Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

BOX AC1AA

BOX AC1AA

Page Order # :

10

BOX INSTRUCTIONS
( ACQ1010 )

IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO ACINTRO - ACINT (
ACQ1030 ).
ELSE IF (SP HAD AN ER VISIT IN THE CURRENT ROUND OR ANY OF THE
2 PREVIOUS ROUNDS) AND (AC6A NOT ALREADY ASKED), GO TO
AC6A - EWAITHRS ( ACQ1130 ).
ELSE GO TO BOX AC1C - (ACQ1170 ).

ASSIGNMENTS

TECHNICAL NOTES
9

SuppORD

SP is in the Supplemental Sample =
MRES.INTTYPE=3/NewFromSupplement on MRES
where MRES.MRESRND = current round.

26

SPHadERVisit

SP had ER visit in current round or 2 previous rounds =
There is an EVNT where (EVNT.EVNTTYPE=ER and
EVNT.EVNTDFLG^=1/Yes and EVNT.EVNTRNDC >=
current round - 2).

31

AC6AAsked

AC6A already asked =
ACCS.EWAITUNT ^= EMPTY on ACCS where
ACCS.ACCSRND = current round.

DESIGN NOTES
The AC section collects Access to Care information based on the SP's
Emergency Room, Outpatient and Medical Provider visits.
The AC section is asked in its entirety for Supplement sample following
the DM section.
The Continuing sample receives a subset of AC questions based on ER,
OP, and MP utilization in the current round. If the SP reports a current
round ER visit, we ask AC6A while administering ER. If the SP reports a
current round OP visit, we ask AC9-AC16A while administering OP. If the
SP reports a current round MP visit, we ask AC20-AC28A1 while
administering MP. Once MP is complete, the AC section is administered
to the continuing sample. The SP will receive ER, OP, MP related
questions in AC based on whether or not the SP reported an ER, OP or
MP visit during the past year. The AC questions will only be asked once,
therefore if the SP has already received a subset of the AC questions in
ER, OP, and/or MP, these questions will be skipped while administering
AC.

6:29:13 PM Monday, July 07, 2008

Page 1 of 85

ACINTRO

ACINTRO

Page Order # :

Design Screen Type:

No Entry

Fields:

Field 1:

ACINT

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

30

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

The next questions are about health care services [you/(SP)] may

have used since (REFERENCE DATE).

Int. Instr II:
INPUT FIELDS / ROUTING

6:29:15 PM Monday, July 07, 2008

Page 2 of 85

ACINTRO
ACINT

Field1:
Cheshire Name:

( ACQ1030 )

TEMP

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC1 - ERVISIT ( ACQ1040 )

English text: CONTINUE
Attribute
Empty

Route
AC1 - ERVISIT ( ACQ1040 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:29:19 PM Monday, July 07, 2008

Page 3 of 85

AC1

AC1

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

ERVISIT

Enable Functions:

HELP
COMMENTS
JUMPBACK

Yes
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

40

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

Since (REFERENCE DATE), did [you/(SP)] go to a hospital

emergency room?

Int. Instr II:
INPUT FIELDS / ROUTING

6:29:21 PM Monday, July 07, 2008

Page 4 of 85

AC1
ERVISIT

Field1:
Cheshire Name:

( ACQ1040 )

ACCS.ERVISIT

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC6A - EWAITHRS ( ACQ1130 )

English text: YES
No

AC8 - OPDVISIT ( ACQ1180 )

English text: NO
Attribute
Don't know

Route
AC8 - OPDVISIT ( ACQ1180 )

Refusal

AC8 - OPDVISIT ( ACQ1180 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:29:25 PM Monday, July 07, 2008

Page 5 of 85

AC6A

AC6A

Page Order # :

Design Screen Type:

Quantity Unit

Fields:

Field 1:

EWAITUNT

Field 2:

EWAITHRS

Field 3:

EWAITMIN

HELP
COMMENTS
JUMPBACK

No
No
No

Enable Functions:

90

Roster Name:
Roster Type:
Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No

No

No

No

Grid Functions:

Add Line
Delete Line

No
No

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Display "most recent" in the first sentence in BOLD.

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

Think about the most recent time [you/(SP)] went to the hospital
emergency room. How long did [you/(SP)] have to wait during
(your/his/her) visit before (you/he/she) saw a doctor or some other
medical person? Please include the time spent in the waiting room
and exam room.

Int. Instr II:

6:29:28 PM Monday, July 07, 2008

Page 6 of 85

AC6A
INPUT FIELDS / ROUTING

Field1:

EWAITUNT

Cheshire Name:

( ACQ1120 )

ACCS.EWAITUNT

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TAcsuntb
1
No
No

Number Label
0 DidNotHaveToWait

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX AC1B - (ACQ1150 )

1

English text: DID NOT HAVE TO WAIT
HoursOnly

AC6A - EWAITHRS ( ACQ1130 )

2

English text: HOURS ONLY
MinutesOnly

AC6A - EWAITMIN ( ACQ1140 )

3

English text: MINUTES ONLY
HoursAndMinutes

AC6A - EWAITHRS ( ACQ1130 )

English text: HOURS AND MINUTES
Attribute
Don't know

Route
BOX AC1B - (ACQ1150 )

Refusal

BOX AC1B - (ACQ1150 )

6:29:34 PM Monday, July 07, 2008

Page 7 of 85

AC6A

Field2:
Cheshire Name:

EWAITHRS

( ACQ1130 )

ACCS.EWAITHRS

Item Text display:
Item Text:
Label:
Label Position:

HOURS:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TAccshrs1
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:

Min Value:
Max Value:
Mask:

1

72

Route
If AC6A - EWAITUNT = 3/HoursAndMinutes, go

to AC6A - EWAITMIN.

Else go to BOX AC1B.

Field3:
Cheshire Name:

EWAITMIN

( ACQ1140 )

ACCS.EWAITMIN

Item Text display:
Item Text:
Label:

Label Position:

MINUTES:
Left

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:

Integer
TAccsmin
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:

Min Value:
Max Value:
Mask:

1

59

Route
BOX AC1B - (ACQ1150 )

BACKGROUND VARIABLE ASSIGNMENTS

6:29:36 PM Monday, July 07, 2008

Page 8 of 85

AC6A
SOFT EDIT CHECKS
Edit #1:

If EWAITUNT = 1/HoursOnly or 3/HoursAndMinutes, EWAITHRS =

1-16.

If not true, display message: "THE VALUE ENTERED FOR

NUMBER OF HOURS SEEMS UNLIKELY. PLEASE VERIFY."

Edit #2:

If EWAITUNT = 2/MinutesOnly or 3/HoursAndMinutes, EWAITMIN =

5 - 59.

If not true, display message: "THE VALUE ENTERED FOR

NUMBER OF MINUTES SEEMS UNLIKELY. PLEASE VERIFY."

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:29:36 PM Monday, July 07, 2008

Page 9 of 85

BOX AC1B

BOX AC1B

Page Order # :

100

BOX INSTRUCTIONS
( ACQ1150 )

IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO AC7 - ERADMT (
ACQ1160 ).
ELSE GO TO BOX AC1C - (ACQ1170 ).

ASSIGNMENTS

TECHNICAL NOTES
9

SuppORD

SP is in the Supplemental Sample =
MRES.INTTYPE=3/NewFromSupplement on MRES
where MRES.MRESRND = current round.

DESIGN NOTES

6:29:36 PM Monday, July 07, 2008

Page 10 of 85

AC7

AC7

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

ERADMT

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
No
No

110

Roster Name:
Roster Type:
Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

[Were you/Was (SP)] admitted to the hospital from the emergency

room?

Int. Instr II:
INPUT FIELDS / ROUTING

6:29:38 PM Monday, July 07, 2008

Page 11 of 85

AC7
ERADMT

Field1:
Cheshire Name:

( ACQ1160 )

ACCS.ERADMT

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX AC1C - (ACQ1170 )

English text: YES
No

BOX AC1C - (ACQ1170 )

English text: NO
Attribute
Don't know

Route
BOX AC1C - (ACQ1170 )

Refusal

BOX AC1C - (ACQ1170 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:29:42 PM Monday, July 07, 2008

Page 12 of 85

BOX AC1C

BOX AC1C

Page Order # :

120

BOX INSTRUCTIONS
( ACQ1170 )

IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO AC8 - OPDVISIT (
ACQ1180 ).
ELSE IF AC6A ASKED WHILE ADMINISTERING ER, GO TO BOX ER6 (ERQ1365 ).
ELSE IF (SP HAD AN OP VISIT IN THE CURRENT ROUND OR ANY OF
THE 2 PREVIOUS ROUNDS) AND (AC9-AC16A NOT ALREADY ASKED),
GO TO AC9 - OPDREAS ( ACQ1190 ).
ELSE GO TO BOX AC1E - (ACQ1380 ).

ASSIGNMENTS

TECHNICAL NOTES
9

SuppORD

SP is in the Supplemental Sample =
MRES.INTTYPE=3/NewFromSupplement on MRES
where MRES.MRESRND = current round.

27

SPHadOPVisit

SP had OP visit in current round or 2 previous rounds =
There is an EVNT where (EVNT.EVNTTYPE=OP and
EVNT.EVNTDFLG^=1/Yes and EVNT.EVNTRNDC >=
current round - 2).

32

AC9AC16AAsked

AC9-AC16A already asked =
ACCS.OPDREAS ^= EMPTY on ACCS where
ACCS.ACCSRND = current round.

DESIGN NOTES
Included in this box is logic that handles exiting AC when being called
from ER. When administering ER, if the SP reports a current round ER
visit, the ER section calls AC6A. When complete, return to ER.

6:29:42 PM Monday, July 07, 2008

Page 13 of 85

AC8

AC8

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

OPDVISIT

Enable Functions:

HELP
COMMENTS
JUMPBACK

Yes
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

130

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

Since (REFERENCE DATE), did [you/(SP)] go to a hospital clinic or

outpatient department?

Int. Instr II:

DO NOT INCLUDE HOSPITAL INPATIENT STAYS.

INPUT FIELDS / ROUTING

6:29:44 PM Monday, July 07, 2008

Page 14 of 85

AC8
OPDVISIT

Field1:
Cheshire Name:

( ACQ1180 )

ACCS.OPDVISIT

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC9 - OPDREAS ( ACQ1190 )

English text: YES
No

AC17 - NHRESEVR ( ACQ1390 )

English text: NO
Attribute
Don't know

Route
AC17 - NHRESEVR ( ACQ1390 )

Refusal

AC17 - NHRESEVR ( ACQ1390 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:29:48 PM Monday, July 07, 2008

Page 15 of 85

AC9

AC9

Page Order # :

Design Screen Type:

Code All

Fields:

Field 1:

OPDREAS

Field 2:

OPDOTHOS

HELP
COMMENTS
JUMPBACK

Yes
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

140

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

DESIGN NOTE: The first sentence is designed to be the
introductory statement for continuing sample SPs when
administering AC. If SP skipped AC6A, then AC9 will be the SP's
first question in AC. The SP does not receive this introductory
statement when AC9 is called from OP.
If SP is in the continuing sample and AC9 is the SP's first question
asked while administering AC, display "I have a few more . . ." .
Else do not display.
Display "in the past" in the first sentence in BOLD.
Display "most recent" in the second sentence in BOLD.

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
6:29:53 PM Monday, July 07, 2008

Page 16 of 85

AC9
Int. Instr I:
Question Text:

[I have a few more questions about visits that [you/(SP)] had in the
past.]
Think about the most recent time [you/(SP)] went to a hospital clinic
or outpatient department. What was the reason [you/(SP)] went to
the hospital clinic or outpatient department?
[PROBE: Any other reason?]

Int. Instr II:

CHECK ALL THAT APPLY.

INPUT FIELDS / ROUTING

6:30:01 PM Monday, July 07, 2008

Page 17 of 85

AC9
OPDREAS

Field1:
Cheshire Name:

( ACQ1190 )

NONE
REPLACES THE FOLLOWING CHESHIRE VARIABLES:
1/MedCondNamed=ACCS.OPDMCOND
2/Tests=ACCS.OPDTESTS
3/Followup=ACCS.OPDFOLUP
4/Checkup=ACCS.OPDCHKUP
5/Referral=ACCS.OPDRFRL
6/Surgery=ACCS.OPDSURGY
7/PreventiveShot=ACCS.OPDPSHOT
8/TreatmentShot=ACCS.OPDTSHOT
9/RefillPM=ACCS.OPDPMED
91/Other=ACCS.OPDOTHER

Item Text display:
Item Text:
Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:

Enumerated
Treason
10
No
No

Number Label
1 MedCondNamed

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX AC1D - (ACQ1220 )

2

English text: MEDICAL CONDITION NAMED
Tests
BOX AC1D - (ACQ1220 )

3

English text: TESTS
Followup

BOX AC1D - (ACQ1220 )

4

English text: FOLLOW-UP
Checkup

BOX AC1D - (ACQ1220 )

5

English text: CHECKUP
Referral

BOX AC1D - (ACQ1220 )

English text: REFERRAL

6:30:13 PM Monday, July 07, 2008

Page 18 of 85

AC9

6

Surgery

BOX AC1D - (ACQ1220 )

7

English text: SURGERY
PreventiveShot

BOX AC1D - (ACQ1220 )

8

English text: PREVENTIVE SHOT
TreatmentShot

BOX AC1D - (ACQ1220 )

9

English text: TREATMENT SHOT
RefillPM

BOX AC1D - (ACQ1220 )

91

English text: TO GET OR REFILL PRESCRIPTION
Other
AC9 - OPDOTHOS ( ACQ1210 )
English text: OTHER

Attribute
Don't know

Route
BOX AC1D - (ACQ1220 )

Refusal

BOX AC1D - (ACQ1220 )

Field2:
Cheshire Name:

OPDOTHOS

( ACQ1210 )

ACCS.OPDOTHOS

Item Text display:

Display "(SPECIFY)" in the same blue font used for
interviewer instructions.

Item Text:

OTHER (SPECIFY)

Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

String
TOthrspec
1

No

No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:

Max Value:

Mask:

30

Route
BOX AC1D - (ACQ1220 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

6:30:21 PM Monday, July 07, 2008

Page 19 of 85

AC9
TECHNICAL NOTES
30

ContinuingSample

Continuing Sample SP =
MRES.INTTYPE ^=3/NewFromSupplement on MRES
where MRES.MRESRND = current round.

DESIGN NOTES

6:30:21 PM Monday, July 07, 2008

Page 20 of 85

BOX AC1D

BOX AC1D

Page Order # :

150

BOX INSTRUCTIONS
( ACQ1220 )

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) AND (RESPONSE TO AC9 OPDREAS INCLUDES 1/MedCondNamed OR 6/Surgery), GO TO AC12 OPDAPPT ( ACQ1260 ).
ELSE IF (SP IS IN THE SUPPLEMENTAL SAMPLE) AND (RESPONSE TO
AC9 - OPDREAS DOES NOT INCLUDE 1/MedCondNamed AND DOES NOT
INCLUDE 6/Surgery), GO TO AC10 - OPDSCOND ( ACQ1230 ).
ELSE GO TO AC12 - OPDAPPT ( ACQ1260 ).

ASSIGNMENTS

TECHNICAL NOTES
9

SuppORD

SP is in the Supplemental Sample =
MRES.INTTYPE=3/NewFromSupplement on MRES
where MRES.MRESRND = current round.

DESIGN NOTES

6:30:21 PM Monday, July 07, 2008

Page 21 of 85

AC10

AC10

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

OPDSCOND

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

160

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

Was that for a specific condition?

Int. Instr II:

INPUT FIELDS / ROUTING

6:30:24 PM Monday, July 07, 2008

Page 22 of 85

AC10
OPDSCOND

Field1:
Cheshire Name:

( ACQ1230 )

ACCS.OPDSCOND

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC12 - OPDAPPT ( ACQ1260 )

English text: YES
No

AC12 - OPDAPPT ( ACQ1260 )

English text: NO
Attribute
Don't know

Route
AC12 - OPDAPPT ( ACQ1260 )

Refusal

AC12 - OPDAPPT ( ACQ1260 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:30:27 PM Monday, July 07, 2008

Page 23 of 85

AC12

AC12

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

OPDAPPT

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

180

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

Did [you/(SP)] have an appointment for this visit to the hospital clinic

or outpatient department, or did (you/he/she) just walk in?

Int. Instr II:
INPUT FIELDS / ROUTING

6:30:30 PM Monday, July 07, 2008

Page 24 of 85

AC12
OPDAPPT

Field1:
Cheshire Name:

( ACQ1260 )

ACCS.OPDAPPT

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TApptwalk
1
No
No

Number Label
1 Appointment
2

English text: APPOINTMENT
WalkedIn

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC13 - OPDDRTEL ( ACQ1270 )
AC16A - OWAITHRS ( ACQ1360 )

English text: WALKED IN
Attribute
Don't know

Route
AC16A - OWAITHRS ( ACQ1360 )

Refusal

AC16A - OWAITHRS ( ACQ1360 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:30:34 PM Monday, July 07, 2008

Page 25 of 85

AC13

AC13

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

OPDDRTEL

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

190

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:
Int. Instr I:
Question Text:

Did someone at the hospital clinic or outpatient department tell
[you/(SP)] when to come back during an
earlier visit, or did [you/(SP)] call for an appointment?

Int. Instr II:
INPUT FIELDS / ROUTING

6:30:36 PM Monday, July 07, 2008

Page 26 of 85

AC13
OPDDRTEL

Field1:

( ACQ1270 )

ACCS.OPDDRTEL

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TApptback
1
No
No

Number Label
1 ToldToComeBack
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC16A - OWAITHRS ( ACQ1360 )

English text: TOLD TO COME BACK DURING EARLIER VISIT
CalledForAnAppointment
AC14 - OPDAWUNT ( ACQ1280 )
English text: CALLED FOR AN APPOINTMENT

Attribute
Don't know

Route
AC16A - OWAITHRS ( ACQ1360 )

Refusal

AC16A - OWAITHRS ( ACQ1360 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:30:40 PM Monday, July 07, 2008

Page 27 of 85

AC14

AC14

Page Order # :

Design Screen Type:

Quantity Unit

Fields:

Field 1:

OPDAWUNT

Field 2:

OPDAWDAY

Field 3:

OPDAWWKS

Field 4:

OPDAWMOS

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

200

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

How long did [you/(SP)] have to wait for the appointment -- about

how many days, weeks, or months?

Int. Instr II:
INPUT FIELDS / ROUTING
6:30:43 PM Monday, July 07, 2008

Page 28 of 85

AC14
OPDAWUNT

Field1:
Cheshire Name:

( ACQ1280 )

ACCS.OPDAWUNT

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TAcsuntc
1
No
No

Number Label
0 NoWait

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC16A - OWAITHRS ( ACQ1360 )

1

English text: DID NOT HAVE TO WAIT
Days

AC14 - OPDAWDAY ( ACQ1290 )

2

English text: DAYS
Weeks

AC14 - OPDAWWKS ( ACQ1300 )

3

English text: WEEKS
Months

AC14 - OPDAWMOS ( ACQ1310 )

English text: MONTHS
Attribute
Don't know

Route
AC16A - OWAITHRS ( ACQ1360 )

Refusal

AC16A - OWAITHRS ( ACQ1360 )

6:30:51 PM Monday, July 07, 2008

Page 29 of 85

AC14

Field2:
Cheshire Name:

OPDAWDAY

( ACQ1290 )

ACCS.OPDAWDAY

Item Text display:
Item Text:
Label:
Label Position:

DAYS:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TAccsday
1
No
No

Number Label
1 [Continuous answer.]
Field3:
Cheshire Name:

OPDAWWKS

FieldSize:

Min Value:
Max Value:
Mask:

1

180

Route
AC16A - OWAITHRS ( ACQ1360 )
( ACQ1300 )

ACCS.OPDAWWKS

Item Text display:
Item Text:
Label:

Label Position:

WEEKS:
Left

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:

Integer
TAccswk
1
No
No

Number Label
1 [Continuous answer.]

6:30:56 PM Monday, July 07, 2008

FieldSize:

Min Value:
Max Value:
Mask:

1

30

Route
AC16A - OWAITHRS ( ACQ1360 )

Page 30 of 85

AC14

Field4:
Cheshire Name:

OPDAWMOS

( ACQ1310 )

ACCS.OPDAWMOS

Item Text display:
Item Text:
Label:
Label Position:

MONTHS:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TAccsmos
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:

Min Value:
Max Value:
Mask:

1

6

Route
AC16A - OWAITHRS ( ACQ1360 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS
Edit #1:

If OPDAWUNT = 1/Days, OPDAWDAY = 1-90.

If not true, display message: "THE VALUE ENTERED FOR

NUMBER OF DAYS SEEMS UNLIKELY. PLEASE VERIFY."

Edit #2:

If OPDAWUNT = 2/Weeks, OPDAWWKS = 1-14.

If not true, display message: "THE VALUE ENTERED FOR

NUMBER OF WEEKS SEEMS UNLIKELY. PLEASE VERIFY."

Edit #3:

If OPDAWUNT = 3/Months, OPDAWMOS = 1-3.

If not true, display message: "THE VALUE ENTERED FOR

NUMBER OF MONTHS SEEMS UNLIKELY. PLEASE VERIFY."

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:30:58 PM Monday, July 07, 2008

Page 31 of 85

AC16A

AC16A

Page Order # :

Design Screen Type:

Quantity Unit

Fields:

Field 1:

OWAITUNT

Field 2:

OWAITHRS

Field 3:

OWAITMIN

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No

No

No

No

Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

220

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Always display first sentence, "[Think about...]" in brackets.

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

[Think about the most recent time [you/(SP)] went to a hospital clinic
or outpatient department.]
How long did [you/(SP)] have to wait during (your/his/her) most
recent visit before (you/he/she) saw a doctor or some other medical
person? Please include the time spent in the waiting room and
exam room.

6:31:01 PM Monday, July 07, 2008

Page 32 of 85

AC16A
Int. Instr II:

INPUT FIELDS / ROUTING

Field1:

OWAITUNT

Cheshire Name:

( ACQ1350 )

ACCS.OWAITUNT

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TAcsuntb
1
No
No

Number Label
0 DidNotHaveToWait

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX AC1E - (ACQ1380 )

1

English text: DID NOT HAVE TO WAIT
HoursOnly

AC16A - OWAITHRS ( ACQ1360 )

2

English text: HOURS ONLY
MinutesOnly

AC16A - OWAITMIN ( ACQ1370 )

3

English text: MINUTES ONLY
HoursAndMinutes

AC16A - OWAITHRS ( ACQ1360 )

English text: HOURS AND MINUTES
Attribute
Don't know

Route
BOX AC1E - (ACQ1380 )

Refusal

BOX AC1E - (ACQ1380 )

6:31:07 PM Monday, July 07, 2008

Page 33 of 85

AC16A

Field2:
Cheshire Name:

OWAITHRS

( ACQ1360 )

ACCS.OWAITHRS

Item Text display:
Item Text:
Label:
Label Position:

HOURS:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TAccshrs1
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:

Min Value:
Max Value:
Mask:

1

72

Route
If AC16A - OWAITUNT = 3/HoursAndMinutes,

go to AC16A - OWAITMIN.

Else go to BOX AC1E.

Field3:
Cheshire Name:

OWAITMIN

( ACQ1370 )

ACCS.OWAITMIN

Item Text display:
Item Text:
Label:

Label Position:

MINUTES:
Left

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:

Integer
TAccsmin
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:

Min Value:
Max Value:
Mask:

1

59

Route
BOX AC1E - (ACQ1380 )

BACKGROUND VARIABLE ASSIGNMENTS

6:31:09 PM Monday, July 07, 2008

Page 34 of 85

AC16A
SOFT EDIT CHECKS
Edit #1:

If OWAITUNT = 1/HoursOnly or 3/HoursAndMinutes, OWAITHRS =

1-16.

If not true, display message: "THE VALUE ENTERED FOR

NUMBER FO HOURS SEEMS UNLIKELY. PLEASE VERIFY."

Edit #2:

If OWAITUNT = 2/MinutesOnly or 3/HoursAndMinutes, OWAITMIN

= 5 - 59.

If not true, display message: "THE VALUE ENTERED FOR

NUMBER OF MINUTES SEEMS UNLIKELY. PLEASE VERIFY."

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:31:09 PM Monday, July 07, 2008

Page 35 of 85

BOX AC1E

BOX AC1E

Page Order # :

230

BOX INSTRUCTIONS
( ACQ1380 )

IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO AC17 - NHRESEVR (
ACQ1390 ).
ELSE IF AC9-AC16A ASKED WHILE ADMINISTERING OP, GO TO BOX
OP7 - (OPQ1505 ).
ELSE IF (SP HAD AN MP VISIT IN THE CURRENT ROUND OR ANY OF
THE 2 PREVIOUS ROUNDS) AND (AC20-AC28A1 NOT ALREADY ASKED),
GO TO AC20 - MDSPCLTY ( ACQ1430 ).
ELSE GO TO BOX AC1G - (ACQ1700 ).

ASSIGNMENTS

TECHNICAL NOTES
9

SuppORD

SP is in the Supplemental Sample =
MRES.INTTYPE=3/NewFromSupplement on MRES
where MRES.MRESRND = current round.

28

SPHadMPVisit

SP had MP visit current round or 2 prev.rounds =
There is an EVNT where ((EVNTRNDC>=(current
round - 2)) & EVNTTYPE=MP & EVNTDFLG^=1/Yes &
MPIPSTAY ^=1/Yes & ((MPTYPE = 1/MedicalDoctor) or
(PROV.PROVSPEC=2/MedicalDoctor on PROV where
PROVNUM=EVNTNUM))).

33

AC20AC28A1Asked

AC20-AC28A1 already asked =
ACCS.MDSPCLTY ^= EMPTY on ACCS where
ACCS.ACCSRND = current round.

DESIGN NOTES
Included in this box is logic that handles exiting AC when being called
from OP. When administering OP, if the SP reports a current round OP
visit, the OP section calls AC9-AC16A. When complete, return to OP.

6:31:09 PM Monday, July 07, 2008

Page 36 of 85

AC17

AC17

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

NHRESEVR

Enable Functions:

HELP
COMMENTS
JUMPBACK

Yes
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

240

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

[Have you/Has (SP)] ever been a resident or patient in a nursing

home or similar place?

Int. Instr II:
INPUT FIELDS / ROUTING

6:31:11 PM Monday, July 07, 2008

Page 37 of 85

AC17
NHRESEVR

Field1:
Cheshire Name:

( ACQ1390 )

ACCS.NHRESEVR

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC18 - NHLRESMM ( ACQ1400 )

English text: YES
No

AC19 - MDVISIT ( ACQ1420 )

English text: NO
Attribute
Don't know

Route
AC19 - MDVISIT ( ACQ1420 )

Refusal

AC19 - MDVISIT ( ACQ1420 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:31:15 PM Monday, July 07, 2008

Page 38 of 85

AC18

AC18

Page Order # :

Design Screen Type:

Date

Fields:

Field 1:

NHLRESMM

Field 2:

NHLRESYY

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

250

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Display the word "last" in BOLD.

Multi Field display:

Horizontal Alignment

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

When [were you/was (SP)] last a resident or patient in a nursing

home or similar place?

Int. Instr II:
INPUT FIELDS / ROUTING

6:31:18 PM Monday, July 07, 2008

Page 39 of 85

AC18
NHLRESMM

Field1:
Cheshire Name:

( ACQ1400 )

ACCS.NHLRESMM

Item Text display:
Item Text:
Label:
Label Position:

MM
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TMonthInt
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
AC18 - NHLRESYY ( ACQ1410 )

Refusal

AC18 - NHLRESYY ( ACQ1410 )

6:31:25 PM Monday, July 07, 2008

FieldSize:
Min Value:
Max Value:
Mask:

2
01
12

Route
AC18 - NHLRESYY ( ACQ1410 )

Page 40 of 85

AC18
( ACQ1410 )

NHLRESYY

Field2:
Cheshire Name:

ACCS.NHLRESYY

Item Text display:
Item Text:
Label:
Label Position:

YY
Under

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TYearDKRF

FieldSize:

Min Value:
Max Value:
Mask:

1
No
No

Number Label
1 [Continuous answer.]

0

99

Route
AC19 - MDVISIT ( ACQ1420 )

Attribute
Don't know

Route
AC19 - MDVISIT ( ACQ1420 )

Refusal

AC19 - MDVISIT ( ACQ1420 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS
In order to check date, set date of last residency to equal

ACCS.NHLRESMM/ '01'/ACCS.NHLRESYY.

Date of last residency is on or between SP's date of birth,

ROST.HHDOBMM/ ROST.HHDOBDD/ROST.HHDOBYY, and

today's date.

If not true, display message "INVALID ENTRY. PLEASE

REENTER."

TECHNICAL NOTES
101

SPDateofBirth

SP's Date of Birth is stored on ROST where
ROST.ROSTNUM='01'.
Month: ROST.HHDOBMM
Day: ROST.HHDOBDD
Year: ROST.HHDOBYY

DESIGN NOTES

6:31:28 PM Monday, July 07, 2008

Page 41 of 85

AC19

AC19

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

MDVISIT

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

260

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:
Int. Instr I:
Question Text:

Next, I want to ask about [your/(SP)’s] visits to doctors since
(REFERENCE DATE). [Have you/Has (SP)] seen a medical doctor
since (REFERENCE DATE)? Please do not include a doctor seen
at home, at an emergency room or outpatient department, or while
an inpatient at a hospital.

Int. Instr II:

INPUT FIELDS / ROUTING

6:31:30 PM Monday, July 07, 2008

Page 42 of 85

AC19
MDVISIT

Field1:
Cheshire Name:

( ACQ1420 )

ACCS.MDVISIT

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC20 - MDSPCLTY ( ACQ1430 )

English text: YES
No

BOX AC1G - (ACQ1700 )

English text: NO
Attribute
Don't know

Route
BOX AC1G - (ACQ1700 )

Refusal

BOX AC1G - (ACQ1700 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:31:34 PM Monday, July 07, 2008

Page 43 of 85

AC20

AC20

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

MDSPCLTY

Field 2:

MDSPCLOS

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

270

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

DESIGN NOTE: The first sentence is designed to be the
introductory statement for continuing sample SPs when
administering AC. If SP skipped AC6A and AC9-AC16A, then
AC20 will be the SP's first question in AC. The SP does not receive
this introductory statement when AC20 is called from MP.
If SP is in the continuing sample and AC20 is the SP's first question
asked while administering AC, display "I have a few more . . ." .
Else do not display.
Display "in the past" in the first sentence in BOLD.
Display "most recent" in the second sentence in BOLD.
Display "other than at home" in the second sentence in BOLD.

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

6:31:41 PM Monday, July 07, 2008

Page 44 of 85

AC20
TEXT:
Context Header:
Int. Instr I:
Question Text:

[I have a few more questions about visits that [you/(SP)] had in the
past.]
Think about the most recent time [you/(SP)] saw a medical doctor
somewhere other than at home or at a hospital. What was the
doctor’s specialty?

Int. Instr II:
INPUT FIELDS / ROUTING

6:31:53 PM Monday, July 07, 2008

Page 45 of 85

AC20
MDSPCLTY

Field1:
Cheshire Name:

( ACQ1430 )

ACCS.MDSPCLTY

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TMdspclty
1
No
No

Number Label
1 Allergy

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC21 - MDREAS ( ACQ1450 )

2

English text: ALLERGY/IMMUNOLOGY
Anesthesiology

AC21 - MDREAS ( ACQ1450 )

3

English text: ANESTHESIOLOGY
Cardiology

AC21 - MDREAS ( ACQ1450 )

5

English text: CARDIOLOGY (HEART)
Dermatology

AC21 - MDREAS ( ACQ1450 )

7

English text: DERMATOLOGY (SKIN)
Endocrinology

AC21 - MDREAS ( ACQ1450 )

8

English text: ENDOCRINOLOGY/METABOLISM (DIABETES,THYROID)
FamilyPractice
AC21 - MDREAS ( ACQ1450 )

9

English text: FAMILY PRACTICE
Gastroenterology

AC21 - MDREAS ( ACQ1450 )

10

English text: GASTROENTEROLOGY
GeneralPractice

AC21 - MDREAS ( ACQ1450 )

11

English text: GENERAL PRACTICE
GeneralSurgery

AC21 - MDREAS ( ACQ1450 )

12

English text: GENERAL SURGERY
Geriatrics

AC21 - MDREAS ( ACQ1450 )

13

English text: GERIATRICS (ELDERLY)
Gynecology

AC21 - MDREAS ( ACQ1450 )

14

English text: GYNECOLOGY - OBSTETRICS
Hematology
AC21 - MDREAS ( ACQ1450 )

15

English text: HEMATOLOGY (BLOOD)
Hospital

AC21 - MDREAS ( ACQ1450 )

English text: HOSPITAL RESIDENCE
6:32:16 PM Monday, July 07, 2008

Page 46 of 85

AC20

16

InternalMed

AC21 - MDREAS ( ACQ1450 )

17

English text: INTERNAL MEDICINE (INTERNIST)
Nephrology
AC21 - MDREAS ( ACQ1450 )

18

English text: NEPHROLOGY (KIDNEYS)
Neurology

AC21 - MDREAS ( ACQ1450 )

19

English text: NEUROLOGY
NuclearMed

AC21 - MDREAS ( ACQ1450 )

20

English text: NUCLEAR MEDICINE
Oncology

AC21 - MDREAS ( ACQ1450 )

21

English text: ONCOLOGY (TUMORS, CANCER)
Ophthalmology
AC21 - MDREAS ( ACQ1450 )

22

English text: OPHTHALMOLOGY (EYES)
Orthopedics

AC21 - MDREAS ( ACQ1450 )

24

English text: ORTHOPEDICS
Osteopathy

AC21 - MDREAS ( ACQ1450 )

25

English text: OSTEOPATHY (DO)
Otorhinolaryngology

AC21 - MDREAS ( ACQ1450 )

26

English text: OTORHINOLARYNGOLOGY (EAR, NOSE, THROAT)
Pathology
AC21 - MDREAS ( ACQ1450 )

27

English text: PATHOLOGY
PhysMed

AC21 - MDREAS ( ACQ1450 )

28

English text: PHYS MED/REHAB
PlasticSurgery

AC21 - MDREAS ( ACQ1450 )

29

English text: PLASTIC SURGERY
Proctology

AC21 - MDREAS ( ACQ1450 )

30

English text: PROCTOLOGY
Psychiatry

AC21 - MDREAS ( ACQ1450 )

31

English text: PSYCHIATRY/PSYCHIATRIST
Pulmonary

AC21 - MDREAS ( ACQ1450 )

32

English text: PULMONARY (LUNGS)
Radiology

AC21 - MDREAS ( ACQ1450 )

33

English text: RADIOLOGY
Rheumatology

AC21 - MDREAS ( ACQ1450 )

34

English text: RHEUMATOLOGY (ARTHRITIS)
ThoracicSurgery
AC21 - MDREAS ( ACQ1450 )

35

English text: THORACIC SURGERY (CHEST)
Urology
AC21 - MDREAS ( ACQ1450 )

91

English text: UROLOGY
OtherSpecialty

AC20 - MDSPCLOS ( ACQ1440 )

English text: OTHER DR SPECIALTY
Attribute
Don't know

Route
AC21 - MDREAS ( ACQ1450 )

6:32:40 PM Monday, July 07, 2008

Page 47 of 85

AC20

Refusal

AC21 - MDREAS ( ACQ1450 )

Field2:

( ACQ1440 )

MDSPCLOS

Cheshire Name:

ACCS.MDSPCLOS

Item Text display:

Display "(SPECIFY)" in the same blue font used for

interviewer instructions.

Item Text:

OTHER DR SPECIALTY (SPECIFY)

Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:

String

TOthrspec

FieldSize:
Min Value:
Max Value:
Mask:

1
No
No

Number Label
1 [Continuous answer.]

30

Route
AC21 - MDREAS ( ACQ1450 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
30

ContinuingSample

Continuing Sample SP =
MRES.INTTYPE ^=3/NewFromSupplement on MRES
where MRES.MRESRND = current round.

DESIGN NOTES

6:32:42 PM Monday, July 07, 2008

Page 48 of 85

AC21

AC21

Page Order # :

Design Screen Type:

Code All

Fields:

Field 1:

MDREAS

Field 2:

MDOTHOS

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

280

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

What was the reason [you/(SP)] saw the doctor?

[PROBE: Any other reason?]

Int. Instr II:

CHECK ALL THAT APPLY.

INPUT FIELDS / ROUTING

6:32:47 PM Monday, July 07, 2008

Page 49 of 85

AC21

6:32:55 PM Monday, July 07, 2008

Page 50 of 85

AC21
MDREAS

Field1:
Cheshire Name:

( ACQ1450 )

NONE
REPLACES THE FOLLOWING CHESHIRE VARIABLES:
1/MedCondNamed=ACCS.MDMCOND
2/Tests=ACCS.MDTESTS
3/Followup=ACCS.MDFOLUP
4/Checkup=ACCS.MDCHKUP
5/Referral=ACCS.MDRFRL
6/Surgery=ACCS.MDSURGY
7/PreventiveShot=ACCS.MDPSHOT
8/TreatmentShot=ACCS.MDTSHOT
9/RefillPM=ACCS.MDPMED
91/Other=ACCS.MDOTHER

Item Text display:
Item Text:
Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:

Enumerated
Treason
10
No
No

Number Label
1 MedCondNamed

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX AC1F - (ACQ1480 )

2

English text: MEDICAL CONDITION NAMED
Tests
BOX AC1F - (ACQ1480 )

3

English text: TESTS
Followup

BOX AC1F - (ACQ1480 )

4

English text: FOLLOW-UP
Checkup

BOX AC1F - (ACQ1480 )

5

English text: CHECKUP
Referral

BOX AC1F - (ACQ1480 )

English text: REFERRAL

6:33:07 PM Monday, July 07, 2008

Page 51 of 85

AC21

6

Surgery

BOX AC1F - (ACQ1480 )

7

English text: SURGERY
PreventiveShot

BOX AC1F - (ACQ1480 )

8

English text: PREVENTIVE SHOT
TreatmentShot

BOX AC1F - (ACQ1480 )

9

English text: TREATMENT SHOT
RefillPM

BOX AC1F - (ACQ1480 )

91

English text: TO GET OR REFILL PRESCRIPTION
Other
AC21 - MDOTHOS ( ACQ1470 )
English text: OTHER

Attribute
Don't know

Route
BOX AC1F - (ACQ1480 )

Refusal

BOX AC1F - (ACQ1480 )

Field2:
Cheshire Name:

MDOTHOS

( ACQ1470 )

ACCS.MDOTHOS

Item Text display:

Display "(SPECIFY)" in the same blue font used for
interviewer instructions.

Item Text:

OTHER (SPECIFY)

Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

String
TOthrspec
1

No

No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:

Max Value:

Mask:

30

Route
BOX AC1F - (ACQ1480 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

6:33:15 PM Monday, July 07, 2008

Page 52 of 85

AC21
TECHNICAL NOTES

DESIGN NOTES

6:33:15 PM Monday, July 07, 2008

Page 53 of 85

BOX AC1F

BOX AC1F

Page Order # :

290

BOX INSTRUCTIONS
( ACQ1480 )

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) AND (RESPONSE TO AC21MDREAS INCLUDES 1/MedCondNamed OR 6/Surgery), GO TO AC24 MDAPPT ( ACQ1520 ).
ELSE IF (SP IS IN THE SUPPLEMENTAL SAMPLE) AND (RESPONSE TO
AC21- MDREAS DOES NOT INCLUDE 1/MedCondNamed AND DOES NOT
INCLUDE 6/Surgery), GO TO AC22 - MDSCOND ( ACQ1490 ).
ELSE GO TO AC24 - MDAPPT ( ACQ1520 ).

ASSIGNMENTS

TECHNICAL NOTES
9

SuppORD

SP is in the Supplemental Sample =
MRES.INTTYPE=3/NewFromSupplement on MRES
where MRES.MRESRND = current round.

DESIGN NOTES

6:33:15 PM Monday, July 07, 2008

Page 54 of 85

AC22

AC22

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

MDSCOND

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

300

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

Was that for a specific condition?

Int. Instr II:

INPUT FIELDS / ROUTING

6:33:17 PM Monday, July 07, 2008

Page 55 of 85

AC22
MDSCOND

Field1:
Cheshire Name:

( ACQ1490 )

ACCS.MDSCOND

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC24 - MDAPPT ( ACQ1520 )

English text: YES
No

AC24 - MDAPPT ( ACQ1520 )

English text: NO
Attribute
Don't know

Route
AC24 - MDAPPT ( ACQ1520 )

Refusal

AC24 - MDAPPT ( ACQ1520 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:33:21 PM Monday, July 07, 2008

Page 56 of 85

AC24

AC24

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

MDAPPT

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

320

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

Did [you/(SP)] have an appointment for this visit with the doctor, or

did (you/he/she) just walk in?

Int. Instr II:
INPUT FIELDS / ROUTING

6:33:24 PM Monday, July 07, 2008

Page 57 of 85

AC24
MDAPPT

Field1:
Cheshire Name:

( ACQ1520 )

ACCS.MDAPPT

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TApptwalk
1
No
No

Number Label
1 Appointment
2

English text: APPOINTMENT
WalkedIn

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC25 - MDDRTEL ( ACQ1530 )
AC28A1 - MWAITHRS ( ACQ1620 )

English text: WALKED IN
Attribute
Don't know

Route
AC28A1 - MWAITHRS ( ACQ1620 )

Refusal

AC28A1 - MWAITHRS ( ACQ1620 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:33:27 PM Monday, July 07, 2008

Page 58 of 85

AC25

AC25

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

MDDRTEL

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

330

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

Did someone in the doctor’s office tell [you/(SP)] when to come back

during an earlier visit, or did [you/(SP)] call for an appointment?

Int. Instr II:
INPUT FIELDS / ROUTING

6:33:30 PM Monday, July 07, 2008

Page 59 of 85

AC25
MDDRTEL

Field1:

( ACQ1530 )

ACCS.MDDRTEL

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TApptback
1
No
No

Number Label
1 ToldToComeBack
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC28A1 - MWAITHRS ( ACQ1620 )

English text: TOLD TO COME BACK DURING EARLIER VISIT
CalledForAnAppointment
AC26 - MDAWUNT ( ACQ1540 )
English text: CALLED FOR AN APPOINTMENT

Attribute
Don't know

Route
AC28A1 - MWAITHRS ( ACQ1620 )

Refusal

AC28A1 - MWAITHRS ( ACQ1620 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:33:33 PM Monday, July 07, 2008

Page 60 of 85

AC26

AC26

Page Order # :

Design Screen Type:

Quantity Unit

Fields:

Field 1:

MDAWUNT

Field 2:

MDAWDAY

Field 3:

MDAWWKS

Field 4:

MDAWMOS

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No

No

No

No

Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

340

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

How long did [you/(SP)] have to wait for the appointment with the

medical doctor -- about how many days, weeks, or months?

Int. Instr II:
INPUT FIELDS / ROUTING
6:33:37 PM Monday, July 07, 2008

Page 61 of 85

AC26
MDAWUNT

Field1:
Cheshire Name:

( ACQ1540 )

ACCS.MDAWUNT

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TAcsuntc
1
No
No

Number Label
0 NoWait

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC28A1 - MWAITHRS ( ACQ1620 )

1

English text: DID NOT HAVE TO WAIT
Days

AC26 - MDAWDAY ( ACQ1550 )

2

English text: DAYS
Weeks

AC26 - MDAWWKS ( ACQ1560 )

3

English text: WEEKS
Months

AC26 - MDAWMOS ( ACQ1570 )

English text: MONTHS
Attribute
Don't know

Route
AC28A1 - MWAITHRS ( ACQ1620 )

Refusal

AC28A1 - MWAITHRS ( ACQ1620 )

6:33:45 PM Monday, July 07, 2008

Page 62 of 85

AC26

Field2:
Cheshire Name:

MDAWDAY

( ACQ1550 )

ACCS.MDAWDAY

Item Text display:
Item Text:
Label:
Label Position:

DAYS:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TAccsday
1
No
No

Number Label
1 [Continuous answer.]
Field3:
Cheshire Name:

MDAWWKS

FieldSize:

Min Value:
Max Value:
Mask:

1

180

Route
AC28A1 - MWAITHRS ( ACQ1620 )
( ACQ1560 )

ACCS.MDAWWKS

Item Text display:
Item Text:
Label:

Label Position:

WEEKS:
Left

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:

Integer
TAccswk
1
No
No

Number Label
1 [Continuous answer.]

6:33:50 PM Monday, July 07, 2008

FieldSize:

Min Value:
Max Value:
Mask:

1

30

Route
AC28A1 - MWAITHRS ( ACQ1620 )

Page 63 of 85

AC26

Field4:
Cheshire Name:

MDAWMOS

( ACQ1570 )

ACCS.MDAWMOS

Item Text display:
Item Text:
Label:
Label Position:

MONTHS:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TAccsmos
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:

Min Value:
Max Value:
Mask:

1

6

Route
AC28A1 - MWAITHRS ( ACQ1620 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS
Edit #1:

If MDAWUNT = 1/Days, MDAWDAY = 1-90.

If not true, display message: "THE VALUE ENTERED FOR

NUMBER OF DAYS SEEMS UNLIKELY. PLEASE VERIFY."

Edit #2:

If MDAWUNT = 2/Weeks, MDAWWKS = 1-14.

If not true, display message: "THE VALUE ENTERED FOR

NUMBER OF WEEKS SEEMS UNLIKELY. PLEASE VERIFY."

Edit #3:

If MDAWUNT = 3/Months, MDAWMOS = 1-3.

If not true, display message: "THE VALUE ENTERED FOR

NUMBER OF MONTHS SEEMS UNLIKELY. PLEASE VERIFY."

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:33:51 PM Monday, July 07, 2008

Page 64 of 85

AC28A1

AC28A1

Page Order # :

Design Screen Type:

Quantity Unit

Fields:

Field 1:

MWAITUNT

Field 2:

MWAITHRS

Field 3:

MWAITMIN

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No

No

No

No

Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

360

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Always display first sentence "[Think about...]" in brackets.
Display "most recent" in first sentence in BOLD.

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

6:33:54 PM Monday, July 07, 2008

[Think about the most recent time [you/(SP)] saw a medical doctor
somewhere other than at home or at a hospital.] How long did
[you/(SP)] have to wait during (your/his/her) most recent visit before
(you/he/she) saw a doctor or some other medical person? Please
include the time spent in the waiting room and exam room.

Page 65 of 85

AC28A1
Int. Instr II:

INPUT FIELDS / ROUTING

Field1:

MWAITUNT

Cheshire Name:

( ACQ1610 )

ACCS.MWAITUNT

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TAcsuntb
1
No
No

Number Label
0 DidNotHaveToWait

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX AC1G - (ACQ1700 )

1

English text: DID NOT HAVE TO WAIT
HoursOnly

AC28A1 - MWAITHRS ( ACQ1620 )

2

English text: HOURS ONLY
MinutesOnly

AC28A1 - MWAITMIN ( ACQ1630 )

3

English text: MINUTES ONLY
HoursAndMinutes

AC28A1 - MWAITHRS ( ACQ1620 )

English text: HOURS AND MINUTES
Attribute
Don't know

Route
BOX AC1G - (ACQ1700 )

Refusal

BOX AC1G - (ACQ1700 )

6:34:00 PM Monday, July 07, 2008

Page 66 of 85

AC28A1

Field2:
Cheshire Name:

MWAITHRS

( ACQ1620 )

ACCS.MWAITHRS

Item Text display:
Item Text:
Label:
Label Position:

HOURS:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TAccshrs1
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:

Min Value:
Max Value:
Mask:

1

72

Route
If AC28A1 - MWAITUNT = 3/HoursAndMinutes,

go to AC28A1 - MWAITMIN.

Else go to BOX AC1G.

Field3:
Cheshire Name:

MWAITMIN

( ACQ1630 )

ACCS.MWAITMIN

Item Text display:
Item Text:
Label:

Label Position:

MINUTES:
Left

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:

Integer
TAccsmin
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:

Min Value:
Max Value:
Mask:

1

59

Route
BOX AC1G - (ACQ1700 )

BACKGROUND VARIABLE ASSIGNMENTS

6:34:02 PM Monday, July 07, 2008

Page 67 of 85

AC28A1
SOFT EDIT CHECKS
Edit #1:

If MWAITUNT = 1/HoursOnly or 3/HoursAndMinutes, MWAITHRS =

1-16.

If not true, display message: "THE VALUE ENTERED FOR

NUMBER OF HOURS SEEMS UNLIKELY. PLEASE VERIFY."

Edit #2:

If MWAITUNT = 2/MinutesOnly or 3/HoursAndMinutes, MWAITMIN

= 5 - 59.

If not true, display message: "THE VALUE ENTERED FOR

NUMBER OF MINUTES SEEMS UNLIKELY. PLEASE VERIFY."

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:34:02 PM Monday, July 07, 2008

Page 68 of 85

BOX AC1G

BOX AC1G

Page Order # :

410

BOX INSTRUCTIONS
( ACQ1700 )

IF AC20-AC28A1 ASKED WHILE ADMINISTERING MP, GO TO MP18 MPPRPRAC ( MPQ1650 ).
ELSE IF SP HAS A CURRENT MEDICARE MANAGED CARE PLAN, GO TO
AC33 - MHREFDIF ( ACQ1710 ).
ELSE GO TO BOX AC3 - (ACQ1790 ).

ASSIGNMENTS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

65

MHMOCurrent

SP has a current Medicare Managed Care plan =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES
Included in this box is logic that handles exiting AC when being called
from MP. When administering MP, if the SP reports a current round MP
visit, the MP section calls AC20-AC28A1. When complete, return to MP,

6:34:03 PM Monday, July 07, 2008

Page 69 of 85

AC33

AC33

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

MHREFDIF

Enable Functions:

HELP
COMMENTS
JUMPBACK

Yes
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

420

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display name of SP's current Medicare Managed Care Plan,
PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

The following questions are about health care that [you/(SP)]
received through (CURRENT MEDICARE MANAGED CARE PLAN
NAME).
While a member of (CURRENT MEDICARE MANAGED CARE
PLAN NAME), [have you/has (SP)] had difficulty in obtaining
referrals for the services of a specialist or other medical person
within (CURRENT MEDICARE MANAGED CARE PLAN NAME) that
[you/(SP)] thought were necessary?

6:34:05 PM Monday, July 07, 2008

Page 70 of 85

AC33
Int. Instr II:

INPUT FIELDS / ROUTING

Field1:

( ACQ1710 )

MHREFDIF

Cheshire Name:

ACCS.MHREFDIF

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TMhrefdif

FieldSize:
Min Value:
Max Value:
Mask:

1
No
No

Number Label
1 Yes

Route
AC34A - MHSPCLTY ( ACQ1730 )

2

English text: YES
No

AC36 - MHREFPAY ( ACQ1780 )

3

English text: NO
NaHaventTriedToObtainReferral

AC36 - MHREFPAY ( ACQ1780 )

English text: N/A, HAVEN'T TRIED TO OBTAIN REFERRAL
Attribute
Don't know

Route
AC36 - MHREFPAY ( ACQ1780 )

Refusal

AC36 - MHREFPAY ( ACQ1780 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans

6:34:11 PM Monday, July 07, 2008

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
Page 71 of 85

AC33
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
65

MHMOCurrent

SP has a current Medicare Managed Care plan =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

6:34:11 PM Monday, July 07, 2008

Page 72 of 85

AC34A

AC34A

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

MHSPCLTY

Field 2:

MHSPCLOS

HELP
COMMENTS
JUMPBACK

Yes
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

440

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

What kind of specialist or medical person was this?

Int. Instr II:

INPUT FIELDS / ROUTING

6:34:18 PM Monday, July 07, 2008

Page 73 of 85

AC34A

6:34:32 PM Monday, July 07, 2008

Page 74 of 85

AC34A
MHSPCLTY

Field1:
Cheshire Name:

( ACQ1730 )

ACCS.MHSPCLTY

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TMhspclty
1
No
No

Number Label
1 Allergy

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC35 - MHDIFCLT ( ACQ1750 )

3

English text: ALLERGY/IMMUNOLOGY
Cardiology

AC35 - MHDIFCLT ( ACQ1750 )

5

English text: CARDIOLOGY (HEART)
Dermatology

AC35 - MHDIFCLT ( ACQ1750 )

7

English text: DERMATOLOGY (SKIN)
Endocrinology

AC35 - MHDIFCLT ( ACQ1750 )

9

English text: ENDOCRINOLOGY/METABOLISM (DIABETES,THYROID)
Gastroenterology
AC35 - MHDIFCLT ( ACQ1750 )

11

English text: GASTROENTEROLOGY
GeneralSurgery

AC35 - MHDIFCLT ( ACQ1750 )

12

English text: GENERAL SURGERY
Geriatrics

AC35 - MHDIFCLT ( ACQ1750 )

13

English text: GERIATRICS (ELDERLY)
Gynecology

AC35 - MHDIFCLT ( ACQ1750 )

14

English text: GYNECOLOGY - OBSTETRICS
Hematology
AC35 - MHDIFCLT ( ACQ1750 )

16

English text: HEMATOLOGY (BLOOD)
InternalMed

17

English text: INTERNAL MEDICINE (INTERNIST)
Nephrology
AC35 - MHDIFCLT ( ACQ1750 )

18

English text: NEPHROLOGY (KIDNEYS)
Neurology

AC35 - MHDIFCLT ( ACQ1750 )

20

English text: NEUROLOGY
Oncology

AC35 - MHDIFCLT ( ACQ1750 )

AC35 - MHDIFCLT ( ACQ1750 )

English text: ONCOLOGY (TUMORS, CANCER)
6:34:56 PM Monday, July 07, 2008

Page 75 of 85

AC34A

21

Ophthalmology

AC35 - MHDIFCLT ( ACQ1750 )

22

English text: OPHTHALMOLOGY (EYES)
Orthopedics

AC35 - MHDIFCLT ( ACQ1750 )

24

English text: ORTHOPEDICS
Osteopathy

AC35 - MHDIFCLT ( ACQ1750 )

25

English text: OSTEOPATHY (DO)
Otorhinolaryngology

AC35 - MHDIFCLT ( ACQ1750 )

26

English text: OTORHINOLARYNGOLOGY (EAR, NOSE, THROAT)
Pathology
AC35 - MHDIFCLT ( ACQ1750 )

27

English text: PATHOLOGY
PhysMed

AC35 - MHDIFCLT ( ACQ1750 )

28

English text: PHYS MED/REHAB
PlasticSurgery

AC35 - MHDIFCLT ( ACQ1750 )

29

English text: PLASTIC SURGERY
Proctology

AC35 - MHDIFCLT ( ACQ1750 )

30

English text: PROCTOLOGY
Psychiatry

AC35 - MHDIFCLT ( ACQ1750 )

31

English text: PSYCHIATRY/PSYCHIATRIST
Pulmonary

AC35 - MHDIFCLT ( ACQ1750 )

33

English text: PULMONARY (LUNGS)
Rheumatology

AC35 - MHDIFCLT ( ACQ1750 )

35

English text: RHEUMATOLOGY (ARTHRITIS)
Urology
AC35 - MHDIFCLT ( ACQ1750 )

36

English text: UROLOGY
Audiologist

AC35 - MHDIFCLT ( ACQ1750 )

37

English text: AUDIOLOGIST
Chiropractor

AC35 - MHDIFCLT ( ACQ1750 )

38

English text: CHIROPRACTOR
Dentist

AC35 - MHDIFCLT ( ACQ1750 )

39

English text: DENTIST
Optometrist

AC35 - MHDIFCLT ( ACQ1750 )

40

English text: OPTOMETRIST
PhysicalTherapist

AC35 - MHDIFCLT ( ACQ1750 )

41

English text: PHYSICAL THERAPIST
Psychologist

AC35 - MHDIFCLT ( ACQ1750 )

91

English text: PSYCHOLOGIST
Other

AC34A - MHSPCLOS ( ACQ1740 )

English text: OTHER DR SPECIALTY
Attribute
Don't know

Route
AC35 - MHDIFCLT ( ACQ1750 )

6:35:19 PM Monday, July 07, 2008

Page 76 of 85

AC34A

Refusal

AC35 - MHDIFCLT ( ACQ1750 )

Field2:
Cheshire Name:

MHSPCLOS

( ACQ1740 )

ACCS.MHSPCLOS

Item Text display:

Display "(SPECIFY)" in the same blue font used for

interviewer instructions.

Item Text:

OTHER (SPECIFY)

Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:

String

TOthrspec
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

30

Route
AC35 - MHDIFCLT ( ACQ1750 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:35:22 PM Monday, July 07, 2008

Page 77 of 85

AC35

AC35

Page Order # :

Design Screen Type:

Code All

Fields:

Field 1:

MHDIFCLT

Field 2:

MHOTHOS

HELP
COMMENTS
JUMPBACK

Yes
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

450

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

What kind of difficulty did [you/(SP)] have?

[PROBE: Any other difficulty?]

Int. Instr II:

CHECK ALL THAT APPLY.

INPUT FIELDS / ROUTING

6:35:25 PM Monday, July 07, 2008

Page 78 of 85

AC35

6:35:32 PM Monday, July 07, 2008

Page 79 of 85

AC35
MHDIFCLT

Field1:
Cheshire Name:

( ACQ1750 )

NONE
REPLACES THE FOLLOWING CHESHIRE VARIABLES:
1/NoAuthorize=ACCS.MHNOAUTH
2/WaitLongAppt=ACCS.MHWAITLG
3/LocateNotConven=ACCS.MHNOCONV
4/NoReferral=ACCS.MHNOREFR
5/DidNotLikeProv=ACCS.MHNOLIKE
6/HoursNotConven=ACCS.MHBADHRS
91/Other=ACCS.MHOTHER

Item Text display:
Item Text:
Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:

Enumerated
TMHDifclt
7
No
No

Number Label
1 NoAuthorize

FieldSize:
Min Value:
Max Value:
Mask:

Route
AC36 - MHREFPAY ( ACQ1780 )

2

English text: PLAN WOULDN’T AUTHORIZE SERVICE
WaitLongAppt
AC36 - MHREFPAY ( ACQ1780 )

3

English text: THE WAIT FOR APPOINTMENT WAS TOO LONG
LocateNotConven
AC36 - MHREFPAY ( ACQ1780 )

4

English text: PROVIDER’S LOCATION WAS NOT CONVENIENT
NoReferral
AC36 - MHREFPAY ( ACQ1780 )

5

English text: DOCTOR/PLAN WOULDN'T GIVE SP REFERRAL TO SEE PROVIDER SP
WANTED TO SEE
DidNotLikeProv
AC36 - MHREFPAY ( ACQ1780 )

6

English text: SP DIDN'T LIKE/NOT CONFIDENT IN PROVIDER PLAN REFERRED SP TO
HoursNotConven
AC36 - MHREFPAY ( ACQ1780 )

91

English text: PROVIDER’S OFFICE HOURS WERE NOT CONVENIENT
Other
AC35 - MHOTHOS ( ACQ1770 )
English text: OTHER

6:35:43 PM Monday, July 07, 2008

Page 80 of 85

AC35

Attribute
Don't know

Route
AC36 - MHREFPAY ( ACQ1780 )

Refusal

AC36 - MHREFPAY ( ACQ1780 )

Field2:
Cheshire Name:

MHOTHOS

( ACQ1770 )

ACCS.MHOTHOS

Item Text display:

Display "(SPECIFY)" in the same blue font used for

interviewer instructions.

Item Text:

OTHER (SPECIFY)

Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:

String

TOthrspec
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

30

Route
AC36 - MHREFPAY ( ACQ1780 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

6:35:45 PM Monday, July 07, 2008

Page 81 of 85

AC36

AC36

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

MHREFPAY

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

460

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display name of SP's current Medicare Managed Care Plan,
PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

Has (CURRENT MEDICARE MANAGED CARE PLAN NAME) ever
refused to pay for emergency treatment that [you/(SP)] felt was
necessary?

Int. Instr II:
INPUT FIELDS / ROUTING

6:35:48 PM Monday, July 07, 2008

Page 82 of 85

AC36
( ACQ1780 )

MHREFPAY

Field1:
Cheshire Name:

ACCS.MHREFPAY

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TMhrefpay

FieldSize:
Min Value:
Max Value:
Mask:

1
No
No

Number Label
1 Yes

Route
BOX AC3 - (ACQ1790 )

2

English text: YES
No

BOX AC3 - (ACQ1790 )

3

English text: NO
NaHaventNeededEmergencyTreatment

BOX AC3 - (ACQ1790 )

English text: N/A, HAVEN'T NEEDED EMERGENCY TREATMENT
Attribute
Don't know

Route
BOX AC3 - (ACQ1790 )

Refusal

BOX AC3 - (ACQ1790 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans

6:35:53 PM Monday, July 07, 2008

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

Page 83 of 85

AC36
65

MHMOCurrent

SP has a current Medicare Managed Care plan =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

6:35:54 PM Monday, July 07, 2008

Page 84 of 85

BOX AC3

BOX AC3

Page Order # :

470

BOX INSTRUCTIONS
( ACQ1790 )

GO TO NEXT SECTION .

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

6:35:54 PM Monday, July 07, 2008

Page 85 of 85