MEPS-HC Core Interview

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

Attachment 54 -- HC Prescribed Medicines 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⚠️ Notice: This form may be outdated.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 Prescribed Medicines (PM) Section

December 8, 2008

Prescribed Medicines (PM) Section

BOX_00

======

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

| CONTEXT HEADER DISPLAY INSTRUCTIONS: |

| DISPLAY PERS.FULLNAME, PRND.BEGREFMM,DD,YY AND |

| PRND.ENDREFMM,DD,YY. |

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

PM01

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

The next questions are about prescription medicines (PERSON)

purchased or received {since (START DATE)/between (START DATE)

and (END DATE)}.

[It would be very helpful for the following questions if we

could look at the bottles, containers, tubes, or bags for each

of the medicines we will be talking about.]

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

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

| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |

| DISPLAY ‘between (START DATE) and (END DATE)’ IF |

| ROUND 5. |

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

| MEDICINES ARE FLAGGED AS ‘CREATED’ ONLY ONCE |

| (I.E., THE ROUND IN WHICH THE MEDICINE IS |

| INITIALLY REPORTED). MEDICINES ARE FLAGGED AS |

| ‘SELECTED’ WHEN CHOSEN IN SUBSEQUENT ROUNDS. |

| THUS, FOR ONE ROUND, A MEDICINE CAN ONLY BE |

| FLAGGED AS EITHER ‘CREATED’ OR ‘SELECTED’, BUT |

| NOT BOTH. |

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

| IF PERSON HAS NO MEDICINES CREATED OR SELECTED |

| ON PERSON’S-PRESCRIBED-MEDICINES-ROSTER DURING |

| THE CURRENT ROUND, GO TO PM04 |

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

| OTHERWISE, CONTINUE WITH PM02 |

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

PM02

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

While we were talking about (PERSON)'s medical care, we listed

the following prescription(s) as purchased or received {since

(START DATE)/between (START DATE) and (END DATE)}. (READ

MEDICINES BELOW.)

{NAME OF PRESCRIPTION MEDICINE}

INFORMATION OKAY ....................... 1 {PM04}

AT LEAST ONE MEDICINE INCORRECT ........ 2

[Code One]

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

| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |

| DISPLAY ‘between (START DATE) and (END DATE)’ IF |

| ROUND 5. |

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

| IF CODED '2' (AT LEAST ONE MEDICINE INCORRECT) AND|

| THERE IS ONLY ONE MEDICINE ON PERSON’S-PRESCRIBED-|

| MEDICINES-ROSTER, SELECT THAT MEDICINE |

| AUTOMATICALLY BY CAPI AT PM03 AND GO TO PM04 |

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

| IF CODED '2' (AT LEAST ONE MEDICINE INCORRECT) AND|

| THERE IS MORE THAN ONE MEDICINE ON PERSON’S- |

| PRESCRIBED-MEDICINES-ROSTER, CONTINUE WITH PM03 |

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

| ROSTER DETAILS: |

| Title: PERSON’S_PRESCRIBED-MEDICINES_1 |

| |

| COL #1 HEADER: DRUG NAME |

| INSTRUCTIONS: DISPLAY NAME OF PRESCRIBED MEDICINE |

| (DRUG.DRUGNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS THE PERSON’S-PRESCRIBED- |

| MEDICINES-ROSTER FOR DISPLAY. |

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

| ROSTER BEHAVIOR: |

| 1. DISPLAY ONLY. |

| |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE PRESCRIBED MEDICINES THAT ARE |

| FLAGGED AS EITHER ‘CREATED’ OR ‘SELECTED’ DURING |

| THE CURRENT ROUND. |

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

PM03

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

SELECT MEDICINE(S) THAT WERE RECORDED INCORRECTLY.

[1. Prescribed Medicine]

[2. Prescribed Medicine]

[3. Prescribed Medicine]

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

| FLAG SELECTED MEDICINES AS 'INCORRECT'. THESE |

| MEDICINES WILL NOT BE ELIGIBLE FOR LOOP_01 (I.E., |

| NOT ‘CREATED’ OR ‘SELECTED’ THIS ROUND). |

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

| GO TO PM04 |

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

| ROSTER DETAILS: |

| Title: PERSON’S_PRESCRIBED-MEDICINES_1 |

| |

| COL #1 HEADER: PRESCRIBED MEDICINE |

| INSTRUCTIONS: DISPLAY NAME OF PRESCRIBED MEDICINE |

| (DRUG.DRUGNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS THE PERSON’S-PRESCRIBED- |

| MEDICINES-ROSTER FOR SELECTION. |

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

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. |

| |

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

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

| ROSTER FILTER: |

| DISPLAY ONLY THOSE PRESCRIBED MEDICINES THAT ARE |

| FLAGGED AS EITHER ‘CREATED’ OR ‘SELECTED’ DURING |

| THE CURRENT ROUND. |

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

PM04

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

{Since (START DATE)/Between (START DATE) and (END DATE)},

(have/has) (PERSON) obtained any medicines [we have not yet

talked about]? For example, (have/has) (PERSON) had any new

prescriptions or a refill of a prescription?

Please include any on-line prescriptions.

YES .................................... 1 {PM05}

NO ..................................... 2 {PM06}

REF ................................... -7 {PM06}

DK .................................... -8 {PM06}

HELP AVAILABLE FOR DEFINITION OF PRESCRIPTIONS AND REFILLS.

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

| DISPLAY ‘Since (START DATE)’ IF NOT ROUND 5. |

| DISPLAY ‘Between (START DATE) and (END DATE)’ IF |

| ROUND 5. |

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

PM05

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

What were the names of these medicines?

PROBE: Any other medicines?

[1. Prescribed Medicine]

[2. Prescribed Medicine]

[3. Prescribed Medicine]

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

| FLAG ANY MEDICINE ADDED TO THE ROSTER AS ‘CREATED’ |

| IN THIS ROUND. |

| |

| FLAG ANY MEDICINE SELECTED FROM THE ROSTER AS |

| ‘SELECTED’ IN THIS ROUND, IF THIS IS THE FIRST TIME|

| THAT THE MEDICINE IS SELECTED IN CAPI IN THIS |

| ROUND. FOR ANY ONE ROUND, A MEDICINE CAN BE FLAGGED|

| ONLY AS ‘CREATED’ OR ‘SELECTED’, BUT NOT BOTH IN |

| THAT SAME ROUND. |

| |

| AT THIS ITEM, THE ROSTER WILL DISPLAY ALL |

| MEDICINES IN PERSON’S-PRESCRIBED-MEDICINES-ROSTER. |

| THAT DISPLAY WILL INCLUDE ALL MEDICINES CREATED IN |

| PREVIOUS ROUNDS AND IN THE CURRENT ROUND. WHEN A |

| MEDICINE CREATED IN A PREVIOUS ROUND IS SELECTED, |

| CREATE A NEW EVENT FOR THAT MEDICINE. FOR SUCH |

| MEDICINES, (AND FOR ADDED MEDICINES), CAPI WILL |

| ASK THE CP SECTION AND THE PHARMACY OF THE |

| PURCHASE. |

| |

| ANY MEDICINE ADDED TO THE ROSTER SHOULD BE FLAGGED |

| AS ‘CREATED’ THIS ROUND (WITH THE ROUND STATUS). |

| ANY MEDICINE SELECTED AT THE ROSTER SHOULD BE |

| FLAGGED AS ‘SELECTED’ THIS ROUND (WITH THE ROUND |

| STATUS). THIS FLAGGING SHOULD OCCUR, AT EACH |

| PERSON’S-PRESCRIBED-MEDICINES-ROSTER THROUGHOUT |

| THE INSTRUMENT (UNLESS OTHERWISE SPECIFIED), THE |

| FIRST TIME THE MEDICINE IS ADDED OR SELECTED DURING|

| THE ROUND. FOR EXAMPLE, IF IT IS ROUND 1, ALL |

| MEDICINES ON THE ROSTER WOULD HAVE THE FLAG |

| ‘CREATED – ROUND 1’. IF A MEDICINE IS CREATED IN |

| HS, BUT SELECTED IN MV, ALL DURING ROUND 1, IT |

| WOULD ONLY HAVE THE FLAG ‘CREATED – ROUND 1’. THUS,|

| FOR ANY ONE ROUND, A MEDICINE CAN ONLY BE FLAGGED |

| AS ‘CREATED’ OR ‘SELECTED’. IF IT IS ROUND 2 AND A |

| MEDICINE THAT WAS CREATED IN ROUND 1 IS SELECTED, |

| IT SHOULD BE FLAGGED AS ‘SELECTED – ROUND 2’. THIS |

| FLAG IS IN ADDITION TO THE ORIGINAL ‘CREATED - |

| ROUND 1’ FLAG. |

| |

| WHEN A MEDICINE FROM A PREVIOUS ROUND IS SELECTED, |

| CREATE A NEW EVENT SINCE IT INVOLVES A NEW |

| PURCHASE. A NEW PURCHASE REQUIRES ASKING THE |

| CHARGE/PAYMENT (CP) SECTION AND PHARMACY OF THE |

| PURCHASE. THE REASON FOR INCLUDING ALL OF THE |

| PRESCRIBED MEDICINES ON THE ROSTER IS SIMPLY TO |

| AVOID THE INTERVIEWER HAVING TO TYPE THEM IN AGAIN |

| (IF THE PERSON IS GETTING REFILLS OF THE SAME |

| MEDICINE EVERY ROUND). |

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

| GO TO PM06 |

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

| ROSTER DETAILS: |

| TITLE: PERSON'S_PRESCRIBED-MEDICINES_1 |

| |

| COL # 1 HEADER: PRESCRIBED MEDICINE |

| INSTRUCTIONS: DISPLAY NAME OF PRESCRIBED MEDICINE |

| (DRUG.DRUGNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS PERSON'S-PRESCRIBED-MEDICINES- |

| ROSTER FOR SELECTION/ADDITION. |

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

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. |

| |

| 2. MULTIPLE ADD ALLOWED. |

| |

| 3. LIMITED DELETE ALLOWED. INTERVIEWER MAY DELETE |

| A PMED ADDED ON THIS SCREEN AS LONG AS CAPI HAS|

| NOT YET CREATED THE LINK BETWEEN THIS PMED AND |

| THE EVENT. |

| |

| 4. EDIT DISALLOWED. |

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

| ROSTER FILTER: |

| DISPLAY ALL; NO FILTER. |

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

PM06

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

{Since (START DATE)/Between (START DATE) and (END DATE)}, did

(PERSON) get any free samples of prescribed medicines from a

medical or dental provider that we have not yet talked about?

YES .................................... 1 {PM07}

NO ..................................... 2 {BOX_01}

REF ................................... -7 {BOX_01}

DK .................................... -8 {BOX_01}

HELP AVAILABLE FOR DEFINITION OF FREE SAMPLES.

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

| DISPLAY ‘Since (START DATE)’ IF NOT ROUND 5. |

| DISPLAY ‘Between (START DATE) and (END DATE)’ IF |

| ROUND 5. |

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

PM07

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

What are the names of the medicines (PERSON) got as free

samples?

PROBE: Any other free samples?

[1. Prescribed Medicine]

[2. Prescribed Medicine]

[3. Prescribed Medicine]

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

| FLAG MEDICINES AS ‘FREE SAMPLE’ ON IF MEDICINE |

| WAS CREATED AT PM07 DURING THE CURRENT ROUND. |

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

| GO TO BOX_01 |

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

| ROSTER DETAILS: |

| TITLE: PERSON'S_PRESCRIBED-MEDICINES_1 |

| |

| COL # 1 HEADER: PRESCRIBED MEDICINE |

| INSTRUCTIONS: DISPLAY NAME OF PRESCRIBED MEDICINE |

| (DRUG.DRUGNAME) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS PERSON'S-PRESCRIPTION- |

| MEDICINES-ROSTER FOR SELECTION/ADDITION. |

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

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. |

| |

| 2. MULTIPLE ADD ALLOWED. |

| |

| 3. LIMITED DELETE ALLOWED. INTERVIEWER MAY DELETE |

| A PMED ADDED ON THIS SCREEN AS LONG AS CAPI HAS|

| NOT YET CREATED THE LINK BETWEEN THIS PMED AND |

| THE EVENT. |

| |

| 4. EDIT DISALLOWED. |

| |

| 5. ANY MEDICINE ADDED TO THE ROSTER SHOULD BE |

| FLAGGED AS ‘CREATED’ THIS ROUND (WITH THE ROUND|

| STATUS). ANY MEDICINE SELECTED AT THE ROSTER |

| SHOULD BE FLAGGED AS ‘SELECTED’ THIS ROUND |

| (WITH THE ROUND STATUS). THIS FLAGGING SHOULD |

| OCCUR, AT EACH PERSON’S-PRESCRIBED-MEDICINES- |

| ROSTER THROUGHOUT THE INSTRUMENT (UNLESS |

| OTHERWISE SPECIFIED), THE FIRST TIME THE |

| MEDICINE IS ADDED OR SELECTED DURING THE ROUND.|

| FOR EXAMPLE, IF IT IS ROUND 1, ALL MEDICINES |

| ON THE ROSTER WOULD HAVE THE FLAG ‘CREATED - |

| ROUND 1’. IF A MEDICINE IS CREATED IN HS, BUT |

| SELECTED IN MV, ALL DURING ROUND 1, IT WOULD |

| ONLY HAVE THE FLAG ‘CREATED - ROUND 1’. THUS, |

| FOR ANY ONE ROUND, A MEDICINE CAN ONLY BE |

| FLAGGED AS ‘CREATED’ OR ‘SELECTED’. IF IT |

| IS ROUND 2 AND A MEDICINE THAT WAS CREATED IN |

| ROUND 1 IS SELECTED, IT SHOULD BE FLAGGED AS |

| ‘SELECTED - ROUND 2’. THIS FLAG IS IN ADDITION|

| TO THE ORIGINAL ‘CREATED - ROUND 1’ FLAG. |

| |

| 6. WHEN A MEDICINE FROM A PREVIOUS ROUND IS |

| SELECTED, A NEW EVENT IS CREATED SINCE IT |

| INVOLVES A NEW PURCHASE. A NEW PURCHASE |

| REQUIRES ASKING THE CHARGE/PAYMENT (CP) SECTION|

| AND THE PHARMACY OF THE PURCHASE. THE REASON |

| FOR INCLUDING ALL OF THE PRESCRIBED MEDICINES |

| ON THE ROSTER IS SIMPLY TO AVOID THE |

| INTERVIEWER HAVING TO TYPE THEM IN AGAIN (IF |

| THE PERSON IS GETTING REFILLS OF THE SAME |

| MEDICINE EVERY ROUND). |

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

| ROSTER FILTER: |

| DISPLAY ALL; NO FILTER. |

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

BOX_01

======

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

| IF NO MEDICINES FLAGGED AS ‘CREATED’ OR ‘SELECTED’|

| DURING THE CURRENT ROUND, GO TO BOX_06 |

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

| OTHERWISE, CONTINUE WITH LOOP_01 |

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

LOOP_01

=======

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

| FOR EACH ELEMENT IN PERSON’S-PRESCRIBED-MEDICINES-|

| ROSTER, ASK BOX_01A-END_LP01 |

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

| LOOP DEFINITION: LOOP_01 COLLECTS INFORMATION |

| ABOUT EACH PRESCRIBED MEDICINE CREATED OR SELECTED|

| DURING THE CURRENT ROUND. THIS LOOP CYCLES ON |

| PRESCRIBED MEDICINES THAT MEET ONE OF THE |

| FOLLOWING CONDITIONS: |

| |

| - PRESCRIBED MEDICINE IS FLAGGED AS ‘CREATED’ |

| DURING THE CURRENT ROUND. |

| OR |

| - PRESCRIBED MEDICINE IS FLAGGED AS ‘SELECTED’ |

| DURING THE CURRENT ROUND. |

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

BOX_01A

=======

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

| IF ROUND 5, CONTINUE WITH PM07A |

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

| OTHERWISE, GO TO PM08 |

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

PM07A

=====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF PRESCRIPTION

MEDICINE.} {STR-DT}

{END-DT}

Now, let’s talk about (MEDICINE).

Was (MEDICINE) purchased or obtained sometime between (START

DATE) and (END DATE)?

YES .................................... 1 {PM08}

NO ..................................... 2 {END_LP01}

REF ................................... -7 {PM08}

DK .................................... -8 {PM08}

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

| IF CODED ‘2’ (NO), FLAG MEDICINE AS ‘INCORRECT’. |

| THIS MEDICINE SHOULD NOT BE FLAGGED AS ‘CREATED’ |

| OR ‘SELECTED’ FOR ROUND 5 AND THE ROUND 5 RECORDS |

| SHOULD BE DELETED. |

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

PM08

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF PRESCRIPTION

MEDICINE.} {STR-DT}

{END-DT}

{Now, let’s talk about (MEDICINE).}

Is (MEDICINE) used for a specific health problem?

YES .................................... 1 {PM09}

NO ..................................... 2 {BOX_02A}

REF ................................... -7 {BOX_02A}

DK .................................... -8 {BOX_02A}

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

| DISPLAY ‘Now let’s talk about (MEDICINE).’ IF NOT |

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

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

PM09

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF PRESCRIPTION

MEDICINE.} {STR-DT}

{END-DT}

What health problem is (MEDICINE) prescribed for?

PROBE: Any other health problems?

IF CONDITION IS ALREADY LISTED, SELECT ENTRY ON ROSTER.

[1. Medical Condition]

[2. Medical Condition]

[3. Medical Condition]

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

| GO TO BOX_02A |

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

| DISPLAY ‘ADD CONDITION’ AS AN OPTION ON THIS |

| SCREEN. |

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

| ROSTER DETAILS: |

| Title: PERS_COND_1 |

| |

| COL #1 HEADER: MEDICAL CONDITION |

| INSTRUCTIONS: DISPLAY NAME OF MEDICAL CONDITION |

| (COND.CONDNAM) |

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

| ROSTER DEFINITION: |

| DISPLAY THE PERSON-MEDICAL-CONDITIONS-ROSTER FOR |

| THE SELECTION AND ADDITION OF ONE OR MANY MEDICAL |

| CONDITION(S) ASSOCIATED WITH THIS EVENT. |

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

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. SELECTION SHOULD NOT |

| IMPACT THE ROUND FLAG OF THE CONDITION. |

| |

| 2. MULTIPLE ADD ALLOWED. INTERVIEWER SHOULD RECORD|

| CONDITION NAME. |

| |

| 3. LIMITED DELETE ALLOWED. INTERVIEWER MAY DELETE |

| A CONDITION ADDED ON THIS SCREEN AS LONG AS |

| CAPI HAS NOT YET CREATED THE LINK BETWEEN THIS |

| CONDITION AND THE EVENT. |

| |

| 4. LIMITED EDIT ALLOWED. INTERVIEWER MAY EDIT A |

| CONDITION NAME NEWLY ADDED ON THIS SCREEN AS |

| LONG AS CAPI HAS NOT YET CREATED THE LINK |

| BETWEEN THIS CONDITION AND THE EVENT. |

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

| ROSTER FILTER: |

| DISPLAY ALL CONDITIONS ON PERSON’S ROSTER; NO |

| FILTER. |

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

BOX_02A

=======

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

| IF MEDICINE BEING ASKED ABOUT IS FLAGGED AS |

| ‘SELECTED’ DURING THE CURRENT ROUND, GO TO PM10 |

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

| IF MEDICINE BEING ASKED ABOUT IS FLAGGED AS |

| ‘CREATED’ DURING THE CURRENT ROUND, CONTINUE WITH |

| PM11 |

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

PM11

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF PRESCRIPTION

MEDICINE.} {STR-DT}

{END-DT}

In what year did (PERSON) first use (MEDICINE)?

XXXX HAS NOT YET TAKEN/USED

[Enter Year-4] ........................

REF ................................... -7 {PM10}

DK .................................... -8 {PM10}

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

| IF XXXX (HAS NOT YET TAKEN/USED) ENTERED, GO TO |

| PM10 |

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

| IF YEAR IS REFERENCE YEAR OR REFERENCE YEAR MINUS |

| 1, CONTINUE WITH PM11OV1 |

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

| OTHERWISE, GO TO PM10 |

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

PM11OV1

=======

MONTH:

[Enter Month-2] .......................

REF ................................... -7

DK .................................... -8

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

| FOR SPECIFICATIONS PURPOSES ONLY (CAPI HANDLES |

| AUTOMATICALLY): ALLOWABLE VALUES FOR MONTH ARE |

| 1-12. |

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

| IF YEAR IS REFERENCE YEAR, CONTINUE WITH PM11OV2 |

| |

| OTHERWISE, GO TO PM10 |

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

PM11OV2

=======

DAY:

[Enter Day-2] ......................... {PM10}

REF ................................... -7 {PM10}

DK .................................... -8 {PM10}

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

| HARD CHECK: |

| |

| ENTRIES FOR DAY MUST CORRESPOND TO CALENDAR |

| MONTHS AND DAYS. THAT IS, |

| - ALLOWABLE VALUES = 01 - 31 IF MONTH CODED |

| ‘01’, ‘03’, ‘05’, ‘07’, ‘08’, ‘10’, ‘12’; |

| - ALLOWABLE VALUES = 01 - 30 IF MONTH CODED |

| ‘04’, ‘06’, ‘09’, ‘11’; |

| - ALLOWABLE VALUES = 01 - 29 IF MONTH CODED |

| ‘02’ AND YEAR IS 2008 (LEAP YEAR); |

| - ALLOWABLE VALUES = 01 - 28 IF MONTH CODED |

| ‘02’ AND YEAR IS NOT 2008 (I.E., NOT LEAP |

| YEAR). |

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

| THE COMPLETE DATE CANNOT BE BEFORE THE PERSON’S |

| DATE OF BIRTH OR AFTER THE REFERENCE PERIOD END |

| DATE FOR THIS PERSON. |

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

PM10

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF PRESCRIPTION

MEDICINE.} {STR-DT}

{END-DT}

How many times was (MEDICINE) obtained or purchased for

(PERSON) {since (START DATE)/between (START DATE) and (END

DATE)}?

[Enter Number of Times] ................ {BOX_02B}

REF ................................... -7 {BOX_02B}

DK .................................... -8 {BOX_02B}

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

| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |

| DISPLAY ‘between (START DATE) and (END DATE)’ IF |

| ROUND 5. |

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

BOX_02B

=======

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

| IF ROUND 3 AND PM10 IS NOT -7 OR –8, CONTINUE |

| WITH PM10A |

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

| OTHERWISE, GO TO BOX_02 |

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

PM10A

=====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF PRESCRIPTION

MEDICINE.} {STR-DT}

{END-DT}

NUMBER OF TIMES OBTAINED/PURCHASED SINCE (START DATE):

{NUMBER OF TIMES}

Of these times, how many were in {YEAR}?

[Enter Number of Times] ................ {BOX_02}

REF ................................... -7 {BOX_02}

DK .................................... -8 {BOX_02}

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

| FOR ‘NUMBER OF TIMES,’ DISPLAY THE NUMBER ENTERED |

| AT PM10. |

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

| FOR SPECIFICATIONS PURPOSES ONLY (CAPI HANDLES |

| AUTOMATICALLY): FOR ‘YEAR’, DISPLAY THE YEAR THAT |

| IS THE FIRST YEAR OF THE GIVEN PANEL. |

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

| HARD CHECK: |

| NUMBER OF TIMES MUST BE <= NUMBER OF TIMES |

| OBTAINED/PURCHASED AT PM10. |

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

BOX_02

======

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

| IF THE CHARGE/PAYMENT (CP) SECTION HAS NOT BEEN |

| ASKED FOR THIS MEDICINE, ASK THE CHARGE/PAYMENT |

| (CP) SECTION |

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

| OTHERWISE, CONTINUE WITH END_LP01 |

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

END_LP01

========

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

| CYCLE ON NEXT MEDICINE IN PERSON’S-PRESCRIBED- |

| MEDICINES-ROSTER THAT MEETS THE CONDITIONS STATED |

| IN THE LOOP DEFINITION. |

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

| IF NO OTHER MEDICINES MEET THE STATED CONDITIONS, |

| END LOOP_01 AND CONTINUE WITH BOX_03 |

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

BOX_03

======

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

| IF ALL PRESCRIBED MEDICINES FOR THIS PERSON ARE |

| FLAGGED AS ‘FREE SAMPLES’ (IN BOTH PM AND CP) |

| DURING THE CURRENT ROUND, GO TO BOX_06 |

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

| OTHERWISE, CONTINUE WITH LOOP_02 |

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

LOOP_02

=======

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

| FOR EACH OF THE FOLLOWING: |

| |

| PHARMACY 1 |

| PHARMACY 2 |

| PHARMACY 3 |

| PHARMACY 4 |

| |

| ASK BOX_04A-END_LP02 |

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

| LOOP DEFINITION: LOOP_02 ENUMERATES PHARMACIES |

| USED BY PERSON FOR PRESCRIBED MEDICINES THAT WERE |

| CREATED OR SELECTED DURING THE CURRENT ROUND. |

| THE RESPONSE TO PM17 DETERMINES IF THE LOOP CYCLES|

| AGAIN. IF PM17 IS CODED ‘1’ (YES), THE LOOP CYCLES|

| TO COLLECT THE NEXT PHARMACY USED BY PERSON. |

| IF PM17 IS CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’|

| (DON’T KNOW), THE LOOP ENDS. |

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

BOX_04A

=======

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

| AS A PHARMACY IS ENTERED OR SELECTED, FLAG THE |

| PERSON-PHARMACY PAIR 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 PERMISSION FORM |

| COLLECTION FOR THIS RU MEMBER. |

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

BOX_04

======

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

| IF THERE ARE NO PHARMACIES ON THE RU-PHARMACIES- |

| ROSTER, GO TO PM14 |

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

| OTHERWISE, CONTINUE WITH PM12 |

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

PM12

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

What is the name of the (next) pharmacy that filled the

prescription(s) for (PERSON)?

[1. Pharmacy] [STREET ADDRESS] [CITY]

[2. Pharmacy] [STREET ADDRESS] [CITY]

[3. Pharmacy] [STREET ADDRESS] [CITY]

REF ................................... -7

DK .................................... -8

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

| DISPLAY 'ADD PHARMACY' AND ‘DELETE PHARMACY’ |

| BUTTONS AS OPTIONS ON THIS SCREEN. |

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

| IF ‘ADD PHARMACY’ IS SELECTED, GO TO PM14 |

| (NOTE THAT PM14 IS ACTUALLY A POPUP ON PM12). |

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

| OTHERWISE, CONTINUE WITH PM13 |

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

| ROSTER DETAILS: |

| Title: RU_PHAR_1 |

| |

| COL #1 HEADER: PHARMACY |

| INSTRUCTIONS: DISPLAY PHARMACY NAME |

| (PHAR.PHARNAME) |

| |

| COL #2 HEADER: STREET ADDRESS |

| INSTRUCTIONS: DISPLAY TRUNCATED STREET ADDRESS |

| (PHAR.PHARADR1) |

| |

| COL #3 HEADER: CITY |

| INSTRUCTIONS: DISPLAY TRUNCATED CITY |

| (PHAR.PHARCITY) |

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

| ROSTER DEFINITION: |

| THIS ITEM DISPLAYS THE RU-PHARMACIES-ROSTER FOR |

| SELECTION/ADDITION. |

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

| ROSTER BEHAVIOR: |

| |

| 1. SELECT ONE ALLOWED. INTERVIEWER MUST SELECT |

| ONE ONLY FROM THE LIST OF PROVIDERS OR MAY |

| SELECT ‘ADD PHARMACY’ |

| |

| 2. ADD ALLOWED. |

| |

| 3. EDITS ARE NOT ALLOWED. |

| |

| 4. LIMITED DELETE ALLOWED. |

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

| ROSTER FILTER: |

| DISPLAY ALL; NO FILTER. |

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

PM13

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

Is the address of (READ NAME AND ADDRESS OF PHARMACY BELOW)...

{PHARMACY NAME SELECTED AT PM12}

{PHARMACY STREET ADDRESS LINE1.}

{PHARMACY STREET ADDRESS LINE2.}

{PHARMACY CITY..,ST,ZIPCODE...}

{PHRM PHONE}

ADDRESS AND TELEPHONE CORRECT .......... 1 {BOX_05}

ADD NEW ADDRESS FOR PHARMACY ........... 2 {PM14}

ABOVE ADDRESS/TELEPHONE NEEDS

CORRECTION ............................. 3 {PM15}

SELECTED WRONG PHARMACY/ADDRESS ........ 4

REF ................................... -7 {BOX_05}

DK .................................... -8 {BOX_05}

[Code One]

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

| IF CODED '4' (SELECTED WRONG PHARMACY/ADDRESS), |

| CAPI REDISPLAYS PM12 TO ALLOW INTERVIEWER TO |

| SELECT CORRECT PHARMACY. |

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

PM14

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

What is the name and address of the (next) pharmacy that filled

the prescription(s) for (PERSON)?

ENTER COMPLETE (NAME AND) ADDRESS AND VERIFY SPELLING.

IF PHARMACY HAS MORE THAN ONE LOCATION, RECORD LOCATION

WHERE PERSON HAD PRESCRIPTION FILLED.

ENTER WEB ADDRESS ON STREET ADDRESS LINE(S).

PHARMACY_NAME: [_____________]

PHARMACY_STR1: [_____________]

PHARMACY_STR2: [_____________]

PHARMACY_CITY: [_____________]

PHARMACY_STATE: [_____________]

PHARMACY_ZIPCDE: [_____________]

PHARMACY_PHONE: [_____________]

REF .................................. -7 {BOX_05}

DK ................................... -8 {BOX_05}

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

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

| IF PM13 IS CODED '2' (ADD NEW ADDRESS FOR |

| PHARMACY), PM14 WILL NOT COLLECT THE PHARMACY |

| NAME, PM14_01 WILL DISPLAY THE PHARMACY NAME AND |

| CANNOT BE EDITED. |

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

| CODES '-7' (REFUSED) AND '-8' (DON’T KNOW) ARE |

| ALLOWED ON EACH FORM ITEM EXCEPT FOR PHARMACY |

| NAME (PM14_01). |

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

| HARD CHECK: CHECK THAT STATE ABBREVIATION IS |

| VALID. |

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

PM15

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

CORRECT ADDRESS OR TELEPHONE FOR: {PHARMACY NAME W/WRONG

ADDRESS.}

TO VERIFY CURRENT INFORMATION OR TO LEAVE A FIELD BLANK, PRESS

ENTER. TO CORRECT ANY INNACURATE FIELDS, TYPE ENTIRE FIELD.

PHARMACY_STR1: [_____________] {BOX_05}

PHARMACY_STR2: [_____________]

PHARMACY_CITY: [_____________]

PHARMACY_STATE: [_____________]

PHARMACY_ZIPCDE: [_____________]

PHARMACY_PHONE: [_____________]

RF ................................... -7 {BOX_05}

DK ................................... -8 {BOX_05}

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

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

| ADDRESS FIELDS CONTAIN PREVIOUSLY COLLECTED |

| INFORMATION WHICH CAN BE UPDATED. |

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

| HARD CHECK: |

| EDIT: CHECK THAT STATE ABBREVIATION IS VALID. |

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

BOX_05

======

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

| IF THE NAME OR ADDRESS FIELDS WERE COMPLETED IN |

| PM14 FOR THE PHARMACY BEING ASKED ABOUT (THAT IS, |

| THE PHARMACY WAS ADDED TO THE RU-PHARMACIES- |

| ROSTER OR A NEW ADDRESS WAS ENTERED FOR AN |

| EXISTING PHARMACY), CONTINUE WITH PM16 |

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

| OTHERWISE, GO TO PM17 |

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

PM16

====

{PERSON'S FIRST MIDDLE AND LAST NAME}{PHARMACY NAME} {STR-DT}

{END-DT}

What type of pharmacy is that? Is it a mail-order pharmacy;

a pharmacy located in another store such as a grocery or

department store; a pharmacy located in an HMO, clinic, or

hospital; a drug store that is not located within another

facility; or is it an on-line pharmacy?

MAIL-ORDER ............................. 1 {PM17}

IN ANOTHER STORE ....................... 2 {PM17}

IN HMO/CLINIC/HOSPITAL ................. 3 {PM17}

DRUG STORE ............................. 4 {PM17}

ON-LINE ................................ 5 {PM17}

REF ................................... -7 {PM17}

DK .................................... -8 {PM17}

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

[Code One]

PM17

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

{END-DT}

Did (PERSON) use another pharmacy {since (START DATE)/between

(START DATE) and (END DATE)}?

FOR CHAIN ESTABLISHMENTS, PLEASE RECORD ALL PHARMACY LOCATIONS

USED (I.E., THOSE WITH THE SAME NAME BUT DIFFERENT ADDRESS).

YES .................................... 1 {END_LP02}

NO ..................................... 2 {END_LP02}

REF ................................... -7 {END_LP02}

DK .................................... -8 {END_LP02}

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

| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |

| DISPLAY ‘between (START DATE) and (END DATE)’ IF |

| ROUND 5. |

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

END_LP02

========

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

| IF PM17 IS CODED '1' (YES), CYCLE TO COLLECT |

| INFORMATION ABOUT THE NEXT PHARMACY USED BY |

| PERSON. |

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

| IF PM17 IS CODED '2' (NO), '-7 (REFUSED), OR '-8' |

| (DON'T KNOW), END LOOP_02 AND CONTINUE WITH BOX_06|

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

BOX_06

======

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

| GO TO NEXT QUESTIONNAIRE SECTION |

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

20-25

File Type	application/msword
File Title	MEPS Prescribed Medicines - P12R5/P13R3/P14R1
Subject	PM Section Item Specifications
Author	Agency for Healthcare Research and Quality
Last Modified By	wcarroll
File Modified	2009-07-10
File Created	2009-07-10