACH ELEMENT ON THE RU-PERSON-PROVIDER-PAIRS-ROSTER, ASK CL04 END_LP02
LOOP DEFINITION: LOOP_02 COLLECTS THE STATUS OF PERSON-PROVIDER
AUTHORIZATION FORMS ELIGIBLE FOR AUTHORIZATION FORM COLLECTION (THIS
INCLUDES NEW AND OUTSTANDING FORMS). THIS LOOP CYCLES ON RU-PERSONPROVIDER-PAIRS WITH AN EVENT-PROVIDER-PAIR THAT MEET THE FOLLOWING
CONDITION(S):
- PAIR IS ELIGIBLE FOR AUTHORIZATION FORM COLLECTION FOR THE CURRENT ROUND
(SEE BOX_01 SAMPLING SPECIFICATIONS) OR
- PAIR WAS ELIGIBLE FOR AUTHORIZATION FORM COLLECTION IN PREVIOUS ROUND,
AND CL04 WAS CODED '3' (LEFT WITH R), ‘4’ (MAILED TO R), ‘5’ (REFUSED),
OR ‘91’ (OTHER) FOR THIS PAIR IN THE PREVIOUS ROUND
PROGRAMMER NOTE:
LOOP ONLY ONE TIME FOR EACH UNIQUE PERSON-PROVIDER-PAIR.
7
Closing (CL) Section
Beta
CL04
Help Enabled (MPSPERMISS)
Comment Enabled
Jump Back Enabled
Variable Name
PPID.FORMSTAT
STATUS OF MPS PERMISSION FORMS
Label
Size
2
PPID.CAPISTAT
PPID.PFSTAT01
STATUS OF PERMISSION FORMS DURING CAPI
MPS PF TRACING STATUSES PER RND - CONT
2
2
PPID.PFSTAT02
PPID.PFSTAT03
MPS PF TRACING STATUSES PER RND - CONT
MPS PF TRACING STATUSES PER RND - CONT
2
2
PPID.PFSTAT04
MPS PF TRACING STATUSES PER RND - CONT
2
PPID.PFSTAT05
MPS PF TRACING STATUSES PER RND - CONT
2
INTERVIEWER: ASK APPROPRIATE PERSON(S) TO SIGN
AUTHORIZATION FORM. IF NOT AVAILABLE TO SIGN, LEAVE AF AND
BOOKLET WITH RESPONDENT. RECORD STATUS BELOW AND
UPDATE AF LOG IF AF UNSIGNED OR PRE-PRINTED.
PID: [PID-3]
PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PROVIDER ID: [ProvID-4]
PROVIDER NAME: [Provider Full Name-65]
PROVIDER ADDRESS: [Street Address from Provider Directory]
[City Name], [ST] [Zip Code] [Telephone]
SIGNATURE DATE ON MPC AF MUST BE ON OR AFTER: {MM/DD/YYYY}
SELECT THE AUTHORIZATION FORM STATUS:
SIGNED, NO PROBLEM
SIGNED WITH PROBLEM
1
2
{CL05}
{CL04OV1}
LEFT WITH RESPONDENT
3
{END_LP02}
MAILED TO RESPONDENT
REFUSED
4
5
{END_LP02}
{CL06}
OTHER
91
{CL04OV2}
HELP AVAILABLE FOR MORE INFORMATION ON MPC AUTHORIZATION
FORMS.
DISPLAY INSTRUCTIONS:
FOR ‘MM/DD/YYYY’ , DISPLAY THE RU END REFERENCE DATE OF THE
MOST RECENT ROUND'S INTERVIEW FOR WHICH PAIR IS/WAS ELIGIBLE
FOR AUTHORIZATION FORM COLLECTION.
8
Closing (CL) Section
Beta
Soft CHECK:
CODE ‘4’ (MAILED TO R) MUST BE VERIFIED (ENTERED TWICE) IF RU IS NOT A
STUDENT RU. IF CODE ‘4’ SELECTED AND RU IS NOT A STUDENT RU, DISPLAY THE
FOLLOWING MESSAGE: ‘UNLIKELY RESPONSE. VERIFY AND RE-ENTER.’
CL04OV1
Help Enabled (MPSPERMISS)
Variable Name
PPID.SIGNPROB
Comment Enabled
Jump Back Enabled
Label
DESCRIPTION OF PROBLEM WHEN SIGNED
PROBLEM: _______________________
Size
45
{CL05}
HELP AVAILABLE FOR MORE INFORMATION ON MPC AUTHORIZATION
FORMS.
9
Closing (CL) Section
Beta
CL04OV2
Help Enabled (MPSPERMISS)
Variable Name
PPID.FORMSTOS
Comment Enabled
Jump Back Enabled
Label
OTHER SPECIFY FOR STATUS OF MPS P.F.
OTHER SPECIFY: _______________________
Size
45
{END_LP02}
HELP AVAILABLE FOR MORE INFORMATION ON MPC AUTHORIZATION
FORMS.
10
Closing (CL) Section
Beta
CL05
Help Enabled
Comment Enabled
Jump Back Enabled
Variable Name
PPID.FORMID
MPS PERMISSION FORM NUMBER
Label
Size
8
PPID.PFIDN01
PPID.PFIDN02
MPS PF TRACING ID NUMBERS PER RND
MPS PF TRACING ID NUMBERS PER RND
8
8
PPID.PFIDN03
PPID.PFIDN04
MPS PF TRACING ID NUMBERS PER RND
MPS PF TRACING ID NUMBERS PER RND
8
8
PPID.PFIDN05
MPS PF TRACING ID NUMBERS PER RND
8
PID: [PID-3]
PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PROVIDER ID: [ProvID-4]
PROVIDER NAME: [Provider Full Name-65]
PROVIDER ADDRESS: [Street Address from Provider Directory]
[City Name], [ST] [Zip Code] [Telephone]
SIGNATURE DATE ON MPC AF MUST BE ON OR AFTER: {MM/DD/YYYY}
ENTER MPC AUTHORIZATION FORM NUMBER:
{NOTE: IF 2 FORMS COLLECTED FOR THE SAME PAIR, ENTER MPC AF
NUMBER FROM THE FORM WITH THE MOST RECENT SIGNATURE
DATE. HOWEVER, COLLECT ALL SIGNED AF(S) AND MAKE A NOTE OF
EXTRA AF(S) IN COMMENT AREA OF THE AF LOG.}
FORM NUMBER: _______________________
{CL05OV}
DISPLAY INSTRUCTIONS:
FOR ‘MM/DD/YYYY', DISPLAY THE RU END REFERENCE DATE OF THE
MOST RECENT ROUND’S INTERVIEW FOR WHICH PAIR IS/WAS ELIGIBLE
FOR AUTHORIZATION FORM COLLECTION.
DISPLAY ‘NOTE: ... LOG.’ IF CURRENT PERSON-PROVIDER-PAIR
ELIGIBLE FOR MPC IN PREVIOUS ROUND AND FORM WAS NOT SIGNED IN
THE PREVIOUS ROUND. OTHERWISE, USE A NULL DISPLAY.
PROGRAMMER NOTES:
EACH AUTHORIZATION FORM HAS A PRE-ASSIGNED AUTHORIZATION FORM
NUMBER.
11
Closing (CL) Section
Beta
Hard CHECK:
NUMBER ENTERED MUST BE 8 CHARACTERS LONG AND MUST BEGIN AND END WITH AN
ALPHA CHARACTER. THE FIRST ALPHA MUST BE A-M, T, OR Y. THE FIRST NUMERIC
12
Closing (CL) Section
Beta
CL05OV
Help Enabled
Comment Enabled
Variable Name
PPID.PFDATEMM
Label
MPS PERMISSION FORM DATE - MONTH
PPID.PFDATEDD
PPID.PFDATEYY
MPS PERMISSION FORM DATE - DAY
MPS PERMISSION FORM DATE - YEAR
Jump Back Enabled
MPC _______________________
AUTHORIZATION
FORM SIGNATURE
DATE:
Size
2
2
4
{END_LP02}
PROGRAMMER NOTES:
INTERVIEWERS WILL BE INSTRUCTED TO COLLECT SIGNED MPC
AUTHORIZATION FORMS WITH DATES EARLIER THAN THE ONE DISPLAYED,
BUT WILL NOT ENTER THE NUMBER IN CAPI SINCE THE CURRENT STATUS
FOR THE AUTHORIZATION FORM WITH THE CORRECT DATE MAY BE
SOMETHING ELSE. THE CAPI STATUS OF THE MPC AUTHORIZATION FORM
SHOULD REFLECT THE FORM WITH THE MOST RECENT DATE.
Hard CHECK:
DATE ENTERED MUST BE ON OR AFTER THE INTERVIEW DATE OF THE MOST RECENT
ROUND’S INTERVIEW FOR WHICH THE PAIR IS/WAS ELIGIBLE FOR AUTHORIZATION FORM
COLLECTION. IF DATE IS BEFORE CORRECT DATE, DISPLAY THE FOLLOWING MESSAGE:
‘MPC AF MUST BE SIGNED ON OR AFTER ABOVE DATE. VERIFY AND RE-ENTER DATE OR
COMPLETE NEW AF.’
13
Closing (CL) Section
Beta
CL06
Help Enabled
Variable Name
PPID.REFUSAL
Comment Enabled
Jump Back Enabled
Label
Size
2
REASON FOR REFUSAL
ENTER MAIN REASON FOR REFUSAL:
PID: [PID-3]
PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PROVIDER ID: [ProvID-4]
PROVIDER NAME: [Provider Full Name-65]
PROVIDER ADDRESS: [Street Address from Provider Directory]
[City Name], [ST] [Zip Code] [Telephone]
DOESN'T WANT TO BOTHER PROVIDER 1
CONFIDENTIALITY/SENSITIVE
2
INFORMATION
{END_LP02}
{END_LP02}
PAYMENT PROBLEM WITH PROVIDER
HAS ALREADY GIVEN ENOUGH
INFORMATION
3
4
{END_LP02}
{END_LP02}
WANTS MORE INFORMATION BEFORE
SIGNING
NOT INTERESTED IN STUDY
5
{END_LP02}
6
{END_LP02}
NO REASON GIVEN
7
{END_LP02}
OTHER SPECIFY
91
{CL06OV}
14
Closing (CL) Section
Beta
CL06OV
Help Enabled
Variable Name
PPID.REFUSEOS
Comment Enabled
Jump Back Enabled
Label
OTHER SPECIFY REASON FOR REFUSAL
OTHER REASON _______________________
FOR REFUSAL:
Size
45
{END_LP02}
END_LP02
CYCLE ON NEXT PAIR ON THE RU-PERSON-PROVIDER-PAIRS-ROSTER THAT MEETS THE
CONDITIONS STATED IN THE LOOP DEFINITION.
IF NO OTHER PAIRS MEET THE STATED CONDITIONS, END LOOP_02 AND CONTINUE
WITH BOX_02
BOX_02
IF NOT ROUND 1 AND ANY KEY RU MEMBER HAD A STATUS OF INSTITUTIONALIZED (IN
A HEALTH CARE INSTITUTION) AT THE PREVIOUS ROUND'S INTERVIEW DATE, BUT HAS
A DIFFERENT STATUS AS OF THE CURRENT ROUND'S INTERVIEW DATE, CONTINUE WITH
LOOP_02A
OTHERWISE, GO TO BOX_03
15
Closing (CL) Section
Beta
LOOP_02A
FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK CL06A - END_LP02A
LOOP DEFINITION: LOOP_02A INSTRUCTS THE INTERVIEWER TO COLLECT THE HEALTH
CARE INSTITUTION HISTORY AND THE APPROPRIATE NUMBER OF MEDICAL PROVIDER
AUTHORIZATION FORMS FOR ALL RU MEMBERS WHO HAD A STATUS OF
INSTITUTIONALIZED (IN A HEALTH CARE INSTITUTION) AT THE PREVIOUS ROUND’S
INTERVIEW DATE, BUT WHO REJOINED THE COMMUNITY (OR CHANGED STATUS) DURING
THE CURRENT ROUND. THIS LOOP CYCLES ON RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS AN RU MEMBER
- PERSON IS KEY
- PERSON DOES NOT HAVE A STATUS OF INSTITUTIONALIZED AS OF THE CURRENT
ROUND’S INTERVIEW DATE
- PERSON HAD A STATUS OF INSTITUTIONALIZED ON THE PREVIOUS ROUND’S
INTERVIEW DATE
16
Closing (CL) Section
Beta
CL06A
Help Enabled
Comment Enabled
Jump Back Enabled
Variable Name
PERS.INSTBACK
Label
INSTITUTIONALIZED PREV RND/BACK THIS RND
Size
4
PERS.INSTBCK2
INSTITUTIONALIZED PREV-RND/BACK 1ST TIME
4
PID: [PID-3]
PERSON: [First, [Middle], Last Name-35]
DOB: [MM/DD/YYYY]
AGE: [XXX]
STATUS: [Status Code
Description]
DATE ORIGINALLY INSTITUTIONALIZED: [MM/DD/YYYY]
DATE REJOINED COMMUNITY/CHANGED STATUS: [MM/DD/YYYY]
INTERVIEWER: THE PERSON NAMED ABOVE WAS INSTITUTIONALIZED
IN A PREVIOUS ROUND AND HAS NOW REJOINED THE COMMUNITY OR
CHANGED STATUS. COMPLETE THE FOLLOWING STEPS:
1. FILL OUT HEALTH CARE INSTITUTION HISTORY.
2. COMPLETE A MPC AF FOR EACH DIFFERENT HEALTH CARE
INSTITUTION LISTED ON HEALTH CARE INSTITUTION HISTORY. WRITE
‘IC’ IN UPPER LEFT CORNER OF MPC AF. REFER TO SECTION 3 OF
HISTORY FOR INSTRUCTIONS ON COMPLETING THESE AF(S).
3. FOR EACH MPC AF CREATED THIS WAY, RECORD PERSON AND
PROVIDER INFORMATION IN THE AF LOG.
4. REQUEST SIGNATURE(S) ON AF(S).
5. LEAVE UNSIGNED AF(S) AND THE AF BOOKLET WITH RESPONDENT.
6. RECORD AF STATUS FOR EACH MPC AF ON THE AF LOG. CAPI WILL
NOT COLLECT THIS INFORMATION.
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
SIGNATURE DATE ON MPC AF MUST BE ON OR AFTER: {MM/DD/YYYY}
17
Closing (CL) Section
Beta
DISPLAY INSTRUCTIONS:
DISPLAY THE INTERVIEW DATE OF THE MOST RECENT ROUND’S
INTERVIEW FOR WHICH PAIR IS/WAS ELIGIBLE FOR AUTHORIZATION
FORM COLLECTION FOR ‘MM/DD/YYYY’.
ROUTING INSTRUCTION:
CONTINUE WITH END_LP02A
END_LP02A
CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER WHO MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION
IF NO OTHER PERSONS MEET THE STATED CONDITIONS, END LOOP_02A AND CONTINUE
WITH BOX_03
18
Closing (CL) Section
Beta
BOX_03
SUBSECTION 2: HIPS AUTHORIZATION FORMS (BEGINNING WITH THE SECOND YEAR OF
PANEL 2 AND THE FIRST YEAR OF PANEL 3 (1998), SAMPLING CONTINUES BUT
AUTHORIZATION FORMS ARE NOT COLLECTED).
SAMPLING BOX FOR ROUNDS 2 AND 3 (TO BASE ON ROUND 1 CRITERIA FOR
COLLECTION OF AFS IN ROUNDS 2 AND 3):
RU-ESTABLISHMENT-PERSON-PAIRS ELIGIBLE FOR HIPS AUTHORIZATION FORM
COLLECTION:
- ALL PAIRS WHERE THE PERSON IS THE POLICYHOLDER OF THIS INSURANCE ON THE
DATE OF THE ROUND 1 INTERVIEW AND THE ESTABLISHMENT IS A PRIVATE SOURCE
OF INSURANCE (DEFINED LATER) HELD ON THE DATE OF THE ROUND 1 INTERVIEW
(DEFINED LATER) WITH FOUR EXCEPTIONS:
1. ESTABLISHMENT IS FLAGGED AS ‘EMPLOYER’ AND EMPLOYER IS THE FEDERAL
GOVERNMENT (EM96=2 OR HP13=1)
2. ESTABLISHMENT IS FLAGGED AS ‘NOT SELF-EMPLOYED’ WITH ONE EMPLOYEE
(EM91=1) AND ONE LOCATION (EM93=2)
3. PERSON IS THE POLICYHOLDER OF THIS INSURANCE AND IS FLAGGED AS
‘POLICYHOLDER NOT LISTED IN RU’
4. ESTABLISHMENT ONLY PROVIDES LONG TERM CARE IN A NURSING HOME, EXTRA
CASH FOR HOSPITAL STAYS, SERIOUS DISEASE OR DREAD DISEASE,
DISABILITY, WORKER’S COMPENSATION, OR ACCIDENT INSURANCE
(HX48 IS CODED ONLY COMBINATIONS OF CODES ‘6’, ‘7’, ‘8’, ‘9’, ‘10’,
AND ‘11’).
SAMPLING BOX FOR ROUND 2 AND 3: (TO BASE ON ROUND 1 CRITERIA FOR
COLLECTION OF AFs IN ROUND 2 AND ROUND 3):
RU-ESTABLISHMENT-PERSON-PAIRS ELIGIBLE FOR HIPS AUTHORIZATION FORM
COLLECTION:
-
ALL PAIRS WHERE THE ESTABLISHMENT IS FLAGGED AS
'EMPLOYER AND THE JOB SUBTYPE OF THAT EMPLOYER
IS FLAGGED AS 'CURRENT MAIN' AND THE JOB IS NOT
FLAGGED AS 'PROVIDES HEALTH INSURANCE' (PERSON
IS THE JOBHOLDER OF THIS CURRENT MAIN JOB ON THE
DATE OF THE ROUND 1 INTERVIEW) AS OF THE ROUND 1
INTERVIEW DATE WITH THREE EXCEPTIONS:
1.
2.
3.
ESTABLISHMENT IS THE FEDERAL GOVERNMENT (EM96 = 2)
ESTABLISHMENT IS FLAGGED AS 'SELF-EMPLOYED'
WITH A FIRM-SIZE=1
ESTABLISHMENT IS FLAGGED AS 'NOT SELF-EMPLOOYED'
WITH ONE EMPLOYEE (EM91=1) AND ONE LOCATION (EM93=2)
SAMPLING BOX FOR ROUNDS 4 AND 5:
RU-ESTABLISHMENT-PERSON-PAIRS ELIGIBLE FOR HIPS AUTHORIZATION FORM
COLLECTION:
- ALL PAIRS WHERE THE ESTABLISHMENT IS FLAGGED AS ‘EMPLOYER’ AND THE JOB
SUBTYPE OF THAT EMPLOYER IS FLAGGED AS ‘CURRENT MAIN’ AND THE JOB IS
NOT FLAGGED AS ‘PROVIDES HEALTH INSURANCE’ (PERSON IS THE JOBHOLDER OF
THIS CURRENT MAIN JOB ON THE DATE OF THE ROUND 1 INTERVIEW) AS OF THE
ROUND 1 INTERVIEW DATE WITH THREE EXCEPTIONS:
1. ESTABLISHMENT IS THE FEDERAL GOVERNMENT (EM96 = 2)
2. ESTABLISHMENT IS FLAGGED AS ‘SELF-EMPLOYED’ WITH A FIRM-SIZE=1
3. ESTABLISHMENT IS FLAGGED AS ‘NOT SELF-EMPLOYED’ WITH ONE EMPLOYEE
(EM91=1) AND ONE LOCATION (EM93=2)
NOTE:
PRIVATE INSURANCE IS DEFINED AS:
19
Closing (CL) Section
Beta
- ESTABLISHMENTS FLAGGED AS ‘EMPLOYER’ AND FLAGGED AS ‘PROVIDES HEALTH
INSURANCE’ (ESTABLISHMENTS FLAGGED AS ‘SELF-EMPLOYED’ WITH A FIRM-SIZE-1
ARE TREATED AS DIRECT PURCHASED, SEE NOTE BELOW)
- DIRECT PURCHASED INSURANCE, THAT IS, ESTABLISHMENTS CREATED FROM THE
HX23 SERIES
NOTE: HELD ON THE DATE OF THE ROUND 1 INTERVIEW:
- FOR PRIVATE SOURCES -- POLICYHOLDER HELD INSURANCE AT THE TIME OF THE
ROUND 1 INTERVIEW DATE (HQ01 IS CODED ‘1’ (WHOLE TIME) OR HQ02 IS CODED
‘1’ (YES, COVERED NOW) FOR THE POLICYHOLDER)
- FOR PRIVATE SOURCES WHERE POLICYHOLDER IS DECEASED -- AT LEAST ONE
DEPENDENT (SELECTED AT HP16) IS COVERED BY THE INSURANCE AT THE TIME
OF THE ROUND 1 INTERVIEW DATE (HQ01 IS CODED ‘1’ (WHOLE TIME) OR HQ02
IS CODED ‘1’ (YES, COVERED NOW) FOR THE COVERED PERSON)
NOTE: ESTABLISHMENTS WHICH ARE EMPLOYERS AND PROVIDE HEALTH INSURANCE AND
ARE FLAGGED AS ‘SELF-EMPLOYED’ WITH A FIRM-SIZE=1 ARE TREATED AS DIRECT
PURCHASED INSURANCE, THAT IS, HIPS WILL CONTACT THE ESTABLISHMENT
PROVIDING THE INSURANCE, (I.E., CREATED FROM THE HX03 SERIES) NOT THE
EMPLOYER.
NOTE: FOR ESTABLISHMENTS WHICH ARE CURRENT MAIN EMPLOYERS (ON THE ROUND 1
INTERVIEW DATE) AND PROVIDE HEALTH INSURANCE, WHERE THE HEALTH INSURANCE
IS ONLY FROM A UNION (EM117=2), A HIPS AUTHORIZATION FORM IS REQUIRED FOR
BOTH THE EMPLOYER AND THE UNION. IN THESE CASES, BOTH ESTABLISHMENTPERSON-PAIRS ARE ELIGIBLE FOR HIPS AUTHORIZATION FORM COLLECTION.
NOTE: IF A CURRENT MAIN JOB IS FLAGGED AS 'PREVIOUS HEALTH INSURANCE' BUT
THAT INSURANCE IS ONLY LONG TERM CARE IN A NURSING HOME, EXTRA CASH FOR
HOSPITAL STAYS, SERIOUS DISEASE OR DREAD DISEASE, DISABILITY, WORKER'S
COMPENSATION, AND/OR ACCIDENT INSURANCE, THE JOB IS PROCESSED AS IF IT
DOES NOT PROVIDE HEALTH INSURANCE BUT IS ELIGIBLE FOR HEALTH INSURANCE
PROVIDER AUTHORIZATION FORM COLLECTION (AS LONG AS OTHER REQUIREMENTS ARE
MET).
NOTE: A ‘RF’ (REFUSED) AND ‘DK’ (DON’T KNOW) RESPONSE AT ANY QUESTION
LISTED ABOVE DOES NOT MEET THE CRITERIA.
NOTE: IN ROUND 4, A NEW HIPS FLAG WILL BE SET AND NEW HIPS AUTHORIZATION
FORMS WILL BE COLLECTED FOR ALL ESTABLISHMENT-PERSON-PAIRS BASED ON THE
ABOVE SAMPLING CRITERIA, BUT USING ROUND 3 DATA.
SAMPLING BOX (TO BASE ON ROUND 3 CRITERIA, FOR COLLECTION OF AFs IN
ROUNDS 4 AND 5):
RU-ESTABLISHMENT-PERSON-PAIRS ELIGIBLE FOR HIPS AUTHORIZATION FORM
COLLECTION:
- ALL PAIRS WHERE THE PERSON IS THE POLICYHOLDER OF THIS INSURANCE ON THE
DATE OF THE ROUND 3 INTERVIEW AND THE ESTABLISHMENT IS A PRIVATE SOURCE
OF INSURANCE (DEFINED LATER) HELD ON THE DATE OF THE ROUND 3 INTERVIEW
(DEFINED LATER) WITH FOUR EXCEPTIONS:
1. ESTABLISHMENT IS FLAGGED AS ‘EMPLOYER’ AND EMPLOYER IS THE FEDERAL
GOVERNMENT (EM96=2 OR HP13=1)
2. ESTABLISHMENT IS FLAGGED AS ‘NOT SELF-EMPLOYED’ WITH ONE EMPLOYEE
(EM91=1) AND ONE LOCATION (EM93=2)
3. PERSON IS THE POLICYHOLDER OF THIS INSURANCE AND IS FLAGGED AS
‘POLICYHOLDER NOT LISTED IN DU’
4. ESTABLISHMENT PROVIDES ONLY LONG TERM CARE IN A NURSING HOME, EXTRA
CASH FOR HOSPITAL STAYS, SERIOUS DISEASE OR DREAD DISEASE,
DISABILITY, WORKER’S COMPENSATION, OR ACCIDENT INSURANCE
(HX48, OE10, OE24, OR OE37 IS CODED ONLY COMBINATIONS OF
20
Closing (CL) Section
Beta
CODES ‘6’ , ‘7’, ‘8’, ‘9’, ‘10’, AND ‘11’).
SAMPLING BOX FOR ROUNDS 4 AND 5: (TO BASE ON ROUND 3 CRITERIA, FOR
COLLECTION OF AFs IN ROUNDS 4 AND 5):
RU-ESTABLISHMENT-PERSON-PAIRS ELIGIBLE FOR HIPS AUTHORIZATION FORM
COLLECTION:
- ALL PAIRS WHERE THE ESTABLISHMENT IS FLAGGED AS ‘EMPLOYER’ AND THE JOB
SUBTYPE OF THAT EMPLOYER IS FLAGGED AS ‘CURRENT MAIN’ AND THE JOB IS
NOT FLAGGED AS ‘PROVIDES HEALTH INSURANCE’ (PERSON IS THE JOBHOLDER OF
THIS CURRENT MAIN JOB ON THE DATE OF THE ROUND 3 INTERVIEW) AS OF THE
ROUND 3 INTERVIEW DATE WITH THREE EXCEPTIONS:
1. ESTABLISHMENT IS THE FEDERAL GOVERNMENT (EM96 = 2)
2. ESTABLISHMENT IS FLAGGED AS ‘SELF-EMPLOYED’ WITH A FIRM-SIZE=1
3. ESTABLISHMENT IS FLAGGED AS ‘NOT SELF-EMPLOYED’ WITH ONE EMPLOYEE
(EM91=1) AND ONE LOCATION (EM93=2)
NOTE: PRIVATE INSURANCE IS DEFINED AS:
- ESTABLISHMENTS FLAGGED AS ‘EMPLOYER’ AND FLAGGED AS ‘PROVIDES HEALTH
INSURANCE’ (ESTABLISHMENTS FLAGGED AS ‘SELF-EMPLOYED’ WITH A
FIRM-SIZE-1 ARE TREATED AS DIRECT PURCHASED, SEE NOTE BELOW)
- DIRECT PURCHASED INSURANCE, THAT IS, ESTABLISHMENTS CREATED FROM THE
HX23 SERIES
21
Closing (CL) Section
Beta
BOX_03 (CONT)
NOTE: HELD ON THE DATE OF THE ROUND 3 INTERVIEW:
- FOR PRIVATE SOURCES -- POLICYHOLDER HELD INSURANCE AT THE TIME OF THE
ROUND 3 INTERVIEW DATE [(HQ01 IS CODED ‘1’ (WHOLE TIME) OR HQ02 IS CODED
‘1’ (YES, COVERED NOW) FOR THE POLICYHOLDER) OR (OE01, OE12, OE26 IS
CODED
‘1’ (YES) FOR THE POLICYHOLDER)
- FOR PRIVATE SOURCES WHERE POLICYHOLDER IS DECEASED -- AT LEAST ONE
DEPENDENT [(SELECTED AT HP16 OR OE45) OR (CONFIRMED AS STILL COVERED AT
OE29 OR OE30)] IS COVERED BY THE INSURANCE AT THE TIME OF THE ROUND 3
INTERVIEW DATE [(HQ01 IS CODED ‘1’ (WHOLE TIME) OR HQ02 IS
CODED ‘1’ (YES, COVERED NOW) FOR THE COVERED PERSON) OR
(OE26 IS CODED ‘1’ (YES) FOR THE COVERED PERSON)]
NOTE: ESTABLISHMENTS WHICH ARE EMPLOYERS AND PROVIDE HEALTH INSURANCE AND
ARE FLAGGED AS ‘SELF-EMPLOYED’ WITH A FIRM-SIZE=1 ARE TREATED AS DIRECT
PURCHASED INSURANCE, THAT IS, HIPS WILL CONTACT THE ESTABLISHMENT
PROVIDING THE INSURANCE, (I.E., CREATED FROM THE HX03 SERIES) NOT THE
EMPLOYER.
NOTE: FOR ESTABLISHMENTS WHICH ARE CURRENT MAIN EMPLOYERS (ON THE ROUND 3
INTERVIEW DATE) AND PROVIDE HEALTH INSURANCE, WHERE THE HEALTH INSURANCE
IS ONLY FROM A UNION (EM117=2), A HIPS AUTHORIZATION FORM IS REQUIRED FOR
BOTH THE EMPLOYER AND THE UNION. IN THESE CASES, BOTH ESTABLISHMENTPERSON-PAIRS ARE ELIGIBLE FOR HIPS AUTHORIZATION FORM COLLECTION.
NOTE: IF A CURRENT MAIN JOB IS FLAGGED AS 'PREVIOUS HEALTH INSURANCE' BUT
THAT INSURANCE IS ONLY LONG TERM CARE IN A NURSING HOME, EXTRA CASH FOR
HOSPITAL STAYS, SERIOUS DISEASE OR DREAD DISEASE, DISABILITY, WORKER'S
COMPENSATION, AND/OR ACCIDENT INSURANCE, THE JOB IS PROCESSED AS IF IT
DOES NOT PROVIDE HEALTH INSURANCE BUT IS ELIGIBLE FOR HEALTH INSURANCE
PROVIDER AUTHORIZATION FORM COLLECTION (AS LONG AS OTHER REQUIREMENTS ARE
MET).
NOTE: A ‘-7’ (REFUSED) AND ‘-8’ (DON’T KNOW) RESPONSE AT ANY QUESTION
LISTED ABOVE DOES NOT MEET THE CRITERIA.
GO TO BOX_10.
BOX_10
SUBSECTION 4:
PHARMACY REQUESTS AND AUTHORIZATION FORMS (ROUND 3 AND 5)
AS A PHARMACY WAS ENTERED OR SELECTED DURING THE PRESCRIBED MEDICINES
SECTION, THE PERSON-PHARMACY-PAIR WAS FLAGGED WITH THE CURRENT ROUND
(I.E., THE MOST RECENT ROUND IT WAS ENTERED/SELECTED). THIS ROUND FLAG IS
USED TO DETERMINE WHETHER THE PHARMACY IS ELIGIBLE FOR PHARMACY
AUTHORIZATION FORM COLLECTION FOR THIS RU MEMBER.
IF ROUND 3 OR ROUND 5, COUNTINUE WITH BOX_11
OTHERWISE, GO TO BOX_14
22
Closing (CL) Section
Beta
BOX_11
IF AT LEAST ONE PERSON-PHARMACY-PAIR ELIGIBLE (SEE SAMPLING BOX BELOW) FOR
PHARMACY AUTHORIZATION FORM COLLECTION, CONTINUE WITH CL29
OTHERWISE, GO TO BOX_14
SAMPLING BOX FOR ROUND 3:
PERSON-PHARMACY-PAIRS ELIGIBLE FOR PHARMACY AUTHORIZATION FORM COLLECTION
IN ROUND 3:
- PERSON IS A KEY, ELIGIBLE RU MEMBER
- PERSON ASSOCIATED WITH THE PHARMACY
- PHARMACY COLLECTED OR USED DURING ROUND 1, 2, OR 3
NOTE: FORMS ASSOCIATED WITH DECEASED AND INSTITUTIONALIZED PERSONS IN
ROUNDS 1 AND 2 WILL BE REQUESTED.
SAMPLING BOX FOR ROUND 5:
PERSON-PHARMACY-PAIRS ELIGIBLE FOR PHARMACY AUTHORIZATION FORM COLLECTION
IN ROUND 5:
- PERSON IS A KEY, ELIGIBLE RU MEMBER
- PERSON ASSOCIATED WITH THE PHARMACY
- PHARMACY COLLECTED OR USED DURING ROUND 3, 4, OR 5
NOTE: FORMS ASSOCIATED WITH DECEASED AND INSTITUTIONALIZED PERSONS IN
ROUNDS 3 AND 4 WILL BE REQUESTED.
NOTE: IF THE SAME PHARMACY IS ASSOCIATED MORE THAN ONCE WITH A PARTICULAR
PERSON, ONLY ONE AUTHORIZATION FORM IS ASKED ABOUT FOR THAT PAIR. IF THE
SAME PHARMACY IS ASSOCIATED WITH MORE THAN ONE PERSON, AN AUTHORIZATION
FORM IS ASKED FOR EACH UNIQUE PERSON-PHARMACY-PAIR.
23
Closing (CL) Section
Beta
CL29
Help Enabled
Comment Enabled
Jump Back Enabled
As you know, the U.S. Public Health Service is very interested in obtaining the
most complete and accurate information about health care use and
expenditures, including prescription medicines.
Many pharmacies now offer their customers a summary of their prescription
medicine charges. People sometimes request these summaries to help in
preparing their taxes or insurance claims.
To help us get the best information about the family’s prescriptions, we would
like to obtain a printed summary from each pharmacy used by this family
during the past year. To do this, we must have written authorization.
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
24
Closing (CL) Section
Beta
CL30
Help Enabled
Variable Name
PLNK.RURNDCOL
Comment Enabled
Jump Back Enabled
Label
RU + RND WHERE PF IS REQUESTED
Size
2
From the information I have, I would like to get a signed authorization form for:
(READ PERSON BELOW)’s prescriptions filled at (READ PHARMACY
BELOW).
[First, [Middle], Last Name]
[First, [Middle], Last Name]
[First, [Middle], Last Name]
[Pharmacy Name]
[Pharmacy Name]
[Pharmacy Name]
[HAND RESPONDENT THE AUTHORIZATION FORM BOOKLET.]
[These materials explain more about why we contact pharmacies and answer
questions people sometimes ask about this part of the study. Please take a
minute to review this information while I gather the forms.]
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
Roster Details
Title:
RU-Pers-PHAR-Pair_1
Col #
Header
Instructions
1
NAME
Display RU members’ first, middle, and last names
PERS.FULLNAME
2
PHARMACY
Display Pharmacy name
PHAR.PHARNAME
Roster Definition:
Display each unique pair on the RU-Person-Pharmacy-PairsRoster.
Roster Behavior:
1. Display only
2. Select, edit, add, and delete disallowed
25
Closing (CL) Section
Beta
Roster Filter:
Display each unique eligible person-pharmacy-pair only once
where pair is eligible for pharmacy authorization form
collection (see BOX_11 sampling specifications) for rounds 1,
2, OR 3 if round 3 or for rounds 3, 4, OR 5 if round 5
LOOP_07
FOR EACH ELEMENT ON THE RU-PERSON-PHARMACY-PAIRS-ROSTER, ASK CL31 END_LP07
LOOP DEFINITION: LOOP_07 PRESENTS EACH UNIQUE PERSON-PHARMACY-PAIR
ELIGIBLE FOR PHARMACY AUTHORIZATION FORM COLLECTION FOR THE INTERVIEWER TO
COMPLETE THE AUTHORIZATION FORM. THIS LOOP CYCLES ON THE RU-PERSONPHARMACY-PAIRS THAT MEET THE FOLLOWING CONDITION:
- PAIR IS ELIGIBLE FOR PHARMACY AUTHORIZATION FORM COLLECTION (SEE BOX_11
SAMPLING SPECIFICATIONS) FOR ROUNDS 1, 2, OR 3 IF ROUND 3 OR FOR ROUNDS
3, 4, OR 5 IF ROUND 5
26
Closing (CL) Section
Beta
CL31
Help Enabled (CL31Help)
Variable Name
PLNK.TEMPVAR
Comment Enabled
Jump Back Enabled
Label
TEMPORARY FLAG SET FOR EXECUTION ONLY
Size
2
INTERVIEWER: {LOCATE APPROPRIATE PREPRINTED PHARMACY
AUTHORIZATION FORMS (COMPLETE NEW ONE IF FORM CANNOT BE
LOCATED)/COMPLETE PHARMACY AUTHORIZATION FORM} FOR THE
FOLLOWING PERSON-PHARMACY-PAIR:
PID: [PID]
PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PHARMID: [PharmID-4]
PHARMACY NAME: [Pharmacy Name-35]
PHARMACY ADDRESS: [Street Address for Pharmacy]
[City Name], [ST] [Zip Code] [Telephone]
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
HELP AVAILABLE FOR MORE INFORMATION ON PHARMACY
AUTHORIZATION FORMS.
DISPLAY INSTRUCTIONS:
DISPLAY ‘LOCATE ... LOCATED)’ IF PERSON-PHARMACY-PAIR WAS
ELIGIBLE FROM ROUNDS 1 OR 2 IF ROUND 3 OR FROM ROUNDS 3 OR 4
IF ROUND 5. OTHERWISE, DISPLAY ‘COMPLETE ... FORM’.
END_LP07
CYCLE ON NEXT PAIR ON THE RU-PERSON-PHARMACY-PAIRS-ROSTER THAT MEETS THE
CONDITIONS STATED IN THE LOOP DEFINITION.
IF NO OTHER PAIRS MEET THE STATED CONDITIONS, END LOOP_07 AND CONTINUE
WITH LOOP_08
27
Closing (CL) Section
Beta
LOOP_08
FOR EACH ELEMENT ON THE RU-PERSON-PHARMACY-PAIRS-ROSTER, ASK CL32 END_LP08
LOOP DEFINITION: LOOP_08 PRESENTS EACH UNIQUE PERSON-PHARMACY-PAIR
ELIGIBLE FOR PHARMACY AUTHORIZATION FORM COLLECTION FOR THE INTERVIEWER TO
RECORD THE STATUS OF THE AUTHORIZATION FORM. THIS LOOP CYCLES ON THE RUPERSON-PHARMACY-PAIRS THAT MEET THE FOLLOWING CONDITION:
- PAIR IS ELIGIBLE FOR PHARMACY AUTHORIZATION FORM COLLECTION (SEE BOX_11
SAMPLING SPECIFICATIONS) FOR ROUNDS 1, 2, OR 3 IF ROUND 3 OR FOR ROUNDS
3, 4, OR 5 IF ROUND 5
NOTE:
LOOP ONLY ONE TIME FOR EACH UNIQUE PERSON-PHARMACY-PAIR.
28
Closing (CL) Section
Beta
CL32
Help Enabled (FARPERMISS2)
Comment Enabled
Variable Name
PLNK.PHARSTAT
Label
STATUS OF PERS - PHARM PAIR PF - R3
PLNK.PHCAPIST
STATUS OF PERS - PHARM PAIR PF - R3
Jump Back Enabled
Size
2
2
INTERVIEWER: ASK APPROPRIATE PERSON(S) TO SIGN
AUTHORIZATION FORM. IF NOT AVAILABLE TO SIGN, LEAVE
AUTHORIZATION FORM AND BOOKLET WITH RESPONDENT. RECORD
STATUS BELOW AND UPDATE AF LOG IF AF UNSIGNED OR PREPRINTED.
PID: [PID]
PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PHARMID: [PharmID-4]
PHARMACY NAME: [Pharmacy Name-35]
PHARMACY ADDRESS: [Street Address for Pharmacy]
[City Name], [ST] [Zip Code] [Telephone]
SELECT THE PHARMACY AUTHORIZATION FORM STATUS:
SIGNED, NO PROBLEM
1
{CL33}
SIGNED WITH PROBLEM
LEFT WITH R
2
3
{CL32OV1}
{END_LP08}
MAILED TO R
REFUSED
4
5
{END_LP08}
{CL34}
OTHER
91
{CL32OV2}
HELP AVAILABLE FOR MORE INFORMATION ON PHARMACY
AUTHORIZATION FORMS.
Hard CHECK:
CODE ‘4’ (MAILED TO R) MUST BE VERIFIED (ENTERED TWICE) IF RU IS NOT A
STUDENT RU. IF CODE ‘4’ SELECTED AND RU IS NOT A STUDENT RU, DISPLAY THE
FOLLOWING MESSAGE: ‘UNLIKELY RESPONSE. VERIFY AND RE-ENTER.’
29
Closing (CL) Section
Beta
CL32OV1
Help Enabled (FARPERMISS2)
Variable Name
PLNK.PHPROB
Comment Enabled
Jump Back Enabled
Label
DESCRIPTION OF PROBLEM WHEN SIGNED-R3
Size
45
PROBLEM: _______________________
{CL33}
HELP AVAILABLE FOR MORE INFORMATION ON PHARMACY
AUTHORIZATION FORMS.
CL32OV2
Help Enabled (FARPERMISS2)
Variable Name
PLNK.PHSTATOS
Comment Enabled
Jump Back Enabled
Label
Size
45
OTHER SPECIFY STATUS OF PF - R3
OTHER SPECIFY: _______________________
{END_LP08}
HELP AVAILABLE FOR MORE INFORMATION ON PHARMACY
AUTHORIZATION FORMS.
30
Closing (CL) Section
Beta
CL33
Help Enabled
Variable Name
PLNK.PHFORMID
Comment Enabled
Jump Back Enabled
Label
Size
8
PERS-PHARM FORM NUMBER - R3
PID: [PID]
PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PHARMID: [PharmID-4]
PHARMACY NAME: [Pharmacy Name-35]
PHARMACY ADDRESS: [Street Address for Pharmacy]
[City Name], [ST] [Zip Code] [Telephone]
ENTER PHARMACY AUTHORIZATION FORM NUMBER:
FORM NUMBER: _______________________
{END_LP08}
PROGRAMMER NOTES:
EACH PHARMACY AUTHORIZATION FORM HAS A PRE-ASSIGNED PHARMACY
AUTHORIZATION FORM NUMBER.
Hard CHECK:
NUMBER ENTERED MUST BE 8 CHARACTERS LONG AND MUST BEGIN AND END WITH AN
ALPHA CHARACTER. THE FIRST ALPHA MUST BE R, S, Z, OR Y. THE FIRST NUMERIC
DIGIT (SECOND CHARACTER OF ENTRY) MUST BE 7, 8, OR 9. THE LAST ALPHA MUST
BE A, B, C, D, OR E.
31
Closing (CL) Section
Beta
CL34
Help Enabled
Variable Name
PLNK.PHREFUSE
Comment Enabled
Jump Back Enabled
Label
Size
2
REASON FOR REFUSAL - R3
SELECT MAIN REASON FOR REFUSAL:
PID: [PID]
PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PHARMID: [PharmID-4]
PHARMACY NAME: [Pharmacy Name-35]
PHARMACY ADDRESS: [Street Address for Pharmacy]
[City Name], [ST] [Zip Code] [Telephone]
DOESN'T WANT TO BOTHER
PHARMACY
CONFIDENTIALITY/SENSITIVE ISSUE
1
{END_LP08}
2
{END_LP08}
PAYMENT PROBLEM WITH PHARMACY
HAS ALREADY GIVEN ENOUGH
INFORMATION
3
4
{END_LP08}
{END_LP08}
WANTS MORE INFORMATION BEFORE
SIGNING
5
{END_LP08}
NOT INTERESTED
NO REASON GIVEN
6
7
{END_LP08}
{END_LP08}
OTHER
91
{CL34OV}
32
Closing (CL) Section
Beta
CL34OV
Help Enabled
Variable Name
PLNK.PHREFOS
Comment Enabled
Jump Back Enabled
Label
OTHER SPECIFY REASON FOR REFUSAL-R3
OTHER REASON _______________________
FOR REFUSAL:
Size
45
{END_LP08}
END_LP08
CYCLE ON NEXT PAIR ON THE RU-PERSON-PHARMACY-PAIRS-ROSTER THAT MEETS THE
CONDITIONS STATED IN THE LOOP DEFINITION.
IF NO OTHER PAIRS MEET THE STATED CONDITIONS, END LOOP_08 AND CONTINUE
WITH BOX_14
BOX_14
SUBSECTION 5:
SELF-ADMINISTERED QUESTIONNAIRE (ROUNDS 2-5)
IF ROUND 2 OR 4, CONTINUE WITH BOX_15
IF ROUND 3 OR 5, GO TO BOX_16
OTHERWISE, GO TO BOX_16A
33
Closing (CL) Section
Beta
BOX_15
IF ROUND 2 OR 4 AND AT LEAST ONE RU MEMBER ELIGIBLE FOR SAQ (I.E., AT
LEAST ONE CURRENT RU MEMBER WHO IS NOT DECEASED OR INSTITUTIONALIZED AND
IS IN THE RU AT THE ROUND 2 OR 4 INTERVIEW DATE AND IS 18 YEARS OF AGE OR
OLDER (OR IN AGE CATEGORIES 4-9) ON JULY 1, {YEAR}, WHERE 'YEAR' IS THE
FIRST CALENDAR YEAR OF THE PANEL, AND THE DATE OF THE INTERVIEW IF ROUND 2
OR ON JULY 1, {YEAR}, WHERE 'YEAR' IS THE SECOND CALENDAR YEAR OF THE
PANEL IF ROUND 4, OR HAS TURNED 18 BETWEEN JULY 1, {YEAR},WHERE 'YEAR' IS
THE FIRST CALENDAR YEAR OF THE PANEL, AND THE DATE OF THE INTERVIEW IF
ROUND 2, OR JULY 1, {YEAR}, WHERE 'YEAR' IS THE SECOND CALENDAR YEAR OF
THE PANEL AND THE DATE OF INTERVIEW IF ROUND 4, CONTINUE WITH CL35
OTHERWISE, GO TO CL41
NOTE: DETERMINING WHICH ADULTS IN THE RU RECEIVE AN SAQ AND WHICH ADULTS
ARE FOLLOWED-UP IN ROUND 3 OR 5 WILL BE BASED ONLY ON ROUND 2 OR 4
INFORMATION. THAT IS, NO RU MEMBERS ADDED IN ROUND 3 OR 5 WILL BE ASKED
TO COMPLETE AN SAQ.
34
Closing (CL) Section
Beta
CL35
Help Enabled (CL35Help)
Comment Enabled
Jump Back Enabled
Now I would like to ask (READ PERSON NAMES BELOW) to complete a brief
survey about health and health opinions.
[First Name, [Middle Name], Last Name]
[First Name, [Middle Name], Last Name]
[First Name, [Middle Name], Last Name]
[PID]
[PID]
[PID]
AS APPROPRIATE, PREPARE AN SAQ FOR EACH PERSON LISTED
ABOVE.
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
Roster Details
Title:
RU-Members_7
Col #
Header
Instructions
1
NAME
Display RU members’ first, middle, and last names
PERS.FULLNAME
2
PID
Display’s RU members’ 3-digit ID
PERS.PID
Roster Definition:
Display persons on the RU-Members_Roster for display only.
Roster Behavior:
1. Display only.
2. Select, edit, add, delete disallowed.
Roster Filter:
Display all persons who meet the following conditions:
- Person does not have a status of deceased or
institutionalized on Round 2 or 4 interview date
- Person currently in RU on Round 2 or 4 interview date
- Person is 18 years of age or older (or in age categories 49) on July 1, {YEAR},where 'year' is the first calendar year
of the panel, if Round 2, or on July 1, {YEAR}, where 'year'
is the second calendar year of the panel, and the interview
35
Closing (CL) Section
Beta
date if Round 4, or has turned 18 between July 1, {YEAR},
where 'year' is the first calendar year of the panel, and
the
date of the interview if Round 2 or July 1, {YEAR},where
'year' is the second calendar year of the panel if Round 4.
LOOP_09
FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK CL36 – END_LP09
LOOP DEFINITION: LOOP_09 COLLECTS THE SAQ STATUS FOR EACH PERSON ELIGIBLE
TO COMPLETE THE SAQ. THIS LOOP CYCLES ON EACH PERSON ON THE RU-MEMBERSROSTER WHO MEETS THE FOLLOWING CONDITIONS:
- PERSON DOES NOT HAVE A STATUS OF DECEASED OR INSTITUTIONALIZED ON ROUND
2 OR 4 INTERVIEW DATE
- PERSON CURRENTLY IN RU ON ROUND 2 OR 4 INTERVIEW
DATE
- PERSON IS 18 YEARS OF AGE OR OLDER (OR IN AGE CATEGORIES 4-9) ON JULY 1,
{YEAR}, WHERE 'YEAR' IS THE FIRST CALENDAR YEAR OF THE PANEL IF ROUND 2
OR ON JULY 1, {YEAR}, WHERE 'YEAR' IS THE SECOND CALENDAR YEAR OF THE
PANEL IF ROUND 4 OR HAS TURNED 18 BETWEEN JULY 1, {YEAR}, WHERE 'YEAR'
IS THE FIRST CALENDAR YEAR OF THE PANEL, AND THE DATE OF THE INTERVIEW
IF ROUND 2 OR JULY 1,{YEAR}, WHERE 'YEAR' IS THE SECOND CALENDAR YEAR
OF THE PANEL, AND THE DATE OF THE INTERVIEW IF ROUND 4.
36
Closing (CL) Section
Beta
CL36
Help Enabled
Comment Enabled
Jump Back Enabled
Variable Name
PRND.SAQSTAT
Label
CL36/CL39 STATUS OF SAQ QUESTIONNAIRE
Size
2
PRND.SAQCAPI
CL36-39 STATUS OF SAQ QUEX DURING CAPI
2
{PERSON’S FIRST MIDDLE AND LAST NAME}
PID: {PID}
COLLECT (PERSON)’S COMPLETED SAQ AND EXPLAIN THAT THEY
WILL RECEIVE $5.00 FOR EACH COMPLETED SAQ.
IF (PERSON) NOT AVAILABLE OR NOT ABLE TO COMPLETE SAQ AT
THIS TIME, LEAVE SAQ WITH (PERSON) OR RESPONDENT AND
EXPLAIN INSTRUCTIONS.
SELECT THE STATUS OF THE SAQ:
COMPLETED AND GIVEN TO
INTERVIEWER
1
{END_LP09}
NOT COMPLETED, WILL PICK UP AT
LATER DATE
NOT COMPLETED, WILL MAIL TO
OFFICE
2
{END_LP09}
3
{END_LP09}
MAILED TO SAQ RESPONDENT
REFUSED TO COMPLETE
4
5
{END_LP09}
{CL37}
OTHER
91
{CL37OV}
DISPLAY INSTRUCTIONS:
DISPLAY THE PERSON’S 3-DIGIT PID FOR 'PID'.
Soft CHECK:
CODE ‘4’ (MAILED TO SAQ RESPONDENT) MUST BE VERIFIED (ENTERED TWICE) IF RU
IS NOT A STUDENT RU. IF CODE ‘4’ SELECTED AND RU IS NOT A STUDENT RU,
DISPLAY THE FOLLOWING MESSAGE: ‘UNLIKELY RESPONSE. VERIFY AND RE-ENTER.’
37
Closing (CL) Section
Beta
CL36OV
Help Enabled
Variable Name
PRND.SAQSTOS
Comment Enabled
Jump Back Enabled
Label
OTHER SPECIFY STATUS OF SAQ
OTHER SPECIFY: _______________________
38
Size
45
{END_LP09}
Closing (CL) Section
Beta
CL37
Help Enabled
Variable Name
PRND.SAQREF
Comment Enabled
Jump Back Enabled
Label
Size
2
CL37-40 REASON FOR REFUSAL
{PERSON’S FIRST MIDDLE AND LAST NAME}
SELECT MAIN REASON FOR REFUSAL:
TOO BUSY/NOT INTERESTED
TOO PERSONAL/SENSITIVE
INFORMATION
1
2
{END_LP09}
{END_LP09}
TOO MUCH OF A PHYSICAL/MENTAL
HARDSHIP
HAS ALREADY GIVEN ENOUGH
INFORMATION
3
{END_LP09}
4
{END_LP09}
WANTS MORE INFORMATION
5
{END_LP09}
NOT INTERESTED
NO REASON GIVEN
6
7
{END_LP09}
{END_LP09}
OTHER
91
{CL37OV}
39
Closing (CL) Section
Beta
CL37OV
Help Enabled
Variable Name
PRND.SAQREFOS
Comment Enabled
Jump Back Enabled
Label
OTHER SPECIFY REASON FOR REFUSAL
OTHER REASON _______________________
FOR REFUSAL:
Size
45
{END_LP09}
END_LP09
CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER WHO MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION
IF NO OTHER PERSONS MEET THE STATED CONDITIONS, END LOOP_09 AND GO TO
BOX_16A
BOX_16
IF AT LEAST ONE PERSON WITH AN SAQ DISPOSITION OF ‘2’ (NOT COMPLETED, WILL
PICK UP AT LATER DATE), ‘3’ (NOT COMPLETED, WILL MAIL TO OFFICE), ‘4’
(MAILED TO SAQ RESPONDENT), ‘5’ (REFUSED TO COMPLETE SAQ), OR ‘91’ (OTHER)
RECORDED AT CL36 DURING ROUND 2 OR 4 AND NOT UPDATED BY RECEIPT CONTROL TO
‘1’ (COMPLETE), ‘2’ (PARTIAL COMPLETE), ‘4’ (PROBLEM), OR ‘6’ (WRONG SAQ
TYPE) ((I.E., RECEIPT CONTROL IS EQUAL TO ‘3’ (REFUSED) OR ‘5’ (NOT
HERE/BLANK)), CONTINUE WITH CL38
OTHERWISE, GO TO BOX_16A
40
Closing (CL) Section
Beta
CL38
Help Enabled (CL38Help)
Comment Enabled
Jump Back Enabled
Variable Name
PRND.SAQSTAT
Label
CL36/CL39 STATUS OF SAQ QUESTIONNAIRE
Size
2
PRND.RCFLG
PERS.SAQAGE1
MAPPING SAQ RC CODES BACK TO CAPI
SAQ AGE OF RU MEMBER - 1ST PERIOD
2
3
PERS.SAQAGE2
SAQ AGE OF RU MEMBER - 2ND PERIOD
3
During the last interview a short survey about health and health opinions was
left with (READ PERSON NAMES BELOW) to complete.
I would like to check to see if I could pick these surveys up or if they were
already mailed back to the home office.}
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[PID]
[PID]
[PID]
1. COLLECT SAQs, IF AVAILABLE.
2. IF ANY REPORTED AS LOST, RE-DISTRIBUTE APPROPRIATE
NUMBER AND TYPE OF SAQs TO THE RESPONDENT.
Roster Details
Title:
RU-Members_7
Col #
Header
Instructions
1
NAME
Display RU members’ first, middle, and last names
PERS.FULLNAME
2
PID
Display’s RU members’ 3-digit ID
PERS.PID
Roster Definition:
Display persons on the RU-Members_Roster for display only.
Roster Behavior:
41
Closing (CL) Section
Beta
1. Display only.
2. Select, edit, add, delete disallowed.
Roster Filter:
Display all persons on the RU Members-Roster who meet the
following conditions:
- Person did not have a status of deceased or
institutionalized on Round 2 or 4 interview date
- Person was currently in RU on Round 2 or 4 interview date
- Person is 18 years of age or older (or in age categories 49) on July 1, {YEAR},where 'year' is the first calendar year
of the panel, if Round 2, or on July 1, {YEAR}, where 'year'
is the second calendar year of the panel, and the interview
date if Round 4, or has turned 18 between July 1, {YEAR},
where 'year' is the first calendar year of the panel, and
the
date of the interview if Round 2 or July 1, {YEAR},where
'year' is the second calendar year of the panel if Round 4.
- CL36 was coded ‘1’ (COMPLETED AND GIVEN TO INTERVIEWER), ‘2’
(NOT COMPLETED, WILL PICK UP AT LATER DATE), ‘3’ (NOT
COMPLETED, WILL MAIL TO OFFICE),‘4’ (MAILED TO SAQ
RESPONDENT), ‘5’ (REFUSED TO COMPLETE SAQ), or ‘91’ (OTHER)
during Round 2 or 4 for person and not updated by receipt
control to ‘1’ (COMPLETE), ‘2’
(PARTIAL COMPLETE), ‘4’
(PROBLEM),
or ‘6’ (WRONG SAQ TYPE) ((I.E., receipt control is equal to
‘3’ (REFUSED)
or ‘5’ (NOT HERE/BLANK))
LOOP_10
FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK CL39 - END_LP10
LOOP DEFINITION: LOOP_10 COLLECTS THE SAQ STATUS FOR EACH PERSON ELIGIBLE
TO COMPLETE THE SAQ. THIS LOOP CYCLES ON EACH PERSON ON THE RU-MEMBERSROSTER WHO MEETS THE FOLLOWING CONDITIONS:
- PERSON DID NOT HAVE A STATUS OF DECEASED OR INSTITUTIONALIZED ON ROUND 2
OR 4 INTERVIEW DATE
- PERSON WAS CURRENTLY IN RU ON ROUND 2 OR 4 INTERVIEW DATE
- PERSON IS 18 YEARS OF AGE OR OLDER (OR IN AGE CATEGORIES 4-9) ON JULY 1,
{YEAR}, WHERE 'YEAR' IS THE FIRST CALENDAR YEAR OF THE PANEL IF ROUND 2
OR ON JULY 1, {YEAR}, WHERE 'YEAR' IS THE SECOND CALENDAR YEAR OF THE
PANEL IF ROUND 4 OR HAS TURNED 18 BETWEEN JULY 1, {YEAR}, WHERE 'YEAR'
IS THE FIRST CALENDAR YEAR OF THE PANEL, AND THE DATE OF THE INTERVIEW
IF ROUND 2 OR JULY 1,{YEAR}, WHERE 'YEAR' IS THE SECOND CALENDAR YEAR
OF THE PANEL, AND THE DATE OF THE INTERVIEW IF ROUND 4.
- CL36 WAS CODED ‘1’ (COMPLETED AND GIVEN TO INTERVIEWER), ‘2’ (NOT
COMPLETED, WILL PICK UP AT LATER DATE), ‘3’ (NOT COMPLETED, WILL MAIL
TO OFFICE),‘4’ (MAILED TO SAQ RESPONDENT), ‘5’ (REFUSED TO COMPLETE
SAQ), OR ‘91’ (OTHER) DURING ROUND 2 OR 4 FOR PERSON AND NOT
UPDATED BY RECEIPT CONTROL TO ‘1’ (COMPLETE), ‘2’ (PARTIAL COMPLETE),
‘4’ (PROBLEM), OR ‘6’ (WRONG SAQ TYPE) ((I.E., RECEIPT CONTROL IS
EQUAL TO ‘3’ (REFUSED) OR ‘5’ (NOT HERE/BLANK))
42
Closing (CL) Section
Beta
CL39
Help Enabled
Comment Enabled
Jump Back Enabled
Variable Name
PRND.SAQSTAT
Label
CL36/CL39 STATUS OF SAQ QUESTIONNAIRE
Size
2
PRND.SAQCAPI
CL36-39 STATUS OF SAQ QUEX DURING CAPI
2
{PERSON’S FIRST MIDDLE AND LAST NAME}
PID: {PID}
SAQ STATUS FROM PREVIOUS ROUND: {PREVIOUS ROUND STATUS}
COLLECT (PERSON)'s COMPLETED SAQ AND EXPLAIN THAT THEY
WILL RECEIVE $5.00 FOR EACH COMPLETED SAQ.
SELECT THE STATUS OF THE SAQ:
COMPLETED AND GIVEN TO
INTERVIEWER
NOT COMPLETED, WILL PICK UP AT
LATER DATE
1
{END_LP10}
2
{END_LP10}
NOT COMPLETED, WILL MAIL TO
OFFICE
3
{END_LP10}
ALREADY MAILED TO HOME OFFICE
REFUSED TO COMPLETE
4
5
{END_LP10}
{CL40}
OTHER
91
{CL39OV}
DISPLAY INSTRUCTIONS:
DISPLAY THE PERSON’S 3-DIGIT PID FOR 'PID'.
DISPLAY ‘SAQ STATUS FROM PREVIOUS ROUND’ {PREVIOUS ROUND
STATUS}: OTHERWISE, USE A NULL DISPLAY.
FOR ‘PREVIOUS ROUND STATUS’, DISPLAY THE TEXT ASSOCIATED WITH
THE ROUND 2 OR 4 (OR RECEIPT CONTROL UPDATED STATUS) STATUS
ENTERED AT CL36. OTHERWISE, USE A NULL DISPLAY.
43
Closing (CL) Section
Beta
CL39OV
Help Enabled
Variable Name
PRND.SAQSTOS
Comment Enabled
Jump Back Enabled
Label
OTHER SPECIFY STATUS OF SAQ
OTHER SPECIFY: _______________________
44
Size
45
{END_LP10}
Closing (CL) Section
Beta
CL40
Help Enabled
Variable Name
PRND.SAQREF
Comment Enabled
Jump Back Enabled
Label
Size
2
CL37-40 REASON FOR REFUSAL
{PERSON’S FIRST MIDDLE AND LAST NAME}
SELECT MAIN REASON FOR REFUSAL:
TOO BUSY/NOT INTERESTED
TOO PERSONAL/SENSITIVE
INFORMATION
1
2
{END_LP10}
{END_LP10}
TOO MUCH OF A PHYSICAL/MENTAL
HARDSHIP
HAS ALREADY GIVEN ENOUGH
INFORMATION
3
{END_LP10}
4
{END_LP10}
WANTS MORE INFORMATION
5
{END_LP10}
NOT INTERESTED
NO REASON GIVEN
6
7
{END_LP10}
{END_LP10}
OTHER
91
{CL40OV}
45
Closing (CL) Section
Beta
CL40OV
Help Enabled
Variable Name
PRND.SAQREFOS
Comment Enabled
Jump Back Enabled
Label
OTHER SPECIFY REASON FOR REFUSAL
OTHER REASON _______________________
FOR REFUSAL:
Size
45
{END_LP10}
END_LP10
CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER WHO MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION
IF NO OTHER PERSONS MEET THE STATED CONDITIONS, END LOOP_10 AND CONTINUE
WITH BOX_16A
BOX_16A
SUBSECTION 5A:
5 ONLY)
DIABETES CARE SUPPLEMENT (DCS) QUESTIONNAIRE (ROUNDS 3 AND
IF ROUND 3 OR 5, CONTINUE WITH BOX_16B
OTHERWISE, GO TO CL41
BOX_16B
IF ROUND 3 OR 5 AND AT LEAST ONE RU MEMBER ELIGIBLE FOR DIABETES CARE
SUPPLEMENT (I.E., AT LEAST ONE RU MEMBER WHO IS CONFIRMED AS HAVING
DIABETES AT PC02A, CONTINUE WITH CL40A
OTHERWISE, GO TO CL41
46
Closing (CL) Section
Beta
CL40A
Help Enabled
Comment Enabled
Variable Name
PRND.DIABRESP
TYPE OF SAQ DISTRIBUTED
PRND.PCDIABET
PERSON HAS DIABETES
Jump Back Enabled
Label
Size
2
2
SELF DIABETES CARE SUPPLEMENT (DCS):
Earlier we asked (READ SELF NAMES BELOW) to complete a few questions
about the care received for diabetes.
PROXY DCS:
Earlier we asked that someone knowledgeable about (READ PROXY NAMES
BELOW) diabetes complete a few questions about the care received.
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[PID] {SELF/PROXY}
[PID] {SELF/PROXY}
[PID] {SELF/PROXY}
AS APPROPRIATE COLLECT A DCS FOR EACH PERSON LISTED ABOVE.
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
DISPLAY INSTRUCTIONS:
DISPLAY THE ROW PERSON’S PID FOR 'PID.'
DISPLAY THE TYPE OF DCS FOR THE PERSON FOR 'SELF/PROXY.' IF
PC03 FOR THE ROW PERSON IS CODED ‘1’ (SELF), DISPLAY ‘SELF.’
IF PC03 FOR THE ROW PERSON IS CODED ‘2’ (PROXY), DISPLAY
‘PROXY.’
Roster Details
Title:
RU-Members_7
47
Closing (CL) Section
Beta
Col #
Header
Instructions
1
NAME
Display RU members’ first, middle, and last names
PERS.FULLNAME
2
PID
Display’s RU members’ 3-digit ID
PERS.PID
Roster Definition:
Display all persons on the RU_Members_Roster for display only.
Roster Behavior:
1. Display only.
2. Select, add, edit delete disallowed.
Roster Filter:
Display all persons who meet the following condition:
- PC02 is coded ‘1’ (YES) for the person
LOOP_10A
FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK CL40B – END_LP10A
LOOP DEFINITION: LOOP_10A COLLECTS THE DCS STATUS FOR EACH PERSON
ELIGIBLE TO COMPLETE THE DCS. THIS LOOP CYCLES ON EACH PERSON ON THE RUMEMBERS-ROSTER WHO MEETS THE FOLLOWING CONDITION:
- PC02 IS CODED ‘1’ (YES) FOR THE PERSON
48
Closing (CL) Section
Beta
CL40B
Help Enabled
Comment Enabled
Jump Back Enabled
Variable Name
PRND.DSAQCAPI
Label
STATUS OF DIABETES SAQ QUESTIONNAIRE
Size
2
PRND.DSAQSTAT
STATUS OF DIABETES SAQ QUESTINONAIRE
2
{PERSON’S FIRST MIDDLE AND LAST NAME}
PID: {PID}
TYPE OF DCS: {SELF/PROXY}
COLLECT (PERSON)’S COMPLETED DIABETES CARE SUPPLEMENT.
IF (PERSON) NOT AVAILABLE OR NOT ABLE TO COMPLETE DCS AT
THIS TIME, LEAVE DCS WITH (PERSON) OR RESPONDENT AND
EXPLAIN INSTRUCTIONS.
ENTER THE STATUS OF THE DCS:
COMPLETED AND GIVEN TO
INTERVIEWER
1
{END_LP10A}
NOT COMPLETED, WILL PICK UP AT
LATER DATE
NOT COMPLETED, WILL MAIL TO
OFFICE
2
{END_LP10A}
3
{END_LP10A}
MAILED TO DCS RESPONDENT
REFUSED TO COMPLETE
4
5
{END_LP10A}
{CL40C}
OTHER
91
{CL40BOV}
DISPLAY INSTRUCTIONS:
DISPLAY THE PERSON’S 3 DIGIT PID FOR 'PID'.
FOR 'SELF PROXY',DISPLAY ‘SELF’ IF THE PERSON BEING LOOPED ON
IS CODED ‘1’ (SELF) AT PC03. DISPLAY ‘PROXY’ IF THE PERSON
BEING LOOPED ON IS CODED ‘2’ (PROXY) AT PC03.
Soft CHECK:
CODE ‘4’ (MAILED TO DCS RESPONDENT) MUST BE VERIFIED (ENTERED TWICE) IF RU
IS NOT A STUDENT RU. IF CODE ‘4’ SELECTED AND RU IS NOT A STUDENT RU,
DISPLAY THE FOLLOWING MESSAGE: ‘UNLIKELY RESPONSE. VERIFY AND RE-ENTER.’
49
Closing (CL) Section
Beta
CL40BOV
Help Enabled
Variable Name
PRND.DSAQSTOS
Comment Enabled
Jump Back Enabled
Label
OTHER SPECIFY STATUS OF DIABETES SAQ
OTHER SPECIFY: _______________________
50
Size
45
{END_LP10A}
Closing (CL) Section
Beta
CL40C
Help Enabled
Variable Name
PRND.DSAQREF
Comment Enabled
Jump Back Enabled
Label
DIABETES SAQ REASON FOR REFUSAL
Size
2
{PERSON’S FIRST MIDDLE AND LAST NAME}
SELECT MAIN REASON FOR REFUSAL:
TOO BUSY/NOT INTERESTED
TOO PERSONAL/SENSITIVE
INFORMATION
1
2
{END_LP10A}
{END_LP10A}
TOO MUCH OF A PHYSICAL/MENTAL
HARDSHIP
HAS ALREADY GIVEN ENOUGH
INFORMATION
3
{END_LP10A}
4
{END_LP10A}
WANTS MORE INFORMATION
5
{END_LP10A}
NOT INTERESTED
NO REASON GIVEN
6
7
{END_LP10A}
{END_LP10A}
OTHER
91
{CL40COV}
51
Closing (CL) Section
Beta
CL40COV
Help Enabled
Variable Name
PRND.DSAQRFOS
Comment Enabled
Jump Back Enabled
Label
OTH SPECIFY DIAB SAQ REASON FOR REFUSAL
Size
45
OTHER REASON _______________________
FOR REFUSAL:
END_LP10A
CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER WHO MEETS THE CONDITION
STATED IN THE LOOP DEFINITION
IF NO OTHER PERSONS MEET THE STATED CONDITION, END LOOP_10A AND GO TO CL41
CL41 BEGINS SUBSECTION 6:
1 THORUGH ROUND 5)
COLLECTING/UPDATING LOCATING INFORMATION (ROUND
52
Closing (CL) Section
Beta
CL41
Help Enabled
Comment Enabled
Jump Back Enabled
{Thank you for your cooperation and for taking the time to participate in this
important study.}
{In the coming months, we will be contacting this family again to collect
information on health care use and expenses./We are nearing the end of this
study. I'd like to thank you for your participation in this important study. Just
in case my supervisor needs to reach you to verify that I was here and
collected this information correctly, I'd like to verify a few pieces of
information.}
{Just to make sure I can reach you for the next interview, I’d like to ask a few
questions about how to find the family./Let me quickly review and update the
information we have for locating the family that was collected during the last
interview.}
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
DISPLAY INSTRUCTIONS:
DISPLAY ‘Thank you ... important study’ IF ROUNDS 1, 2, 3, OR
4. OTHERWISE, USE A NULL DISPLAY.
DISPLAY ‘In the coming months, ... use and expenses.’ IF
ROUNDS 1, 2, 3, OR 4. OTHERWISE, DISPLAY We are nearing ...
pieces of information.’
DISPLAY ‘Just ... family.’ IF ROUND 1.
‘Let ... interview.’
OTHERWISE, DISPLAY
ROUTING INSTRUCTION:
IF NOT ROUND 5, CONTINUE WITH CL42
OTHERWISE (I.E., IF ROUND 5), GO TO BOX_17
53
Closing (CL) Section
Beta
CL42
Help Enabled
Comment Enabled
Jump Back Enabled
Variable Name
INFO.INFOID
INFO ID KEY: HOMEID + COUNTER(2)
Label
Size
10
INFO.CREATEQ
INFO.INFORURN
CREATION STAMP
ROUND STAMP: RU LETTER + ROUND NUMBER
2
2
INFO.BESTTIM1
INFO.BESTTIM2
BEST TIME TO REACH RESPONDENT
BEST TIME TO REACH RESPONDENT
45
45
INFO.BESTTIM3
BEST TIME TO REACH RESPONDENT
45
INFO.BESTTIM4
BEST TIME TO REACH RESPONDENT
45
What is the best time of day and day of the week to get in touch with you?
ENTER BEST TIME TO CONTACT RESPONDENT/PROXY.
TEXT: _______________________
{CL42OV1}
PROGRAMMER NOTES:
FOUR LINES OF 45 CHARACTERS SHOULD BE AVAILABLE FOR ENTRY OF
FREE FORM TEXT.
54
Closing (CL) Section
Beta
CL42OV1
Help Enabled
Variable Name
INFO.WHOBESTM
Comment Enabled
Jump Back Enabled
Label
Size
2
WHO BEST TIME RECORDED FOR
SELECT WHO BEST TIME RECORDED FOR:
CURRENT RESPONDENT
CURRENT PROXY
1
2
{BOX_17}
{BOX_17}
ENTIRE RU
3
{BOX_17}
OTHER
91
{CL42OV2}
CL42OV2
Help Enabled
Variable Name
INFO.WHOBSTOS
Comment Enabled
Jump Back Enabled
Label
OTHER WHO BEST TIME RECORDED FOR
OTHER SPECIFY: _______________________
55
Size
25
{BOX_17}
Closing (CL) Section
Beta
BOX_17
IF NO CURRENT RU MEMBER PART OF THE RU ON THE CURRENT INTERVIEW DATE
(I.E., ALL RU MEMBERS DECEASED, INSTITUTIONALIZED, OR OUT OF THE COUNTRY
ON CURRENT INTERVIEW DATE), GO TO BOX_18
OTHERWISE, CONTINUE WITH CL43
56
Closing (CL) Section
Beta
CL43
Help Enabled
Variable Name
HOME.OTHPHONE
Comment Enabled
Jump Back Enabled
Label
OTHER PHONE WHERE CAN BE REACHED
Size
2
ITEM: SECOND PHONE (WORK, FRIEND, RELATIVE, OTHER) WHERE
FAMILY COULD BE REACHED.
INTERVIEWER: IF AVAILABLE, VERIFY CURRENT SECOND PHONE
SHOWN BELOW. IF NO CURRENT INFORMATION, PROBE:
DO YOU HAVE A SECOND PHONE NUMBER WHERE YOU CAN BE
REACHED, SUCH AS A WORK NUMBER, THE NUMBER OF A FRIEND OR
RELATIVE?
CURRENT INFO: [2ND TELEPHONE]
ENTER NEW SECOND PHONE
1
{CL44}
SECOND PHONE CORRECT
SECOND PHONE NEEDS CORRECTION
2
3
{CL46}
{CL44}
NO CURRENT SECOND PHONE
4
{CL46}
----------------------------------------------------------------------------------------------------------------------------------
Refused
Don't Know
RF
DK
{CL46}
{CL46}
PROGRAMMER NOTES:
ASSUMPTION: THE QUESTIONS IN CLOSING IN WHICH CONTACT AND
LOCATING INFORMATION IS PRE-RECORDED IN CAPI (CL43-CL64) ARE
SPECIFIED WITH THE FOLLOWING BASIC ASSUMPTIONS:
1. LOCATING AND CONTACTING INFORMATION WILL NOT BE WRITTEN
OVER FROM ROUND TO ROUND.
2. ONLY THE MOST CURRENT INFORMATION WILL APPEAR IN THE TEXT
OF THESE QUESTIONS AND NO HISTORY OF CONTACT AND LOCATING
INFORMATION WILL APPEAR ON THE CAPI SCREEN FOR THE
INTERVIEWER.
3. IF INFORMATION STAYS THE SAME, IT WILL BE CARRIED FORWARD.
4. WHETHER OR NOT PREVIOUS ROUND’S INFORMATION OR ANY CONTACT
HISTORY WILL BE PRINTED ON THE FACE SHEET FOR ANY OF THE
CONTACTING AND LOCATING QUESTIONS IS STILL NOT KNOWN.
57
Closing (CL) Section
Beta
Hard CHECK:
CODES ‘2’ (SECOND PHONE CORRECT) AND ‘3’ (SECOND PHONE NEEDS CORRECTION)
CANNOT BE SELECTED IF NO CURRENT SECOND PHONE INFORMATION AVAILABLE. IF
CODES ‘2’ OR ‘3’ SELECTED WHEN NO CURRENT SECOND PHONE, DISPLAY THE
FOLLOWING MESSAGE: ‘CODE NOT AVAILABLE. NO CURRENT SECOND PHONE. VERIFY
AND RE-ENTER.’
58
Closing (CL) Section
Beta
CL44
Help Enabled
Comment Enabled
Jump Back Enabled
Variable Name
HOME.OTHPAREA
Label
OTH PHONE WHERE CAN BE REACHED-AREA CODE
Size
3
HOME.OTHPEXCH
HOME.OTHPLOCL
OTH PHONE WHERE CAN BE REACHED-EXCHANGE
OTH PHONE WHERE CAN BE REACHED-LOCAL
3
4
[What is that telephone number?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT SECOND PHONE.
IF UNAVAILABLE, ENTER COMPLETE SECOND TELEPHONE NUMBER.
TO VERIFY CURRENT INFORMATION ENTER ALL ZEROES. TO
CORRECT OR ENTER INFORMATION, TYPE ENTIRE FIELD.
CURRENTINFO: [2ND _TELEPHONE]
AREA CODE: _______________________
EXCHANGE: _______________________
LOCAL: _______________________
{CL45}
----------------------------------------------------------------------------------------------------------------------------------
Refused
Don't Know
RF
DK
{CL45}
{CL45}
PROGRAMMER NOTES:
FLAG SECOND PHONE INFORMATION FOR THE RU WITH THE NUMBER
ENTERED OR CORRECTED AT CL44 FOR THE CURRENT ROUND.
Hard CHECK:
DISALLOW LEADING ZEROS AS AN ENTRY.
IF NO CURRENT SECOND PHONE AVAILABLE, AN ENTRY MUST BE MADE FOR EVERY FIELD
(REF AND DK ARE ALLOWED).
IF CURRENT SECOND PHONE AVAILABLE, AT LEAST ONE FIELD MUST BE UPDATED.
59
Closing (CL) Section
Beta
CL45
Help Enabled
Variable Name
HOME.OTHPHLOC
Comment Enabled
Jump Back Enabled
Label
WHERE IS OTHER TELEPHONE LOCATED
Size
2
Where is that telephone located?
OFFICE/PLACE OF BUSINESS
1
{CL45OV2}
RELATIVE
NEIGHBOR
2
3
{CL45OV2}
{CL45OV2}
FRIEND
4
{CL45OV2}
OTHER SPECIFY
91
{CL45OV1}
----------------------------------------------------------------------------------------------------------------------------------
Refused
Don't Know
RF
DK
60
{CL45OV2}
{CL45OV2}
Closing (CL) Section
Beta
CL45OV1
Help Enabled
Variable Name
HOME.OTHPHLOS
Comment Enabled
Jump Back Enabled
Label
Size
45
OTHER LOCATION-SPECIFY
OTHER SPECIFY: _______________________
{CL45OV2}
----------------------------------------------------------------------------------------------------------------------------------
Refused
Don't Know
RF
DK
61
{CL45OV2}
{CL45OV2}
Closing (CL) Section
Beta
CL45OV2
Help Enabled
Comment Enabled
Jump Back Enabled
Variable Name
HOME.OTHPNAM1
NAME OF OTHER PHONE LOCATION-1
Label
Size
45
HOME.OTHPNAM2
NAME OF OTHER PHONE LOCATION-2
45
What is the name of that location?
ENTER NAME AND/OR DESCRIPTION. ALSO, INCLUDE ANY SPECIAL
INSTRUCTIONS FOR CALLING AT THE ALTERNATE TELEPHONE
NUMBER (FOR EXAMPLE, CALL ONLY IN EMERGENCY).
DESCRIPTION: _______________________
{CL46}
----------------------------------------------------------------------------------------------------------------------------------
Refused
RF
{CL46}
Don't Know
DK
{CL46}
PROGRAMMER NOTES:
ALLOW 2 LINES OF 45 CHARACTERS FOR DESCRIPTION.
62
Closing (CL) Section
Beta
CL46
Help Enabled
Variable Name
HOME.MAILADDR
Comment Enabled
Jump Back Enabled
Label
Size
2
SEPARATE MAILING ADDRESS
ITEM: MAILING ADDRESS DIFFERENT FROM LOCATING (STREET)
ADDRESS.
INTERVIEWER: IF AVAILABLE, VERIFY CURRENT MAILING ADDRESS
SHOWN BELOW.
IF NO CURRENT INFORMATION, PROBE: DO YOU HAVE A MAILING
ADDRESS THAT IS DIFFERENT FROM YOUR PHYSICAL ADDRESS,
SUCH AS A P.O. BOX?
CURRENT INFO:
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY]
[STATE]
[ZIP CODE]
ENTER NEW MAILING ADDRESS
MAILING ADDRESS CORRECT
1
2
{CL47}
{BOX_17A}
MAILING ADDRESS NEEDS
CORRECTION
NO CURRENT MAILING ADDRESS
3
{CL47}
4
{BOX_17A}
----------------------------------------------------------------------------------------------------------------------------------
Refused
Don't Know
RF
DK
{BOX_17A}
{BOX_17A}
Hard CHECK:
CODES ‘2’ (MAILING ADDRESS CORRECT) AND ‘3’ (MAILING ADDRESS NEEDS
CORRECTION) CANNOT BE SELECTED IF NO CURRENT MAILING ADDRESS INFORMATION
AVAILABLE. IF CODES ‘2’ OR ‘3’ SELECTED WHEN NO CURRENT MAILING ADDRESS,
DISPLAY THE FOLLOWING MESSAGE: ‘CODE NOT AVAILABLE. NO CURRENT MAILING
ADDRESS. VERIFY AND RE-ENTER.’
63
Closing (CL) Section
Beta
CL47
Help Enabled (STATE)
Comment Enabled
Jump Back Enabled
Variable Name
HOME.MAILSTR1
MAILING STREET ADDRESS
Label
Size
30
HOME.MAILSTR2
HOME.MAILCITY
MAILING STREET ADDRESS 2
MAILING CITY
30
20
HOME.MAILST
HOME.MAILZIP
MAILING STATE
MAILING ZIP CODE
2
5
[What is that address?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT MAILING ADDRESS.
IF UNAVAILABLE, ENTER COMPLETE MAILING ADDRESS.
TO VERIFY CURRENT INFORMATION ENTER 'NU'. TO CORRECT OR
ENTER INFORMATION, TYPE ENTIRE FIELD.
CURRENT INFO:
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
1ST_STR_ADDRESS: _______________________
2ND_STR_ADDRESS: _______________________
CITY: _______________________
STATE: _______________________
ZIP CODE: _______________________
{BOX_17A}
USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.
Hard CHECK:
IF NO CURRENT MAILING ADDRESS AVAILABLE, AN ENTRY MUST BE MADE FOR EVERY
FIELD EXCEPT SECOND STREET ADDRESS (REF AND DK ARE ALLOWED).
IF CURRENT MAILING ADDRESS AVAILABLE, AT LEAST ONE FIELD MUST BE UPDATED.
64
Closing (CL) Section
Beta
BOX_17A
IF NOT ROUND 5, CONTINUE WITH CL48
OTHERWISE (I.E., IF ROUND 5), GO TO CL62
65
Closing (CL) Section
Beta
CL48
Help Enabled
Variable Name
HOME.SECNHOME
Comment Enabled
Jump Back Enabled
Label
Size
2
HAVE ANOTHER/VACATION HOME
ITEM: ANOTHER HOME SUCH AS SECOND HOME OR VACATION
HOME WHERE FAMILY CAN SOMETIMES BE CONTACTED.
INTERVIEWER: IF AVAILABLE, VERIFY CURRENT SECOND HOME
INFORMATION SHOWN BELOW.
IF NO CURRENT INFORMATION, PROBE: DO YOU HAVE A SECOND
HOME, SUCH AS A VACATION HOME WHERE WE COULD CONTACT
YOU IF YOU ARE NOT AVAILABLE AT YOUR USUAL ADDRESS?
CURRENT INFO:
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
ENTER NEW SECOND HOME ADDRESS
AND TELEPHONE
SECOND HOME ADDRESS AND
TELEPHONE CORRECT
1
{CL49}
2
{CL50}
SECOND HOME ADDRESS OR
TELEPHONE NEEDS CORRECTION
3
{CL49}
NO CURRENT SECOND HOME
4
{CL50}
----------------------------------------------------------------------------------------------------------------------------------
Refused
Don't Know
RF
DK
{CL50}
{CL50}
Hard CHECK:
CODES ‘2’ (SECOND HOME ADDRESS AND TELEPHONE CORRECT) AND ‘3’ (SECOND HOME
ADDRESS OR TELEPHONE NEEDS CORRECTION) CANNOT BE SELECTED IF NO CURRENT
SECOND HOME ADDRESS INFORMATION AVAILABLE. IF CODES ‘2’ OR ‘3’ SELECTED
WHEN NO CURRENT SECOND HOME ADDRESS, DISPLAY THE FOLLOWING MESSAGE: ‘CODE
66
NOT AVAILABLE.
Closing (CL) Section
Beta
NO CURRENT SECOND HOME ADDRESS. VERIFY AND RE-ENTER.’
67
Closing (CL) Section
Beta
CL49
Help Enabled (STATE)
Comment Enabled
Jump Back Enabled
Variable Name
HOME.SECNSTR1
SECOND HOME STREET ADDRESS
Label
Size
30
HOME.SECNSTR2
HOME.SECNCITY
SECOND HOME STREET ADDRESS 2
SECOND HOME CITY
30
20
HOME.SECNST
HOME.SECNZIP
SECOND HOME STATE
SECOND HOME ZIP CODE
2
5
HOME.SECNAREA
2ND HOME WHERE CAN CONTACT-AREA CODE
3
HOME.SECNEXCH
HOME.SECNLOCL
2ND HOME WHERE CAN CONTACT-EXCHANGE
2ND HOME WHERE CAN CONTACT-LOCAL
3
4
[What is the address and phone number of that home?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT SECOND HOME
ADDRESS.
IF UNAVAILABLE, ENTER COMPLETE SECOND HOME ADDRESS.
TO VERIFY CURRENT ADDRESS ENTER 'NU'. TO VERIFY CURRENT
PHONE ENTER ALL ZEROES. TO CORRECT OR ENTER INFORMATION,
TYPE ENTIRE FIELD.
CURRENT INFO:
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
1ST STR ADDRESS: _______________________
2ND STR ADDRESS: _______________________
CITY: _______________________
STATE: _______________________
ZIP CODE: _______________________
TELEPHONE: _______________________
{CL50}
USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.
68
Closing (CL) Section
Beta
Hard CHECK:
IF NO CURRENT SECOND HOME ADDRESS AVAILABLE, AN ENTRY MUST BE MADE FOR EVERY
FIELD EXCEPT SECOND STREET ADDRESS (REF AND DK ARE ALLOWED).
IF CURRENT SECOND HOME ADDRESS AVAILABLE, AT LEAST ONE FIELD MUST BE UPDATED.
69
Closing (CL) Section
Beta
CL50
Help Enabled
Variable Name
HOME.CONTPERS
Comment Enabled
Jump Back Enabled
Label
Size
2
CONTACT PERS TO LOCATE FAMILY
ITEM: LOCATING CONTACT - RELATIVE OR FRIEND WHO DOES NOT
LIVE HERE WHO WILL ALWAYS KNOW HOW TO GET IN TOUCH
WITH FAMILY.
INTERVIEWER: IF AVAILABLE, VERIFY CURRENT CONTACT
INFORMATION SHOWN BELOW.
IF NO CURRENT INFORMATION, PROBE: DO YOU HAVE A FRIEND OR
RELATIVE WHO DOES NOT LIVE HERE WHO WILL ALWAYS KNOW HOW
TO GET IN TOUCH WITH THE FAMILY?
CURRENT INFO:
[CONTACT_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
ENTER NEW CONTACT
PERSON/ADDRESS
CONTACT PERSON/ADDRESS
CORRECT
1
{CL51}
2
{CL52}
CONTACT PERSON/ADDRESS NEEDS
CORRECTION
NO CURRENT CONTACT PERSON
3
{CL51}
4
{CL53}
----------------------------------------------------------------------------------------------------------------------------------
Refused
Don't Know
RF
DK
{CL53}
{CL53}
Hard CHECK:
CODES ‘2’ (CONTACT PERSON/ADDRESS CORRECT) AND ‘3’ (CONTACT PERSON/ADDRESS
NEEDS CORRECTION) CANNOT BE SELECTED IF NO CURRENT CONTACT PERSON
INFORMATION AVAILABLE. IF CODES ‘2’ OR ‘3’ SELECTED WHEN NO CURRENT CONTACT
70
Closing (CL) Section
Beta
INFORMATION, DISPLAY THE FOLLOWING MESSAGE: ‘CODE NOT AVAILABLE. NO
CURRENT CONTACT INFORMATION. VERIFY AND RE-ENTER.’
71
Closing (CL) Section
Beta
CL51
Help Enabled (STATE)
Comment Enabled
Jump Back Enabled
Variable Name
HOME.CONTFNAM
CONTACT PERSON - FIRST NAME
Label
Size
20
HOME.CONTMNAM
HOME.CONTLNAM
CONTACT PERSON - MIDDLE NAME
CONTACT PERSON - LAST NAME
20
25
HOME.CONTSTR1
HOME.CONTSTR2
CONTACT PERSON - STREET ADDRESS
CONTACT PERSON - STREET ADDRESS 2
30
30
HOME.CONTCITY
CONTACT PERSON - CITY
20
HOME.CONTST
HOME.CONTZIP
CONTACT PERSON - STATE
CONTACT PERSON - ZIP CODE
2
5
HOME.CONTAREA
CONTACT PERSON - AREA CODE
3
HOME.CONTEXCH
HOME.CONTLOCL
CONTACT PERSON - EXCHANGE
CONTACT PERSON - LOCAL
3
4
[What is the name, address, and phone number of that person?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT CONTACT
INFORMATION.
IF UNAVAILABLE, ENTER COMPLETE CONTACT INFORMATION.
TO VERIFY CURRENT ADDRESS ENTER 'NU'. TO VERIFY CURRENT
PHONE ENTER ALL ZEROES. TO CORRECT OR ENTER INFORMATION,
TYPE ENTIRE FIELD.
ENTER ‘NMN’ IF NO MIDDLE NAME.
CURRENT INFO:
[CONTACT_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
CONTACT_NAME: _______________________
1ST STR ADDRESS: _______________________
2ND STR ADDRESS: _______________________
CITY: _______________________
STATE: _______________________
ZIP CODE: _______________________
72
Closing (CL) Section
Beta
TELEPHONE: _______________________
{CL52}
USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.
Hard CHECK:
IF NO CURRENT CONTACT ADDRESS AVAILABLE, AN ENTRY MUST BE MADE FOR EVERY
FIELD EXCEPT SECOND STREET ADDRESS (REF AND DK ARE ALLOWED).
IF CURRENT CONTACT ADDRESS AVAILABLE, AT LEAST ONE FIELD MUST BE UPDATED.
73
Closing (CL) Section
Beta
CL52
Help Enabled
Variable Name
HOME.CONTRELS
Comment Enabled
Jump Back Enabled
Label
CONTACT PERSON'S RELATIONSHIP TO REF P
Size
45
CONTACT PERSON: {NAME OF CONTACT PERSON FROM CL51}
REFERENCE PERSON: {NAME OF REFERENCE PERSON}
[What is (CONTACT PERSON)’s relationship to (REFERENCE PERSON)?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT CONTACT
RELATIONSHIP.
IF UNAVAILABLE, ENTER COMPLETE CONTACT RELATIONSHIP.
TO VERIFY CURRENT INFORMATION ENTER 'NU'. TO CORRECT OR
ENTER INFORMATION, TYPE ENTIRE FIELD.
CURRENT INFO: [CONTACT_RELATIONSHIP]
CONTACT _______________________
RELATIONSHIP:
{CL53}
DISPLAY INSTRUCTIONS:
DISPLAY THE NAME ENTERED AT CL51 FOR ‘NAME OF CONTACT PERSON
FROM CL51’.
DISPLAY THE NAME OF THE REFERENCE PERSON FOR THE RU FOR ‘NAME
OF REFERENCE PERSON’.
Hard CHECK:
IF NO CURRENT CONTACT RELATIONSHIP AVAILABLE, AN ENTRY MUST BE MADE (REF AND
DK ARE ALLOWED).
IF CURRENT CONTACT RELATIONSHIP AVAILABLE, ACCEPT AN ENTRY, REF OR DK, OR NO
UPDATE.
74
Closing (CL) Section
Beta
CL53
Help Enabled
Variable Name
HOME.ALTRRESP
Comment Enabled
Jump Back Enabled
Label
BEST PERSON TO PROVIDE HLTH AND EXP INFO
Size
2
ITEM: ALTERNATE RESPONDENT - BEST PERSON TO PROVIDE
HEALTH CARE AND EXPENSES INFORMATION FOR THIS FAMILY IF
CURRENT RESPONDENT IS UNAVAILABLE DURING NEXT INTERVIEW.
INTERVIEWER: IF AVAILABLE, VERIFY CURRENT ALTERNATE
RESPONDENT INFORMATION SHOWN BELOW.
IF NO CURRENT INFORMATION, PROBE: IF YOU ARE NOT AVAILABLE
FOR THE NEXT INTERVIEW, WHO WOULD BE THE BEST PERSON TO
PROVIDE INFORMATION ABOUT THE FAMILY FOR THE NEXT
INTERVIEW?
CURRENT INFO: [ALTERNATE_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
ENTER NEW ALTERNATE
RESPONDENT INFORMATION
ALTERNATE RESPONDENT
INFORMATION CORRECT
1
{CL54}
2
{CL56}
ALTERNATE RESPONDENT
INFORMATION NEEDS CORRECTION
NO CURRENT ALTERNATE
RESPONDENT
3
{CL54}
4
{CL57}
----------------------------------------------------------------------------------------------------------------------------------
Refused
Don't Know
RF
DK
75
{CL57}
{CL57}
Closing (CL) Section
Beta
PROGRAMMER NOTES:
IF CURRENT ALTERNATE RESPONDENT IS A DU MEMBER, DO NOT DISPLAY
CURRENT ADDRESS AND PHONE INFORMATION. ONLY DISPLAY CURRENT
ADDRESS AND PHONE INFORMATION IF CURRENT ALTERNATE RESPONDENT
IS OUTSIDE OF THE DU.
Hard CHECK:
CODES ‘2’ (ALTERNATE RESPONDENT INFORMATION CORRECT) AND ‘3’ (ALTERNATE
RESPONDENT INFORMATION NEEDS CORRECTION) CANNOT BE SELECTED IF NO CURRENT
ALTERNATE RESPONDENT INFORMATION AVAILABLE. IF CODES ‘2’ OR ‘3’ SELECTED
WHEN NO CURRENT ALTERNATE RESPONDENT INFORMATION, DISPLAY THE FOLLOWING
MESSAGE: ‘RESPONSE NOT AVAILABLE. NO CURRENT ALTERNATE INFORMATION. VERIFY
AND RE-ENTER.’
76
Closing (CL) Section
Beta
CL54
Help Enabled
Comment Enabled
Jump Back Enabled
Variable Name
HOME.BESTRPID
Label
PID OF RU MEMBER TO PROVIDE HEALTH INFO
Size
3
HOME.ALTRFNAM
HOME.ALTRMNAM
ALTERNATE RESP - FIRST NAME
ALTERNATE RESP - MIDDLE NAME
20
20
HOME.ALTRLNAM
ALTERNATE RESP - LAST NAME
25
INTERVIEWER: SELECT PERSON NAMED FROM ROSTER.
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
{CL55}
ROUTING INSTRUCTION:
IF ‘SOMEONE OUTSIDE DU’ SELECTED, CONTINUE WITH CL55
OTHERWISE, GO TO CL57
Roster Definition:
Display persons on DU-Members_Roster for selection.
Roster Behavior:
1. Select one allowed.
2. Multiple select, edit, add, delete disallowed.
3. Display 'SOMEONE OUTSIDE DU' as last entry on roster.
Roster Filter:
Display those DU members who meet the following conditions:
- Person is not current respondent
- Person is not deceased
77
Closing (CL) Section
Beta
CL55
Help Enabled (STATE)
Comment Enabled
Jump Back Enabled
Variable Name
HOME.ALTRFNAM
ALTERNATE RESP - FIRST NAME
Label
Size
20
HOME.ALTRMNAM
HOME.ALTRLNAM
ALTERNATE RESP - MIDDLE NAME
ALTERNATE RESP - LAST NAME
20
25
HOME.ALTRSTR1
HOME.ALTRSTR2
ALTERNATE RESP - STREET ADDRESS
ALTERNATE RESP - STREET ADDRESS #2
30
30
HOME.ALTRCITY
ALTERNATE RESP - CITY
20
HOME.ALTRST
HOME.ALTRZIP
ALTERNATE RESP - STATE
ALTERNATE RESP - ZIP CODE
2
5
HOME.ALTRAREA
ALTERNATE RESP - AREA CODE
3
HOME.ALTREXCH
HOME.ALTRLOCL
ALTERNATE RESP - EXCHANGE
ALTERNATE RESP - LOCAL
3
4
[What is the name, address, and phone number of that person?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT ALTERNATE
RESPONDENT.
IF UNAVAILABLE, ENTER COMPLETE ALTERNATE RESPONDENT
INFORMATION.
TO VERIFY CURRENT ADDRESS ENTER 'NU'. TO VERIFY CURRENT
PHONE ENTER ALL ZEROES. TO CORRECT OR ENTER INFORMATION,
TYPE ENTIRE FIELD.
ENTER ‘NMN’ IF NO MIDDLE NAME.
CURRENT INFO: [ALTERNATE_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
ALTERNATE_NAME: _______________________
1ST STR ADDRESS: _______________________
2ND STR ADDRESS: _______________________
CITY: _______________________
STATE: _______________________
78
Closing (CL) Section
Beta
ZIP CODE: _______________________
TELEPHONE: _______________________
{CL56}
USE HELP TO DISPLAY LIST OF STATE ABBREVIATIONS.
Hard CHECK:
IF NO CURRENT ALTERNATE ADDRESS AVAILABLE, AN ENTRY MUST BE MADE FOR EVERY
FIELD EXCEPT SECOND STREET ADDRESS (REF AND DK ARE ALLOWED).
IF CURRENT ALTERNATE ADDRESS AVAILABLE, AT LEAST ONE FIELD MUST BE UPDATED.
79
Closing (CL) Section
Beta
CL56
Help Enabled
Variable Name
HOME.ALTRRELS
Comment Enabled
Jump Back Enabled
Label
ALTERNATE PERSON'S RELATIONSHIP: RU MEMB
Size
45
ALTERNATE RESPONDENT: {NAME OF ALTERNATE RESPONDENT
CL55}
REFERENCE PERSON: {NAME OF REFERENCE PERSON}
[What is (ALTERNATE RESPONDENT)’s relationship to (REFERENCE
PERSON)?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT ALTERNATE
RESPONDENT.
IF UNAVAILABLE, ENTER COMPLETE ALTERNATE RESPONDENT
RELATIONSHIP.
TO VERIFY CURRENT INFORMATION ENTER 'NU'. TO CORRECT OR
ENTER INFORMATION, TYPE ENTIRE FIELD.
CURRENT INFO: [ALTERNATE_RELATIONSHIP]
ALTERNATE _______________________
RELATIONSHIP:
{CL57}
DISPLAY INSTRUCTIONS:
DISPLAY THE NAME ENTERED AT CL55 FOR ‘NAME OF ALTERNATE
RESPONDENT CL55’.
DISPLAY THE NAME OF THE REFERENCE PERSON FOR THE RU FOR ‘NAME
OF REFERENCE PERSON’.
Hard CHECK:
IF NO CURRENT ALTERNATE RELATIONSHIP AVAILABLE, AN ENTRY MUST BE MADE (REF
AND DK ARE ALLOWED).
IF CURRENT ALTERNATE RELATIONSHIP AVAILABLE, ACCEPT AN ENTRY, REF OR DK, OR
NO UPDATE.
80
Closing (CL) Section
Beta
CL57
Help Enabled
Comment Enabled
Variable Name
INFO.INFOID
INFO ID KEY: HOMEID + COUNTER(2)
INFO.INFORURN
INFO.ANYMOVE
ROUND STAMP: RU LETTER + ROUND NUMBER
IS ANYONE IN RU MOVING WITHIN NEXT 3 MTH
Jump Back Enabled
Label
Size
10
2
2
Is anyone in the family planning to move within the next 3 months?
YES
1
{CL58}
NO
2
{BOX_18}
----------------------------------------------------------------------------------------------------------------------------------
Refused
Don't Know
RF
DK
81
{BOX_18}
{BOX_18}
Closing (CL) Section
Beta
CL58
Help Enabled
Variable Name
PRND.FUTMOVER
Comment Enabled
Jump Back Enabled
Label
PERSON SELECTED AS FUTURE MOVER
Size
2
Who is that?
PROBE: Anyone else?
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
{LOOP_11}
Roster Details
Title:
RU_MEMBERS_1
Col #
Header
Instructions
NAME
RU member's first, middle and last names
PERS.FULLNAME
1
Roster Definition:
Display the RU-MEMBERS-ROSTER for selection.
Roster Behavior:
1. Multiple select allowed.
2. Add, edit, delete disallowed.
Roster Filter:
Display all persons who are current RU members (i.e., a member
of the RU on the interview date).
82
Closing (CL) Section
Beta
LOOP_11
FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK CL59 - END_LP11
LOOP DEFINITION: LOOP_11 COLLECTS ADDRESS INFORMATION FOR POTENTIAL
FUTURE MOVERS. THIS LOOP CYCLES ON PERSONS ON THE RU-MEMBERS-ROSTER WHO
MEET THE FOLLOWING CONDITIONS:
- PERSON IS A CURRENT RU MEMBER (I.E., PERSON PART OF THE RU ON INTERVIEW
DATE)
- PERSON SELECTED AS A FUTURE MOVER (I.E., SELECTED AT CL58)
- PERSON NOT FLAGGED AS ‘PROCESSED FUTURE MOVER’ (I.E., PERSON HAS NOT
YET BEEN PROCESSED THROUGH THIS LOOP OR SELECTED AT CL61)
83
Closing (CL) Section
Beta
CL59
Help Enabled (STATE)
Comment Enabled
Jump Back Enabled
Variable Name
TRAC.TRACID
TRAC ID KEY: INFOID + COUNTER(2)
Label
Size
12
TRAC.TRACRURN
TRAC.MOVESTR1
ROUND STAMP: RU LETTER + ROUND NUMBER
MOVING STREET ADDRESS 1
2
30
TRAC.MOVESTR2
TRAC.MOVECITY
MOVING STREET ADDRESS 2
MOVING CITY
30
25
TRAC.MOVEST
MOVING STATE
2
TRAC.MOVEZIP
TRAC.MOVEAREA
ZIP CODE (STUDENT/SPLIT/FUTURE MOVERS)
MOVING AREA CODE
5
3
TRAC.MOVEEXCH
MOVING TELEPHONE EXCHANGE
3
TRAC.MOVELOCL
TRAC.TRACTYPE
MOVING TELEPHONE LOCAL
TRACE TYPE (STUDENT/RU SPLIT/MOVERS)
4
2
PRND.TRACLINK
SEQUENTIAL # OF TRACING REC WITH RU LET.
3
{PERSON’S FIRST MIDDLE AND LAST NAME}
Please give me the address and telephone number of the place where
(PERSON) is planning to move.
1ST STR ADDRESS: _______________________
2ND STR ADDRESS: _______________________
CITY: _______________________
STATE: _______________________
ZIP CODE: _______________________
TELEPHONE: _______________________
{CL60}
USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.
PROGRAMMER NOTES:
REFUSED AND DON’T KNOW ALLOWED FOR EACH FIELD.
FLAG PERSON AS ‘PROCESSED FUTURE MOVER’.
ROUTING INSTRUCTION:
IF ALL PERSONS SELECTED AS FUTURE MOVERS (I.E., SELECTED AT
CL58) ARE FLAGGED AS ‘PROCESSED FUTURE MOVER’, GO TO END_LP11
OTHERWISE, CONTINUE WITH CL60
84
Closing (CL) Section
Beta
CL60
Help Enabled
Comment Enabled
Jump Back Enabled
{PERSON’S FIRST MIDDLE AND LAST NAME}
IF KNOWN, CODE WITHOUT ASKING.
Is (PERSON) planning to move with anyone in the family?
YES
1
{CL61}
NO
2
{END_LP11}
----------------------------------------------------------------------------------------------------------------------------------
Refused
Don't Know
RF
DK
85
{END_LP11}
{END_LP11}
Closing (CL) Section
Beta
CL61
Help Enabled
Comment Enabled
Variable Name
PRND.FUTMOVER
Label
PERSON SELECTED AS FUTURE MOVER
PRND.TRACLINK
SEQUENTIAL # OF TRACING REC WITH RU LET.
Jump Back Enabled
Size
2
3
{PERSON’S FIRST MIDDLE AND LAST NAME}
IF KNOWN, CODE WITHOUT ASKING.
Who is (PERSON) planning to move with?
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
{END_LP11}
PROGRAMMER NOTES:
FLAG ALL SELECTED PERSONS AS ‘PROCESSED FUTURE MOVER’.
Roster Details
Title:
RU_Members_1
Col #
Header
Instructions
NAME
Display RU member's first, middle, and last names
PERS.FULLNAME
1
Roster Definition:
Display persons on the RU_Members_Roster for selection.
Roster Behavior:
1. Multiple select allowed.
2. Add, edit, delete disallowed.
Roster Filter:
Display all persons in the RU-Members_Roster who meet the
following conditions:
- Person is a current RU member (I.E., person part of the RU
on interview date)
- Person selected as a future mover (I.E., selected at CL58)
- Person not flagged as ‘Processed future mover’
86
Closing (CL) Section
Beta
END_LP11
CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER WHO MEETS THE CONDITIONS
STATED IN THE LOOP DEFINITION
IF NO OTHER PERSONS MEET THE STATED CONDITIONS, END LOOP_11 AND CONTINUE
WITH BOX_18
BOX_18
IF CURRENT RESPONDENT IS A PROXY, CONTINUE WITH BOX_18A
OTHERWISE, GO TO CL62
BOX_18A
IF NOT ROUND 5, CONTINUE WITH CL61A
OTHERWISE (I.E., IF ROUND 5), GO TO CL62
87
Closing (CL) Section
Beta
CL61A
Help Enabled
Variable Name
HOME.PROXINFO
Comment Enabled
Jump Back Enabled
Label
PROXY INFORMATION-ADDRESS/PHONE NUMBER
Size
2
ITEM: PROXY INFORMATION - NEED ADDRESS AND PHONE NUMBER
OF CURRENT PROXY.
INTERVIEWER: IF AVAILABLE, VERIFY CURRENT PROXY ADDRESS
SHOWN BELOW.
IF NO CURRENT INFORMATION, PROBE FOR NEW PROXY ADDRESS (IF
AVAILABLE).
CURRENT INFO:
[PROXY_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
ENTER NEW PROXY ADDRESS AND
TELEPHONE
PROXY ADDRESS AND TELEPHONE
CORRECT
1
{CL61B}
2
{CL62}
PROXY ADDRESS OR TELEPHONE
NEEDS CORRECTION
3
{CL61B}
NO CURRENT PROXY ADDRESS
4
{CL62}
----------------------------------------------------------------------------------------------------------------------------------
Refused
Don't Know
RF
DK
{CL62}
{CL62}
Hard CHECK:
CODES ‘2’ (PROXY ADDRESS AND TELEPHONE CORRECT) AND ‘3’ (PROXY ADDRESS OR
TELEPHONE NEEDS CORRECTION) CANNOT BE SELECTED IF NO CURRENT PROXY ADDRESS
INFORMATION AVAILABLE. IF CODES ‘2’ OR ‘3’ SELECTED WHEN NO CURRENT PROXY
ADDRESS, DISPLAY THE FOLLOWING MESSAGE: ‘CODE NOT AVAILABLE. NO CURRENT
PROXY ADDRESS. VERIFY AND RE-ENTER.’
88
Closing (CL) Section
Beta
CL61B
Help Enabled (STATE)
Comment Enabled
Jump Back Enabled
Variable Name
HOME.PROXFNAM
PROXY - FIRST NAME
Label
Size
20
HOME.PROXMNAM
HOME.PROXLNAM
PROXY - MIDDLE NAME
PROXY - LAST NAME
20
25
HOME.PROXSTR1
HOME.PROXSTR2
PROXY'S STREET ADDRESS 1
PROXY'S STREET ADDRESS 2
30
30
HOME.PROXCITY
PROXY'S CITY
20
HOME.PROXST
HOME.PROXZIP
PROXY'S STATE
PROXY'S ZIP CODE
2
5
HOME.PROXAREA
PROXY HOME PHONE - AREA CODE
3
HOME.PROXEXCH
HOME.PROXLOCL
PROXY HOME PHONE - EXCHANGE
PROXY HOME PHONE - LOCAL
3
4
[What is your address and phone number?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT PROXY ADDRESS.
IF UNAVAILABLE, ENTER COMPLETE PROXY ADDRESS.
TO VERIFY CURRENT ADDRESS ENTER 'NU'. TO VERIFY CURRENT
PHONE ENTER ALL ZEROES. TO CORRECT OR ENTER INFORMATION,
TYPE ENTIRE FIELD.
CURRENT INFO:
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
1ST STR ADDRESS: _______________________
2ND STR ADDRESS: _______________________
CITY: _______________________
STATE: _______________________
ZIP CODE: _______________________
TELEPHONE: _______________________
{CL62}
USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.
89
Closing (CL) Section
Beta
PROGRAMMER NOTES:
FLAG PROXY ADDRESS INFORMATION FOR THE RU WITH THE ADDRESS AND
PHONE ENTERED OR CORRECTED AT CL61B FOR THE CURRENT ROUND.
Hard CHECK:
IF NO CURRENT PROXY ADDRESS AVAILABLE, AN ENTRY MUST BE MADE FOR EVERY FIELD
EXCEPT SECOND STREET ADDRESS (REF AND DK ARE ALLOWED).
IF CURRENT PROXY ADDRESS AVAILABLE, AT LEAST ONE FIELD MUST BE UPDATED.
CL62
Help Enabled
Variable Name
HOME.INTVTYPE
Comment Enabled
Jump Back Enabled
Label
WAS INTERVIEW IN-PERSON OR BY PHONE
Size
2
INTERVIEWER: DID YOU COMPLETE THIS INTERVIEW IN-PERSON OR
BY TELEPHONE? (YOU MUST HAVE SUPERVISOR APPROVAL PRIOR
TO INTERVIEWING BY TELEPHONE.)
IN-PERSON
1
{CL62A}
BY TELEPHONE
2
{CL62A}
90
Closing (CL) Section
Beta
CL62A
Help Enabled
Variable Name
HOME.INTVLANG
Comment Enabled
Jump Back Enabled
Label
LANGUAGE INTERVIEW WAS COMPLETED
Size
2
INTERVIEWER: WHAT LANGUAGE WAS THIS INTERVIEW COMPLETED
IN?
ENGLISH
SPANISH
1
2
{CL63}
{CL63}
BOTH ENGLISH AND SPANISH
OTHER LANGUAGE
3
91
{CL63}
{CL62AOV}
CL62AOV
Help Enabled
Variable Name
HOME.INTVLAOS
Comment Enabled
Jump Back Enabled
Label
OTHER LANGUAGE INTERVIEW WAS COMPLETED
ENTER OTHER _______________________
LANGUAGE:
91
Size
45
{CL63}
Closing (CL) Section
Beta
CL63
Help Enabled
Variable Name
HOME.ANYPRES
Comment Enabled
Jump Back Enabled
Label
ANYONE PRESENT ALL/PART OF INTERVIEW
Size
2
INTERVIEWER: WAS ANYONE OTHER THAN THE
{RESPONDENT/PROXY} PRESENT FOR ALL OR PART OF THE
INTERVIEW?
NO ONE ELSE PRESENT
SOMEONE ELSE PRESENT FOR ALL OF
INTERVIEW
1
2
{CL65}
{CL64}
SOMEONE ELSE PRESENT FOR PART
OF INTERVIEW
3
{CL64}
DISPLAY INSTRUCTIONS:
DISPLAY ‘RESPONDENT’ IF CURRENT RESPONDENT IS AN RU MEMBER.
DISPLAY ‘PROXY’ IF CURRENT RESPONDENT IS A PROXY.
92
Closing (CL) Section
Beta
CL64
Help Enabled
Variable Name
HOME.WHOPRES
Comment Enabled
Jump Back Enabled
Label
WHO IS PRESENT FOR ALL/PART INTERVIEW
Size
2
INTERVIEWER: SELECT ALL OTHER PERSONS PRESENT DURING
INTERVIEW.
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
{CL65}
PROGRAMMER NOTES:
DISPLAY ‘SOMEONE OUTSIDE DU’ AS AN OPTION ON THIS SCREEN.
Roster Details
Title:
PROVIDER DIRECTORY
Col #
Header
Instructions
1
PROVIDER_MATCHES Display Truncated Provider Name
PROV.DRFNAME (10),
PROV.LORPNAME (15)
2
STREET
Display Truncated Street Address
PROV.PVSTRT1,
PROV.PVSTRT2 (15)
Roster Definition:
Display persons on the DU_Members_Roster for selection.
Roster Behavior:
1. Multiple select allowed.
2. Add, edit, delete disallowed.
Roster Filter:
Display persons on the DU-Members-Roster who meet the
following condition(s):
- Person is on the DU roster, but not the RU roster or
93
Closing (CL) Section
Beta
- Person on the RU roster and was eligible at the end of
re-enumeration and is physically in the RU on the
interview date and
- Person is not identified as current respondent
CL65
Help Enabled
Comment Enabled
Jump Back Enabled
INTERVIEWER: USE BLACK BALL POINT PEN TO COMPLETE CHECKS
AND FORMS.
{1a. FILL OUT SAQ CHECK(S) WITH SAQ RESPONDENT NAME(S).}
1b. FILL OUT INTERVIEW CHECK FOR PARTICIPATION WITH
RESPONDENT'S NAME.
{2a. COMPLETE THE RECEIPT AND AGREEMENT FORM AND RECORD
THE SAQ CHECK(S).}
2b. COMPLETE THE RECEIPT AND AGREEMENT FORM AND RECORD
THE INTERVIEW PARTICIPATION CHECK AND HAVE RESPONDENT
SIGN IT.
{3a. COMPLETE SAQ CHECK LOG.}
3b. COMPLETE THE RESPONDENT PAYMENT CHECK LOG.
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
DISPLAY INSTRUCTIONS:
DISPLAY '1a. FILL OUT. . . NAME(S).', '2a. COMPLETE. . .
CHECK(S).', AND '3a. COMPLETE. . .LOG.' IF ROUNDS 2-5 AND IF
CL36 OR CL39 IS CODED '1' (COMPLETED AND GIVEN TO INTERVIEWER)
FOR ANY SAQ. OTHERWISE, USE A NULL DISPLAY.
94
Closing (CL) Section
Beta
CL66
Help Enabled
Comment Enabled
Jump Back Enabled
INTERVIEWER:
4. GIVE RESPONDENT CHECK(S) AND READ STATEMENTS BELOW:
Thank you again for your cooperation in this important research. {This check
is payment in advance for keeping records from today until the next interview.
This next interview will take place in {the fall of {YEAR}/early {YEAR}/the fall of
{YEAR}/early {YEAR}./This check is for your efforts in keeping records and
participating in this survey.}
5. THANK RESPONDENT FOR THIS INTERVIEW.
6. {ASK RESPONDENT TO KEEP RECORDS FOR NEXT INTERVIEW AND
GIVE RESPONDENT GIFT./GIVE RESPONDENT CERTIFICATE:
I would also like to thank you on behalf of the two Public Health Service
agencies that sponsor this study -- the Agency for Healthcare Research and
Quality and the National Center for Health Statistics. As a token of their
appreciation, they would like you to have this certificate of commendation
recognizing your contributions of time and effort in a research project to help
enlighten Americans about our health care system.}
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
DISPLAY INSTRUCTIONS:
DISPLAY ‘This check ... /early 2009}.’ IF ROUNDS 1 OR 2 OR 3
OR 4. OTHERWISE, DISPLAY ‘This check ... this survey’
DISPLAY ‘the fall of {YEAR}’, WHERE 'YEAR' IS THE FIRST
CALENDAR YEAR OF THE PANEL, IF ROUND 1. DISPLAY ‘early
{YEAR}’, WHERE 'YEAR' IS THE SECOND CALENDAR YEAR OF THE
PANEL, IF ROUND 2. DISPLAY ‘the fall of {YEAR}’, WHERE 'YEAR'
IS THE SECOND CALENDAR YEAR OF THE PANEL, IF ROUND 3. DISPLAY
‘early {YEAR}’, WHERE 'YEAR' IS THE YEAR SUBSEQUENT TO THE
SECOND CALENDAR YEAR OF THE PANEL, IF ROUND 4.
DISPLAY ‘ASK ... GIFT.’ IF ROUNDS 1 OR 2 OR 3 OR 4.
‘GIVE ... health care system.’ IF ROUND 5.
95
DISPLAY
Closing (CL) Section
Beta
CL67
Help Enabled
Comment Enabled
Jump Back Enabled
INTERVIEWER: WERE ANY OF THE FOLLOWING MEMORY AIDS USED
BY THE RESPONDENT(S) DURING THE INTERVIEW?
CL67_01
Help Enabled
Variable Name
HOME.NMESCAL1
Comment Enabled
Jump Back Enabled
Label
MEMORY AID: HLTH EVS REC WITH ENTRIES
MONTHLY PLANNER, WITH ENTRIES
96
Size
2
YES
NO
Closing (CL) Section
Beta
CL67_02
Help Enabled
Variable Name
HOME.NMESCAL2
Comment Enabled
Jump Back Enabled
Label
MEMORY AID:HLTH EVS REC WITHOUT ENTRIES
MONTHLY PLANNER, WITHOUT ENTRIES
Size
2
YES
NO
CL67_03
Help Enabled
Variable Name
HOME.NMESCAL3
Comment Enabled
Jump Back Enabled
Label
MEMORY AID: HLTH EVS REC WORKSHEET
HEALTH EVENTS WORKSHEET
Size
2
YES
97
NO
Closing (CL) Section
Beta
CL67_04
Help Enabled
Variable Name
HOME.RECORDF
Comment Enabled
Jump Back Enabled
Label
Size
2
MEMORY AID: RECORD FILE
RECORD FILE
YES
NO
CL67_05
Help Enabled
Variable Name
HOME.OTCALNDR
Comment Enabled
Jump Back Enabled
Label
Size
2
MEMORY AID: OTHER CLENDAR
OTHER CALENDAR
YES
98
NO
Closing (CL) Section
Beta
CL67_06
Help Enabled
Variable Name
HOME.CHKBOOK
Comment Enabled
Jump Back Enabled
Label
Size
2
MEMORY AID: CHECKBOOK
CHECK BOOK
YES
NO
CL67_07
Help Enabled
Variable Name
HOME.PROVSTMT
Comment Enabled
Jump Back Enabled
Label
MEMORY AID: BILL/STATEMENT FROM PROVIDER
BILL/STATEMENT FROM PROVIDER
99
Size
2
YES
NO
Closing (CL) Section
Beta
CL67_08
Help Enabled
Variable Name
HOME.INSSTMT
Comment Enabled
Jump Back Enabled
Label
MEMORY AID:INSURANCE PAYMENT STATEMENT
INSURANCE PAYMENT STATEMENT
Size
2
YES
NO
CL67_09
Help Enabled
Variable Name
HOME.BOTLRCPT
Comment Enabled
Jump Back Enabled
Label
MEMORY AID: MEDICINE BOTTLE/RECEIPT
MEDICINE BOTTLE/RECEIPT
Size
2
YES
100
NO
Closing (CL) Section
Beta
CL67_10
Help Enabled
Variable Name
HOME.OTHERAID
Comment Enabled
Jump Back Enabled
Label
Size
2
MEMORY AID: OTHER
OTHER
YES
NO
ROUTING INSTRUCTION:
IF CL67_10 IS CODED '1' (YES), CONTINUE WITH CL68
OTHERWISE, GO TO BOX_20
CL68
Help Enabled
Comment Enabled
WHICH OTHER MEMORY AIDS?
101
Jump Back Enabled
Closing (CL) Section
Beta
CL68_01
Help Enabled
Variable Name
HOME.PROVCARD
Comment Enabled
Jump Back Enabled
Label
OTH MEMORY AID:DR'S CARD/APPT SLIP
DOCTOR'S CARD OR APPOINTMENT SLIP
Size
2
YES
NO
CL68_02
Help Enabled
Variable Name
HOME.INSPLCY
Comment Enabled
Jump Back Enabled
Label
OTH MEMORY AID: INSURANCE POLICY
INSURANCE POLICY
Size
2
YES
102
NO
Closing (CL) Section
Beta
CL68_03
Help Enabled
Variable Name
HOME.INSCARD
Comment Enabled
Jump Back Enabled
Label
OTH MEMORY AID: INSURANCE CARDS
INSURANCE CARDS
Size
2
YES
NO
CL68_04
Help Enabled
Variable Name
HOME.PHONBOOK
Comment Enabled
Jump Back Enabled
Label
OTH MEMORY AID: TELEPHONE BOOK
TELEPHONE BOOK
Size
2
YES
103
NO
Closing (CL) Section
Beta
CL68_05
Help Enabled
Variable Name
HOME.OTHAID
Comment Enabled
Jump Back Enabled
Label
Size
2
OTH MEMORY AID: OTHER
OTHER
YES
NO
PROGRAMMER NOTES:
IF CL68_01 THROUGH CL68_05 ARE ALL CODED `2’ (NO), CAPI
DISPLAYS THE FOLLOWING MESSAGE: `AT LEAST ONE FIELD SHOULD BE
CODED 1.’ THE INTERVIEWER MUST RE-ENTER RESPONSES TO CL68_01
THROUGH CL68_05.
ROUTING INSTRUCTION:
IF CL68_05 IS CODED '1' (YES), CONTINUE WITH CL68OV
OTHERWISE, GO TO BOX_20
CL68OV
Help Enabled
Variable Name
HOME.OTHAIDOS
Comment Enabled
Jump Back Enabled
Label
Size
25
OTH MEMORY AID: OTHER SPECIFY
OTHER SPECIFY: _______________________
104
{BOX_20}
Closing (CL) Section
Beta
BOX_20
END INTERVIEW.
105
| File Type | application/pdf |
| File Title | C:\Documents and Settings\POLACHEK_L\Local Settings\Temporary Internet Files\OLK8\CL (BETA).snp |
| Author | polachek_l |
| File Modified | 2006-02-20 |
| File Created | 2006-02-20 |