Patient Short interview

OMB Number: 0920-0740

Expiration Date: 06/30/2010

2009 Short Questionnaire for

Medical Monitoring Project (MMP)

VERSION 5.0.1

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC, Project Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0011). Do not send the completed form to this address.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

P

ublic Health Service

Centers for Disease Control and Prevention

Atlanta, GA 30333

2009 MMP Short Questionnaire

Preliminary Information

Interviewer instructions: Enter Preliminary Information prior to interview.

I1. Participant ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

[PARID] Site ID Facility ID Respondent ID

I2. Interviewer ID: ___ ___ ___

[INTID]

I3. Interview setting: [CHECK ONLY ONE.]

Outpatient health facility  1

Inpatient health facility  2

Prison or jail facility  3

Community-based organization  4

Private home  5

Public venue (i.e., coffee shop, library)  6

Other (Specify_____________)  7

I4. Interview date: __ __/ __ __ / __ __ __ __

[IDATE] ^{(M M / D D / Y Y Y Y)}

I5. Interview language:

English  1

Spanish  2

Other (Specify_______________________)  3

I6. Time questionnaire began: __ __:__ __  □ AM    □ PM

[STDEMO] Hour Minute

I7. Was the interview originally administered on paper?

No  0

Yes 

Demographics

SAY: “I'd like to thank you for taking part in this interview. Remember that all the information you give me will be kept confidential and your name won’t be recorded anywhere on this paper (computer). The answers to some questions may seem obvious to you, but I need to ask you all of the questions.”

Q1. Have you ever participated in the MMP interview?

N

Skip to Q2

o  0

Yes  1

R

Skip to Q2

efused to answer  7

Don’t know  8

Q1a. What month and year did you participate in the MMP interview?

__ __ / __ __ __ __

^{( M M Y Y Y Y )} [Month: 77 = Refused to answer, 88= Don’t know;

Year: 7777 = Refused to answer, 8888 = Don’t know]

Inconsistency check: Q1a (date participated in MMP) cannot be earlier than January 2005 or later than I4 (interview date).

Q1b. In what city and state were you interviewed?

_____________________________________ (City)

_____________________________________ (State)

[7 = Refused, 8 = Don’t know]

Interview instructions: If the respondent was interviewed during the 2009 data collection cycle, go to Say box before Q2; otherwise, skip to Q2.

SAY: “We are only interviewing people who haven’t already been interviewed during 2009 (2009). Thank you very much for your time.” [DISCONTINUE INTERVIEW AND SKIP TO INTERVIEW COMPLETION.]

Programming note for Say box after Q1b: use 2009 if date of interview is in 2009. Use 2009 if date of interview is in 2009.

Q2. What is your date of birth?

__ __/ __ __ / __ __ __ __

^{(M M / D D / Y Y Y Y )}

Inconsistency check: Q2 (date of birth) cannot be earlier than January 1, 1900 or later than the I4 (interview date).

Interviewer instructions: If the respondent was less than 18 on January 1, 2009 (PDP start date), go to Say box before Q3; otherwise, skip to Q3.

SAY: “We are only interviewing people who were 18 years or older on January 1, 2009. Thank you very much for your time.” [DISCONTINUE INTERVIEW AND SKIP TO INTERVIEW COMPLETION.]

Q3. What is the highest level of education you completed? [DON’T READ CHOICES. CHECK ONLY ONE.]

Never attended school  1

Grades 1 through 8  2

Grades 9 through 11  3

Grade 12 or GED  4

Some college, associate’s degree, or technical degree  5

Bachelor’s degree  6

Any post-graduate studies  7

Refused to answer  77

Don’t know  88

Q4. Do you consider yourself to be Hispanic or Latino?

No  0

Yes  1

Refused to answer  7

Don’t know  8

Q5. Which racial group or groups do you consider yourself to be in? You may choose more than one option. [READ CHOICES. CHECK ALL THAT APPLY.]

American Indian or Alaska Native  1

Asian  2

Black or African American  3

Native Hawaiian or Other Pacific Islander  4

White  5

Refused to answer  77

Don’t know  88

Q6. What was your sex at birth? [READ CHOICES EXCEPT “Intersex/ambiguous”. CHECK ONLY ONE.]

Male  1

Female  2

Intersex/ambiguous  3

Refused to answer  7

Don’t know  8

Q7. Do you consider yourself to be male, female, or transgender? [READ CHOICES. CHECK ONLY ONE.]

Male  1

Female  2

Transgender  3

Refused to answer  7

Don’t know  8

Q8. In what country or territory were you born? [DON’T READ CHOICES. CHECK ONLY ONE.

Skip to Say box before Q9

United States  1

Puerto Rico  2

Mexico  3

Cuba  4

Other (Specify____________________________)  5

Skip to Say box before Q9

Refused to answer  7

Don’t know  8

Interviewer instructions: If Q8a (years living in the U.S.) is < 1 year, enter “0.”

Q8a. How many years have you been living in the United States?

___ ___ ___ years [Years: 777 = Refused to answer, 888 = Don’t know]

SAY: “Now I am going to ask you about the past 12 months. The past 12 months is last year (DATE WITH PREVIOUS YEAR) to now (TODAY’S DATE).” [SHOW RESPONDENT CALENDAR.]

Q9. During the past 12 months, did you have any kind of health insurance or health coverage? This includes Medicaid and Medicare.

N

Skip to Say box before Q10

o  0

Yes  1

R

Skip to Say box before Q10

efused to answer  7

Don’t know  8

Q9a. During the past 12 months, was there a time that you didn’t have any health insurance coverage?

No  0

Yes  1

Refused to answer  7

Don’t know  8

Access to Care

SAY: “Now I’m going to ask you some questions about getting tested for HIV.”

Q10. What month and year did you first test positive for HIV? Tell me when you got your result, not when you got your test.

__ __/ __ __ __ __

^{(M M / Y Y Y Y )} [Month: 77 = Refused to answer, 88= Don’t know;

Year: 7777 = Refused to answer, 8888 = Don’t know]

Inconsistency check: Q10 (date first tested positive for HIV) cannot be earlier than Q2 (date of birth) or March 1985 and later than April 30, 2009, the PDP end date.

Interviewer instructions: If Q10 (date first tested positive for HIV) is 5 years or less than April 30, 2009, go to Q11; otherwise skip to Q13.

Q11. Since testing positive for HIV, what month and year did you first visit a doctor, nurse, or other health care worker for HIV medical care?

__ __/ __ __ __ __

^{(M M / Y Y Y Y )} [Month: 77 = Refused to answer, 88= Don’t know;

Year: 7777 = Refused to answer, 8888 = Don’t know]

Inconsistency check: Confirm response if Q11 (date first went to provider for HIV care) is earlier than the Q10 (date first tested positive for HIV). Q11 (date first went to provider for HIV care) cannot be later than April 30, 2009, the PDP end date.

Interviewer instructions: If Q11 (date first went to provider for HIV care) is more than 3 months from Q10 (date first tested positive for HIV), go to Q12; otherwise, skip to Q13.

Q12. What was the main reason you didn’t go to a doctor, nurse, or other health care worker for HIV medical care within 3 months of testing positive for HIV? [DON’T READ CHOICES. CHECK ONLY ONE.]

Felt good  1

Initial CD4 count and viral load were good  2

Didn’t believe test result  3

Didn’t want to think about being HIV positive  4

Didn’t have enough money or health insurance  5

Had other responsibilities such as child care or work  6

Experienced homelessness  7

Was drinking or using drugs  8

Felt sick  9

Forgot to go  10

Missed appointment(s)  11

Moved or out of town  12

Unable to get transportation  13

Facility is inconvenient (location, facility hours, wait-time)  14

Didn’t know where to go  15

Couldn’t find the right HIV health care provider  16

Unable to get earlier appointment  17

Unaware of recommendation to enter care within 3 months  18

Other (Specify:________________________________)  19

Refused to answer  77

Don’t know  88

Interviewer instructions: If Q11 (date of first HIV care visit) is after April 30, 2009, go to the Say box below; otherwise, skip to Say box before Q14.

SAY: “We are only interviewing people who received HIV medical care before April 30, 2009. Thank you very much for your time.” [DISCONTINUE INTERVIEW AND SKIP TO INTERVIEW COMPLETION.]

Q13. When was your most recent visit to a doctor, nurse, or other health care worker for HIV medical care? Please tell me the month and year.

__ __/ __ __ __ __

^{(M M / Y Y Y Y )} [Month: 77 = Refused to answer, 88= Don’t know;

Year: 7777 = Refused to answer, 8888 = Don’t know]

Inconsistency check: Q13 (date of most recent visit to a provider for HIV care) cannot be earlier than Q11 (first visit to a provider for HIV care) and later than I4 (interview date).

Interviewer instructions: If Q13 (date of most recent visit to a provider for HIV care) is more than 6 months prior to I4 (interview date), go to Q13a; otherwise, skip to Say box before Q14.

Q13a. What was the main reason you didn’t visit a doctor, nurse, or other health care worker for HIV medical care during the past 6 months? [DON’T READ CHOICES. CHECK ONLY ONE. SHOW CALENDAR.]

Felt good  1

CD4 count and viral load were good  2

Didn’t believe test result  3

Didn’t want to think about being HIV positive  4

Didn’t have enough money or health insurance  5

Had other responsibilities such as child care or work  6

Experienced homelessness  7

Was drinking or using drugs  8

Felt sick  9

Forgot to go  10

Missed appointment(s)  11

Moved or out of town  12

Unable to get transportation  13

Facility is inconvenient (location, facility hours, wait-time)  14

Didn’t know where to go  15

Couldn’t find the right HIV health care provider  16

Unable to get earlier appointment  17

Unaware of recommendation to enter care within 3 months  18

Other (Specify:________________________________)  19

Refused to answer  77

Don’t know  88

SAY: “Now I’m going to ask you some questions about the places where you get HIV medical care. If you don’t remember everything, that’s okay. Tell me what you remember.”

Q14. During the past 12 months, was there one usual place, like a doctor’s office or clinic, where you went for most of your HIV medical care?

Skip to Q14b

No  0

Yes  1

Skip to Q15

Refused to answer  7

Don’t know  8

Q14a. What was the main reason you didn’t have a usual place to get HIV medical care during the past 12 months? [DON’T READ CHOICES. CHECK ONLY ONE.]

Couldn’t afford a usual source of HIV care  1

Didn’t know where to find a usual source of HIV care  2

Couldn’t get regular appointments anywhere  3

It wasn’t available in the area  4

Didn’t think it was necessary  5

Thought it was necessary, but never tried to get a usual

source of care  6

Other (Specify___________________________________)  7

Refused to answer  77

Don’t know  88

Interviewer instructions: Skip to Q15.

Q14b. What is the name of this place where you went for most of your HIV medical care

during the past 12 months?

Interviewer instructions: Go to paper Facility Visits Log and enter facility information for this place. Write USL in the Facility Type Code column. After entering this information, continue with the next question.

Q14c. Did you get any sort of care at [USE FACILITY NAME] between January 1, 2009

and April 30, 2009?

Skip to Q15

No  0

Yes  1

Skip to Q15

Refused to answer  7

Don’t know  8

Q14d. Between January 1, 2009 and April 30, 2009, how many times had you been to [USE FACILTY NAME] for any sort of care?

___ ___ ___ [777 = Refused to answer, 888 = Don’t know]

Inconsistency check: The number of times the respondent visited a particular facility must be ≥ 1 and ≤ 121.

Q15. During the past 12 months, had you been to any other doctor’s office or clinic for HIV medical care?

Skip to Q15

No  0

Yes  1

Skip to Q15

Refused to answer  7

Don’t know  8

Q15a. What is the name of this place where you got HIV medical care?

Interviewer instructions: Go to paper Facility Visits Log and enter facility information for this place. Write OTH in the Facility Type Code column. After entering this information, continue with the next question.

Q

Skip to Q16

15b. Did you get any sort of care at [USE FACILITY NAME] between January 1, 2009 and April 30, 2009?

No  0

Yes  1

Skip to Q16

Refused to answer  7

Don’t know  8

Q15c. Between January 1, 2009 and April 30, 2009, how many times had you been to [USE FACILITY NAME] for any sort of care?

___ ___ ___ [777 = Refused to answer, 888 = Don’t know]

Inconsistency check: The number of times the respondent visited a particular facility must be ≥ 1 and ≤ 121.

Q16. During the past 12 months, how many times did you go to an emergency room or urgent care center for HIV medical care?

___ ___ [77 = Refused to answer, 88 = Don’t know]

Inconsistency check: Q16 (number of times respondent visited the emergency room or urgent care center for HIV care) must be ≤ 76.

Q17. During the past 12 months, how many times were you admitted to a hospital because of an HIV-related illness? (Please don’t include visits that were made only to the emergency room.)

___ ___ [77 = Refused to answer, 88 = Don’t know]

Inconsistency check: Q17 (number of times respondent was admitted to a hospital for an HIV-related illness) must be ≤ 76.

Q18. During the past 12 months, were you enrolled in an inpatient mental health facility?

No  0

Yes  1

Refused to answer  7

Don’t know  8

Q19. During the past 12 months, were you enrolled in an inpatient drug or alcohol treatment facility?

No  0

Yes  1

Refused to answer  7

Don’t know  8

SAY: “Now I am going to ask you some questions about your need for services related to HIV.”

Interviewer instructions: Use Response Card C. If response to Q20a is “No,” go to Q20b; otherwise, skip to Q21a. If response to Q20b is “Yes,” go to Q20c; otherwise, skip to Q21a. Follow the same pattern for Q20–Q36.

Interviewer instructions: For Q20c–Q36c: [DON’T READ CHOICES. CHECK ONLY ONE.]

		During the past 12 months, did you get:	IF “NO” IN Q20a–Q36a, ASK: During the past 12 months, have you needed:	IF “YES” IN Q20b–Q36b, ASK: What was the main reason you haven’t been able to get this service during the past 12 months?
		CODE: No = 0, Yes = 1, Refused to answer = 7, Don’t know = 8	CODE: No = 0, Yes = 1, Refused to answer = 7, Don’t know = 8	CODE: SEE CODE LIST BELOW FOR RESPONSES. [DON’T READ CHOICES. CHECK ONLY ONE]
Q20.	HIV case management services	a. [______]	b. [______]	c. [______]
Q21.	Counseling about how to prevent the spread of HIV	a. [______]	b. [______]	c. [______]
Q22.	Medicine through the AIDS Drug Assistance Program (ADAP)	a. [______]	b. [______]	c. [______]
Q23.	Professional help remembering to take your HIV medicines on time or correctly	a. [______]	b. [______]	c. [______]
Q24.	HIV peer group support	a. [______]	b. [______]	c. [______]
Q25.	Dental care	a. [______]	b. [______]	c. [______]
Q26.	Mental health services	a. [______]	b. [______]	c. [______]
Q27.	Drug or alcohol counseling or treatment	a. [______]	b. [______]	c. [______]
Q28.	Public benefits including Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)	a. [______]	b. [______]	c. [______]
Q29.	Domestic violence services	a. [______]	b. [______]	c. [______]
Q30.	Shelter or housing services	a. [______]	b. [______]	c. [______]
Q31.	Meal or food services	a. [______]	b. [______]	c. [______]
Q32.	Home health services	a. [______]	b. [______]	c. [______]
Q33.	Transportation assistance	a. [______]	b. [______]	c. [______]
Q34.	Childcare services	a. [______]	b. [______]	c. [______]
Q35.	Interpreter services	a. [______]	b. [______]	c. [______]
Q36.	Other HIV-related services (Specify:____________)	a. [______]	b. [______]	c. [______]

1 Didn’t know where to go or whom to call

2 Didn’t complete application process

3 Waiting list is too long

4 Service isn’t available

5 Not eligible or denied services

6 Service hours are inconvenient

7 Service costs too much/lack of insurance

8 Transportation problems

9 Language barrier

10 Too sick to get service

11 Other (Specify____________________)

77 Refused to answer

88 Don’t know

HIV Treatment and Adherence

SAY: “Now I’m going to ask some questions about medicines the doctor may have prescribed for your HIV. These medicines are called antiretrovirals, also known as ART, HAART, or the AIDS cocktail.”

Q37. Have you ever taken any antiretroviral medicines for your HIV?

No………………….…………………..……  0

Skip to Q38

Yes………………………………………..……  1

Skip to Interview completion

Refused to answer……………………………  7

Don’t know…..........  8

Q37a. What are the reasons you never took any antiretroviral medicines?

[DON’T READ CHOICES. CHECK ALL THAT APPLY.]

Doctor advised to delay treatment  1

Recently into HIV medical care or hasn’t had time  2

CD4 count or viral load are good  3

Feel good, don’t need them  4

Worried about side effects  5

Drinking or using drugs  6

Didn’t want to think about being HIV positive  7

No money  8

No insurance  9

Worried about ability to adhere or often forget  10

Homeless  11

Taking alternative or complementary medicines  12

Other 1 (Specify:______________________________)  13

Other 2 (Specify:______________________________)  14

Other 3 (Specify:______________________________)  15

Other 4 (Specify:______________________________)  16

Refused to answer  77

Don’t know  88

Interviewer instructions: Skip to Interview completion.

Q38. Are you currently taking any antiretroviral medicines for your HIV?

No………………….…………………..……  0

Skip to Q39a

Yes………………………………………..……  1

Skip to Q39

Refused to answer……………………………  7

Don’t know…..........  8

Q38a. What is the main reason you aren’t currently taking any antiretroviral medicines?

[DON’T READ CHOICES. CHECK ONLY ONE.]

Doctor advised to delay treatment  1

Recently into HIV medical care or hasn’t had time  2

CD4 count or viral load are good  3

Feel good, don’t need them  4

Worried about side effects  5

Drinking or using drugs  6

Didn’t want to think about being HIV positive  7

No money  8

No insurance  9

Worried about ability to adhere or often forget  10

Homeless  11

Taking alternative or complementary medicines  12

Other 1 (Specify:_____________________________)  13

Other 2 (Specify:_____________________________)  14

Other 3 (Specify:_____________________________)  15

Other 4 (Specify:_____________________________)  16

Refused to answer  77

Don’t know  88

Q39. During the past 12 months, have you taken antiretroviral medicines?

N

Skip to Interview completion

o………………….…………………..……  0 Yes………………………………………..……  1

Skip to Interview completion

Refused to answer……………………………  7

Don’t know…..........  8

Q39a. During the past 12 months, what were the ways your antiretroviral medicines were paid for? [DON’T READ CHOICES. CHECK ALL THAT APPLY.]

Private health insurance  1

Medicaid  2

Medicare  3

AIDS Drug Assistance Program (ADAP)  4

An AIDS service organization provided medicines  5

Got medicines at a public clinic  6

7

Clinical trial or drug study provided medicines  7

Paid for medicines out of pocket  8

Other 1 (Specify: _____________________________)  9

Other 2 (Specify: _____________________________)  10

Other 3 (Specify: _____________________________)  11

Other 4 (Specify: _____________________________)  12

Refused to answer  77

Don’t know  88

Time questionnaire ended:  ___ ___:___ ___  □ AM    □ PM

Hour Minute

Interview Completion

End of Interview

SAY: “Thank you again for taking part in this interview. Please remember that all the information you have given me will be kept confidential.”

Interviewer instructions:

Offer assistance with information and resources, according to local protocol.

Don’t pay the respondent if the respondent already participated in an MMP interview during the 2009 data collection cycle OR the respondent is less than 18 years old.

Pay the respondent if the respondent’s first HIV positive test was after the PDP, OR the interview was partially or fully completed.

Payment Verification

E1. Payment made:

No  0

Y es  1 Skip to E2

E1a. Why was payment not made?

Skip to E3

Participant refused payment  1

Other (Specify:_____________________________)  2

E2. Receipt signed (or initialed):

No  0

Yes  1 Skip to E3

E2a. Why was receipt not signed?

Participant refused to sign  1

Other (Specify:_____________________________)  2

Data Validity

E3. How confident are you of the validity of the respondent’s answers?

Confident  1

Some doubts  2

Not confident at all  3

E4. Record any additional comments, including disruptions that might have taken place during the interview, reason the interview might have been stopped, or why the respondent’s answers may not have been reliable.

Facility Visits Log – Medical Monitoring Project 2009

Record information on facilities as indicated in the questionnaire. Only obtain contact information (street address/city/state) for facilities with which you are not familiar or those outside of your MMP project area’s jurisdiction.

Interview Date: ___ ___/___ ___ ___ ___ Participant ID: ___ ___ ___ ___ ___ ___ ___ ___ _­­___ ___ ___ ___ Interviewer ID: ___ ___ ___

Site ID Facility ID Respondent ID

Facility type1 (from question)	What was the name of this facility?	What was the name of the person you usually saw there?		About how many times did you go to this facility during the past 12 months?	What was the street address of this facility? (complete as needed)	What city and state was this facility in? (complete as needed)
		Provider first name	Provider last name			City	State
SAMP

Facility Type Codes:

USL = usual HIV care INC = care while incarcerated OTH = other HIV care OBGYN = OB or GYN care MED = general medical care HO = inpatient hospital

Response Card C

HIV case management services

Counseling about how to prevent the spread of HIV

Medicine through the AIDS Drug Assistance Program (ADAP)

Professional help remembering to take your HIV medicines on time or correctly

HIV peer group support

Dental care

Mental health services

Drug or alcohol counseling or treatment

Public benefits including Supplemental Security Income (SSI) or Social Security

Disability Insurance (SSDI)

Domestic violence services

Shelter or housing services

Meal or food services

Home health services

Transportation assistance

Childcare services

Interpreter services

Other HIV-related services

January	February	March
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
April	May	June
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
July	August	September
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
October	November	December
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

2008 Calendar

2009 Calendar

January	February	March
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
April	May	June
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
July	August	September
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
October	November	December
Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30	Su Mo Tu We Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

2

2009 MMP Short Questionnaire v5.0.1