Download:
pdf |
pdfSC1
SC1
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MCQUALTY
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
20
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
If (SP is in the supplemental sample) or (SP did not receive the Fall
supplement sections in the previous year), display "over the past
year".
Else display "since (SURVEY REFERENCE MONTH AND YEAR)"
Display "past year" in BOLD.
Display Survey Reference month and year from current round
MRES.SRPBDAT in "Month YYYY" format.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
SURVEY REFERENCE DATE: (SURVEY REFERENCE DATE)
Int. Instr I:
SHOW CARD SC1
Question Text:
We’re interested in how you feel about the health care [you
have/(SP) has] received [over the past year/
since (SURVEY REFERENCE MONTH AND YEAR)] from doctors
10:07:54 AM Wednesday, March 27, 2013
Page 1 of 120
SC1
and hospitals. Please tell me how satisfied you have been with the
following:
The overall quality of the health care [you have /(SP) has] received
[over the past year/since (SURVEY REFERENCE DATE)].
Int. Instr II:
INPUT FIELDS / ROUTING
MCQUALTY
Field1:
Cheshire Name:
( SCQ1005 )
ACCS.MCQUALTY
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSatisfy
1
No
No
Number Label
1 VerySatisfied
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC2 - MCAVAIL ( SCQ1010 )
2
English text: VERY SATISFIED
Satisfied
SC2 - MCAVAIL ( SCQ1010 )
3
English text: SATISFIED
Dissatisfied
SC2 - MCAVAIL ( SCQ1010 )
4
English text: DISSATISFIED
VeryDissatisfied
SC2 - MCAVAIL ( SCQ1010 )
5
English text: VERY DISSATISFIED
NotApplicable
SC2 - MCAVAIL ( SCQ1010 )
English text: NOT APPLICABLE
Attribute
Don't know
Route
SC2 - MCAVAIL ( SCQ1010 )
Refusal
SC2 - MCAVAIL ( SCQ1010 )
BACKGROUND VARIABLE ASSIGNMENTS
10:07:56 AM Wednesday, March 27, 2013
Page 2 of 120
SC1
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
9
SuppORD
SP is in the Supplemental Sample =
MRES.INTTYPE=3/NewFromSupplement on MRES
where MRES.MRESRND = current round.
462
NoFallSupp
SP did not receive the Fall supplement sections in the
previous year = There is no HEST where
HEST.HESTRND = (currentround – 3).
DESIGN NOTES
10:07:56 AM Wednesday, March 27, 2013
Page 3 of 120
SC2
SC2
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MCAVAIL
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:
Always display "[Please tell me…]" in brackets.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
SHOW CARD SC1
Question Text:
[Please tell me how satisfied you have been with . . .]
The availability of health care at night and on weekends.
Int. Instr II:
INPUT FIELDS / ROUTING
10:07:57 AM Wednesday, March 27, 2013
Page 4 of 120
SC2
Field1:
MCAVAIL
Cheshire Name:
( SCQ1010 )
ACCS.MCAVAIL
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSatisfy
1
No
No
Number Label
1 VerySatisfied
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC3 - MCEASE ( SCQ1015 )
2
English text: VERY SATISFIED
Satisfied
SC3 - MCEASE ( SCQ1015 )
3
English text: SATISFIED
Dissatisfied
SC3 - MCEASE ( SCQ1015 )
4
English text: DISSATISFIED
VeryDissatisfied
SC3 - MCEASE ( SCQ1015 )
5
English text: VERY DISSATISFIED
NotApplicable
SC3 - MCEASE ( SCQ1015 )
English text: NOT APPLICABLE
Attribute
Route
Don't know
SC3 - MCEASE ( SCQ1015 )
Refusal
SC3 - MCEASE ( SCQ1015 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
10:07:59 AM Wednesday, March 27, 2013
Page 5 of 120
SC2
DESIGN NOTES
10:07:59 AM Wednesday, March 27, 2013
Page 6 of 120
SC3
SC3
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MCEASE
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
40
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
If respondent is SP, display "live".
Else display "lives".
Always display "[Please tell me…]" in brackets.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
SHOW CARD SC1
Question Text:
[Please tell me how satisfied you have been with . . .]
The ease and convenience of getting to a doctor from where
[you/(SP)] (live/lives).
Int. Instr II:
10:08:00 AM Wednesday, March 27, 2013
Page 7 of 120
SC3
INPUT FIELDS / ROUTING
MCEASE
Field1:
Cheshire Name:
( SCQ1015 )
ACCS.MCEASE
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSatisfy
1
No
No
Number Label
1 VerySatisfied
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC4 - MCCOSTS ( SCQ1020 )
2
English text: VERY SATISFIED
Satisfied
SC4 - MCCOSTS ( SCQ1020 )
3
English text: SATISFIED
Dissatisfied
SC4 - MCCOSTS ( SCQ1020 )
4
English text: DISSATISFIED
VeryDissatisfied
SC4 - MCCOSTS ( SCQ1020 )
5
English text: VERY DISSATISFIED
NotApplicable
SC4 - MCCOSTS ( SCQ1020 )
English text: NOT APPLICABLE
Attribute
Don't know
Route
SC4 - MCCOSTS ( SCQ1020 )
Refusal
SC4 - MCCOSTS ( SCQ1020 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
10:08:02 AM Wednesday, March 27, 2013
Page 8 of 120
SC3
DESIGN NOTES
10:08:02 AM Wednesday, March 27, 2013
Page 9 of 120
SC4
SC4
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MCCOSTS
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
50
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "[Please tell me…]" in brackets.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
SHOW CARD SC1
Question Text:
[Please tell me how satisfied you have been with . . .]
The out-of-pocket costs [you/(SP)] paid for health care.
Int. Instr II:
INPUT FIELDS / ROUTING
10:08:03 AM Wednesday, March 27, 2013
Page 10 of 120
SC4
Field1:
MCCOSTS
Cheshire Name:
( SCQ1020 )
ACCS.MCCOSTS
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSatisfy
1
No
No
Number Label
1 VerySatisfied
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC5 - MCINFO ( SCQ1025 )
2
English text: VERY SATISFIED
Satisfied
SC5 - MCINFO ( SCQ1025 )
3
English text: SATISFIED
Dissatisfied
SC5 - MCINFO ( SCQ1025 )
4
English text: DISSATISFIED
VeryDissatisfied
SC5 - MCINFO ( SCQ1025 )
5
English text: VERY DISSATISFIED
NotApplicable
SC5 - MCINFO ( SCQ1025 )
English text: NOT APPLICABLE
Attribute
Route
Don't know
SC5 - MCINFO ( SCQ1025 )
Refusal
SC5 - MCINFO ( SCQ1025 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
10:08:05 AM Wednesday, March 27, 2013
Page 11 of 120
SC4
DESIGN NOTES
10:08:05 AM Wednesday, March 27, 2013
Page 12 of 120
SC5
SC5
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MCINFO
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
60
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
If respondent is SP, display "you".
Else display "you or (SP)".
Always display "[Please tell me…]" in brackets.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
SHOW CARD SC1
Question Text:
[Please tell me how satisfied you have been with . . .]
The information given to [you/you or (SP)] about what was wrong
with [you/(SP)].
Int. Instr II:
10:08:06 AM Wednesday, March 27, 2013
Page 13 of 120
SC5
INPUT FIELDS / ROUTING
MCINFO
Field1:
Cheshire Name:
( SCQ1025 )
ACCS.MCINFO
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSatisfy
1
No
No
Number Label
1 VerySatisfied
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC6 - MCFOLUP ( SCQ1030 )
2
English text: VERY SATISFIED
Satisfied
SC6 - MCFOLUP ( SCQ1030 )
3
English text: SATISFIED
Dissatisfied
SC6 - MCFOLUP ( SCQ1030 )
4
English text: DISSATISFIED
VeryDissatisfied
SC6 - MCFOLUP ( SCQ1030 )
5
English text: VERY DISSATISFIED
NotApplicable
SC6 - MCFOLUP ( SCQ1030 )
English text: NOT APPLICABLE
Attribute
Don't know
Route
SC6 - MCFOLUP ( SCQ1030 )
Refusal
SC6 - MCFOLUP ( SCQ1030 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
10:08:08 AM Wednesday, March 27, 2013
Page 14 of 120
SC5
DESIGN NOTES
10:08:08 AM Wednesday, March 27, 2013
Page 15 of 120
SC6
SC6
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MCFOLUP
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
70
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "[Please tell me…]" in brackets.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
SHOW CARD SC1
Question Text:
[Please tell me how satisfied you have been with . . .]
The follow-up care [you/(SP)] received after an initial treatment or
operation.
Int. Instr II:
INPUT FIELDS / ROUTING
10:08:09 AM Wednesday, March 27, 2013
Page 16 of 120
SC6
Field1:
MCFOLUP
Cheshire Name:
( SCQ1030 )
ACCS.MCFOLUP
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSatisfy
1
No
No
Number Label
1 VerySatisfied
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC7 - MCCONCRN ( SCQ1035 )
2
English text: VERY SATISFIED
Satisfied
SC7 - MCCONCRN ( SCQ1035 )
3
English text: SATISFIED
Dissatisfied
SC7 - MCCONCRN ( SCQ1035 )
4
English text: DISSATISFIED
VeryDissatisfied
SC7 - MCCONCRN ( SCQ1035 )
5
English text: VERY DISSATISFIED
NotApplicable
SC7 - MCCONCRN ( SCQ1035 )
English text: NOT APPLICABLE
Attribute
Route
Don't know
SC7 - MCCONCRN ( SCQ1035 )
Refusal
SC7 - MCCONCRN ( SCQ1035 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
10:08:11 AM Wednesday, March 27, 2013
Page 17 of 120
SC6
DESIGN NOTES
10:08:11 AM Wednesday, March 27, 2013
Page 18 of 120
SC7
SC7
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MCCONCRN
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
80
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "[Please tell me…]" in brackets.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
SHOW CARD SC1
Question Text:
[Please tell me how satisfied you have been with . . .]
The concern of doctors for [your/(SP’s)] overall health rather than
just for an isolated symptom or disease.
Int. Instr II:
INPUT FIELDS / ROUTING
10:08:12 AM Wednesday, March 27, 2013
Page 19 of 120
SC7
Field1:
MCCONCRN
Cheshire Name:
( SCQ1035 )
ACCS.MCCONCRN
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSatisfy
1
No
No
Number Label
1 VerySatisfied
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC8 - MCSAMLOC ( SCQ1040 )
2
English text: VERY SATISFIED
Satisfied
SC8 - MCSAMLOC ( SCQ1040 )
3
English text: SATISFIED
Dissatisfied
SC8 - MCSAMLOC ( SCQ1040 )
4
English text: DISSATISFIED
VeryDissatisfied
SC8 - MCSAMLOC ( SCQ1040 )
5
English text: VERY DISSATISFIED
NotApplicable
SC8 - MCSAMLOC ( SCQ1040 )
English text: NOT APPLICABLE
Attribute
Route
Don't know
SC8 - MCSAMLOC ( SCQ1040 )
Refusal
SC8 - MCSAMLOC ( SCQ1040 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
10:08:14 AM Wednesday, March 27, 2013
Page 20 of 120
SC7
DESIGN NOTES
10:08:14 AM Wednesday, March 27, 2013
Page 21 of 120
SC8
SC8
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MCSAMLOC
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
90
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "[Please tell me…]" in brackets.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
SHOW CARD SC1
Question Text:
[Please tell me how satisfied you have been with . . .]
Getting all [your/(SP’s)] health care needs taken care of at the same
location.
Int. Instr II:
INPUT FIELDS / ROUTING
10:08:16 AM Wednesday, March 27, 2013
Page 22 of 120
SC8
Field1:
MCSAMLOC
Cheshire Name:
( SCQ1040 )
ACCS.MCSAMLOC
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSatisfy
1
No
No
Number Label
1 VerySatisfied
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC8A - MCSPECAR ( SCQ1045 )
2
English text: VERY SATISFIED
Satisfied
SC8A - MCSPECAR ( SCQ1045 )
3
English text: SATISFIED
Dissatisfied
SC8A - MCSPECAR ( SCQ1045 )
4
English text: DISSATISFIED
VeryDissatisfied
SC8A - MCSPECAR ( SCQ1045 )
5
English text: VERY DISSATISFIED
NotApplicable
SC8A - MCSPECAR ( SCQ1045 )
English text: NOT APPLICABLE
Attribute
Route
Don't know
SC8A - MCSPECAR ( SCQ1045 )
Refusal
SC8A - MCSPECAR ( SCQ1045 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
10:08:18 AM Wednesday, March 27, 2013
Page 23 of 120
SC8
DESIGN NOTES
10:08:18 AM Wednesday, March 27, 2013
Page 24 of 120
SC8A
SC8A
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MCSPECAR
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
100
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
If respondent is SP, display "feel".
Else display "feels".
If respondent is SP, display "need".
Else display "needs".
Always display "[Please tell me…]" in brackets.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
SHOW CARD SC1
Question Text:
[Please tell me how satisfied you have been with . . .]
The availability of care by specialists when [you/(SP)] (feel/feels)
(you/he/she) (need/needs) it.
10:08:19 AM Wednesday, March 27, 2013
Page 25 of 120
SC8A
Int. Instr II:
INPUT FIELDS / ROUTING
MCSPECAR
Field1:
Cheshire Name:
( SCQ1045 )
ACCS.MCSPECAR
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSatisfy
1
No
No
Number Label
1 VerySatisfied
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC8B - MCTELANS ( SCQ1050 )
2
English text: VERY SATISFIED
Satisfied
SC8B - MCTELANS ( SCQ1050 )
3
English text: SATISFIED
Dissatisfied
SC8B - MCTELANS ( SCQ1050 )
4
English text: DISSATISFIED
VeryDissatisfied
SC8B - MCTELANS ( SCQ1050 )
5
English text: VERY DISSATISFIED
NotApplicable
SC8B - MCTELANS ( SCQ1050 )
English text: NOT APPLICABLE
Attribute
Route
Don't know
SC8B - MCTELANS ( SCQ1050 )
Refusal
SC8B - MCTELANS ( SCQ1050 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
10:08:21 AM Wednesday, March 27, 2013
Page 26 of 120
SC8A
TECHNICAL NOTES
DESIGN NOTES
10:08:21 AM Wednesday, March 27, 2013
Page 27 of 120
SC8B
SC8B
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MCTELANS
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
110
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "[Please tell me…]" in brackets.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
SHOW CARD SC1
Question Text:
[Please tell me how satisfied you have been with . . .]
The ease of obtaining answers to questions over the telephone
about [your/(SP’s)] treatment or prescriptions.
Int. Instr II:
INPUT FIELDS / ROUTING
10:08:22 AM Wednesday, March 27, 2013
Page 28 of 120
SC8B
Field1:
MCTELANS
Cheshire Name:
( SCQ1050 )
ACCS.MCTELANS
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSatisfy
1
No
No
Number Label
1 VerySatisfied
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC8C - MCAMTPAY ( SCQ1051 )
2
English text: VERY SATISFIED
Satisfied
SC8C - MCAMTPAY ( SCQ1051 )
3
English text: SATISFIED
Dissatisfied
SC8C - MCAMTPAY ( SCQ1051 )
4
English text: DISSATISFIED
VeryDissatisfied
SC8C - MCAMTPAY ( SCQ1051 )
5
English text: VERY DISSATISFIED
NotApplicable
SC8C - MCAMTPAY ( SCQ1051 )
English text: NOT APPLICABLE
Attribute
Route
Don't know
SC8C - MCAMTPAY ( SCQ1051 )
Refusal
SC8C - MCAMTPAY ( SCQ1051 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
10:08:24 AM Wednesday, March 27, 2013
Page 29 of 120
SC8B
DESIGN NOTES
10:08:24 AM Wednesday, March 27, 2013
Page 30 of 120
SC8C
SC8C
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MCAMTPAY
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
112
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "[Please tell me…]" in brackets.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
SHOW CARD SC1
Question Text:
[Please tell me how satisfied you have been with . . .]
The amount [you have/(SP) has] to pay for [your/(SP's)] prescribed
medicines.
Int. Instr II:
INPUT FIELDS / ROUTING
10:08:25 AM Wednesday, March 27, 2013
Page 31 of 120
SC8C
Field1:
MCAMTPAY
Cheshire Name:
( SCQ1051 )
ACCS.MCAMTPAY
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSatisfy
1
No
No
Number Label
1 VerySatisfied
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX SC1A - (SCQ1052 )
2
English text: VERY SATISFIED
Satisfied
BOX SC1A - (SCQ1052 )
3
English text: SATISFIED
Dissatisfied
BOX SC1A - (SCQ1052 )
4
English text: DISSATISFIED
VeryDissatisfied
BOX SC1A - (SCQ1052 )
5
English text: VERY DISSATISFIED
NotApplicable
BOX SC1A - (SCQ1052 )
English text: NOT APPLICABLE
Attribute
Route
Don't know
BOX SC1A - (SCQ1052 )
Refusal
BOX SC1A - (SCQ1052 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
10:08:27 AM Wednesday, March 27, 2013
Page 32 of 120
SC8C
DESIGN NOTES
10:08:27 AM Wednesday, March 27, 2013
Page 33 of 120
BOX SC1A
BOX SC1A
Page Order # :
114
BOX INSTRUCTIONS
( SCQ1052 )
IF (SP HAD PRESCRIPTION DRUG COVERAGE ANYTIME IN THE
CURRENT ROUND) OR (SP IS COVERED BY A MEDICARE
PRESCRIPTION DRUG PLAN ANYTIME IN THE CURRENT ROUND), GO TO
SC8D - MCDRGLST ( SCQ1053 ).
ELSE GO TO SC9 - MDISSFY ( SCQ1084 ).
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.
417
PMDrugCoverageCurrR
nd
SP had PM drug coverage current round =
There is a PLAN & PLRO where
(PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round & (MCDRXCOV=1/Yes
or TRIRXCOV=1/Yes or PUBRXCOV=1/Yes or
PRVRXCOV=1/Yes or MHMORX=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
351
MPDPAnytimeCurrRnd
SP covered by an MPDP plan anytime during current
round =
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVANYTM=1/Yes).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
10:08:27 AM Wednesday, March 27, 2013
Page 34 of 120
SC8D
SC8D
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MCDRGLST
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
116
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "[Please tell me…]" in brackets.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
SHOW CARD SC1
Question Text:
[Please tell me how satisfied you have been with . . .]
[Your/(SP's)] prescription drug plan's formulary or the list of drugs
covered by the plan.
[EXPLAIN IF NECESSARY: By prescription drug plan, we mean any
health insurance plan that provides drug coverage.]
Int. Instr II:
10:08:28 AM Wednesday, March 27, 2013
Page 35 of 120
SC8D
INPUT FIELDS / ROUTING
MCDRGLST
Field1:
Cheshire Name:
( SCQ1053 )
ACCS.MCDRGLST
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSatisfy
1
No
No
Number Label
1 VerySatisfied
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC8E - MCFNDPCY ( SCQ1054 )
2
English text: VERY SATISFIED
Satisfied
SC8E - MCFNDPCY ( SCQ1054 )
3
English text: SATISFIED
Dissatisfied
SC8E - MCFNDPCY ( SCQ1054 )
4
English text: DISSATISFIED
VeryDissatisfied
SC8E - MCFNDPCY ( SCQ1054 )
5
English text: VERY DISSATISFIED
NotApplicable
SC8E - MCFNDPCY ( SCQ1054 )
English text: NOT APPLICABLE
Attribute
Don't know
Route
SC8E - MCFNDPCY ( SCQ1054 )
Refusal
SC8E - MCFNDPCY ( SCQ1054 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
10:08:30 AM Wednesday, March 27, 2013
Page 36 of 120
SC8D
DESIGN NOTES
10:08:30 AM Wednesday, March 27, 2013
Page 37 of 120
SC8E
SC8E
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MCFNDPCY
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
118
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Always display "[Please tell me…]" in brackets.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
SHOW CARD SC1
Question Text:
[Please tell me how satisfied you have been with . . .]
The ease of finding a pharmacy which accepts your prescription drug
plan.
[EXPLAIN IF NECESSARY: By prescription drug plan, we mean any
health insurance plan that provides drug coverage.]
Int. Instr II:
10:08:31 AM Wednesday, March 27, 2013
Page 38 of 120
SC8E
INPUT FIELDS / ROUTING
MCFNDPCY
Field1:
Cheshire Name:
( SCQ1054 )
ACCS.MCFNDPCY
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSatisfy
1
No
No
Number Label
1 VerySatisfied
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC8F - MCRECPLN ( SCQ1055 )
2
English text: VERY SATISFIED
Satisfied
SC8F - MCRECPLN ( SCQ1055 )
3
English text: SATISFIED
Dissatisfied
SC8F - MCRECPLN ( SCQ1055 )
4
English text: DISSATISFIED
VeryDissatisfied
SC8F - MCRECPLN ( SCQ1055 )
5
English text: VERY DISSATISFIED
NotApplicable
SC8F - MCRECPLN ( SCQ1055 )
English text: NOT APPLICABLE
Attribute
Don't know
Route
SC8F - MCRECPLN ( SCQ1055 )
Refusal
SC8F - MCRECPLN ( SCQ1055 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
10:08:33 AM Wednesday, March 27, 2013
Page 39 of 120
SC8E
DESIGN NOTES
10:08:33 AM Wednesday, March 27, 2013
Page 40 of 120
SC8F
SC8F
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
MCRECPLN
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
119
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:
Would [you/(SP)] recommend (your/his/her) prescription drug plan to
other people like (you/him/her)?
[EXPLAIN IF NECESSARY: By prescription drug plan, we mean any
health insurance plan that provides your drug coverage.]
Int. Instr II:
INPUT FIELDS / ROUTING
10:08:34 AM Wednesday, March 27, 2013
Page 41 of 120
SC8F
Field1:
MCRECPLN
Cheshire Name:
( SCQ1055 )
ACCS.MCRECPLN
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TYesnona3
1
No
No
Number Label
1 Yes
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC8G - DHEVHEAR ( SCQ1057 )
2
English text: YES
No
SC8G - DHEVHEAR ( SCQ1057 )
3
English text: NO
NotApplicable
SC8G - DHEVHEAR ( SCQ1057 )
English text: NOT APPLICABLE
Attribute
Don't know
Route
SC8G - DHEVHEAR ( SCQ1057 )
Refusal
SC8G - DHEVHEAR ( SCQ1057 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:08:36 AM Wednesday, March 27, 2013
Page 42 of 120
SC8G
SC8G
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
DHEVHEAR
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
No
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:
If SP has a "current" Medicare Prescription Drug plan, display "[You
receive/(SP) receives] (your/his/her) prescription drug coverage
through a Medicare Prescription Drug plan".
Else if SP has a "current" Medicare Advantage plan, display "[You
receive/(SP) receives] (your/his/her) prescription drug coverage
through a Medicare Advantage plan".
Else display "Some Medicare beneficiaries receive their prescription
drug coverage through Medicare Prescription Drug plans, also
called "Medicare Part D" plans."
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
[[You receive/(SP) receives] (your/his/her) prescription drug
coverage through a (Medicare Prescription Drug Plan/Medicare
Advantage plan)./Some Medicare beneficiaries receive their
10:08:36 AM Wednesday, March 27, 2013
Page 43 of 120
SC8G
prescription drug coverage through Medicare Prescription Drug
plans, also called "Medicare Part D" plans.]
In many Medicare drug plans there is a coverage gap, sometimes
called a "doughnut hole", during which there is a reduction in
coverage and people have to pay a higher share of their drug costs..
Before today, have you heard about the coverage gap or "doughnut
hole" that is part of most Medicare drug plans?
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
DHEVHEAR
Cheshire Name:
( SCQ1057 )
ACCS.DHEVHEAR
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 SC1AA - (SCQ1058 )
English text: YES
No
BOX SC1AA - (SCQ1058 )
English text: NO
Attribute
Route
Don't know
BOX SC1AA - (SCQ1058 )
Refusal
BOX SC1AA - (SCQ1058 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
10:08:38 AM Wednesday, March 27, 2013
Page 44 of 120
SC8G
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.
342
MPDPCurrent
SP has a "current" Medicare Prescription Drug plan =
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.
344
MHMOCurrWithRx
SP has "current" Medicare Managed care plan (Medicare
Advantage plan) with RX coverage=
There is a PLAN where PLANTYPE=5/MHMO & PLRO
where (PLROPLAN=PLANNUM & PLRORND=current
round & COVCURNT=1/Yes & MHMORX=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
10:08:38 AM Wednesday, March 27, 2013
Page 45 of 120
BOX SC1AA
BOX SC1AA
Page Order # :
132
BOX INSTRUCTIONS
( SCQ1058 )
IF (SP HAS A "CURRENT" MEDICARE PRESCRIPTION DRUG PLAN) OR
(SP HAS A "CURRENT" MEDICARE ADVANTAGE PLAN THAT HAS RX
COVERAGE), GO TO SC8I - DHPLAN ( SCQ1062 ).
ELSE GO TO SC9 - MDISSFY ( SCQ1084 ).
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.
342
MPDPCurrent
SP has a "current" Medicare Prescription Drug plan =
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.
344
MHMOCurrWithRx
SP has "current" Medicare Managed care plan (Medicare
Advantage plan) with RX coverage=
There is a PLAN where PLANTYPE=5/MHMO & PLRO
where (PLROPLAN=PLANNUM & PLRORND=current
round & COVCURNT=1/Yes & MHMORX=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
10:08:38 AM Wednesday, March 27, 2013
Page 46 of 120
SC8I
SC8I
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
DHPLAN
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
136
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:
If SP has a "current" Medicare Prescription Drug plan, display
"(CURRENT MEDICARE PRESCRIPTION DRUG PLAN)".
Else display "(CURRENT MEDICARE ADVANTAGE PLAN)".
Question display:
If SP has a "current" Medicare Prescription Drug plan, display
"(CURRENT MEDICARE PRESCRIPTION DRUG PLAN)".
Else display "(CURRENT MEDICARE ADVANTAGE PLAN)".
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
PLAN NAME: (CURRENT MEDICARE PRESCRIPTION DRUG
PLAN)/ (CURRENT MEDICARE ADVANTAGE PLAN)
Int. Instr I:
Question Text:
Does [your/(SP's)] [(CURRENT MEDICARE PRESCRIPTION DRUG
PLAN)/(CURRENT MEDICARE ADVANTAGE PLAN)] plan have a
coverage gap, or “doughnut hole”?
[EXPLAIN IF NECESSARY: The coverage gap, or "doughnut hole",
is a phase in coverage during which there is a reduction in coverage
10:08:39 AM Wednesday, March 27, 2013
Page 47 of 120
SC8I
and people have to pay a higher share of their drug costs.]
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
( SCQ1062 )
DHPLAN
Cheshire Name:
ACCS.DHPLAN
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
SC8L - DHTHISYR ( SCQ1068 )
English text: YES
No
SC9 - MDISSFY ( SCQ1084 )
English text: NO
Attribute
Route
Don't know
SC9 - MDISSFY ( SCQ1084 )
Refusal
SC9 - MDISSFY ( SCQ1084 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
52
DeletedPlans
10:08:40 AM Wednesday, March 27, 2013
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 48 of 120
SC8I
342
MPDPCurrent
SP has a "current" Medicare Prescription Drug plan =
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.
344
MHMOCurrWithRx
SP has "current" Medicare Managed care plan (Medicare
Advantage plan) with RX coverage=
There is a PLAN where PLANTYPE=5/MHMO & PLRO
where (PLROPLAN=PLANNUM & PLRORND=current
round & COVCURNT=1/Yes & MHMORX=1/Yes)).
Exclude Deleted Plans. See T.N. 52.
DESIGN NOTES
10:08:41 AM Wednesday, March 27, 2013
Page 49 of 120
SC8L
SC8L
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
DHTHISYR
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
142
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)] reached the start of the coverage gap during
[CURRENT YEAR]?
[EXPLAIN IF NECESSARY: If [you have/(SP) has] reached the start
of the coverage gap, it means (you have/he has/she has) reached a
phase during which there is a reduction in coverage and
(you/he/she) will have to pay a higher share of (your/his/her) drug
costs.]
Int. Instr II:
10:08:41 AM Wednesday, March 27, 2013
REFER TO THE MOST RECENT MEDICARE PRESCRIPTION
DRUG PLAN STATEMENT TO HELP THE RESPONDENT VERIFY
Page 50 of 120
SC8L
THIS INFORMATION.
INPUT FIELDS / ROUTING
DHTHISYR
Field1:
Cheshire Name:
( SCQ1068 )
ACCS.DHTHISYR
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
SC8M - DHSTART ( SCQ1070 )
English text: YES
No
SC9 - MDISSFY ( SCQ1084 )
English text: NO
Attribute
Route
Don't know
SC9 - MDISSFY ( SCQ1084 )
Refusal
SC9 - MDISSFY ( SCQ1084 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:08:43 AM Wednesday, March 27, 2013
Page 51 of 120
SC8M
SC8M
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
DHSTART
Field 2:
DHSTAROS
HELP
COMMENTS
JUMPBACK
No
No
No
Enable Functions:
144
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 "first" in BOLD.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
How did [you/(SP)] first find out that (you/he/she) reached the start of
the coverage gap?
Int. Instr II:
INPUT FIELDS / ROUTING
10:08:44 AM Wednesday, March 27, 2013
Page 52 of 120
SC8M
Field1:
DHSTART
Cheshire Name:
( SCQ1070 )
ACCS.DHSTART
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TDHStart
1
No
No
Number Label
1 SPOrSomeoneKeptTrack
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC8N - DHEND ( SCQ1072 )
2
English text: SP OR SOMEONE FOR THE SP KEPT TRACK OF TOTAL MEDICINE SPENDING
InfoProvidedByPartD
SC8N - DHEND ( SCQ1072 )
3
English text: INFORMATION PROVIDED BY THE PART D PLAN
InfoProvidedByPharmacy
SC8N - DHEND ( SCQ1072 )
91
English text: INFORMATION PROVIDED BY THE PHARMACY
Other
SC8M - DHSTAROS ( SCQ1071 )
English text: OTHER
Attribute
Route
Don't know
SC8N - DHEND ( SCQ1072 )
Refusal
SC8N - DHEND ( SCQ1072 )
10:08:46 AM Wednesday, March 27, 2013
Page 53 of 120
SC8M
Field2:
Cheshire Name:
DHSTAROS
( SCQ1071 )
ACCS.DHSTAROS
Item Text display:
Display (SPECIFY) in 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
SC8N - DHEND ( SCQ1072 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:08:47 AM Wednesday, March 27, 2013
Page 54 of 120
SC8N
SC8N
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
DHEND
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
146
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:
If respondent is SP, display "you pay".
Else display "(he/she) pays".
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
[Have you/Has (SP)] reached the end of the coverage gap during
[CURRENT YEAR]?
[EXPLAIN IF NECESSARY: If [you have/(SP) has] reached the end
of the coverage gap, it means (you have/he has/she has) reached a
phase in coverage when [you pay/(he/she) pays] a small percentage
of the total cost of each prescription and (your/his/her) drug plan
pays the remaining amount.]
Int. Instr II:
REFER TO THE MOST RECENT MEDICARE PRESCRIPTION
10:08:48 AM Wednesday, March 27, 2013
Page 55 of 120
SC8N
DRUG PLAN STATEMENT TO HELP THE RESPONDENT VERIFY
THIS INFORMATION.
INPUT FIELDS / ROUTING
Field1:
DHEND
Cheshire Name:
( SCQ1072 )
ACCS.DHEND
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
SC8O - DHWORRY ( SCQ1074 )
English text: YES
No
SC8O - DHWORRY ( SCQ1074 )
English text: NO
Attribute
Route
Don't know
SC9 - MDISSFY ( SCQ1084 )
Refusal
SC9 - MDISSFY ( SCQ1084 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:08:49 AM Wednesday, March 27, 2013
Page 56 of 120
SC8O
SC8O
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
DHWORRY
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
148
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:
If SC8N-DHEND = 2/No:
If SP is respondent, display "are".
Else display "is".
Else then:
If SP is respondent, display "were".
Else display "was".
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
For [CURRENT YEAR], how worried (are/is/were/was) [you/(SP)]
about (your/his/her) ability to pay for (your/his/her) medicines during
the coverage gap?
Would you say that [you/(SP)] (are/is/were/was) very worried,
somewhat worried, or not at all worried?
10:08:50 AM Wednesday, March 27, 2013
Page 57 of 120
SC8O
Int. Instr II:
INPUT FIELDS / ROUTING
DHWORRY
Field1:
Cheshire Name:
( SCQ1074 )
ACCS.DHWORRY
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TDHWorry
1
No
No
Number Label
1 VeryWorried
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC9 - MDISSFY ( SCQ1084 )
2
English text: VERY WORRIED
SomewhatWorried
SC9 - MDISSFY ( SCQ1084 )
3
English text: SOMEWHAT WORRIED
NotWorried
SC9 - MDISSFY ( SCQ1084 )
English text: NOT AT ALL WORRIED
Attribute
Route
Don't know
SC9 - MDISSFY ( SCQ1084 )
Refusal
SC9 - MDISSFY ( SCQ1084 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:08:51 AM Wednesday, March 27, 2013
Page 58 of 120
SC8O
10:08:51 AM Wednesday, March 27, 2013
Page 59 of 120
SC9
SC9
Page Order # :
Design Screen Type:
Verbatim Text
Fields:
Field 1:
MDISSFY
Field 2:
MCDISVB
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:
160
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
If respondent is SP, display "receive".
Else display "receives".
Multi Field display:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
Please think about all of the health care services [you/(SP)]
(receive/receives), including services provided by doctors, hospitals
and pharmacies.
What things, if anything, about the health care services [you/(SP)]
(receive/receives) are you dissatisfied with?
Int. Instr II:
10:08:52 AM Wednesday, March 27, 2013
Page 60 of 120
SC9
INPUT FIELDS / ROUTING
MDISSFY
Field1:
Cheshire Name:
( SCQ1084 )
ACCS.MCDISSFY
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TMcdissfy
1
No
No
Number Label
1 NotDissatisfiedWithAnything
91
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC10A - MCWORRY ( SCQ1087 )
English text: RESPONDENT IS NOT DISSATISFIED WITH ANYTHING
WhatDissatisfiedWithrecVerbatim
SC9 - MCDISVB ( SCQ1085 )
English text: RESPONDENT IS DISSATISFIED (RECORD VERBATIM BELOW)
Attribute
Don't know
Route
SC10A - MCWORRY ( SCQ1087 )
Refusal
SC10A - MCWORRY ( SCQ1087 )
10:08:55 AM Wednesday, March 27, 2013
Page 61 of 120
SC9
Field2:
Cheshire Name:
MCDISVB
( SCQ1085 )
NONE
REPLACES CHESHIRE VARIABLES:
ACCS.MCDISVB1
ACCS.MCDISVB2
ACCS.MCDISVB3
DATA EDITING CODING VARIABLES:
ACCS.VCMCDIS1
ACCS.VCMCDIS2
ACCS.VCMCDIS3
ACCS.VCMCDIS4
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Open
TOpen270
1
No
No
Number Label
1 [Continuous answer.]
FieldSize:
Min Value:
Max Value:
Mask:
135
Route
SC10A - MCWORRY ( SCQ1087 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:08:55 AM Wednesday, March 27, 2013
Page 62 of 120
SC10A
SC10A
Page Order # :
Design Screen Type:
List
Fields:
Field 1:
MCWORRY
Field 2:
MCAVOID
Field 3:
MCSICK
Field 4:
MCDRSOON
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:
170
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:
Please tell me whether each of the following statements is true or
false.
Int. Instr II:
INPUT FIELDS / ROUTING
10:08:57 AM Wednesday, March 27, 2013
Page 63 of 120
SC10A
Field1:
MCWORRY
Cheshire Name:
Item Text display:
( SCQ1087 )
ACCS.MCWORRY
Display "a." before the question text.
If respondent is SP display "worry".
Else display "worries".
Always display "[Is this statement…]" in brackets.
[You/(SP)] (worry/worries) about (your/his/her) health more
than other people (your/his/her) age.
[Is this statement true or false?]
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TTrufalse
1
No
No
Number Label
1 Tru
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC10A - MCAVOID ( SCQ1088 )
English text: TRUE
Fals
SC10A - MCAVOID ( SCQ1088 )
English text: FALSE
Attribute
Route
Don't know
SC10A - MCAVOID ( SCQ1088 )
Refusal
SC10A - MCAVOID ( SCQ1088 )
10:08:59 AM Wednesday, March 27, 2013
Page 64 of 120
SC10A
Field2:
MCAVOID
Cheshire Name:
( SCQ1088 )
ACCS.MCAVOID
Item Text display:
Display "b." before the question text.
Item Text:
[You/(SP)] will do just about anything to avoid going to the
doctor.
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TTrufalse
1
No
No
Number Label
1 Tru
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC10A - MCSICK ( SCQ1089 )
English text: TRUE
Fals
SC10A - MCSICK ( SCQ1089 )
English text: FALSE
Attribute
Don't know
Route
SC10A - MCSICK ( SCQ1089 )
Refusal
SC10A - MCSICK ( SCQ1089 )
10:09:02 AM Wednesday, March 27, 2013
Page 65 of 120
SC10A
Field3:
MCSICK
Cheshire Name:
Item Text display:
( SCQ1089 )
ACCS.MCSICK
Display "c." before the question text.
If respondent is SP display "are" and "try".
Else display "is" and "tries".
When [you/(SP)] (are/is) sick, (you/he/she) (try/tries) to keep
it to (yourself/himself/herself).
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TTrufalse
1
No
No
Number Label
1 Tru
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC10A - MCDRSOON ( SCQ1090 )
English text: TRUE
Fals
SC10A - MCDRSOON ( SCQ1090 )
English text: FALSE
Attribute
Route
Don't know
SC10A - MCDRSOON ( SCQ1090 )
Refusal
SC10A - MCDRSOON ( SCQ1090 )
10:09:06 AM Wednesday, March 27, 2013
Page 66 of 120
SC10A
Field4:
MCDRSOON
Cheshire Name:
Item Text display:
( SCQ1090 )
ACCS.MCDRSOON
Display "d." before the question text.
If respondent is SP display "go" and "start".
Else display "goes" and "starts".
Usually, [you/(SP)] (go/goes) to the doctor as soon as
(you/he/she) (start/starts) to feel bad.
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TTrufalse
1
No
No
Number Label
1 Tru
2
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC11 - MCDRNSEE ( SCQ1095 )
English text: TRUE
Fals
SC11 - MCDRNSEE ( SCQ1095 )
English text: FALSE
Attribute
Route
Don't know
SC11 - MCDRNSEE ( SCQ1095 )
Refusal
SC11 - MCDRNSEE ( SCQ1095 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:09:08 AM Wednesday, March 27, 2013
Page 67 of 120
SC11
SC11
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
MCDRNSEE
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:
During (CURRENT YEAR), did [you/(SP)] have any health problem
or condition about which you think (you/he/she) should have seen a
doctor or other medical person, but did not?
Int. Instr II:
INPUT FIELDS / ROUTING
10:09:09 AM Wednesday, March 27, 2013
Page 68 of 120
SC11
Field1:
MCDRNSEE
Cheshire Name:
( SCQ1095 )
ACCS.MCDRNSEE
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
SC12AA - TEMPCOND1 ( SCQ1100 )
English text: YES
No
SC15 - PMNOTGET ( SCQ1135 )
English text: NO
Attribute
Route
Don't know
SC15 - PMNOTGET ( SCQ1135 )
Refusal
SC15 - PMNOTGET ( SCQ1135 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:09:10 AM Wednesday, March 27, 2013
Page 69 of 120
SC12AA
SC12AA
Page Order # :
Design Screen Type:
Text
Fields:
Field 1:
TEMPCOND1
Field 2:
TEMPCOND2
Field 3:
TEMPCOND3
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:
190
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Vertical Alignment
Display all input fields at one time.
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
What was the health problem or condition?
Int. Instr II:
ENTER ALL CONDITIONS.
INPUT FIELDS / ROUTING
10:09:12 AM Wednesday, March 27, 2013
Page 70 of 120
SC12AA
Field1:
TEMPCOND1
Cheshire Name:
( SCQ1100 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
CONDITION 1:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TCondtion
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 [Continuous answer.]
TEMPCOND2
Field2:
Cheshire Name:
30
Route
SC12AA - TEMPCOND2 ( SCQ1105 )
( SCQ1105 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
CONDITION 2:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TConditionEmpty
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Empty
SC12A - MCDRATMP ( SCQ1110 )
10:09:16 AM Wednesday, March 27, 2013
FieldSize:
Min Value:
Max Value:
Mask:
30
Route
SC12AA - TEMPCOND3 ( SCQ1108 )
Page 71 of 120
SC12AA
Field3:
TEMPCOND3
Cheshire Name:
( SCQ1108 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
CONDITION 3:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TConditionEmpty
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Empty
SC12A - MCDRATMP ( SCQ1110 )
FieldSize:
Min Value:
Max Value:
Mask:
30
Route
SC12A - MCDRATMP ( SCQ1110 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:09:17 AM Wednesday, March 27, 2013
Page 72 of 120
SC12A
SC12A
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
MCDRATMP
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
200
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display SC12AA - TEMPCOND1 response.
If SC12AA - TEMPCOND2 ^= empty, display SC12AA
TEMPCOND2 response.
Else do not display.
If SC12AA - TEMPCOND3 ^= empty, display SC12AA
TEMPCOND3 response.
Else do not display.
Always display "(s)" in the probe in parenthesis.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
10:09:18 AM Wednesday, March 27, 2013
Did [you/(SP)] attempt to see a doctor about this [READ
Page 73 of 120
SC12A
CONDITION(S) BELOW]?
(CONDITION 1 FROM SC12AA)
(CONDITION 2 FROM SC12AA)
(CONDITION 3 FROM SC12AA)
[PROBE: By "attempt" I mean, did [you/(SP)] contact a doctor’s
office or other medical place in order to set an appointment or talk to
someone about the condition(s)?]
Int. Instr II:
INPUT FIELDS / ROUTING
Field1:
MCDRATMP
Cheshire Name:
( SCQ1110 )
ACCS.MCDRATMP
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
SC13A - SCRCODES ( SCQ1120 )
English text: YES
No
SC13A - SCRCODES ( SCQ1120 )
English text: NO
Attribute
Route
Don't know
SC13A - SCRCODES ( SCQ1120 )
Refusal
SC13A - SCRCODES ( SCQ1120 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
10:09:19 AM Wednesday, March 27, 2013
Page 74 of 120
SC12A
TECHNICAL NOTES
DESIGN NOTES
10:09:20 AM Wednesday, March 27, 2013
Page 75 of 120
SC13A
SC13A
Page Order # :
Design Screen Type:
Code All
Fields:
Field 1:
SCRCODES
Field 2:
SCROTOS
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
225
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display SC12AA - TEMPCOND1 response.
If SC12AA - TEMPCOND2 ^= empty, display SC12AA
TEMPCOND2 response.
Else do not display.
If SC12AA - TEMPCOND3 ^= empty, display SC12AA
TEMPCOND3 response.
Else do not display.
Multi Field display:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
SHOW CARD SC2
Question Text:
This card lists some reasons people have given for not seeing a
10:09:21 AM Wednesday, March 27, 2013
Page 76 of 120
SC13A
doctor or other medical person about a health problem or condition.
Which of these reasons explains why [you/(SP)] did not see a doctor
about the [READ CONDITION(S) BELOW]?
(CONDITION 1 FROM SC12AA)
(CONDITION 2 FROM SC12AA)
(CONDITION 3 FROM SC12AA)
[PROBE: Any other reason?]
Int. Instr II:
CHECK ALL THAT APPLY.
INPUT FIELDS / ROUTING
10:09:23 AM Wednesday, March 27, 2013
Page 77 of 120
SC13A
Field1:
SCRCODES
Cheshire Name:
( SCQ1120 )
NONE
REPLACES THE FOLLOWING CHESHIRE VARIABLES:
1=ACCS.SCRNSERS
2=ACCS.SCRCOST
3=ACCS.SCRTROUB
4=ACCS.SCRSCHED
5=ACCS.SCRDRCDM
6=ACCS.SCRFEAR
7=ACCS.SCRNACCP
91=ACCS.SCROTHR
Item Text display:
For response option 91/Other, display "OTHER" as the
English Response Text.
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSCRMAIN
12
No
No
Number Label
1 ProbNotSerious
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX SC1B - (SCQ1125 )
2
English text: DIDN'T THINK THE PROBLEM WAS SERIOUS
CostTooMuch
BOX SC1B - (SCQ1125 )
3
English text: THOUGHT IT WOULD COST TOO MUCH
TroubleFinding
BOX SC1B - (SCQ1125 )
4
English text: TROUBLE FINDING/GETTING TO DOCTOR
Schedule
BOX SC1B - (SCQ1125 )
5
English text: TIME/SCHEDULE OR PERSONAL CONFLICTS
DrNotDoMuch
BOX SC1B - (SCQ1125 )
6
English text: THOUGHT DOCTOR COULDN'T DO MUCH ABOUT PROBLEM
AfraidToKnow
BOX SC1B - (SCQ1125 )
7
English text: WAS AFRAID OF FINDING OUT WHAT WAS WRONG
DrNoAcceptIns
BOX SC1B - (SCQ1125 )
91
English text: DOCTOR WOULD NOT ACCEPT MY INSURANCE
Other
SC13A - SCROTOS ( SCQ1122 )
English text: (OTHER/SC13A - SCROTOS OTHER SPECIFY TEXT)
Attribute
Route
Don't know
SC15 - PMNOTGET ( SCQ1135 )
10:09:25 AM Wednesday, March 27, 2013
Page 78 of 120
SC13A
Don't know
Refusal
SC15 - PMNOTGET ( SCQ1135 )
Field2:
Cheshire Name:
SCROTOS
( SCQ1122 )
ACCS.SCROTOS
Item Text display:
Display (SPECIFY) in 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 SC1B - (SCQ1125 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:09:26 AM Wednesday, March 27, 2013
Page 79 of 120
BOX SC1B
BOX SC1B
Page Order # :
230
BOX INSTRUCTIONS
( SCQ1125 )
IF SC13A - SCRCODES INCLUDES MORE THAN ONE RESPONSE, GO TO
SC14A - SCRMAIN ( SCQ1130 ).
ELSE GO TO SC15 - PMNOTGET ( SCQ1135 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
10:09:26 AM Wednesday, March 27, 2013
Page 80 of 120
SC14A
SC14A
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
SCRMAIN
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
No
No
245
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:
If SC12AA - TEMPCOND2 = empty and SC12AA - TEMPCOND3 =
empty, display "this condition".
Else display "these conditions".
Display SC12AA - TEMPCOND1 response.
If SC12AA - TEMPCOND2 ^= empty, display SC12AA
TEMPCOND2 response.
Else do not display.
If SC12AA - TEMPCOND3 ^= empty, display SC12AA
TEMPCOND3 response.
Else do not display.
Multi Field display:
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
10:09:28 AM Wednesday, March 27, 2013
CURRENT YEAR: (CURRENT YEAR)
Page 81 of 120
SC14A
Int. Instr I:
Question Text:
Which of these was the main reason [you/(SP)] did not see a doctor
about (this condition/these conditions) during (CURRENT YEAR)?
[READ REASONS BELOW IF NECESSARY.]
(CONDITION 1 FROM SC12AA)
(CONDITION 2 FROM SC12AA)
(CONDITION 3 FROM SC12AA)
Int. Instr II:
INPUT FIELDS / ROUTING
10:09:29 AM Wednesday, March 27, 2013
Page 82 of 120
SC14A
Field1:
SCRMAIN
Cheshire Name:
Item Text display:
( SCQ1130 )
ACCS.SCRMAIN
The response options for MCRMAIN will be displayed
based on the response to SC13A - SCRCODES. If
corresponding response included at SC13A, display same
response option at SC14A. Else do not display response
option. See detailed instructions below.
If SC13A - SCRCODES includes 1/ProbNotSerious,
display SCRMAIN response option 1/ProbNotSerious.
If SC13A - SCRCODES includes 2/CostTooMuch, display
SCRMAIN response option 2/CostTooMuch.
If SC13A - SCRCODES includes 3/TroubleFinding, display
SCRMAIN response option 3/TroubleFinding.
If SC13A - SCRCODES includes 4/Schedule, display
SCRMAIN response option 4/Schedule.
If SC13A - SCRCODES includes 5/DrNotDoMuch, display
SCRMAIN response option 5/DrNotDoMuch.
If SC13A - SCRCODES includes 6/AfraidToKnow, display
SCRMAIN response option 6/AfraidToKnow.
If SC13A - SCRCODES includes 7/DrNoAcceptIns, display
SCRMAIN response option 7/DrNoAcceptIns.
If SC13A - SCRCODES includes 91/Other, display
SCRMAIN response option 91/Other. Display SC13A -
SCROTOS Other Specify Response text as the English
response text (not "OTHER").
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
TSCRMAIN
1
No
No
Number Label
1 ProbNotSerious
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC15 - PMNOTGET ( SCQ1135 )
2
English text: DIDN'T THINK THE PROBLEM WAS SERIOUS
CostTooMuch
SC15 - PMNOTGET ( SCQ1135 )
3
English text: THOUGHT IT WOULD COST TOO MUCH
TroubleFinding
SC15 - PMNOTGET ( SCQ1135 )
4
English text: TROUBLE FINDING/GETTING TO DOCTOR
Schedule
SC15 - PMNOTGET ( SCQ1135 )
5
English text: TIME/SCHEDULE OR PERSONAL CONFLICTS
DrNotDoMuch
SC15 - PMNOTGET ( SCQ1135 )
English text: THOUGHT DOCTOR COULDN'T DO MUCH ABOUT PROBLEM
10:09:32 AM Wednesday, March 27, 2013
Page 83 of 120
SC14A
6
AfraidToKnow
SC15 - PMNOTGET ( SCQ1135 )
7
English text: WAS AFRAID OF FINDING OUT WHAT WAS WRONG
DrNoAcceptIns
SC15 - PMNOTGET ( SCQ1135 )
91
English text: DOCTOR WOULD NOT ACCEPT MY INSURANCE
Other
SC15 - PMNOTGET ( SCQ1135 )
English text: (OTHER/SC13A - SCROTOS OTHER SPECIFY TEXT)
Attribute
Don't know
Route
SC15 - PMNOTGET ( SCQ1135 )
Refusal
SC15 - PMNOTGET ( SCQ1135 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:09:33 AM Wednesday, March 27, 2013
Page 84 of 120
SC15
SC15
Page Order # :
Design Screen Type:
Yes/No
Fields:
Field 1:
PMNOTGET
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
250
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:
CURRENT YEAR: (CURRENT YEAR)
Int. Instr I:
Question Text:
During (CURRENT YEAR), were any medicines prescribed for
[you/(SP)] that (you/he/she) did not get? Please include refills of
earlier prescriptions as well as prescriptions that were written or
phoned in by a doctor.
Int. Instr II:
INPUT FIELDS / ROUTING
10:09:34 AM Wednesday, March 27, 2013
Page 85 of 120
SC15
Field1:
PMNOTGET
Cheshire Name:
( SCQ1135 )
ACCS.PMNOTGET
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
SC16 - TEMPMED1 ( SCQ1140 )
English text: YES
No
SC20 - GENERRX ( SCQ1185 )
English text: NO
Attribute
Route
Don't know
SC20 - GENERRX ( SCQ1185 )
Refusal
SC20 - GENERRX ( SCQ1185 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:09:35 AM Wednesday, March 27, 2013
Page 86 of 120
SC16
SC16
Page Order # :
Design Screen Type:
Text
Fields:
Field 1:
TEMPMED1
Field 2:
TEMPMED2
Field 3:
TEMPMED3
Field 4:
TEMPMED4
Field 5:
TEMPMED5
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:
260
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:
Vertical Alignment
Display all input fields at one time.
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
Int. Instr I:
Question Text:
What were the names of those medicines?
Int. Instr II:
ENTER ALL MEDICINES.
10:09:36 AM Wednesday, March 27, 2013
Page 87 of 120
SC16
INPUT FIELDS / ROUTING
TEMPMED1
Field1:
Cheshire Name:
( SCQ1140 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
MEDICINE 1:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
Tmedicine
FieldSize:
Min Value:
Max Value:
Mask:
1
No
No
Number Label
1 [Continuous answer.]
TEMPMED2
Field2:
Cheshire Name:
30
Route
SC16 - TEMPMED2 ( SCQ1145 )
( SCQ1145 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
MEDICINE 2:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TMedicineEmpty
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Empty
SC17INTR - SCINT2 ( SCQ1165 )
10:09:39 AM Wednesday, March 27, 2013
FieldSize:
Min Value:
Max Value:
Mask:
30
Route
SC16 - TEMPMED3 ( SCQ1150 )
Page 88 of 120
SC16
Field3:
TEMPMED3
Cheshire Name:
( SCQ1150 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
MEDICINE 3:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TMedicineEmpty
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Empty
SC17INTR - SCINT2 ( SCQ1165 )
10:09:41 AM Wednesday, March 27, 2013
FieldSize:
Min Value:
Max Value:
Mask:
30
Route
SC16 - TEMPMED4 ( SCQ1155 )
Page 89 of 120
SC16
Field4:
TEMPMED4
Cheshire Name:
( SCQ1155 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
MEDICINE 4:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TMedicineEmpty
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Empty
SC17INTR - SCINT2 ( SCQ1165 )
10:09:44 AM Wednesday, March 27, 2013
FieldSize:
Min Value:
Max Value:
Mask:
30
Route
SC16 - TEMPMED5 ( SCQ1160 )
Page 90 of 120
SC16
Field5:
TEMPMED5
Cheshire Name:
( SCQ1160 )
TEMP
Item Text display:
Item Text:
Label:
Label Position:
MEDICINE 5:
Left
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
String
TMedicineEmpty
1
No
No
Number Label
1 [Continuous answer.]
Attribute
Route
Empty
SC17INTR - SCINT2 ( SCQ1165 )
FieldSize:
Min Value:
Max Value:
Mask:
30
Route
SC17INTR - SCINT2 ( SCQ1165 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:09:45 AM Wednesday, March 27, 2013
Page 91 of 120
SC17INTR
SC17INTR
Page Order # :
Design Screen Type:
No Entry
Fields:
Field 1:
SCINT2
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
270
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:
SHOW CARD SC3
Question Text:
This card lists some reasons people have given for not having
prescriptions filled or refilled.
Int. Instr II:
INPUT FIELDS / ROUTING
10:09:45 AM Wednesday, March 27, 2013
Page 92 of 120
SC17INTR
Field1:
SCINT2
Cheshire Name:
( SCQ1165 )
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
SC17A - SCPMCODS ( SCQ1170 )
English text: CONTINUE
Attribute
Route
Empty
SC17A - SCPMCODS ( SCQ1170 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:09:47 AM Wednesday, March 27, 2013
Page 93 of 120
SC17A
SC17A
Page Order # :
Design Screen Type:
Code All
Fields:
Field 1:
SCPMCODS
Field 2:
SCPMOTOS
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
285
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Display SC16 - TEMPMED1 response.
If SC16 - TEMPMED2 ^= empty, display SC16 - TEMPMED2
response.
Else do not display.
If SC16 - TEMPMED3 ^= empty, display SC16 - TEMPMED3
response.
Else do not display.
If SC16 - TEMPMED4 ^= empty, display SC16 - TEMPMED4
response.
Else do not display.
If SC16 - TEMPMED5 ^= empty, display SC16 - TEMPMED5
response.
Else do not display.
Multi Field display:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
10:09:48 AM Wednesday, March 27, 2013
Page 94 of 120
SC17A
TEXT:
Context Header:
Int. Instr I:
Question Text:
Which of these reasons explains why [you/(SP)] did not obtain the
[READ MEDICINE(S) BELOW]?
[MEDICINE 1 FROM SC16]
[MEDICINE 2 FROM SC16]
[MEDICINE 3 FROM SC16]
[MEDICINE 4 FROM SC16]
[MEDICINE 5 FROM SC16]
[PROBE: Any other reason?]
Int. Instr II:
CHECK ALL THAT APPLY.
INPUT FIELDS / ROUTING
10:09:50 AM Wednesday, March 27, 2013
Page 95 of 120
SC17A
Field1:
SCPMCODS
Cheshire Name:
( SCQ1170 )
NONE
REPLACES THE FOLLOWING CHESHIRE VARIABLES:
1=ACCS.SCPMCOST
2=ACCS.SCNOHELP
3=ACCS.SCPMREAC
4=ACCS.SCPMNLKE
5=ACCS.SCPMNCND
6=ACCS.SCPMNOCV
7=ACCS.SCPMTROB
8=ACCS.SCPMSMPL
9=ACCS.SCPMSUBS
91=ACCS.SCPMOTHR
Item Text display:
For response option 91/Other, display "OTHER" as the
English Response Text.
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
Tscpmmain
12
No
No
Number Label
1 CostTooMuch
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX SC2 - (SCQ1175 )
2
English text: THOUGHT IT WOULD COST TOO MUCH
MedNotHelpCondition
BOX SC2 - (SCQ1175 )
3
English text: DIDN'T THINK MEDICINE WOULD HELP CONDITION
AfraidOfReactions
BOX SC2 - (SCQ1175 )
4
English text: WAS AFRAID OF MEDICINE REATIONS/CONTRAINDICATIONS
DontLikeToTakeMed
BOX SC2 - (SCQ1175 )
5
English text: DON'T LIKE TO TAKE MEDICINE
MedNotNecessary
BOX SC2 - (SCQ1175 )
6
English text: DIDN'T THINK MEDICINE WAS NECESSARY
NotCovered
BOX SC2 - (SCQ1175 )
7
English text: NOT COVERED BY INSURANCE/NOT ON PLAN FORMULARY
TroubleObtaining
BOX SC2 - (SCQ1175 )
8
English text: TROUBLE OBTAINING MEDICINE
ObtainedSamples
BOX SC2 - (SCQ1175 )
English text: OBTAINED/USED SAMPLES
10:09:53 AM Wednesday, March 27, 2013
Page 96 of 120
SC17A
9
91
UsedSubtitute
BOX SC2 - (SCQ1175 )
English text: USED ANOTHER MEDICINE AS A SUBSTITUTION
Other
SC17A - SCPMOTOS ( SCQ1172 )
English text: (OTHER/SC17A - SCPMOTOS OTHER SPECIFY TEXT)
Attribute
Route
Don't know
SC20 - GENERRX ( SCQ1185 )
Refusal
SC20 - GENERRX ( SCQ1185 )
Field2:
Cheshire Name:
SCPMOTOS
( SCQ1172 )
ACCS.SCPMOTOS
Item Text display:
Display (SPECIFY) in 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 SC2 - (SCQ1175 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:09:54 AM Wednesday, March 27, 2013
Page 97 of 120
BOX SC2
BOX SC2
Page Order # :
290
BOX INSTRUCTIONS
( SCQ1175 )
IF SC17A - SCPMCODS INCLUDES MORE THAN ONE RESPONSE, GO TO
SC18A - SCPMMAIN ( SCQ1180 ).
ELSE GO TO SC20 - GENERRX ( SCQ1185 ).
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
10:09:54 AM Wednesday, March 27, 2013
Page 98 of 120
SC18A
SC18A
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
SCPMMAIN
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
305
Roster Name:
Roster Type:
DISPLAY INSTRUCTIONS:
Context header display:
Question display:
If SC16 - TEMPMED2 = empty and SC16 - TEMPMED3 = empty
and SC16 - TEMPMED4 = empty and SC16 - TEMPMED5 = empty,
display "this medicine".
Else display "these medicines".
Display SC16 - TEMPMED1 response.
If SC16 - TEMPMED2 ^= empty, display SC16 - TEMPMED2
response.
Else do not display.
If SC16 - TEMPMED3 ^= empty, display SC16 - TEMPMED3
response.
Else do not display.
If SC16 - TEMPMED4 ^= empty, display SC16 - TEMPMED4
response.
Else do not display.
If SC16 - TEMPMED5 ^= empty, display SC16 - TEMPMED5
response.
Else do not display.
Multi Field display:
Roster/Grid Instructions:
10:09:55 AM Wednesday, March 27, 2013
Page 99 of 120
SC18A
Roster/Grid display:
Report display:
TEXT:
Context Header:
CURRENT YEAR: (CURRENT YEAR)
Int. Instr I:
Question Text:
Which of these was the main reason [you/(SP)] did not obtain (this
medicine/these medicines) during (CURRENT YEAR)?
[READ REASONS BELOW IF NECESSARY.]
[MEDICINE 1 FROM SC16]
[MEDICINE 2 FROM SC16]
[MEDICINE 3 FROM SC16]
[MEDICINE 4 FROM SC16]
[MEDICINE 5 FROM SC16]
Int. Instr II:
INPUT FIELDS / ROUTING
10:09:57 AM Wednesday, March 27, 2013
Page 100 of 120
SC18A
Field1:
SCPMMAIN
Cheshire Name:
Item Text display:
( SCQ1180 )
ACCS.SCPMMAIN
The response options for SCPMMAIN will be displayed
based on the response to SC17A - SCPMCODS. If
corresponding response included at SC17A, display same
response option at SC18A. Else do not display response
option. See detailed instructions below.
If SC17A - SCPMCODS includes 1/CostTooMuch, display
SCPMMAIN response option 1/CostTooMuch.
If SC17A - SCPMCODS includes 2/MedNotHelpCondition,
display SCPMMAIN response option
2/MedNotHelpCondition.
If SC17A - SCPMCODS includes 3/AfraidOfReactions,
display SCPMMAIN response option 3/AfraidOfReactions.
If SC17A - SCPMCODS includes 4/DontLikeToTakeMe,
display SCPMMAIN response option 4/DontLikeToTakeMe.
If SC17A - SCPMCODS includes 5/MedNotNecessary,
display SCPMMAIN response option 5/MedNotNecessary.
If SC17A - SCPMCODS includes 6/NotCovered, display
SCPMMAIN response option 6/NotCovered.
If SC17A - SCPMCODS includes 7/TroubleObtaining,
display SCPMMAIN response option 7/TroubleObtaining.
If SC17A - SCPMCODS includes 8/ObtainedSamples,
display SCPMMAIN response option 8/ObtainedSamples.
If SC17A - SCPMCODS includes 9/UsedSubstitute, display
SCPMMAIN response option 9/UsedSubstitute.
If SC17A - SCPMCODS includes 91/OtherReason, display
SCPMMAIN response option 91/Other. Display SC17A -
SCPMOTOS Other Specify Text as the English Response
Text (instead of "OTHER").
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
Tscpmmain
1
No
No
Number Label
1 CostTooMuch
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC20 - GENERRX ( SCQ1185 )
2
English text: THOUGHT IT WOULD COST TOO MUCH
MedNotHelpCondition
SC20 - GENERRX ( SCQ1185 )
3
English text: DIDN'T THINK MEDICINE WOULD HELP CONDITION
AfraidOfReactions
SC20 - GENERRX ( SCQ1185 )
English text: WAS AFRAID OF MEDICINE REATIONS/CONTRAINDICATIONS
10:10:00 AM Wednesday, March 27, 2013
Page 101 of 120
SC18A
4
DontLikeToTakeMed
5
English text: DON'T LIKE TO TAKE MEDICINE
MedNotNecessary
SC20 - GENERRX ( SCQ1185 )
6
English text: DIDN'T THINK MEDICINE WAS NECESSARY
NotCovered
SC20 - GENERRX ( SCQ1185 )
7
English text: NOT COVERED BY INSURANCE/NOT ON PLAN FORMULARY
TroubleObtaining
SC20 - GENERRX ( SCQ1185 )
8
English text: TROUBLE OBTAINING MEDICINE
ObtainedSamples
SC20 - GENERRX ( SCQ1185 )
9
English text: OBTAINED/USED SAMPLES
UsedSubtitute
91
SC20 - GENERRX ( SCQ1185 )
SC20 - GENERRX ( SCQ1185 )
English text: USED ANOTHER MEDICINE AS A SUBSTITUTION
Other
SC20 - GENERRX ( SCQ1185 )
English text: (OTHER/SC17A - SCPMOTOS OTHER SPECIFY TEXT)
Attribute
Route
Don't know
SC20 - GENERRX ( SCQ1185 )
Refusal
SC20 - GENERRX ( SCQ1185 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:10:02 AM Wednesday, March 27, 2013
Page 102 of 120
SC20
SC20
Page Order # :
Design Screen Type:
List
Fields:
Field 1:
GENERRX
Field 2:
MAILRX
Field 3:
DOSESRX
Field 4:
SKIPRX
Field 5:
DELAYRX
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:
307
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:
CURRENT YEAR: (CURRENT YEAR)
Int. Instr I:
SHOW CARD SC4
Question Text:
Please tell me how often during (CURRENT YEAR) [you have /(SP)
has] done any of the following things. [Have you/has (SP)] often,
sometimes, or never…
Int. Instr II:
10:10:03 AM Wednesday, March 27, 2013
Page 103 of 120
SC20
INPUT FIELDS / ROUTING
GENERRX
Field1:
Cheshire Name:
( SCQ1185 )
ACCS.GENERRX
Item Text display:
Display "a. " before the Item text.
Item Text:
asked for generics instead of brand name drugs?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
THowOften
1
No
No
Number Label
1 Often
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC20 - MAILRX ( SCQ1190 )
2
English text: OFTEN
Sometimes
SC20 - MAILRX ( SCQ1190 )
3
English text: SOMETIMES
Never
SC20 - MAILRX ( SCQ1190 )
English text: NEVER
Attribute
Route
Don't know
SC20 - MAILRX ( SCQ1190 )
Refusal
SC20 - MAILRX ( SCQ1190 )
10:10:07 AM Wednesday, March 27, 2013
Page 104 of 120
SC20
Field2:
MAILRX
Cheshire Name:
( SCQ1190 )
ACCS.MAILRX
Item Text display:
Display "b. " before the Item text.
Item Text:
purchased prescription drugs through the mail or on the
Internet?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
THowOften
1
No
No
Number Label
1 Often
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC20 - DOSESRX ( SCQ1195 )
2
English text: OFTEN
Sometimes
SC20 - DOSESRX ( SCQ1195 )
3
English text: SOMETIMES
Never
SC20 - DOSESRX ( SCQ1195 )
English text: NEVER
Attribute
Route
Don't know
SC20 - DOSESRX ( SCQ1195 )
Refusal
SC20 - DOSESRX ( SCQ1195 )
10:10:10 AM Wednesday, March 27, 2013
Page 105 of 120
SC20
Field3:
DOSESRX
Cheshire Name:
( SCQ1195 )
ACCS.DOSESRX
Item Text display:
Display "c. " before the Item text.
Item Text:
taken smaller doses than prescribed of a medicine to make
the medicine last longer?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
THowOften
1
No
No
Number Label
1 Often
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC20 - SKIPRX ( SCQ1200 )
2
English text: OFTEN
Sometimes
SC20 - SKIPRX ( SCQ1200 )
3
English text: SOMETIMES
Never
SC20 - SKIPRX ( SCQ1200 )
English text: NEVER
Attribute
Route
Don't know
SC20 - SKIPRX ( SCQ1200 )
Refusal
SC20 - SKIPRX ( SCQ1200 )
10:10:13 AM Wednesday, March 27, 2013
Page 106 of 120
SC20
Field4:
SKIPRX
Cheshire Name:
( SCQ1200 )
ACCS.SKIPRX
Item Text display:
Display "d. " before the Item text.
Item Text:
skipped doses to make the medicine last longer?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
THowOften
1
No
No
Number Label
1 Often
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC20 - DELAYRX ( SCQ1205 )
2
English text: OFTEN
Sometimes
SC20 - DELAYRX ( SCQ1205 )
3
English text: SOMETIMES
Never
SC20 - DELAYRX ( SCQ1205 )
English text: NEVER
Attribute
Don't know
Route
SC20 - DELAYRX ( SCQ1205 )
Refusal
SC20 - DELAYRX ( SCQ1205 )
10:10:16 AM Wednesday, March 27, 2013
Page 107 of 120
SC20
Field5:
DELAYRX
Cheshire Name:
( SCQ1205 )
ACCS.DELAYRX
Item Text display:
Display "e. " before the Item text.
Item Text:
delayed getting a prescription filled because the medicine
cost too much?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
THowOften
1
No
No
Number Label
1 Often
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC21 - SAMPLERX ( SCQ1210 )
2
English text: OFTEN
Sometimes
SC21 - SAMPLERX ( SCQ1210 )
3
English text: SOMETIMES
Never
SC21 - SAMPLERX ( SCQ1210 )
English text: NEVER
Attribute
Route
Don't know
SC21 - SAMPLERX ( SCQ1210 )
Refusal
SC21 - SAMPLERX ( SCQ1210 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:10:17 AM Wednesday, March 27, 2013
Page 108 of 120
SC21
SC21
Page Order # :
Design Screen Type:
List
Fields:
Field 1:
SAMPLERX
Field 2:
COMPARRX
Field 3:
NOFILLRX
Field 4:
SPENTLRX
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
Enable Functions:
308
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:
CURRENT YEAR: (CURRENT YEAR)
Int. Instr I:
SHOW CARD SC4
Question Text:
Please tell me how often during (CURRENT YEAR) [you have /(SP)
has] done any of the following things. [Have you/has (SP)] often,
sometimes, or never…
Int. Instr II:
10:10:19 AM Wednesday, March 27, 2013
Page 109 of 120
SC21
INPUT FIELDS / ROUTING
SAMPLERX
Field1:
Cheshire Name:
( SCQ1210 )
ACCS.SAMPLERX
Item Text display:
Display "f. " before the Item text.
Item Text:
asked for or received free samples from (your/his/her) doctor
or health provider?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
THowOften
1
No
No
Number Label
1 Often
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC21 - COMPARRX ( SCQ1215 )
2
English text: OFTEN
Sometimes
SC21 - COMPARRX ( SCQ1215 )
3
English text: SOMETIMES
Never
SC21 - COMPARRX ( SCQ1215 )
English text: NEVER
Attribute
Route
Don't know
SC21 - COMPARRX ( SCQ1215 )
Refusal
SC21 - COMPARRX ( SCQ1215 )
10:10:22 AM Wednesday, March 27, 2013
Page 110 of 120
SC21
Field2:
COMPARRX
Cheshire Name:
( SCQ1215 )
ACCS.COMPARRX
Item Text display:
Display "g. " before the Item text.
Item Text:
compared prices or shopped around for the best price?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
THowOften
1
No
No
Number Label
1 Often
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC21 - NOFILLRX ( SCQ1220 )
2
English text: OFTEN
Sometimes
SC21 - NOFILLRX ( SCQ1220 )
3
English text: SOMETIMES
Never
SC21 - NOFILLRX ( SCQ1220 )
English text: NEVER
Attribute
Don't know
Route
SC21 - NOFILLRX ( SCQ1220 )
Refusal
SC21 - NOFILLRX ( SCQ1220 )
10:10:25 AM Wednesday, March 27, 2013
Page 111 of 120
SC21
Field3:
NOFILLRX
Cheshire Name:
( SCQ1220 )
ACCS.NOFILLRX
Item Text display:
Display "h. " before the Item text.
Item Text:
decided not to fill a prescription because it cost too much?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
THowOften
1
No
No
Number Label
1 Often
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC21 - SPENTLRX ( SCQ1225 )
2
English text: OFTEN
Sometimes
SC21 - SPENTLRX ( SCQ1225 )
3
English text: SOMETIMES
Never
SC21 - SPENTLRX ( SCQ1225 )
English text: NEVER
Attribute
Don't know
Route
SC21 - SPENTLRX ( SCQ1225 )
Refusal
SC21 - SPENTLRX ( SCQ1225 )
10:10:29 AM Wednesday, March 27, 2013
Page 112 of 120
SC21
Field4:
SPENTLRX
Cheshire Name:
( SCQ1225 )
ACCS.SPENTLRX
Item Text display:
Display "i. " before the Item text.
Item Text:
spent less money on food, heat, or other basic needs so that
(you/he/she) would have money for medicine?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
THowOften
1
No
No
Number Label
1 Often
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC22 - CHAINRX ( SCQ1230 )
2
English text: OFTEN
Sometimes
SC22 - CHAINRX ( SCQ1230 )
3
English text: SOMETIMES
Never
SC22 - CHAINRX ( SCQ1230 )
English text: NEVER
Attribute
Route
Don't know
SC22 - CHAINRX ( SCQ1230 )
Refusal
SC22 - CHAINRX ( SCQ1230 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:10:30 AM Wednesday, March 27, 2013
Page 113 of 120
SC22
SC22
Page Order # :
Design Screen Type:
List
Fields:
Field 1:
CHAINRX
Field 2:
STOPRX
Field 3:
CREDRX
HELP
COMMENTS
JUMPBACK
No
No
No
Enable Functions:
309
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:
Vertical Alignment
Roster/Grid Instructions:
Roster/Grid display:
Report display:
TEXT:
Context Header:
CURRENT YEAR: (CURRENT YEAR)
Int. Instr I:
SHOW CARD SC4
Question Text:
Please tell me how often during (CURRENT YEAR) [you have /(SP)
has] done any of the following things. [Have you/has (SP)] often,
sometimes, or never…
Int. Instr II:
INPUT FIELDS / ROUTING
10:10:32 AM Wednesday, March 27, 2013
Page 114 of 120
SC22
Field1:
CHAINRX
Cheshire Name:
( SCQ1230 )
ACCS.CHAINRX
Item Text display:
Display "j. " before the Item text.
Item Text:
purchased prescription drugs from a large retail chain, like
Wal-Mart or Target, because of its discount plan?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
THowOften
1
No
No
Number Label
1 Often
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC22 - STOPRX ( SCQ1235 )
2
English text: OFTEN
Sometimes
SC22 - STOPRX ( SCQ1235 )
3
English text: SOMETIMES
Never
SC22 - STOPRX ( SCQ1235 )
English text: NEVER
Attribute
Route
Don't know
SC22 - STOPRX ( SCQ1235 )
Refusal
SC22 - STOPRX ( SCQ1235 )
10:10:35 AM Wednesday, March 27, 2013
Page 115 of 120
SC22
Field2:
STOPRX
Cheshire Name:
( SCQ1235 )
ACCS.STOPRX
Item Text display:
Display "k. " before the Item text.
Item Text:
talked with (your/his/her) doctor about stopping a medicine to
save money or substituting a medicine with one that is less
expensive?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
THowOften
1
No
No
Number Label
1 Often
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC22 - CREDRX ( SCQ1240 )
2
English text: OFTEN
Sometimes
SC22 - CREDRX ( SCQ1240 )
3
English text: SOMETIMES
Never
SC22 - CREDRX ( SCQ1240 )
English text: NEVER
Attribute
Route
Don't know
SC22 - CREDRX ( SCQ1240 )
Refusal
SC22 - CREDRX ( SCQ1240 )
10:10:38 AM Wednesday, March 27, 2013
Page 116 of 120
SC22
Field3:
CREDRX
Cheshire Name:
( SCQ1240 )
ACCS.CREDRX
Item Text display:
Display "l. " before the Item text.
Item Text:
used a credit card so that (you/he/she) could pay for
prescription drugs over time?
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
THowOften
1
No
No
Number Label
1 Often
FieldSize:
Min Value:
Max Value:
Mask:
Route
SC23 - NOINSRX ( SCQ1265 )
2
English text: OFTEN
Sometimes
SC23 - NOINSRX ( SCQ1265 )
3
English text: SOMETIMES
Never
SC23 - NOINSRX ( SCQ1265 )
English text: NEVER
Attribute
Route
Don't know
SC23 - NOINSRX ( SCQ1265 )
Refusal
SC23 - NOINSRX ( SCQ1265 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:10:39 AM Wednesday, March 27, 2013
Page 117 of 120
SC23
SC23
Page Order # :
Design Screen Type:
Code 1
Fields:
Field 1:
NOINSRX
Enable Functions:
HELP
COMMENTS
JUMPBACK
No
Yes
No
Roster Functions:
Add Item
Edit Item
Delete Item
Search Item
No
No
No
No
Grid Functions:
Add Line
Delete Line
No
No
315
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:
CURRENT YEAR: (CURRENT YEAR)
Int. Instr I:
SHOW CARD SC4
Question Text:
Some pharmacies offer discounted prices for some generic
prescription drugs that are lower than a typical insurance
copayment. For example, the discounted price may be $4 to fill a
one-month prescription.
Please tell me how often during (CURRENT YEAR) [you have /(SP)
has] purchased discounted prescription drugs, without using any
drug insurance, in order to reduce (your/his/her) own spending on
drugs?
Int. Instr II:
10:10:40 AM Wednesday, March 27, 2013
Page 118 of 120
SC23
INPUT FIELDS / ROUTING
NOINSRX
Field1:
Cheshire Name:
( SCQ1265 )
ACCS.NOINSRX
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:
Enumerated
THowOften
1
No
No
Number Label
1 Often
FieldSize:
Min Value:
Max Value:
Mask:
Route
BOX SCEND - (SCQ1280 )
2
English text: OFTEN
Sometimes
BOX SCEND - (SCQ1280 )
3
English text: SOMETIMES
Never
BOX SCEND - (SCQ1280 )
English text: NEVER
Attribute
Route
Don't know
BOX SCEND - (SCQ1280 )
Refusal
BOX SCEND - (SCQ1280 )
BACKGROUND VARIABLE ASSIGNMENTS
SOFT EDIT CHECKS
HARD EDIT CHECKS
TECHNICAL NOTES
DESIGN NOTES
10:10:41 AM Wednesday, March 27, 2013
Page 119 of 120
BOX SCEND
BOX SCEND
Page Order # :
320
BOX INSTRUCTIONS
( SCQ1280 )
GO TO NEXT SECTION .
ASSIGNMENTS
TECHNICAL NOTES
DESIGN NOTES
10:10:41 AM Wednesday, March 27, 2013
Page 120 of 120
| File Type | application/pdf |
| File Title | SC_09.01.0000.pdf |
| Subject | SC_09.01.0000.pdf |
| Author | CMS |
| File Modified | 2013-07-01 |
| File Created | 2013-03-27 |