MEPS-HC Core Interview

Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC through 2009)

Attachment 69 -- HC Closing Section

MEPS-HC Core Interview

OMB: 0935-0118

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0935-0118 can be found here:

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MEPS FAMES P12R5/P13R3/P14R1 Closing (CL) Section

December 8, 2008

Closing (CL) Section

----------------------------------------------------

| Subsection 1: MPC Authorization Forms (Round 1 |

| through Round 5) |

----------------------------------------------------

BOX_00

======

----------------------------------------------------

| CONTEXT HEADER DISPLAY INSTRUCTIONS: |

| DISPLAY PERS.FULLNAME |

----------------------------------------------------

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-PROVIDER-PAIR 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) AND CARE WAS PROVIDED TO PERSON |

| 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) |

| |

| 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. |

----------------------------------------------------

| SAMPLING BOX (FOR ROUNDS 2-5) CONT’D: |

| |

| 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. |

----------------------------------------------------

CL01

====

{[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:

TO SCROLL, USE ARROW KEYS. TO LEAVE SCREEN, PRESS ESC.

[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.]

----------------------------------------------------

| 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’. |

----------------------------------------------------

| DISPLAY EACH UNIQUE ELIGIBLE PERSON NAME ONLY |

| ONCE. |

----------------------------------------------------

| CONTINUE WITH LOOP_01 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU_ESTB_PERS_PAIRS_1 |

| |

| COL # 1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE, |

| AND LAST NAMES (PERS.FULLNAME) |

----------------------------------------------------

| 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 |

----------------------------------------------------

CL02

====

OMITTED.

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-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 |

----------------------------------------------------

| NOTE: LOOP ONLY ONE TIME FOR EACH UNIQUE PERSON- |

| PROVIDER-PAIR. |

----------------------------------------------------

CL03

====

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]

RU ID: [RUID-7] 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.

----------------------------------------------------

| 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|

| PERSON-PROVIDER-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-PERSON-PROVIDER-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 |

----------------------------------------------------

| NOTE: LOOP ONLY ONE TIME FOR EACH UNIQUE PERSON- |

| PROVIDER-PAIR. |

----------------------------------------------------

CL04

====

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]

RU ID: [RUID-7] 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 ..................... 1 {CL05}

SIGNED WITH PROBLEM .................... 2 {CL04OV1}

LEFT WITH RESPONDENT ................... 3 {END_LP02}

MAILED TO RESPONDENT ................... 4 {END_LP02}

REFUSED ................................ 5 {CL06}

OTHER ................................. 91 {CL04OV2}

HELP AVAILABLE FOR MORE INFORMATION ON MPC AUTHORIZATION FORMS.

[Code One]

----------------------------------------------------

| 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. |

----------------------------------------------------

| 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

=======

PROBLEM:

[Enter Problem-45] ..................... {CL05}

HELP AVAILABLE FOR MORE INFORMATION ON MPC AUTHORIZATION FORMS.

CL04OV2

=======

OTHER:

[Enter Other Specify-45] ............... {END_LP02}

HELP AVAILABLE FOR MORE INFORMATION ON MPC AUTHORIZATION FORMS.

CL05

====

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.}

[Enter Number-8] ....................... {CL05OV}

----------------------------------------------------

| 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. |

----------------------------------------------------

| NOTE: EACH AUTHORIZATION FORM HAS A PRE-ASSIGNED |

| AUTHORIZATION FORM NUMBER. |

----------------------------------------------------

| HARD CHECK – PANEL 12 MPC AUTHORIZATION FORMS: |

| AUTHORIZATION FORM NUMBERS ARE PANEL AND ROUND |

| SPECIFIC. NUMBER ENTERED MUST BE 8 CHARACTERS LONG|

| AND MUST BEGIN AND END WITH AN ALPHA CHARACTER. |

| PANEL 12 MPC AUTHORIZATION FORMS ARE PRINTED ON |

| GREEN PAPER. |

| |

|ORIGIN LETTER 5-NUMBER CHECK ROUND |

| SEQUENCE DIGIT IDENTIFIER|

|PRE- A-M 00001- CONSTANT A,B,C,D,E |

|GENERATED 29499 |

| |

|FIELD A-M 29500- CONSTANT A,B,C,D,E |

|GENERATED 44999 |

| |

|HOME T 45000- CONSTANT A,B,C,D,E |

|OFFICE 49999 |

| |

|TRAINING/ Y 96000- CONSTANT A,B,C,D,E |

|QC 96399 |

----------------------------------------------------

| HARD CHECK – PANEL 13 MPC AUTHORIZATION FORMS: |

| AUTHORIZATION FORM NUMBERS ARE PANEL AND ROUND |

| SPECIFIC. NUMBER ENTERED MUST BE 8 CHARACTERS LONG|

| AND MUST BEGIN AND END WITH AN ALPHA CHARACTER. |

| PANEL 13 MPC AUTHORIZATION FORMS ARE PRINTED ON |

| WHITE PAPER. |

| |

|ORIGIN LETTER 5-NUMBER CHECK ROUND |

| SEQUENCE DIGIT IDENTIFIER|

|PRE- A-M 00001- CONSTANT G,H,J,K,L |

|GENERATED 29499 |

| |

|FIELD A-M 29500- CONSTANT G,H,J,K,L |

|GENERATED 44999 |

| |

|HOME T 45000- CONSTANT G,H,J,K,L |

|OFFICE 49999 |

| |

|TRAINING/ Y 96000- CONSTANT G,H,J,K,L |

|QC 96399 |

----------------------------------------------------

| HARD CHECK – PANEL 14 MPC AUTHORIZATION FORMS: |

| AUTHORIZATION FORM NUMBERS ARE PANEL AND ROUND |

| SPECIFIC. NUMBER ENTERED MUST BE 8 CHARACTERS LONG|

| AND MUST BEGIN AND END WITH AN ALPHA CHARACTER. |

| PANEL 14 MPC AUTHORIZATION FORMS ARE PRINTED ON |

| BLUE PAPER. |

| |

|ORIGIN LETTER 5-NUMBER CHECK ROUND |

| SEQUENCE DIGIT IDENTIFIER|

|PRE- A-M 00001- CONSTANT M,N,P,Q,R |

|GENERATED 29499 |

| |

|FIELD A-M 29500- CONSTANT M,N,P,Q,R |

|GENERATED 44999 |

| |

|HOME T 45000- CONSTANT M,N,P,Q,R |

|OFFICE 49999 |

| |

|TRAINING/ Y 96000- CONSTANT M,N,P,Q,R |

|QC 96399 |

----------------------------------------------------

| SOME IMPORTANT POINTS TO REMEMBER ABOUT MPC |

| AUTHORIZATION FORMS: |

| - THE PREFIX LETTER CHANGES BASED ON THE TYPE OF |

| AUTHORIZATION FORM AND THE ORIGIN OF THE FORM. |

| THIS MEANS THAT A PRE-PRINTED OR FIELD |

| GENERATED MPC AUTHORIZATION FORM WILL DRAW FROM|

| THE SAME LETTER OR RANGE OF LETTERS IN EACH |

| PANEL. |

| - THE 5-NUMBER SEQUENCE REPEATS ITSELF FOR EACH |

| PANEL. |

| - THE CHECK-DIGIT ALWAYS REMAINS CONSTANT. |

| - THE ROUND IDENTIFIER IS DIFFERENT FOR EACH |

| PANEL. THE ROUND IDENTIFIER WILL REMAIN THE |

| SAME FOR ALL AUTHORIZATION FORMS COLLECTED |

| WITHIN A PANEL, BUT CHANGES BASED ON THE ROUND.|

| FOR EXAMPLE: AUTHORIZATION FORMS GENERATED FOR |

| PANEL 14, ROUND 1 WILL USE THE ROUND IDENTIFIER|

| “M”; “M” OR “N” FOR ROUND 2; “M”, “N”, OR “P” |

| FOR ROUND 3; “M”, “N”, “P” OR “Q” FOR ROUND 4; |

| AND “M”, “N”, “P”, “Q” OR “R” FOR ROUND 5. |

----------------------------------------------------

CL05OV

======

MPC AUTHORIZATION FORM SIGNATURE DATE:

[Enter Month, Day, Year-4] .................. {END_LP02}

----------------------------------------------------

| NOTE: 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.’ |

----------------------------------------------------

CL06

====

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]

SELECT MAIN REASON FOR REFUSAL:

DOESN’T WANT TO BOTHER PROVIDER ........ 1 {END_LP02}

CONFIDENTIALITY/SENSITIVE INFO ......... 2 {END_LP02}

PAYMENT PROBLEM WITH PROVIDER .......... 3 {END_LP02}

HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP02}

WANTS MORE INFO BEFORE SIGNING ......... 5 {END_LP02}

NOT INTERESTED IN STUDY ................ 6 {END_LP02}

NO REASON GIVEN ........................ 7 {END_LP02}

OTHER SPECIFY ......................... 91 {CL06OV}

[Code One]

CL06OV

======

OTHER REASON FOR REFUSAL:

[Enter Other Specify-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 |

----------------------------------------------------

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 |

----------------------------------------------------

CL06A

=====

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]

SIGNATURE DATE ON MPC AF MUST BE ON OR AFTER: {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.

----------------------------------------------------

| 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’. |

----------------------------------------------------

| 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 |

----------------------------------------------------

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 ROUND 2 |

| AND ROUND 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 ROUNDS 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. 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) |

----------------------------------------------------

| 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: |

| - 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 |

| ESTABLISHMENT-PERSON-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. |

----------------------------------------------------

| 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 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 |

----------------------------------------------------

| 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 |

| ESTABLISHMENT-PERSON-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_04A

=======

OMITTED.

BOX_04

======

OMITTED.

CL07

====

OMITTED.

LOOP_03

=======

OMITTED.

CL08

====

OMITTED.

CL09

====

OMITTED.

CL09OV1

=======

OMITTED.

CL09OV2

=======

OMITTED.

CL10

====

OMITTED.

CL11

====

OMITTED.

CL11OV

======

OMITTED.

END_LP03

========

OMITTED.

BOX_05

======

OMITTED.

BOX_06

======

OMITTED.

CL12

====

OMITTED.

CL13

====

OMITTED.

CL14

====

OMITTED.

LOOP_04

=======

OMITTED.

CL15

====

OMITTED.

CL15OV

======

OMITTED.

CL16

====

OMITTED.

CL17

====

OMITTED.

CL17OV

======

OMITTED.

END_LP04

========

OMITTED.

BOX_07

======

OMITTED.

CL18

====

OMITTED.

CL18OV

======

OMITTED.

CL19

====

OMITTED.

CL20

====

OMITTED.

CL20OV

======

OMITTED.

BOX_08

======

OMITTED.

LOOP_04A

========

OMITTED.

CL21

====

OMITTED.

END_LP04A

=========

OMITTED.

BOX_09

======

OMITTED.

CL22

====

OMITTED.

BOX_10

======

----------------------------------------------------

| Subsection 4: Pharmacy Requests and Authorization|

| Forms (Round 3 and Round 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, CONTINUE WITH BOX_11 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_14 |

----------------------------------------------------

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. |

----------------------------------------------------

CL23

====

OMITTED.

CL24

====

OMITTED.

LOOP_05

=======

OMITTED.

CL25

====

OMITTED.

END_LP05

========

OMITTED.

CL26

====

OMITTED.

BOX_12

======

OMITTED.

CL27

====

OMITTED.

LOOP_06

=======

OMITTED.

CL28

====

OMITTED.

END_LP06

========

OMITTED.

BOX_13

======

OMITTED.

CL29

====

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.

CL30

====

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).

TO SCROLL, USE ARROW KEYS. TO LEAVE SCREEN, PRESS ESC.

|---------------------------------|-------------------------------------|

| ROSTER. PERSON | CL30_01. PHARMACY |

|---------------------------------|-------------------------------------|

| [First, [Middle], Last Name-35] | [Name of Pharmacy.............-30] |

|---------------------------------|-------------------------------------|

| [First, [Middle], Last Name-35] | [Name of Pharmacy.............-30] |

|---------------------------------|-------------------------------------|

| [First, [Middle], Last Name-35] | [Name of Pharmacy.............-30] |

|---------------------------------|-------------------------------------|

[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 # 1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY RU MEMBERS’ FIRST, MIDDLE, |

| AND LAST NAMES (PERS.FULLNAME) |

| |

| COL # 2 HEADER: PHARMACY |

| INSTRUCTIONS: DISPLAY PHARMACY NAME |

| (PHAR.PHARNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| DISPLAY EACH UNIQUE PAIR ON THE RU-PERSON- |

| PHARMACY-PAIRS-ROSTER. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. DISPLAY ONLY. |

| |

| 2. SELECT, EDIT, ADD, AND DELETE DISALLOWED. |

----------------------------------------------------

| 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-PERSON-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. |

----------------------------------------------------

CL31

====

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]

RU ID: [RUID-7] 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 ‘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 |

----------------------------------------------------

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 RU-PERSON-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. |

----------------------------------------------------

CL32

====

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

PRE-PRINTED.

PID: [PID] PERSON: [First,[Middle],Last Name-35]

DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]

RU ID: [RUID-7] 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 .................... 2 {CL32OV1}

LEFT WITH R ............................ 3 {END_LP08}

MAILED TO R ............................ 4 {END_LP08}

REFUSED ................................ 5 {CL34}

OTHER ................................. 91 {CL32OV2}

[Code One]

HELP AVAILABLE FOR MORE INFORMATION ON PHARMACY

AUTHORIZATION FORMS.

----------------------------------------------------

| 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.’ |

----------------------------------------------------

CL32OV1

=======

PROBLEM:

[Enter Problem-45] ..................... {CL33}

HELP AVAILABLE FOR MORE INFORMATION ON PHARMACY

AUTHORIZATION FORMS.

CL32OV2

=======

OTHER:

[Enter Other Specify-45] ............... {END_LP08}

HELP AVAILABLE FOR MORE INFORMATION ON PHARMACY

AUTHORIZATION FORMS.

CL33

====

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:

[Enter Number-8] ....................... {END_LP08}

----------------------------------------------------

| NOTE: EACH PHARMACY AUTHORIZATION FORM HAS A |

| PRE-ASSIGNED PHARMACY AUTHORIZATION FORM NUMBER. |

----------------------------------------------------

| HARD CHECK–PANEL 12 PHARMACY AUTHORIZATION FORMS: |

| AUTHORIZATION FORM NUMBERS ARE PANEL AND ROUND |

| SPECIFIC. NUMBER ENTERED MUST BE 8 CHARACTERS LONG|

| AND MUST BEGIN AND END WITH AN ALPHA CHARACTER. |

| PANEL 12 PHARMACY AUTHORIZATION FORMS ARE PRINTED |

| ON GRAY PAPER. |

| |

|ORIGIN LETTER 5-NUMBER CHECK ROUND |

| SEQUENCE DIGIT IDENTIFIER|

|PRE- R-S 70000- CONSTANT A,B,C,D,E |

|GENERATED 79999 |

| |

|FIELD R-S 80000- CONSTANT A,B,C,D,E |

|GENERATED 89999 |

| |

|HOME Z 90000- CONSTANT A,B,C,D,E |

|OFFICE 95999 |

| |

|TRAINING/ Y 96600- CONSTANT A,B,C,D,E |

|QC 96799 |

----------------------------------------------------

| HARD CHECK–PANEL 13 PHARMACY AUTHORIZATION FORMS: |

| AUTHORIZATION FORM NUMBERS ARE PANEL AND ROUND |

| SPECIFIC. NUMBER ENTERED MUST BE 8 CHARACTERS LONG|

| AND MUST BEGIN AND END WITH AN ALPHA CHARACTER. |

| PANEL 13 PHARMACY AUTHORIZATION FORMS ARE PRINTED |

| ON ORCHID PAPER. |

| |

|ORIGIN LETTER 5-NUMBER CHECK ROUND |

| SEQUENCE DIGIT IDENTIFIER|

|PRE- R-S 70000- CONSTANT G,H,J,K,L |

|GENERATED 79999 |

| |

|FIELD R-S 80000- CONSTANT G,H,J,K,L |

|GENERATED 89999 |

| |

|HOME Z 90000- CONSTANT G,H,J,K,L |

|OFFICE 95999 |

| |

|TRAINING/ Y 96600- CONSTANT G,H,J,K,L |

|QC 96799 |

----------------------------------------------------

| HARD CHECK–PANEL 14 PHARMACY AUTHORIZATION FORMS: |

| AUTHORIZATION FORM NUMBERS ARE PANEL AND ROUND |

| SPECIFIC. NUMBER ENTERED MUST BE 8 CHARACTERS LONG|

| AND MUST BEGIN AND END WITH AN ALPHA CHARACTER. |

| PANEL 14 PHARMACY AUTHORIZATION FORMS ARE PRINTED |

| ON PINK PAPER. |

| |

|ORIGIN LETTER 5-NUMBER CHECK ROUND |

| SEQUENCE DIGIT IDENTIFIER|

|PRE- Q,R,S 70000- CONSTANT M,N,P,Q,R |

|GENERATED 79999 |

| |

|FIELD Q,R,S 80000- CONSTANT M,N,P,Q,R |

|GENERATED 89999 |

| |

|HOME Z 90000- CONSTANT M,N,P,Q,R |

|OFFICE 95999 |

| |

|TRAINING/ Y 96600- CONSTANT M,N,P,Q,R |

|QC 96799 |

----------------------------------------------------

| SOME IMPORTANT POINTS TO REMEMBER ABOUT PHARMACY |

| AUTHORIZATION FORMS: |

| - THE PREFIX LETTER CHANGES BASED ON THE TYPE OF |

| AUTHORIZATION FORM AND THE ORIGIN OF THE FORM. |

| THIS MEANS THAT A PRE-PRINTED OR FIELD |

| GENERATED AUTHORIZATION FORM WILL DRAW FROM |

| THE SAME LETTER OR RANGE OF LETTERS IN EACH |

| PANEL. THE EXCEPTION IS PANEL 14 PHARMACY |

| AUTHORIZATION FORMS WHICH WILL DRAW FROM AN |

| EXPANDED LIST OF PREFIX LETTERS TO ACCOMMODATE |

| A CHANGE IN COLLECTION PROCEDURES. |

| - THE 5-NUMBER SEQUENCE REPEATS ITSELF FOR EACH |

| PANEL. |

| - THE CHECK-DIGIT ALWAYS REMAINS CONSTANT. |

| - THE ROUND IDENTIFIER IS DIFFERENT FOR EACH |

| PANEL. THE ROUND IDENTIFIER WILL REMAIN THE |

| SAME FOR ALL AUTHORIZATION FORMS COLLECTED |

| WITHIN A PANEL, BUT CHANGES BASED ON THE ROUND.|

| FOR EXAMPLE: AUTHORIZATION FORMS GENERATED FOR |

| PANEL 14, ROUND 1 WILL USE THE ROUND IDENTIFIER|

| “M”; “M” OR “N” FOR ROUND 2; “M”, “N”, OR “P” |

| FOR ROUND 3; “M”, “N”, “P” OR “Q” FOR ROUND 4; |

| AND “M”, “N”, “P”, “Q” OR “R” FOR ROUND 5. |

----------------------------------------------------

CL34

====

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 MAIN REASON FOR REFUSAL:

DOESN’T WANT TO BOTHER PHARMACY ........ 1 {END_LP08}

CONFIDENTIALITY/SENSITIVE ISSUE ........ 2 {END_LP08}

PAYMENT PROBLEM WITH PHARMACY .......... 3 {END_LP08}

HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP08}

WANTS MORE INFORMATION BEFORE SIGNING .. 5 {END_LP08}

NOT INTERESTED ......................... 6 {END_LP08}

NO REASON GIVEN ........................ 7 {END_LP08}

OTHER ................................. 91 {CL34OV}

[Code One]

CL34OV

======

OTHER REASON FOR REFUSAL:

[Enter Other Specify-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 THROUGH 5) |

----------------------------------------------------

| IF ROUND 2 OR 4, CONTINUE WITH BOX_15 |

----------------------------------------------------

| IF ROUND 3 OR 5, GO TO BOX_16 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_16A |

----------------------------------------------------

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, 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, |

| 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. |

----------------------------------------------------

CL35

====

Now I would like to ask (READ PERSON NAMES BELOW) to complete

a brief survey about health and health opinions.

TO SCROLL, USE ARROW KEYS. TO LEAVE SCREEN, PRESS ESC.

|-------------------------------------------|---------------|

| ROSTER. PERSON | CL35_01. PID |

|-------------------------------------------|---------------|

| [First Name, [Middle Name], Last Name-65] | [PID] |

|-------------------------------------------|---------------|

| [First Name, [Middle Name], Last Name-65] | [PID] |

|-------------------------------------------|---------------|

| [First Name, [Middle Name], Last Name-65] | [PID] |

|-------------------------------------------|---------------|

AS APPROPRIATE, PREPARE AN SAQ FOR EACH PERSON LISTED ABOVE.

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

HELP AVAILABLE FOR MORE INFORMATION ON SAQ COLLECTION.

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU-MEMBERS_7 |

| |

| COL # 1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY RU MEMBERS’ FIRST, MIDDLE, |

| AND LAST NAMES (PERS.FULLNAME) |

| |

| COL # 2 HEADER: PID |

| INSTRUCTIONS: DISPLAY 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 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. |

----------------------------------------------------

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-MEMBERS-|

| ROSTER 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. |

----------------------------------------------------

CL36

====

{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 ........................... 2 {END_LP09}

NOT COMPLETED, WILL MAIL TO OFFICE ..... 3 {END_LP09}

MAILED TO SAQ RESPONDENT ............... 4 {END_LP09}

REFUSED TO COMPLETE .................... 5 {CL37}

OTHER ................................. 91 {CL36OV}

[Code One]

----------------------------------------------------

| 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.’ |

----------------------------------------------------

CL36OV

======

OTHER:

[Enter Other Specify-45] ............... {END_LP09}

CL37

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

SELECT MAIN REASON FOR REFUSAL:

TOO BUSY/NOT INTERESTED ................ 1 {END_LP09}

TOO PERSONAL/SENSITIVE INFORMATION ..... 2 {END_LP09}

TOO MUCH OF A PHYSICAL/MENTAL HARDSHIP . 3 {END_LP09}

HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP09}

WANTS MORE INFORMATION ................. 5 {END_LP09}

NOT INTERESTED ......................... 6 {END_LP09}

NO REASON GIVEN ........................ 7 {END_LP09}

OTHER ................................. 91 {CL37OV}

[Code One]

CL37OV

======

OTHER REASON FOR REFUSAL:

[Enter Other Specify-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 |

----------------------------------------------------

CL38

====

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.}

TO SCROLL, USE ARROW KEYS. TO LEAVE SCREEN, PRESS ESC.

|-------------------------------------------|---------------|

| ROSTER. PERSONAL | CL38_01. PID |

|-------------------------------------------|---------------|

| [First Name, [Middle Name], Last Name-65] | [PID] |

|-------------------------------------------|---------------|

| [First Name, [Middle Name], Last Name-65] | [PID] |

|-------------------------------------------|---------------|

| [First Name, [Middle Name], Last Name-65] | [PID] |

|-------------------------------------------|---------------|

1. COLLECT SAQs, IF AVAILABLE.

2. IF ANY REPORTED AS LOST, RE-DISTRIBUTE APPROPRIATE

NUMBER AND TYPE OF SAQs TO THE RESPONDENT.

HELP AVAILABLE FOR MORE INFORMATION ON SAQ COLLECTION.

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU-MEMBERS_7 |

| |

| COL # 1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY RU MEMBERS’ FIRST, MIDDLE, |

| AND LAST NAMES (PERS.FULLNAME) |

| |

| COL # 2 HEADER: PID |

| INSTRUCTIONS: DISPLAY 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 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 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)) |

----------------------------------------------------

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-MEMBERS-|

| ROSTER 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)) |

----------------------------------------------------

CL39

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

PID: {PID}

{SAQ STATUS FROM PREVIOUS ROUND: {PREVIOUS ROUND STATUS -40}}

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 ..... 1 {END_LP10}

NOT COMPLETED, WILL PICK UP AT

LATER DATE ........................... 2 {END_LP10}

NOT COMPLETED, WILL MAIL TO OFFICE ..... 3 {END_LP10}

MAILED TO SAQ RESPONDENT/HOME OFFICE.... 4 {END_LP10}

REFUSED TO COMPLETE .................... 5 {CL40}

OTHER ................................. 91 {CL39OV}

[Code One]

----------------------------------------------------

| DISPLAY THE PERSON’S 3-DIGIT PID FOR ‘PID’. |

----------------------------------------------------

| DISPLAY ‘SAQ STATUS FROM PREVIOUS ROUND’ {PREVIOUS|

| ROUND STATUS -40}’. OTHERWISE, USE A NULL |

| DISPLAY. |

| |

| FOR ‘PREVIOUS ROUND STATUS-40’, DISPLAY THE TEXT |

| ASSOCIATED WITH THE ROUND 2 OR 4 (OR RECEIPT |

| CONTROL UPDATED STATUS) STATUS ENTERED AT CL36. |

| OTHERWISE, USE A NULL DISPLAY. |

----------------------------------------------------

CL39OV

======

OTHER:

[Enter Other Specify-45] ............... {END_LP10}

CL40

====

{PERSON’S FIRST MIDDLE AND LAST NAME}

SELECT MAIN REASON FOR REFUSAL:

TOO BUSY/NOT INTERESTED ................ 1 {END_LP10}

TOO PERSONAL/SENSITIVE INFORMATION ..... 2 {END_LP10}

TOO MUCH OF A PHYSICAL/MENTAL HARDSHIP . 3 {END_LP10}

HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP10}

WANTS MORE INFORMATION ................. 5 {END_LP10}

NOT INTERESTED ......................... 6 {END_LP10}

NO REASON GIVEN ........................ 7 {END_LP10}

OTHER ................................. 91 {CL40OV}

[Code One]

CL40OV

======

OTHER REASON FOR REFUSAL:

[Enter Other Specify-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: DIABETES CARE SUPPLEMENT (DCS) |

| QUESTIONNAIRE (ROUNDS 3 AND 5 ONLY) |

----------------------------------------------------

| 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 |

----------------------------------------------------

CL40A

=====

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.

TO SCROLL, USE ARROW KEYS. TO LEAVE SCREEN, PRESS ESC.

|-------------------------------------------|----------------|-----------------------|

| ROSTER. PERSON | CL40A_01. PID | CL40A_02. TYPE OF DCS |

|-------------------------------------------|----------------|-----------------------|

| [First Name, [Middle Name], Last Name-65] | [PID] | {SELF/PROXY} |

|-------------------------------------------|----------------|-----------------------|

| [First Name, [Middle Name], Last Name-65] | [PID] | {SELF/PROXY} |

|-------------------------------------------|----------------|-----------------------|

| [First Name, [Middle Name], Last Name-65] | [PID] | {SELF/PROXY} |

|-------------------------------------------|----------------|-----------------------|

AS APPROPRIATE, COLLECT A DCS FOR EACH PERSON LISTED ABOVE.

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

----------------------------------------------------

| 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 |

| |

| COL # 1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY RU MEMBERS’ FIRST, MIDDLE, |

| AND LAST NAMES (PERS.FULLNAME) |

| |

| COL # 2 HEADER: PID |

| INSTRUCTIONS: DISPLAY 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 RU- |

| MEMBERS-ROSTER WHO MEETS THE FOLLOWING CONDITION: |

| |

| - PC02 IS CODED ‘1’ (YES) FOR THE PERSON |

----------------------------------------------------

CL40B

=====

{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.

SELECT THE STATUS OF THE DCS:

COMPLETED AND GIVEN TO INTERVIEWER ..... 1 {END_LP10A}

NOT COMPLETED, WILL PICK UP AT

LATER DATE ........................... 2 {END_LP10A}

NOT COMPLETED, WILL MAIL TO OFFICE ..... 3 {END_LP10A}

MAILED TO DCS RESPONDENT ............... 4 {END_LP10A}

REFUSED TO COMPLETE .................... 5 {CL40C}

OTHER ................................. 91 {CL40BOV}

[Code One]

----------------------------------------------------

| 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.’ |

----------------------------------------------------

CL40BOV

=======

OTHER:

[Enter Other Specify-45] ............... {END_LP10A}

CL40C

=====

{PERSON’S FIRST MIDDLE AND LAST NAME}

SELECT MAIN REASON FOR REFUSAL:

TOO BUSY/NOT INTERESTED ................ 1 {END_LP10A}

TOO PERSONAL/SENSITIVE INFORMATION ..... 2 {END_LP10A}

TOO MUCH OF A PHYSICAL/MENTAL HARDSHIP . 3 {END_LP10A}

HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP10A}

WANTS MORE INFORMATION ................. 5 {END_LP10A}

NOT INTERESTED ......................... 6 {END_LP10A}

NO REASON GIVEN ........................ 7 {END_LP10A}

OTHER ................................. 91 {CL40COV}

[Code One]

CL40COV

=======

OTHER REASON FOR REFUSAL:

[Enter Other Specify-45] ................. {END_LP10A}

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: COLLECTING/UPDATING |

| LOCATING INFORMATION (ROUND 1 THROUGH ROUND 5) |

----------------------------------------------------

CL41

====

{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 ‘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 ... of information.’ |

| |

| DISPLAY ‘Just ... family.’ IF ROUND 1. OTHERWISE,|

| DISPLAY ‘Let ... interview.’ |

----------------------------------------------------

| IF NOT ROUND 5, CONTINUE WITH CL42 |

----------------------------------------------------

| OTHERWISE (I.E., IF ROUND 5), GO TO BOX_17 |

----------------------------------------------------

CL42

====

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.

RECORD VERBATIM. TO LEAVE BOX, PRESS TAB.

[Enter Text] ............................. {CL42OV1}

CL42OV1

=======

SELECT WHO BEST TIME RECORDED FOR:

CURRENT RESPONDENT ..................... 1 {BOX_17}

CURRENT PROXY .......................... 2 {BOX_17}

ENTIRE RU .............................. 3 {BOX_17}

OTHER ................................. 91 {CL42OV2}

[Code One]

----------------------------------------------------

| NOTE: CL42OV1 IS ALWAYS DISPLAYED ON THE SCREEN |

| WITH CL42. IT IS NOT A TRUE ‘OVERLAY’. |

----------------------------------------------------

CL42OV2

=======

OTHER:

[Enter Other Specify] .................... {BOX_17}

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 |

----------------------------------------------------

CL43

====

Do you have a second phone number where you can be reached

such as a cell phone, a work number, or the number of a

friend or relative?

IF AVAILABLE, VERIFY CURRENT SECOND PHONE SHOWN BELOW.

Current Info: [2ND_TELEPHONE]

YES, ENTER NEW SECOND PHONE ............ 1 {CL44}

YES, SECOND PHONE ABOVE CORRECT ........ 2 {CL46}

YES, SECOND PHONE ABOVE NEEDS

CORRECTION ........................... 3 {CL44_2}

NO ..................................... 4 {CL46}

REF ................................... -7 {CL46}

DK .................................... -8 {CL46}

----------------------------------------------------

| 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. |

----------------------------------------------------

| HARD CHECK: |

| CODES ‘2’ (YES, SECOND PHONE ABOVE CORRECT) AND |

| ‘3’ (YES, SECOND PHONE ABOVE 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.’ |

----------------------------------------------------

CL44

====

[What is that telephone number?]

ENTER COMPLETE SECOND TELEPHONE NUMBER.

Current Info: [2ND_TELEPHONE]

[Enter Area Code,Exchange,Local] ...... {CL45}

REF ................................... -7 {CL45}

DK .................................... -8 {CL45}

----------------------------------------------------

| FLAG SECOND PHONE INFORMATION FOR THE RU WITH THE |

| NUMBER ENTERED OR CORRECTED AT CL44 FOR THE |

| CURRENT ROUND. |

----------------------------------------------------

| HARD CHECK: |

| DISALLOW LEADING ZEROES AS AN ENTRY. |

| |

| AN ENTRY MUST BE MADE FOR EVERY FIELD (REF AND DK |

| ARE ALLOWED). |

----------------------------------------------------

CL44_2

======

[What is that telephone number?]

UPDATE CURRENT SECOND PHONE.

TO CORRECT OR ENTER NEW INFORMATION, TYPE ENTIRE FIELD.

Current Info: [2ND_TELEPHONE]

[Enter Area Code,Exchange,Local] ...... {CL45}

REF ................................... -7 {CL45}

DK .................................... -8 {CL45}

----------------------------------------------------

| 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. |

----------------------------------------------------

CL45

====

Where is that telephone located?

OFFICE/PLACE OF BUSINESS ............... 1 {CL45OV2}

RELATIVE ............................... 2 {CL45OV2}

NEIGHBOR ............................... 3 {CL45OV2}

FRIEND ................................. 4 {CL45OV2}

CELL PHONE ............................. 5 {CL45OV2}

OTHER ..................................91 {CL45OV1}

REF ................................... -7 {CL45OV2}

DK .................................... -8 {CL45OV2}

[Code One]

CL45OV1

=======

OTHER:

[Enter Other Specify-45] .............. {CL45OV2}

REF ................................... -7 {CL45OV2}

DK .................................... -8 {CL45OV2}

CL45OV2

=======

ENTER NAME AND/OR DESCRIPTION OF SECOND PHONE. ALSO, INCLUDE

ANY SPECIAL INSTRUCTIONS FOR CALLING AT THE ALTERNATE TELEPHONE

NUMBER (FOR EXAMPLE, CALL ONLY IN EMERGENCY).

[Enter Description] ................... {CL46}

REF ................................... -7 {CL46}

DK .................................... -8 {CL46}

----------------------------------------------------

| ALLOW 2 LINES OF 45 CHARACTERS FOR DESCRIPTION. |

----------------------------------------------------

CL46

====

Do you receive your mail at an address different from your home

address, such as a P.O. Box?

IF AVAILABLE, VERIFY CURRENT MAILING ADDRESS SHOWN BELOW.

Current Info: [1ST_STR_ADDRESS]

[2ND_STR_ADDRESS]

[CITY]

[STATE]

[ZIP CODE]

YES, ENTER NEW MAILING ADDRESS

(DIFFERENT FROM HOME ADDRESS) ........ 1 {CL47}

YES, MAILING ADDRESS ABOVE CORRECT ..... 2 {BOX_17A}

YES, MAILING ADDRESS ABOVE NEEDS

CORRECTION ........................... 3 {CL47_2}

NO (RECEIVE MAIL AT HOME ADDRESS) ...... 4 {BOX_17A}

REF ................................... -7 {BOX_17A}

DK .................................... -8 {BOX_17A}

----------------------------------------------------

| HARD CHECK: |

| CODES ‘2’ (YES, MAILING ADDRESS ABOVE CORRECT) |

| AND ‘3’ (YES, MAILING ADDRESS ABOVE 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.’ |

----------------------------------------------------

CL47

====

[What is that address?]

ENTER COMPLETE MAILING ADDRESS.

Current Info: [1ST_STR_ADDRESS]

[2ND_STR_ADDRESS]

[CITY],[STATE] [ZIP CODE]

1ST_STR_ADDRESS: [_____________]

2ND_STR_ADDRESS: [_____________]

CITY: [_____________]

STATE: [_____________]

ZIP CODE: [_____________] {BOX_17A}

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

----------------------------------------------------

| CONTINUE WITH BOX_17A |

----------------------------------------------------

| HARD CHECK: |

| AN ENTRY MUST BE MADE FOR EVERY FIELD EXCEPT |

| SECOND STREET ADDRESS (REF AND DK ARE ALLOWED). |

----------------------------------------------------

CL47_2

======

[What is that address?]

USE TAB TO MOVE THROUGH FIELDS REQUIRING NO CORRECTION.

TO CORRECT OR ENTER NEW INFORMATION, TYPE ENTIRE FIELD.

TYPE THREE Xs (XXX) TO DELETE 2ND STREET ADDRESS.

Current Info: [1ST_STR_ADDRESS]

[2ND_STR_ADDRESS]

[CITY],[STATE] [ZIP CODE]

1ST_STR_ADDRESS: [_____________]

2ND_STR_ADDRESS: [_____________]

CITY: [_____________]

STATE: [_____________]

ZIP CODE: [_____________] {BOX_17A}

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

BOX_17A

=======

----------------------------------------------------

| IF NOT ROUND 5, CONTINUE WITH CL48 |

----------------------------------------------------

| OTHERWISE (I.E., IF ROUND 5), GO TO BOX_18 |

----------------------------------------------------

CL48

====

Do you have a second home, such as a vacation home, where we

could contact you if you’re not available at your usual

address?

IF AVAILABLE, VERIFY CURRENT SECOND HOME INFORMATION SHOWN BELOW.

Current Info: [1ST_STR_ADDRESS]

[2ND_STR_ADDRESS]

[CITY], [STATE] [ZIP CODE]

[TELEPHONE]

YES, ENTER NEW SECOND HOME ADDRESS AND

TELEPHONE ............................ 1 {CL49}

YES, SECOND HOME ADDRESS AND TELEPHONE

ABOVE CORRECT ........................ 2 {CL50}

YES, SECOND HOME ADDRESS OR TELEPHONE

ABOVE NEEDS CORRECTION ............... 3 {CL49_2}

NO ..................................... 4 {CL50}

REF ................................... -7 {CL50}

DK .................................... -8 {CL50}

----------------------------------------------------

| HARD CHECK: |

| CODES ‘2’ (YES, SECOND HOME ADDRESS AND TELEPHONE |

| ABOVE CORRECT) AND ‘3’ (YES, SECOND HOME ADDRESS |

| OR TELEPHONE ABOVE 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 NOT |

| AVAILABLE. NO CURRENT SECOND HOME ADDRESS. |

| VERIFY AND RE-ENTER.’ |

----------------------------------------------------

CL49

====

[What is the address and phone number of that home?]

ENTER COMPLETE SECOND HOME ADDRESS.

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.

----------------------------------------------------

| HARD CHECK: |

| AN ENTRY MUST BE MADE FOR EVERY FIELD EXCEPT |

| SECOND STREET ADDRESS (REF AND DK ARE ALLOWED). |

----------------------------------------------------

CL49_2

======

[What is the address and phone number of that home?]

USE TAB TO MOVE THROUGH FIELDS REQUIRING NO CORRECTION.

TO CORRECT OR ENTER NEW INFORMATION, TYPE ENTIRE FIELD.

TYPE THREE Xs (XXX) TO DELETE 2ND STREET ADDRESS.

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.

CL50

====

Do you have a friend or relative who does not live here who

will always know how to get in touch with the family?

YES .................................... 1 {CL51}

NO ..................................... 4 {CL53}

REF ................................... -7 {CL53}

DK .................................... -8 {CL53}

CL51

====

What is the name, address, and phone number of that person?

ENTER COMPLETE CONTACT INFORMATION.

ENTER ‘NMN’ IF NO MIDDLE NAME.

NAME [FIRST, MIDDLE, LAST] [_____________]

1ST_STR_ADDRESS [_____________]

2ND_STR_ADDRESS [_____________]

CITY [_____________]

STATE [_____________]

ZIP CODE [_____________]

TELEPHONE [_____________]

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

----------------------------------------------------

| GO TO CL52. |

----------------------------------------------------

| HARD CHECK: |

| AN ENTRY MUST BE MADE FOR EVERY FIELD EXCEPT |

| SECOND STREET ADDRESS (REF AND DK ARE ALLOWED). |

----------------------------------------------------

CL51_2

======

OMITTED.

CL52

====

What is {NAME OF CONTACT PERSON FROM CL51}’s relationship to

{NAME OF REFERENCE PERSON}?

ENTER COMPLETE CONTACT RELATIONSHIP.

CONTACT_RELATIONSHIP: [_____________] {CL53}

----------------------------------------------------

| 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: |

| AN ENTRY MUST BE MADE (REF AND DK ARE ALLOWED). |

----------------------------------------------------

CL52_2

======

OMITTED

CL53

====

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?

IF AVAILABLE, VERIFY CURRENT ALTERNATE RESPONDENT INFORMATION

SHOWN BELOW.

Current Info: [ALTERNATE_NAME]

[1ST_STR_ADDRESS]

[2ND_STR_ADDRESS]

[CITY], [STATE] [ZIP CODE]

[TELEPHONE]

ENTER NEW ALTERNATE RESPONDENT

INFORMATION .......................... 1 {CL54}

ALTERNATE RESPONDENT INFORMATION

ABOVE CORRECT ........................ 2 {CL56}

ALTERNATE RESPONDENT INFORMATION ABOVE

NEEDS CORRECTION ..................... 3 {CL54}

NO ALTERNATE RESPONDENT AVAILABLE ...... 4 {CL57}

REF ................................... -7 {CL57}

DK .................................... -8 {CL57}

----------------------------------------------------

| 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 ABOVE |

| CORRECT) AND ‘3’ (ALTERNATE RESPONDENT |

| INFORMATION ABOVE 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.’ |

----------------------------------------------------

CL54

====

INTERVIEWER: SELECT PERSON NAMED FROM ROSTER.

[First Name, [Middle Name], Last Name-65]

----------------------------------------------------

| IF ‘SOMEONE OUTSIDE DU’ SELECTED AND CL53 IS |

| ‘ENTER NEW ALTERNATE RESPONDENT INFORMATION, |

| CONTINUE WITH CL55. |

| ELSE IF ‘SOMEONE OUTSIDE DU’ SELECTED AND CL53 IS |

| ‘ALTERNATE RESPONDENT INFORMATION NEEDS |

| CORRECTION’, CONTINUE WITH CL55_2. |

----------------------------------------------------

| OTHERWISE, GO TO CL57 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: DU_MEMBERS_1 |

| |

| COL # 1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY DU MEMBER’S FIRST, MIDDLE, |

| AND LAST NAMES (PERS.FULLNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| DISPLAY PERSONS ON THE 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 |

----------------------------------------------------

CL55

====

What is the name, address, and phone number of that person?

ENTER COMPLETE ALTERNATE RESPONDENT INFORMATION.

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: [_____________]

ZIP CODE: [_____________]

TELEPHONE: [_____________]

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

----------------------------------------------------

| IF THERE IS NO CURRENT ALTERNATE RELATIONSHIP, |

| PROCEED TO CL56. |

| OTHERWISE, PROCEED TO CL56_2. |

----------------------------------------------------

| HARD CHECK: |

| AN ENTRY MUST BE MADE FOR EVERY FIELD EXCEPT |

| SECOND STREET ADDRESS (REF AND DK ARE ALLOWED). |

----------------------------------------------------

CL55_2

======

[What is the name, address, and phone number of that person?]

USE TAB TO MOVE THROUGH FIELDS REQUIRING NO CORRECFTION.

TO CORRECT OR ENTER NEW INFORMATION, TYPE ENTIRE FIELD.

ENTER ‘NMN’ IF NO MIDDLE NAME.

TYPE THREE Xs (XXX) TO DELETE 2ND STREET ADDRESS.

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: [_____________]

ZIP CODE: [_____________]

TELEPHONE: [_____________]

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

----------------------------------------------------

| IF THERE IS NO CURRENT ALTERNATE RELATIONSHIP, |

| PROCEED TO CL56. |

| OTHERWISE, PROCEED TO CL56_2. |

----------------------------------------------------

CL56

====

What is {NAME OF ALTERNATE RESPONDENT CL55}’s relationship to

{NAME OF REFERENCE PERSON}?

ENTER COMPLETE ALTERNATE RESPONDENT RELATIONSHIP.

Current Info: [ALTERNATE_RELATIONSHIP]

ALTERNATE_RELATIONSHIP: [_____________] {CL57}

----------------------------------------------------

| 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: |

| AN ENTRY MUST BE MADE (REF AND DK ARE ALLOWED). |

----------------------------------------------------

CL56_2

======

[What is {NAME OF ALTERNATE RESPONDENT CL55}’s relationship to

{NAME OF REFERENCE PERSON}?]

UPDATE CURRENT ALTERNATE RESPONDENT.

TO CORRECT OR ENTER NEW INFORMATION, TYPE ENTIRE FIELD.

Current Info: [ALTERNATE_RELATIONSHIP]

ALTERNATE_RELATIONSHIP: [_____________] {CL57}

----------------------------------------------------

| 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’. |

----------------------------------------------------

CL57

====

Is anyone in the family planning to move within the next 3

months?

YES .................................... 1 {CL58}

NO ..................................... 2 {BOX_18}

REF ................................... -7 {BOX_18}

DK .................................... -8 {BOX_18}

CL58

====

Who is that?

PROBE: Anyone else?

[First Name, [Middle Name], Last Name-65]

----------------------------------------------------

| CONTINUE WITH LOOP_11 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU_MEMBERS_1 |

| |

| COL # 1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE, |

| AND LAST NAMES (PERS.FULLNAME) |

----------------------------------------------------

| 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) |

----------------------------------------------------

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) |

----------------------------------------------------

CL59

====

{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.

----------------------------------------------------

| REFUSED AND DON’T KNOW ALLOWED FOR EACH FIELD. |

----------------------------------------------------

| FLAG PERSON AS ‘PROCESSED FUTURE MOVER’. |

----------------------------------------------------

| 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 |

----------------------------------------------------

| HARD CHECK: CAPI REQUIRES AN ENTRY IN ALL FIELDS |

| EXCEPT SECOND STREET ADDRESS. |

----------------------------------------------------

CL60

====

{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}

REF ................................... -7 {END_LP11}

DK .................................... -8 {END_LP11}

CL61

====

{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]

----------------------------------------------------

| FLAG ALL SELECTED PERSONS AS ‘PROCESSED FUTURE |

| MOVER’. |

----------------------------------------------------

| CONTINUE WITH END_LP11 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU_MEMBERS_1 |

| |

| COL # 1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE, |

| AND LAST NAMES (PERS.FULLNAME) |

----------------------------------------------------

| 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’ |

----------------------------------------------------

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 |

| CL61A |

----------------------------------------------------

| OTHERWISE, GO TO CL62 |

----------------------------------------------------

BOX_18A

=======

OMITTED.

CL61A

=====

FOR PROXY RESPONDENT: May I please have your address and

telephone number?

IF AVAILABLE, VERIFY CURRENT PROXY ADDRESS SHOWN BELOW.

Current Info: [PROXY_NAME]

[1ST_STR_ADDRESS]

[2ND_STR_ADDRESS]

[CITY], [STATE] [ZIP CODE]

[TELEPHONE]

YES, ENTER NEW PROXY ADDRESS AND

TELEPHONE ............................ 1 {CL61B}

YES, PROXY ADDRESS AND TELEPHONE ABOVE

CORRECT .............................. 2 {CL62}

YES, PROXY ADDRESS OR TELEPHONE ABOVE

NEEDS CORRECTION ..................... 3 {CL61B_2}

NO ..................................... 4 {CL62}

REF ................................... -7 {CL62}

DK .................................... -8 {CL62}

----------------------------------------------------

| HARD CHECK: |

| CODES ‘2’ (YES, PROXY ADDRESS AND TELEPHONE ABOVE |

| CORRECT) AND ‘3’ (YES, PROXY ADDRESS OR TELEPHONE |

| ABOVE 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.’ |

----------------------------------------------------

CL61B

=====

What is your address and phone number?

ENTER COMPLETE PROXY ADDRESS.

Current Info: [1ST_STR_ADDRESS]

[2ND_STR_ADDRESS]

[CITY], [STATE] [ZIP CODE]

[TELEPHONE]

1ST_STR_ADDRESS: [_____________]

2ND_STR_ADDRESS: [_____________]

CITY: [_____________]

STATE: [_____________]

ZIP CODE: [_____________]

TELEPHONE: [_____________]

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

----------------------------------------------------

| FLAG PROXY ADDRESS INFORMATION FOR THE RU WITH THE|

| ADDRESS AND PHONE ENTERED OR CORRECTED AT CL61B |

| FOR THE CURRENT ROUND. |

----------------------------------------------------

| CONTINUE WITH CL62 |

----------------------------------------------------

| HARD CHECK: |

| AN ENTRY MUST BE MADE FOR EVERY FIELD EXCEPT |

| SECOND STREET ADDRESS (REF AND DK ARE ALLOWED). |

----------------------------------------------------

CL61B_2

=======

[What is your address and phone number?]

USE TAB TO MOVE THROUGH FIELDS REQUIRING NO CORRECTION.

TO CORRECT OR ENTER NEW INFORMATION, TYPE ENTIRE FIELD.

TYPE THREE Xs (XXX) TO DELETE 2ND STREET ADDRESS.

Current Info: [1ST_STR_ADDRESS]

[2ND_STR_ADDRESS]

[CITY], [STATE] [ZIP CODE]

[TELEPHONE]

1ST_STR_ADDRESS: [_____________]

2ND_STR_ADDRESS: [_____________]

CITY: [_____________]

STATE: [_____________]

ZIP CODE: [_____________]

TELEPHONE: [_____________]

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

----------------------------------------------------

| FLAG PROXY ADDRESS INFORMATION FOR THE RU WITH THE|

| ADDRESS AND PHONE ENTERED OR CORRECTED AT CL61B |

| FOR THE CURRENT ROUND. |

----------------------------------------------------

| CONTINUE WITH CL62 |

----------------------------------------------------

CL62

====

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}

[Code One]

CL62A

=====

INTERVIEWER: WHAT LANGUAGE WAS THIS INTERVIEW COMPLETED IN?

ENGLISH ................................ 1 {CL63}

SPANISH ................................ 2 {CL63}

BOTH ENGLISH AND SPANISH ............... 3 {CL63}

OTHER LANGUAGE ........................ 91 {CL62AOV}

[Code One]

CL62AOV

=======

ENTER OTHER LANGUAGE:

[Enter Other Specify-45] ............... {CL63}

CL63

====

INTERVIEWER: WAS ANYONE OTHER THAN THE {RESPONDENT/PROXY}

PRESENT FOR ALL OR PART OF THE INTERVIEW?

NO ONE ELSE PRESENT .................... 1 {CL65}

SOMEONE ELSE PRESENT FOR ALL OF

INTERVIEW ........................... 2 {CL64}

SOMEONE ELSE PRESENT FOR PART OF

INTERVIEW ........................... 3 {CL64}

[Code One]

----------------------------------------------------

| DISPLAY ‘RESPONDENT’ IF CURRENT RESPONDENT IS AN |

| RU MEMBER. DISPLAY ‘PROXY’ IF CURRENT RESPONDENT |

| IS A PROXY. |

----------------------------------------------------

CL64

====

INTERVIEWER: SELECT ALL OTHER PERSONS PRESENT DURING INTERVIEW.

TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.

TO LEAVE, PRESS ESC.

[First Name, [Middle Name], Last Name-65]

----------------------------------------------------

| DISPLAY ‘SOMEONE OUTSIDE DU’ AS AN OPTION ON THIS |

| SCREEN. |

----------------------------------------------------

| CONTINUE WITH CL65 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: DU_MEMBERS_1 |

| |

| COL # 1 HEADER: NAME |

| INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE, |

| AND LAST NAMES (PERS.FULLNAME) |

----------------------------------------------------

| 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 |

| - 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

====

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 RESPONDENT PAYMENT SECTION OF THE CASE FOLDER

AND RECORD THE SAQ CHECK(S).}

2b. COMPLETE THE RESPONDENT PAYMENT SECTION OF THE CASE FOLDER,

RECORD THE INTERVIEW PARTICIPATION CHECK, AND HAVE RESPONDENT

SIGN IT.

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

----------------------------------------------------

| DISPLAY ‘1a. FILL ... NAME(S).’ AND ‘2a. COMPLETE |

| ... SAQ CHECK(S)’. IF ROUNDS 2-5 AND IF ANY CL36 |

| OR CL39 IS CODED ‘1’ (COMPLETED AND GIVEN TO |

| INTERVIEWER) FOR ANY SAQ. OTHERWISE, USE A NULL |

| DISPLAY. |

----------------------------------------------------

CL66

====

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.}

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

----------------------------------------------------

| DISPLAY ‘This check ... /early {YEAR}}.’ 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 ‘6. ASK ... GIFT.’ IF ROUNDS 1 OR 2 OR 3 |

| OR 4. IF ROUND 5, USE A NULL DISPLAY. |

----------------------------------------------------

CL67

====

INTERVIEWER: WERE ANY OF THE FOLLOWING MEMORY AIDS USED BY THE

RESPONDENT(S) DURING THE INTERVIEW?

CL67_01

=======

MONTHLY PLANNER

WITH ENTRIES YES NO

CL67_02

=======

MONTHLY PLANNER

WITHOUT ENTRIES YES NO

CL67_03

=======

OMITTED

CL67_04

=======

RECORD FILE YES NO

CL67_05

=======

OTHER CALENDAR YES NO

CL67_06

=======

CHECK BOOK YES NO

CL67_07

=======

BILL/STATEMENT FROM

PROVIDER YES NO

CL67_08

=======

INSURANCE PAYMENT

STATEMENT YES NO

CL67_09

=======

MEDICINE

BOTTLE/RECEIPT YES NO

CL67_10

=======

OTHER YES NO

----------------------------------------------------

| IF CL67_10 IS CODED '1' (YES), CONTINUE WITH |

| CL68 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_20 |

----------------------------------------------------

CL68

====

WHICH OTHER MEMORY AIDS?

CL68_01

=======

DOCTOR'S CARD OR

APPOINTMENT SLIP YES NO

CL68_02

=======

INSURANCE POLICY YES NO

CL68_03

=======

INSURANCE CARDS YES NO

CL68_04

=======

TELEPHONE BOOK YES NO

CL68_05

=======

OTHER YES NO

----------------------------------------------------

| IF CL68_01 THROUGH CL68_05 ARE ALL CODED `2’ (NO),|

| CAPI DISPLAYS THE FOLLOWING MESSAGE: ‘AT LEAST |

| ONE FIELD SHOULD BE CODED YES.’ THE INTERVIEWER |

| MUST RE-ENTER RESPONSES TO CL68_01 THROUGH |

| CL68_05. |

----------------------------------------------------

| IF CL68_05 IS CODED '1' (YES), CONTINUE WITH |

| CL68OV |

----------------------------------------------------

| OTHERWISE, GO TO BOX_20 |

----------------------------------------------------

CL68OV

======

OTHER:

[Enter Other Specify] .................. {BOX_20}

BOX_20

======

----------------------------------------------------

| END INTERVIEW. |

----------------------------------------------------

33-109

File Type	application/msword
File Title	MEPS Closing - P12R5/P13R3/P14R1
Subject	CL Section Item Specifications
Author	Agency for Healthcare Research and Quality
Last Modified By	wcarroll
File Modified	2009-07-08
File Created	2009-07-08