Form #1 Form #1 Validation Interview Form



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REG

PSU

RUID

MEPS VALIDATION INTERVIEW

The Federal government requires that all persons asked to respond to one of its surveys be given the following information: Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

ASSURANCE OF CONFIDENTIALITY This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure.

BOX A. IF VALIDATION IS FOR A COMPLETED CASE (DISPOSITION CODES 60-63), GO TO SECTION A OF VALIDATION INTERVIEW. IF VALIDATION IS FOR A FINAL NON RESPONSE CASE (DISPOSITION CODES 88 – 99) OR OUT-OF-SCOPE CASE (DISPOSITION CODES 70 – 87), GO TO SECTION B.

SECTION A

BOX B. REVIEW VALIDATION ABSTRACT FORM FOR DETAILS OF THE CASE. ASK FOR THE APPROPRIATE RESPONDENT. IF THE RESPONDENT IS NOT AVAILABLE, ARRANGE A CALL BACK. IF THE RESPONDENT WILL NOT BE AVAILABLE IN NEAR FUTURE, TALK TO ANYONE WHO SELF RESPONDED DURING THE ROUND.

INTRODUCTION FOR RESPONDENT OR PROXY: Hello. My name is (NAME) with the Medical Expenditure Panel Survey being conducted for the Department of Health and Human Services. Recently one of our staff interviewed you.

1. Do you recall the interview?

YES 1 (6) PHONE/(8)-IN PERSON

NO 2 (2)

2. The interviewer asked about (your/your family’s) health care including health care visits and use of prescribed medicines between (DATES OF REFERENCE PERIOD) and a few other questions. Our records show that (NAME OF INTERVIEWER) was there on (DATE OF INTERVIEW). (He/she) would have used a small computer to record the answers. Do you remember that?

YES 1 (6) PHONE/(8)-IN PERSON

NO 2 (3) PHONE/(4)-IN PERSON

3. (VERIFY THAT YOU HAVE REACHED THE CORRECT TELEPHONE NUMBER AND THAT YOU ARE SPEAKING WITH THE CORRECT RESPONDENT. IF SO CONTINUE.) Perhaps there is some mistake. Is your telephone number (NUMBER) and you live at (ADDRESS)?

YES 1 (5)

NO 2 (4)

4. Did you live at (ADDRESS) on (DATE OF INTERVIEW)?

YES 1

NO 2

5. PROBE FOR EXPLANATION. (COULD THIS HOUSEHOLD BE A SPLIT? ARE THERE OTHER PEOPLE IN THE HOUSEHOLD WHO COULD HAVE ANSWERED THE QUESTIONS -- WHAT ABOUT VISITORS?) [ENTER IN COMMENTS SECTION ON THE LAST PAGE]

BOX C. THANK THE RESPONDENT. TERMINATE THE INTERVIEW. ADD ANY PERTINENT NOTES ABOVE AND IN THE COMMENTS SECTION ON THE LAST PAGE. REPORT PROBLEM TO SUPERVISOR IMMEDIATELY.

6. First, I would like to thank you very much for participating in this important study. On all of our surveys we routinely recontact some people who were interviewed to make sure our interviewers are following procedures correctly. I have just a few questions to ask about the interview. According to the information I have, on (DATE OF INTERVIEW) you lived at (ADDRESS). Is that correct?

YES 1 (8)

NO 2 (7)

7. What was your address on (DATE OF INTERVIEW)?

BOX D. UPDATE ADDRESS ON VALIDATION ABSTRACT AND RECORD IN COMMENTS SECTION.

8. On (DATE OF INTERVIEW), the following people lived in your household: (READ EACH NAME ON ABSTRACT FORM). Is that correct?

YES 1 (10)

NO 2 (9)

9. How should this information be changed to make it correct? (MAKE CHANGES ON VALIDATION ABSTRACT. TRY TO DETERMINE REASON FOR DISCREPANCY AND NOTE IN COMMENTS SECTION.)

10. Did the interviewer enter your responses into a small computer?

YES 1

NO 2

DONE BY PHONE 3

BOX E. IF R SAYS INTERVIEWER DID NOT USE A COMPUTER, PROBE FOR REASON AND EXPLAIN IN COMMENTS SECTION.

11. Approximately how long did the interview take?

_______ HOURS AND ______ minutes

12. During the interview, the interviewer should have shown you some cards assembled in a notebook/binder that included the answer categories to some of the survey questions. Did the interviewer use a set of cards like these?

Yes 1

No 2 (PROBE AND EXPLAIN IN COMMENTS SECTION)

13. Did the interviewer ask about (your/your household’s) purchase(s) of prescribed medicines between (REFERENCE PERIOD DATES)?

YES 1

NO 2

ASKED, NO PRES MEDS PURCHASED 3

BOX F. REVIEW THE VALIDATION ABSTRACT TO SEE IF ANY AUTHORIZATION FORMS ARE LISTED IN SECTION D. IF NO AUTHORIZATION FORMS ARE LISTED ON ABSTRACT FORM, SKIP TO QUESTION 15; OTHERWISE GO TO QUESTION 14.

14. Toward the end of the interview, the interviewer may have prepared authorization forms for medical providers or pharmacies that you talked about during the interview.

Did the interviewer ask you or anyone in your household to sign any authorization forms?

YES 1

NO 2

14A. Did the interviewer clearly explain the purpose of the form(s)?

YES 1

NO 2

DON’T REMEMBER 3

14B. Did the interviewer give you time to read the form(s)?

YES 1

NO 2

DON’T REMEMBER 3

14C. Did the interviewer explain who should sign the form(s)?

YES 1

NO 2

DON’T REMEMBER 3

14D. Was everyone over the age of 14 asked to sign their own authorization forms at the time of the interview or did the interviewer leave the form(s) to be signed later? CODE ALL THAT APPLY

SIGNED ON DAY OF INTERVIEW 1

INTERVIEWER LEFT FORM(S) FOR SIGNATURE 2

DON’T REMEMBER 3

IF VOLUNTEERED, REFUSED TO SIGN FORM 5

15. Did you receive a monetary gift from the interviewer?

Yes 1

No 2 (PROBE AND EXPLAIN IN COMMENTS)

15A. How much did you receive? _______ AMOUNT

16. Was the interview conducted in your home or someplace else?

IN RESPONDENT’S HOME 1

SOMEPLACE ELSE 2

ON THE PHONE 3

17. Now I’d like to ask about the interviewer who conducted the MEPS interview with you.

Was the interviewer very courteous, somewhat courteous, or not courteous?

VERY COURTEOUS 1

SOMEWHAT COURTEOUS 2

NOT COURTEOUS 3

18. Are there any comments you would like to make about the interview or the interviewer?

YES 1 (ENTER IN COMMENTS)

NO 2

SECTION B

AFTER COMPLETING THE VALIDATION CALL WITH THE RESPONDENT, COMPLETE SECTION B

B1. WERE YOU ABLE TO VERIFY THE FINAL DISPOSITION CODE?

YES - NO PROBLEM…………………. 1 (GO TO BOX H)

VERIFIED - POSSIBLE PROBLEM 2 (B2)

NO 3 (B2)

B2. EXPLAIN THE DISCREPANCY/REASON YOU COULD NOT VERIFY FINAL DISPOSITION IN COMMENTS SECTION.

BOX G. RECORD ANY ADDITIONAL COMMENTS IN THE COMMENTS SECTION. COMPLETE RECORD OF CALLS AND VALIDATION DISPOSITION AND RESULTS. REFER TO SUPERVISOR IF PROBLEM OR POTENTIAL PROBLEM.

VALIDATOR COMMENTS AND ADDITIONAL QUESTIONS ASKED:

Westat, 1600 Research Blvd, Rockville, MD 20850

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