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pdfIntroduction (INQ)
Variable Name
MR Screen Name
BOX IN1
Question type
routing
Question text/description
GO TO INV1 - CARIVER.
Code list
Text Fill Logic
Input mask Routing
(THIS IS AN EXIT INTERVIEW: SELECT "RESPONDENT DOES
NOT WANT TO BE RECORDED" WITHOUT READING SCREEN.)
Some of this interview will be recorded for quality control purposes.
I'd like to continue now, unless you have any questions.
CARIVER
NOCARI
INV1
INV2
code one
no entry
[INTERVIEWS COMPLETED BY TELEPHONE CANNOT BE
RECORDED.]
That's fine. The interview will not be recorded.
(01) RESPONDENT AGREES TO CONTINUE WITH
RECORDING
(02) RESPONDENT DOES NOT WANT TO BE
RECORDED
(01) IN1AA - ATDOOR
(02) INV2 - NOCARI
IN1AA - ATDOOR
REVIEW WITH THE RESPONDENT THE FOLLOWING
IMPORTANT FACTS FROM THE "AT-THE-DOOR" SHEET:
All survey information will be kept in strict confidence under the laws
prescribed by the Privacy Act of 1974.
Medicare benefits will not be affected in any way by survey
responses or participation.
VERIFYSP
IN2
yes/no
REFER TO THE "AT-THE-DOOR" SHEET IF THE RESPONDENT
NEEDS ADDITIONAL REASSURANCE.
VERIFY THE SP’S NAME. IS THE SP’S NAME CORRECT AND
COMPLETE?
FIRST NAME: (SP'S FIRST NAME)
MIDDLE INITIAL: (SP'S MIDDLE INITIAL)
LAST NAME: (SP'S LAST NAME)
ROSTFNAM
IN3
text
MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.
IN3 - ROSTMINI
ROSTMINI
IN3
text
MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.
IN3 - ROSTLNAM
ROSTLNAM
IN3
text
MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.
BOX IN1A
ATDOOR
SPAISTATUS
IN1AA
INS1
no entry
code one
IS THE SP CURRENTLY:
IN2 - VERIFYSP
(01) BOX IN1A
(02) IN3 - ROSTFNAM
(01) YES
(02) NO
(01) ALIVE AND NOT INSTITUTIONALIZED
(02) ALIVE AND INSTITUTIONALIZED
(03) DECEASED - DIED IN COMMUNITY
(04) DECEASED - DIED IN INSTITUTION
(01) BOX INS1
(02) INS2 - SPINSTMM
(03) INS3 - SPDIEMM
(04) INS2 - SPINSTMM
What was the first date since [REFERENCE DATE] that [SP]
entered the facility?
SPINSTMM
INS2
date
[EXPLAIN IF NECESSARY: By "facility" we mean a place that
provides long term care. By "first date" we mean the earliest date
that an SP enters any facility and does not enter a hospital or return
home.]
(01) continuous answer
(-8) Don't Know
IF MORE THAN ONE DATE, ENTER THE EARLIEST.
(-9) Refused
MM
IN2 - SPINSTDD
DD
SPINSTYY
YYYY
BOX INSA
What was the first date since [REFERENCE DATE] that [SP]
entered the facility?
SPINSTDD
INS2
date
[EXPLAIN IF NECESSARY: By "facility" we mean a place that
provides long term care. By "first date" we mean the earliest date
that an SP enters any facility and does not enter a hospital or return
home.]
(01) continuous answer
(-8) Don't Know
IF MORE THAN ONE DATE, ENTER THE EARLIEST.
(-9) Refused
What was the first date since (REFERENCE DATE) that (SP)
entered the facility?
[EXPLAIN IF NECESSARY: By "facility" we mean a place that
provides long term care. By "first date" we mean the earliest date
that an SP enters any facility and does not enter a hospital or return
home.]
SPINSTYY
INS2
date
IF MORE THAN ONE DATE, ENTER THE EARLIEST.
(01) continuous answer
SPDIEMM
INS3
date
On what date did (SP) die?
SPDIEDD
INS3
date
On what date did (SP) die?
SPDIEYY
INS3
date
On what date did (SP) die?
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM
DD
YYYY
(01) INS3 - SPDIEDD
(-8) INS3 - SPDIEDD
(-9) INS3 - SPDIEDD
(01) INS3 - SPDIEYY
(-8) INS3 - SPDIEYY
(-9) INS3 - SPDIEYY
(01) BOX INSA1
(-8) BOX INSA1
(-9) BOX INSA1
YOU HAVE ENTERED THAT THE SP, (SP), WAS
INSTITUTIONALIZED BEFORE JANUARY 1ST OF THIS YEAR. IF
THIS IS NOT CORRECT, GO TO THE PREVIOUS PAGE AND
ENTER THE CORRECT DATE AT INS2.
INSTDATE
INS3A1
no entry
INTHANK
INS3B
BOX INSB1
no entry
routing
PERSON_PROXY
INS3B - INTHANK
BOX INSB1
END1 - INTLANG.
IN4
code one
IF SP IS DECEASED OR INSTITUTIONALIZED, SET
RESPONDENT TO PROXY AND GO TO IN4A - PERSON_PROXY.
ELSE GO TO IN4 - SPPROXY.
WILL THIS INTERVIEW BE CONDUCTED WITH THE SAMPLE
(01) SAMPLE PERSON
PERSON OR WITH A PROXY?
(02) PROXY
BOX INS2A
routing
IF SP IS IN THE EXIT SAMPLE, GO TO BOX INS4A.
ELSE GO TO BOX INS5.
roster
SELECT OR ADD THE NAME/RELATIONSHIP OF THE PROXY TO
THE SP FOR THIS INTERVIEW.
SELECT OR ADD ONLY ONE PERSON.
routing
IF PERSON IS ADDED AT IN4A, GO TO BOX INS2A-1.
ELSE GO TO IN5 - VRFYPROX.
(01) YES
(02) NO
(01) BOX INS2A-1
(02) IN6 - ROSTFNAM
BOX INS1
SPPROXY
IF THIS IS CORRECT, YOU WILL NOT BE CONDUCTING THE
COMMUNITY INTERVIEW WITH THE RESPONDENT. THIS CASE
WILL BE CODED A 14 ON THE RECORD OF CALLS. DISCUSS
THE CASE WITH YOUR SUPERVISOR.
AFTER CLICKING "NEXT PAGE", YOU WILL RETURN TO CMFIELD.
I would like to thank you for your time and cooperation during this
interview. We may be contacting you in the future for further
information.
GO TO END1 - INTLANG.
IN4A
BOX INS2AA
routing
(01) BOX INS2A
(02) IN4A - PERSON_PROXY
BOX INS2AA
VRFYPROX
IN5
yes/no
I would like to verify your name and relationship to (SP). I have you
listed as [READ NAME AND RELATIONSHIP LISTED BELOW]. Is
that correct?
FIRST NAME: (PROXY'S FIRST NAME)
LAST NAME: (PROXY'S LAST NAME)
RELATIONSHIP: (PROXY'S RELATIONSHIP TO SP)
ROSTFNAM
IN6
text
[What is your correct name and relationship to (SP)?]
(01) continuous answer
IN6 - ROSTLNAM
ROSTLNAM
IN6
text
[What is your correct name and relationship to (SP)?]
(01) continuous answer
IN6 - ROSTREL
ROSTREL
IN6
BOX INS2A-1
WHYPROXY
IN6A
code one
[What is your correct name and relationship to (SP)?]
routing
IF SP IS INSTITUTIONALIZED (SPALIVE = 2), SET REASON WHY
RESPONDENT IS PROXY TO "SP IS INSTITUTIONALIZED"
(WHYPROXY = 07) AND GO TO BOX INS3.
ELSE IF SP IS DECEASED (SPALIVE = 3), SET REASON WHY
RESPONDENT IS PROXY TO "SP IS DECEASED" (WHYPROXY =
06) AND GO TO BOX INS3.
ELSE GO TO IN6A - WHYPROXY.
code one
WHY IS WHAT IS THE MAIN REASON THAT A PROXY
RESPONDENT NECESSARY?
CHECK ALL THAT APPLY.
(01) SAMPLE PERSON
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(50) PARTNER/ROOMMATE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER RELATIVE
(92) OTHER NON-RELATIVE
(-8) Don't Know
(-9) Refused
(01) BOX INS2A-1 DO NOT DISPLAY
(02) BOX INS2A-1
(03) BOX INS2A-1
(04) BOX INS2A-1
(05) BOX INS2A-1
(06) BOX INS2A-1
(07) BOX INS2A-1
(08) BOX INS2A-1
(09) BOX INS2A-1
(10) BOX INS2A-1
(11) BOX INS2A-1
(12) BOX INS2A-1
(13) BOX INS2A-1
(14) BOX INS2A-1
(50) BOX INS2A-1 DO NOT DISPLAY
(51) BOX INS2A-1
(52) BOX INS2A-1
(53) BOX INS2A-1
(54) BOX INS2A-1
(55) BOX INS2A-1
(56) BOX INS2A-1
(57) BOX INS2A-1
(91) IN6 - ROSTREOS
(92) IN6 - ROSTREOS
(-8) BOX INS2A-1
(-9) BOX INS2A-1
(01) SP NOT CAPABLE
PHYSICALLY/SICK/BLIND/CAN’T SPEAK/HEAR
(02) SP NOT CAPABLE MENTALLY/POOR
MEMORY/PSYCHIATRIC DISORDER
(03) SP UNABLE TO PROVIDE INFORMATION
REGARDING MEDICAL RECORDS
(04) SP IN HOSPITAL
(05) LANGUAGE PROBLEM
(06) SP IS DECEASED
(07) SP IS INSTITUTIONALIZED
(08) SP NOT AVAILABLE THIS ROUND
(09) AUTHORIZED PROXY MUST ANSWER
QUESTIONS FOR SP (CODE REASON WHY)
(91) OTHER
(01) BOX INS2B
(02) BOX INS2B
(03) BOX INS2B
(04) BOX INS2B
(05) BOX INS2B
(06) BOX INS2B
(07) BOX INS2B
(08) BOX INS2B
(09) BOX INS2B
(91) IN6A - PNSPOS
IF RESPONSE TO IN6a - WHYPROXY ONLY INCLUDES
9/CodeReasonWhy, GO TO IN6B - PNSPVB.
ELSE GO TO BOX INS3.
PNSPVB
BOX INS2B
routing
IN6B
verbatim text
BRIEFLY EXPLAIN WHY PROXY MUST ANSWER QUESTIONS.
routing
IF SP IS IN THE SUPPLEMENTAL SAMPLE AND IN6A WHYPROXY = 6/SPIsDeceased, GO TO IN6B1 - SUPPDIED.
ELSE IF SP IS IN THE SUPPLEMENTAL SAMPLE AND IN6A WHYPROXY = 7/SPIsInstitute, GO TO IN6B2 - SUPPINST.
ELSE IF SP IS IN THE EXIT SAMPLE AND SP IS NOT DECEASED,
GO TO BOX INS4A.
ELSE GO TO BOX INS5.
BOX INS3
BOX INS3
BOXINS4A
routing
IF THIS IS A RESTART INTERVIEW AND CURRENT
RESPONDENT IS THE SAME AS THE LAST RESPONDENT AT
THE TIME OF THE BREAKOFF, GO TO BOX INS5.
ELSE IF THIS IS A RESTART INTERVIEW AND CURRENT
RESPONDENT IS NOT THE SAME AS THE LAST RESPONDENT
AT THE TIME OF THE BREAKOFF, GO TO INS6A - EXITINFR.
ELSE GO TO INS6 - EXITINFO.
As you know from all of the interviews that we have conducted, the
Medicare Current Beneficiary Survey has been collecting data from
over 100,000 beneficiaries since 1991. Data from the study have
been extremely useful to many researchers who are looking at the
availability and the cost of medical care for people such as
[you/(SP)].
At this time, the survey is going to start interviewing some new
beneficiaries and we will stop interviewing some of the people who
have been with the survey for quite some time. [You are/(SP) is] one
of the people that we will no longer interview.
EXITINFO
INS6
no entry
[you] respondent is the SP
[SP] when respondent is proxy
[You are] respondent is the SP
[(SP) is] respondent is proxy
[with you] respondent is the SP
[for (SP)] respondent is proxy
BOX IN8
[You are] respondent is the SP
[(SP) is] respondent is proxy
[with you] respondent is the SP
[for (SP)] respondent is proxy
BOX INS5
[your] respondent is the SP
[(SP)'s] respondent is proxy
(01) IN10 - CHEKAGE
(02) IN9 - HHDOBMM
(-8) IN11 - ROSTSEX
(-9) IN11 - ROSTSEX
[your] respondent is the SP
[(SP)'s] respondent is proxy
IN9 - HHDOBDD
[your] respondent is the SP
[(SP)'s] respondent is proxy
IN9 - HHDOBYY
[your] respondent is the SP
[(SP)'s] respondent is proxy
BOX IN3A
(01) YES
(02) NO
[you] respondent is the SP
[SP] when respondent is proxy
(01) IN11 - ROSTSEX
(02) IN9 - HHDOBMM
(01) MALE
(02) FEMALE
[Are you] respondent is SP
[Is (SP)] respondent is proxy
BOX IN4
Therefore, this will be the last interview that will be conducted [with
you/for (SP)]. I will not collect any new health care visit information.
However, I will ask a series of income and assets questions. This
will be a shorter interview, different from most of the others
conducted.
At this time, the survey is going to start interviewing some new
beneficiaries and we will stop interviewing some of the people who
have been with the survey for quite some time. [You are/(SP) is] one
of the people that we will no longer interview.
EXITINFR
INS6A
BOX INS5
no entry
Therefore, this will be the last interview that will be conducted [with
you/for (SP)]. I will not collect any new health care visit information.
However, I will ask a series of income and assets questions. This
will be a shorter interview, different from most of the others
conducted.
routing
IF THIS IS A RESTART INTERVIEW, GO TO BOX CEBEG.
ELSE IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS
NEW FROM FACILITY), GO TO IN8 - CHEKBRTH.
ELSE IF IT'S A FALL ROUND, GO TO BOX IN6.
ELSE GO TO BOX IN8.
CHEKBRTH
IN8
yes/no
I have [your/(SP’s)] date of birth listed as (CMS BIRTH DATE). Is
that correct?
HHDOBMM
IN9
date
What is [your/(SP’s)] date of birth?
HHDOBDD
HHDOBYY
IN9
IN9
BOX IN3A
CHECKAGE
ROSTSEX
IN10
IN11
BOX IN4
date
What is [your/(SP’s)] date of birth?
date
What is [your/(SP’s)] date of birth?
routing
IF SP'S DATE OF BIRTH MONTH, DAY OR YEAR COLLECTED AT
IN9 = DK OR RF, GO TO IN11 - ROSTSEX.
ELSE GO TO IN10 - CHEKAGE.
code one
That makes [you/(SP)] (AGE) today. Is that correct?
THE SP IS LISTED AS A (MALE/FEMALE). IF SEX IS OBVIOUS,
CODE BELOW WITHOUT ASKING. IF SEX IS NOT OBVIOUS,
ASK:
[Are you/Is (SP)] male or female?
routing
IF NOT MISSING GENDER FROM CMS FILES AND SP'S GENDER
FROM CMS DOES NOT MATCH GENDER ENTERED AT IN11 ROSTSEX, GO TO IN12 - CHNGSEX.
ELSE GO TO BOX IN6.
yes/no
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
CHNGSEX
IN12
BOX IN6
SPMARSTA
IN13
BOX IN7
SPCHNLNM
IN14
BOX IN8
yes/no
YOU JUST CHANGED SP’S SEX FROM (MALE/FEMALE) TO
(FEMALE/MALE). DID YOU INTEND TO DO THAT?
routing
IF SP'S AGE IS > 16, DK OR RF, GO TO IN13 - SPMARSTA.
ELSE GO TO BOX IN8.
code one
[Are you/Is (SP)/Was (SP)/Is (SP) currently/Are you currently]
married, widowed, divorced, separated, or never married?
routing
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW
FROM FACILITY), GO TO IN14 - SPCHNLNM.
ELSE GO TO BOX IN8.
numeric
routing
Including natural, adopted, and stepchildren, how many living
children [did (SP)/does (SP)/do you] have?
GO TO NEXT SECTION
(01) YES
(02) NO
(01) BOX IN6
(02) IN11 - ROSTSEX
(01) MARRIED
(02) WIDOWED
(03) DIVORCED
(04) SEPARATED
(05) NEVER MARRIED
(-8) Don't Know
(-9) Refused
[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP alive
[Was (SP)] respondent is proxy, SP
deceased
BOX IN7
(01) continuous answer
(-8) Don't Know
(-9) Refused
[did (SP)] respondent is proxy, SP
deceased
[does (SP)] respondent is proxy, SP alive
[do you] respondent is SP
BOX IN8
Oupatient Utilization (OPQ)
Variable Name
OPPROBE
MR Screen Name
OP1
Question type
yes/no
Question text/description)
Code list
(01) YES
(02) NO
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF
(03) INDICATED YES BY DATAPREP
DEATH/DATE OF INSTITUTIONALIZATION)], [have you gone/has (SP) gone/did (SP) go] (-8) Don't Know
to the outpatient department or the outpatient clinic at any hospital for medical care?
(-9) Refused
Text Fill Logic
Input mask
Routing
[Since (REFERENCE DATE)] respondent is SP
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is
proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized
[have you gone] respondent is SP
[has (SP) gone] respondent is proxy, SP alive
[did (SP) go] respondent is proxy, SP deceased
(01) OP2 - PROVIDER_OP
(02) BOX OP7
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX OP7
(-9) BOX OP7
[you] respondent is SP
[(SP)] respondent is proxy
BOX OP1
Where did [you/(SP)] go (to which hospital)?
SELECT OR ADD ONLY ONE HOSPITAL.
PROVIDER_OP
VAPLACE
roster
[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE HOSPITAL.]
BOX OP1
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE
CURRENT ROUND OR ANY PREVIOUS ROUND) AND (IF THIS PROVIDER IS
ASSOCIATED WITH V.A. IS UNKNOWN), GO TO OP3 - VAPLACE.
ELSE GO TO BOX OP1B.
OP3
yes/no
Is (HOSPITAL NAME) a Department of Veterans Affairs, or V.A., facility?
routing
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT
ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN
IS UNKNOWN), GO TO OP3A - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND) AND (THIS PROVIDER IS NOT ASSOCIATED WITH A MANAGED
CARE PLAN), GO TO OP3B - HMOREFER.
ELSE GO TO OP4 - EVENT_OP
yes/no
Is (HOSPITAL NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN
NAME(S) BELOW] plan?
OP2
BOX OP1B
HMOASSOC
OP3A
[Were you/Was (SP)] referred to (HOSPITAL NAME) by [READ MANAGED CARE PLAN
NAME(S) BELOW]?
HMOREFER
OP3B
yes/no
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN
(PCP).]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX OP1B
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)]
(01) OP4 - EVENT_OP
(02) OP3B - HMOREFER
(-8) OP3B - HMOREFER
(-9) OP3B - HMOREFER
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Were you] respondent is SP
[Was (SP)] respondent is proxy
OP4 - EVENT_OP
[you] respondent is SP
[(SP)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP not deceased
or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is
proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized
OP4_IN - NAVIGATOR
When did [you/(SP)] go to an outpatient department at (HOSPITAL NAME)? Please tell me
all the dates [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)].
ENTER ALL DATES.
EVENT_OP
NAVIGATOR
OP4
OP4_IN
roster
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY,
ENTER THE DATE ONLY ONCE.]
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
instance navigator
Were any operations or other surgical procedures performed on [you/(SP)] during [any of
the/the] [VISIT ON EVENT DATE]?
ANYOPERS
OP5
yes/no
[Operations include surgery and other surgical procedures like setting bones, stitching or
removing growths, or any cutting of the skin.]
SPECCOND
OP8
yes/no
[Was this visit/Were any of these visits] to the outpatient department for any specific
condition?
routing
IF CURRENTLY ADMINISTERING ST, GO TO BOX ST23B.
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS23B.
ELSE GO TO OP10 - PRESMDCN.
BOX OP2A
PRESMDCN
OP10
yes/no
During [this visit/any of these visits] to the outpatient department, were any medicines
prescribed for [you/(SP)]?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) OP5 - ANYOPERS
(02) OP15 - OPMORE
[you] respondent is SP
[(SP)] respondent is proxy
[any of the] refers to multiple visits
[the] refers to one visit
(01) BOX OP2A
(02) OP8 - SPECCOND
(-8) OP8 - SPECCOND
(-9) OP8 - SPECCOND
[Was this visit] refers to one visit
[Were any of these visits] refers to mutiple visits
BOX OP2A
[this visit] refers to one visit
[any of these visits] refers to multiple visits
[you] respondent is SP
[SP] respondent is proxy
(01) OP11 - PRESFILL
(02) BOX OP3
(-8) BOX OP3
(-9) BOX OP3
Were any of the prescriptions filled?
PRESFILL
OP11
BOX OP2B
yes/no
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE
RESPONDENT, WHEN IT WAS OBTAINED, WHETHER OR NOT THE
PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE RESPONDENT
ACTUALLY TOOK THE MEDICINE.]
routing
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN
THE CURRENT ROUND, GO TO OP11A - OPPMMEDS.
ELSE GO TO OP12 - MEDICINE_OP.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX OP2B
(02) BOX OP3
(-8) BOX OP3
(-9) BOX OP3
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you
have so that I can spell the medicine name correctly and enter the strength of the medicine.
[Also, please take out [your/(SP's)] (MEDICARE PRESCRIPTION DRUG PLAN NAME)
medicine statements, which should have that same information on them.]
OPPMMEDS
OP11A
no entry
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the
medicines [you/(SP)] obtained since the last interview, if you’d like to get those bottles, too.
OP12 - MEDICINE_OP
Please tell me the names of these medicines.
MEDICINE_OP
OPMORE
OP12
BOX OP3
OP15
BOX OP6
BOX OP7
roster
routing
ENTER ALL MEDICINES.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
INCLUDE STRENGTH WITH NAME.
GO TO OP4_IN - NAVIGATOR.
yes/no
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], did [you/(SP)] have any other visits to the
outpatient department at this or any other hospital for services?
routing
routing
IF FALL ROUND AND ((SP REPORTED AN OUTPATIENT DEPARTMENT VISIT AT
OP4) AND (SP IS ALIVE AND NOT INSTITUTIONALIZED)), GO TO AC9 - OPDREAS.
ELSE GO TO BOX OP7.
GO TO NEXT SECTION
BOX OP3
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Since (REFERENCE DATE)] respondent is SP or proxy, SP not deceased
or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is
proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
(01) OP2 - PROVIDER_OP
(02) BOX OP6
(-8) BOX OP6
(-9) BOX OP6
Institutional Utilization (IUQ)
Variable Name
MR Screen Name
Question type
Question text/description
Code list
Text Fill Logic
Input mask
Routing
SHOW CARD IU1
[Since (REFERENCE DATE), [have you/has (SP)] been/Between
(REFERENCE DATE) and (DATE OF DEATH), was (SP)/Other than the
current institutional stay that started on (DATE OF INSTITUTIONALIZATION),
between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION) was
(SP)] a patient in (a/another) nursing home or any similar place that provides
long-term care -- such as the places shown on this card?
IUPROBE
IU1
yes/no
LONG-TERM CARE PLACES INCLUDE SKILLED NURSING HOMES,
INTERMEDIATE CARE FACILITIES, BOARD AND CARE HOMES, NURSING
HOME UNITS IN HOSPITALS, FACILITIES FOR THE MENTALLY
(01) YES
RETARDED, PSYCHIATRIC FACILITIES AND GROUP HOMES.
(02) NO
(03) INDICATED YES BY DATAPREP
[ENTER A STAY AT A DRUG AND REHABILITATION CENTER AS AN IP
(-8) Don't Know
EVENT, NOT AN IU EVENT.]
(-9) Refused
[Since (REFERENCE DATE), have you been]
respondent is SP
[Since (RFERENCE DATE), has (SP) been]
respondent is proxy, SP alive
[Between (REFERENCE DATE) and (DATE OF
DEATH), was (SP)] respondent is proxy, SP
deceased
[Other than the current institutional stay that
started on (DATE OF INSTITUTIONALIZATION),
between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION) was (SP)] respondent
is proxy, SP institutionalized
[a] first loop
[another] second or more loop
(01) IU2 - PROVIDER_IU
(02) BOX IU3
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX IU3
(-9) BOX IU3
[were you] respondent is SP
[was (SP)] respondent is proxy
BOX IU1
Where [were you/was (SP)] a patient -- in which nursing home?
SELECT OR ADD ONLY ONE FACILITY.
PROVIDER_IU
IU2
roster
[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE
INSTITUTION.]
(01) continuous answer
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A.
IN THE CURRENT ROUND OR ANY PREVIOUS ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO IU3 VAPLACE.
BOX IU1
routing
ELSE TO IU4 - EVBEGMM.
VAPLACE
IU3
yes/no
Is (FACILITY NAME) a Department of Veterans Affairs, or V.A., facility?
EVBEGMM
IU4
date
When [were you/was (SP)] admitted to and discharged from (FACILITY
NAME)?
EVBEGDD
IU4
date
When [were you/was (SP)] admitted to and discharged from (FACILITY
NAME)?
EVBEGYY
IU4
date
When [were you/was (SP)] admitted to and discharged from (FACILITY
NAME)?
EVENDMM
IU4
date
When [were you/was (SP)] admitted to and discharged from (FACILITY
NAME)?
EVENDDD
IU4
date
When [were you/was (SP)] admitted to and discharged from (FACILITY
NAME)?
EVENDYY
IU4
date
When [were you/was (SP)] admitted to and discharged from (FACILITY
NAME)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
IF RESPONDENT HAS ALREADY MENTIONED ANOTHER STAY AT A
NURSING HOME, ENTER “YES” WITHOUT ASKING. OTHERWISE, ASK:
IUMORE
IU7
BOX IU3
yes/no
routing
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], [have you had/has (SP) had/did
(SP) have] any other stays in this or any other nursing home or similar place
that provides long-term care?
(01) YES
(02) NO
[ENTER A STAY AT A DRUG AND REHABILITATION CENTER AS AN IP
(-8) Don't know
EVENT, NOT AN IU EVENT.]
(-9) Refused
GO TO NEXT SECTION
IU4 - EVBEGMM
[were you] respondent is SP
[was (SP)] respondent is proxy
MM
IU4 - EVBEGDD
[were you] respondent is SP
[was (SP)] respondent is proxy
DD
IU4 - EVBEGYY
[were you] respondent is SP
[was (SP)] respondent is proxy
YY
IU4 - EVENDMM
[were you] respondent is SP
[was (SP)] respondent is proxy
MM
IU4 - EVENDDD
[were you] respondent is SP
[was (SP)] respondent is proxy
DD
IU4 - EVENDYY
[were you] respondent is SP
[was (SP)] respondent is proxy
YY
IU7 - IUMORE
[Since (Reference Date)] respondent is SP or
proxy, SP alive and not institutionalized
[Between (REFERENCE DATE) and (DATE OF
DEATH)] respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[have you had] respondent is SP
[has (SP) had] respondent is proxy, SP alive
[did (SP) have] respondent is proxy, SP deceased
(01) IU2 - PROVIDER_IU
(02) BOX IU3
(-8) BOX IU3
(-9) BOX IU3
Home Health Summary (HHS)
Variable Name
PROFPROB
FRNDPROB
OTHMEALS
MR Screen Name
Question type
Question text/description)
BOX HHS1
routing
BOX HHS1A
routing
IF SP RECEIVED CARE FROM AT LEAST ONE HOME HEALTH
PROFESSIONAL DURING THE PREVIOUS ROUND, GO TO BOX HHS1A.
ELSE GO TO BOX HHS2
CREATE CURRENT ROUND HERO RECORD FOR HH PROVIDER BEING
ASKED ABOUT
GO TO HHS1 - PROFPROB.
yes/no
[you] respondent is SP
We recorded that [you/(SP)] had been helped at home by (someone from) [READ
[(SP)] respondent is proxy
PROVIDER BELOW] between (SUMMARY REFERENCE DATE) and
[you] respondent is SP
(REFERENCE DATE). Has (anyone from) [READ PROVIDER BELOW] helped
[since (REFERENCE DATE)] respondent is SP or proxy, SP not
[you/(SP)] at home [since (REFERENCE DATE)/between (REFERENCE DATE) (01) YES
deceased or institutionalized
and (DATE OF DEATH)/ (DATE OF INSTITUTIONALIZATION)]?
(02) NO
[between (REFERENCE DATE) and (DATE OF DEATH)]
(03) HOME HEALTH ENTERED IN ERROR IN PREVIOUS respondent is proxy, SP deceased
[IF THE RESPONDENT SAYS "SOMEONE ELSE CAME," PROBE TO
ROUND
[between (REFERENCE DATE) and (DATE OF
DETERMINE IF THE PERSON WORKED FOR THE AGENCY SHOWN ON
(-8) Don't Know
INSTITUTIONALIZATION)] respondent is proxy, SP deceased
THE SCREEN.]
(-9) Refused
[(SP)] respondent is proxy, SP institutionalized
HHS1
Code list
Text Fill Logic
BOX HHS2
routing
BOX HHS2A
routing
IF SP RECEIVED HOME HEALTH CARE FROM AT LEAST ONE FRIEND OR
RELATIVE DURING THE PREVIOUS ROUND, GO TO BOX HHS2A.
ELSE GO TO BOX HHS6.
CREATE CURRENT ROUND HERO RECORD FOR HH PROVIDER BEING
ASKED ABOUT
GO TO HHS2 - FRNDPROB.
yes/no
[you] respondent is SP
[(SP)] respondent is proxy
We recorded that [you/(SP)] had received personal care or help with daily needs
[Have you] respondent is SP
at home from (someone from) [READ PROVIDER BELOW] between
[Has (SP)] respondent is proxy
(SUMMARY REFERENCE DATE) and (REFERENCE DATE). [Have you/Has
[since (REFERENCE DATE)] respondent is SP or proxy, SP not
(SP)] received personal care or help with daily needs at home from (anyone from)
deceased or institutionalized
[READ PROVIDER BELOW] [since (REFERENCE DATE)/between
[between (REFERENCE DATE) and (DATE OF DEATH)]
(REFERENCE DATE) and (DATE OF DEATH)/ (DATE OF
(01) YES
respondent is proxy, SP deceased
INSTITUTIONALIZATION)]?
(02) NO
[between (REFERENCE DATE) and (DATE OF
(03) HOME HEALTH ENTERED IN ERROR IN PREVIOUS INSTITUTIONALIZATION)] respondent is proxy, SP
[IF THE RESPONDENT SAYS "SOMEONE ELSE CAME," PROBE TO
ROUND
institutionalized
DETERMINE IF THE PERSON WORKED FOR THE AGENCY SHOWN ON
(-8) Don't Know
If someone works for this Provider, display "someone from" and
THE SCREEN.]
(-9) Refused
"anyone from". Else do not display.
BOX HHS3
routing
IF TYPE OF HOME HEALTH PROVIDER ORGANIZATION IS A MEAL
PROGRAM, GO TO HHS3 - OTHMEALS.
ELSE GO TO BOX HH1BB
HHS3
yes/no
Since (REFERENCE DATE), has (PROVIDER NAME) provided any services to
[you/(SP)] other than delivering meals?
routing
routing
IF ASKING ABOUT HOME HEALTH PROFESSIONALS FROM THE
PREVIOUS ROUND, THEN
IF SP RECEIVED CARE FROM ANOTHER HOME HEALTH
PROFESSIONAL DURING THE PREVIOUS ROUND, GO TO BOX HHS1A.
ELSE GO TO BOX HHS2.
ELSE IF ASKING ABOUT HOME HEALTH CARE FROM A FRIEND OR
RELATIVE FROM THE PREVIOUS ROUND, THEN
IF SP RECEIVED HOME HEALTH CARE FROM ANOTHER FRIEND OR
RELATIVE DURING THE PREVIOUS ROUND, GO TO BOX HHS2A.
ELSE GO TO BOX HHS6.
ELSE GO TO BOX HHS6.
GO TO NEXT SECTION
HHS2
BOX HHS5
BOX HHS6
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
Input mask
Routing
(01) BOX HHS3
(02) BOX HHS5
(03) BOX HHS5
(-8) BOX HHS5
(-9) BOX HHS5
BOX HHS3
(01) BOX HH1BB
(02) BOX HHS5
(-8) BOX HHS5
(-9) BOX HHS5
Home Health Utilization (HHQ)
Variable Name
MR Screen Name
Question type
Question text/description
Code list
SHOW CARD HH1
HHPRPROF
HH1
yes/no
(Besides what you have already mentioned,) [(Since/since) (REFERENCE
DATE)/(Between/between) (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], [have you been/has (SP)
been/was (SP)] helped at home by any (other) health or medical professionals,
such as those listed on this card?
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP. DO NOT DISPLAY. DATA
EDITING ONLY.
(-8) DON'T KNOW
(-9) REFUSED
[Health professionals include nurse (visiting nurse, private duty nurse, etc.),
doctor, social worker, therapist, and hospice worker.]
Text fills
If SP reported a Home Health visit during the current round, display "Besides
what you already mentioned, [since (REFERENCE DATE)/between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]".
Else display "[Since (REFERENCE ATE)/Between(REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]".
If SP is deceased, display "was (SP)"
Else if proxy interview, display "has (SP) been".
Else display "have you been".
Input mask
Routing
(01) HH2 - PROVIDER_HHP
(02) HH18 - HHPRFRND
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) HH18 - HHPRFRND
(-9) HH18 - HHPRFRND
If SP reported a Home Health Professional in Home Health Summary, display
"other".
PROVIDER_HHP
HH2
roster
What is the name of the health professional who helped [you/(SP)] at home
[since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
ENTER NAME OF PERSON WHO HELPED. DO NOT ENTER THE NAME
OF PLACE OR ORGANIZATION.
[you] respondent is SP
[(SP)] respondent is proxy
(01) CONTINUOUS ANSWER
[ADD OR SELECT ONLY ONE PROVIDER IF DIFFERENT PEOPLE COME
FROM THE SAME ORGANIZATION, PROBE FOR THE PERSON WHO
USUALLY COMES OR WHO COMES MOST OFTEN.]
BOX HH1AAA
routing
PROVSPEC
HH3
code one
PROVSPOS
HH3
text
WORKSFOR
HH4
code one
HH5
BOX HH1AA
roster
routing
HHPLACE
HH6
code one
HHPLACOS
HH6
text
BOX HH1BBB
routing
OTHMEALS
HH7
yes/no
BOX HH1AAA
IF (HOME HEALTH PROVIDER WAS ADDED AT HH2) OR (AN EXISTING
PROVIDER WAS SELECTED AT HH2 THAT WAS NOT ASSOCIATED WITH
A HOME HEALTH EVENT), GO TO HH3 - PROVSPEC.
ELSE GO TO BOX HH1BBB.
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
What kind of health professional is (PROVIDER NAME)?
(12) NURSE (RN)
[SELECT THE RESPONSE CATEGORY FOR A GIVEN SPECIALTY ONLY IF (13) NURSE PRACTITIONER
THE RESPONDENT SPECIFICALLY NAMES THE LISTED SPECIALTY OR (14) NURSE'S AIDE
MENTIONS THE WORDS OR INITIALS IN PARENTHESES FOLLOWING
(15) OCCUPATIONAL THERAPIST (OT)
THAT PROVIDER SPECIALTY.]
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
OTHER MEDICAL PROVIDER (SPECIFY)
(01) NAME OF ORGANIZATION GIVEN
Who does (PROVIDER NAME) work for, that is, for what place or organization?
(02) WORKS FOR SELF
(-8) DON'T KNOW
[PROBE: Or does (PROVIDER NAME) work for himself/herself?]
(-9) REFUSED
[Who does (PROVIDER NAME) work for, that is, what place or organization?]
PROVIDER_HHPORG
[since (REFERENCE DATE)] - respondent is SP
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy,
SP deceased
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)]
respondent is proxy, SP institutionalized
[PROBE: Who would (you/SP) call if (PROVIDER NAME) did not show up?]
ADD OR SELECT ONLY ONE PROVIDER.
[DO NOT ADD A NEW ROSTER ENTRY IF A DIFFERENT PERSON CAME
FROM AN ORGANIZATION ALREADY LISTED ON THE ROSTER.]
IF HH4 - WORKSFOR = 1/OrganizationGiven, SET HOME HEALTH
PROVIDER FOR THIS VISIT TO THE HOME HEALTH ORGANIZATION
SELECTED AT HH5, AND GO TO HH6 - HHPLACE.
ELSE SET HOME HEALTH PROVIDER FOR THIS VISIT TO THE
PROVIDER SELECTED AT HH2, HH19, ST27 OR NS27, AND GO TO BOX
HH1BB.
PROVIDER NAME: (PROVIDER NAME)
What kind of place or organization is (PROVIDER NAME)?
OTHER (SPECIFY)
SET HOME HEALTH PROVIDER FOR THIS VISIT TO THE PROVIDER
SELECTED AT HH2 OR HH19.
IF TYPE OF HOME HEALTH PROVIDER ORGANIZATION IS A MEAL
PROGRAM, GO TO HH7 - OTHMEALS.
ELSE GO TO BOX HH1BB.
[Between (REFERENCE DATE) and (today/DATE OF DEATH/ DATE OF
INSTITUTIONALIZATION)], did (PROVIDER NAME) provide any services to
[you/(SP)] other than delivering meals?
Display Provider Name for Home Health provider currently being asked about,
(PROVIDER NAME).
Display Provider Name for Home Health provider currently being asked about,
(PROVIDER NAME).
The SP has just reported that the Provider just selected works for an
organization. HH5 will collect the name of this organization. At HH5, continue
to display the Provider Name for the Home Health provider selected prior to
HH5, (PROVIDER NAME).
(01) CONTINUOUS ANSWER
(01)-(34), (-8), (-9) HH4 - WORKSFOR
(91) HH3 - PROVSPOS
HH4 - WORKSFOR
(01) HH5 - PROVIDER_HHPORG
(02) BOX HH1AA
(-8) BOX HH1AA
(-9) BOX HH1AA
BOX HH1AA
Always display "Who does (PROVIDER NAME)….]" in brackets.
[you] respondent is SP
[(SP)] respondent is proxy
(01) MANAGED CARE PLAN (SUCH AS HMO)
(02) MEAL PROGRAM (SUCH AS MEALS ON WHEELS)
(03) VISITING NURSE ASSOCIATION
(04) HOME HEALTH AGENCY
(05) HOSPITAL
(06) PRIVATE PHYSICIAN/GROUP PRACTICE
(07) HOSPICE
(08) REHABILITATION OR SPORTS MEDICINE THERAPY
(09) LOCAL GOVERNMENT ORGANIZATION
(10) CHURCH OR COMMUNITY ORGANIZATION
(11) ASSISTED LIVING/RETIREMENT HOME
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
Display Provider Name for Home Health provider currently being asked about,
(PROVIDER NAME).
If PROV.HHPLACOS has already been filled, PROV.HHPLACOS ^= empty,
display previously collected response and allow it to be updated.
(01) BOX HH1BB
(02) BOX HH1BBB
(03) BOX HH1BB
(04) BOX HH1BB
(05) BOX HH1BB
(06) BOX HH1BB
(07) BOX HH1BB
(08) BOX HH1BB
(09) BOX HH1BB
(10) BOX HH1BB
(11) BOX HH1BB
(91) HH6 - HHPLACOS
(-8) BOX HH1BB
Display Provider Name for Home Health provider currently being asked about,
(PROVIDER NAME).
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[between (REFERENCE DATE) and today] - respondent is SP
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy,
SP deceased
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)]
respondent is proxy, SP institutionalized
BOX HH1BB
[you] respondent is SP
VAPLACE
BOX HH1BB
routing
BOX HH1
routing
HH8
yes/no
IF TYPE OF HOME HEALTH PROVIDER IS A MEAL PROGRAM THAT DID
NOT PROVIDE ANY OTHER SERVICES BESIDES MEALS, GO TO BOX
HH3.
ELSE IF (HOME HEALTH PROVIDER IS A FRIEND OR RELATIVE) OR
(TYPE OF HOME HEALTH PROVIDER IS A LOCAL GOVERNMENT,
CHURCH OR COMMUNITY ORGANIZATION), GO TO HH11 - HELPUNIT.
ELSE GO TO BOX HH1.
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A.
IN THE CURRENT ROUND OR ANY PREVIOUS ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO HH8 VAPLACE.
ELSE GO TO BOX HH1A.
(01) YES
Is [(PROVIDER NAME) associated with/(PROVIDER NAME)] a Department of (02) NO
Veterans Affairs, or V.A., facility?
(-8) DON'T KNOW
(-9) REFUSED
Display Provider Name for Home Health provider currently being asked about,
(PROVIDER NAME). If someone works for this provider, display "(PROVIDER
NAME)". Else display "(PROVIDER NAME) associated with".
BOX HH1A
BOX HH1A
HMOASSOC
HMOREFER
HH10A
HH10B
routing
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH A
MANAGED CARE PLAN IS UNKNOWN), GO TO HH10A - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING
THE CURRENT ROUND) AND (THIS PROVIDER IS NOT ASSOCIATED
WITH A MANAGED CARE PLAN), GO TO HH10B - HMOREFER.
ELSE GO TO HH11 - HELPUNIT.
yes/no
(01) YES
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE (02) NO
PLAN NAME(S) BELOW] plan?
(-8) DON'T KNOW
(-9) REFUSED
yes/no
HELPUNIT
HH11
quantity unit
HELPNUM
HH11
numeric
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED
CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE
PHYSICIAN (PCP).]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[Between (REFERENCE DATE) and (today/DATE OF DEATH/ DATE OF
INSTITUTIONALIZATION)], how many times (has/did) [(PROVIDER
NAME)/someone from (PROVIDER NAME)] come to the home to help
(01) TOTAL NUMBER OF TIMES
[you/(SP)]? [Remember to include all home health providers from (PROVIDER (02) NUMBER OF TIMES PER DAY
NAME).]
(03) NUMBER OF TIMES PER WEEK
(04) NUMBER OF TIMES PER MONTH
[ENTER "TOTAL NUMBER OF TIMES" WHENEVER POSSIBLE.]
(-8) DON'T KNOW
(-9) REFUSED
[DO NOT ENTER VISITS SEPARATELY FOR PEOPLE WHO WORK FOR
THE SAME ORGANIZATION.]
(01) CONTINUOUS ANSWER
(Generally speaking, how long did/Generally speaking, how long does/How
(01) HOURS ONLY
long did)[PROVIDER NAME)/someone from (PROVIDER NAME)] stay with
(02) MINUTES ONLY
[you/(SP)]? [INCLUDE TIME SPENT SHOPPING OR RUNNING ERRANDS.] (03) HOURS AND MINUTES
(-8) DON'T KNOW
[PROBE: We just need to know in general.]
(-9) REFUSED
STAYUNIT
HH12
quantity unit
STAYHOUR
HH12
numeric
(01) CONTINUOUS ANSWER
STAYMIN
HH12
numeric
(01) CONTINUOUS ANSWER
SHOW CARD HH2
NEEDNURS
HH13
yes/no
(Generally speaking, did/Generally speaking, does/Did) [(PROVIDER
NAME)/someone from (PROVIDER NAME)] help [you/(SP)] by giving any
medical or nursing treatment, such as the things shown on this card?
["MEDICAL OR NURSING TREATMENT" MEANS SUCH THINGS AS
APPLYING STERILE BANDAGES OR DRESSINGS, GIVING
MEDICATIONS, TAKING BLOOD PRESSURE, GIVING SHOTS OR
INJECTIONS.]
(01) YES, AT LEAST ONE
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[PROBE: We just need to know in general.]
SHOW CARD HH3
NEEDMEAL
HH14
yes/no
(Generally speaking, did/Generally speaking, does/Did) [(PROVIDER
NAME)/someone from (PROVIDER NAME)] help with [your/(SP’s)] daily needs
by doing things, such as the ones shown on this card? [HELP WITH DAILY
NEEDS MEANS HELP IN USING THE TELEPHONE, DOING HOUSEWORK,
PREPARING MEALS.]
(01) YES, AT LEAST ONE
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[PROBE: We just need to know in general.]
SHOW CARD HH4
NEEDCARE
HH15
yes/no
(Generally speaking, did/Generally speaking, does/Did) [(PROVIDER
NAME)/someone from (PROVIDER NAME)] help with [your/(SP’s)] personal
care by doing things such as those shown on this card? [HELP WITH
PERSONAL CARE MEANS HELP WITH BATHING, SHOWERING,
DRESSING, EATING, WALKING, USING THE TOILET.]
(01) YES, AT LEAST ONE
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[PROBE: We just need to know in general.]
BOX HH3
HHPMORE
HHPOMORE
HH16
HH17
routing
yes/no
yes/no
IF CURRENTLY ADMINISTERING ST, GO TO BOX ST31B.
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS31B.
ELSE IF CURRENTLY ADMINISTERING HHS, GO TO BOX HHS5.
ELSE IF CURRENTLY ASKING ABOUT HOME HEALTH FRIENDS OR
FAMILY, GO TO BOX HH6.
ELSE IF HOME HEALTH PROVIDER WORKED FOR SELF, GO TO HH16 HHPMORE.
ELSE GO TO HH17 - HHPOMORE.
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], [have you been/has (SP)
been/was (SP)] helped at home by any other health professionals?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
Other than the persons who (have) visited [you/(SP)] from (PROVIDER NAME)
[or from the other(s) we’ve talked about], [have you been/has (SP) been/was
(SP)] helped at home by any other health professionals [since (REFERENCE (01) YES
DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION)]?
(-8) DON'T KNOW
(-9) REFUSED
[DON’T INCLUDE ANY OTHER PERSONS COMING FROM THE SAME
ORG/ AGENCY LISTED BELOW]
Display Provider Name for Home Health provider currently being asked about,
(PROVIDER NAME).
[your] respondent is SP
[(SP)'s] respondent is proxy
[Were you] - respondent is SP
[Was (SP)] - respondent is proxy
(01) HH11 - HELPUNIT
(02) HH10B - HMOREFER
(-8) HH10B - HMOREFER
(-9) HH10B - HMOREFER
HH11 - HELPUNIT
Display Provider Name for Home Health provider currently being asked about,
(PROVIDER NAME).
[Between (REFERENCE DATE) and today] - respondent is SP
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy,
SP deceased
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)]
respondent is proxy, SP institutionalized
If someone works for this Provider, display "someone from (PROVIDER
NAME)". Else display "(PROVIDER NAME)".
If someone works for this Provider, display "[Remember to include all home
health providers from (PROVIDER NAME)]". Always display this sentence in
brackets. Else do not display.
Display Provider Name for Home Health provider currently being asked about,
(PROVIDER NAME).
Display Provider Name for Home Health provider currently being asked about,
(PROVIDER NAME).
If someone works for this provider, display "someone from (PROVIDER
NAME)".
Else display "(PROVIDER NAME)".
If Home Health provider only visited the SP once during the specified reference
period, HH11- HELPUNIT = 1/NumberOfTimes and HH11 - HELPNUM = 1,
display "How long did".
Else if SP is deceased or institutionalized, display "Generally speaking, how
long did.."
Else display "Generally speaking, how long does".
(01) HH11 - HELPNUM
(02) HH11 - HELPNUM
(03) HH11 - HELPNUM
(04) HH11 - HELPNUM
(-8) HH12 - STAYUNIT
(-9) HH12 - STAYUNIT
HH12 - STAYUNIT
(01) HH12 - STAYHOUR
(02) HH12 - STAYMIN
(03) HH12 - STAYHOUR
(-8) HH13 - NEEDNURS
(-9) HH13 - NEEDNURS
If HH12 - STAYUNIT = 1/HoursOnly, go to
HH13 - NEEDNURS.
Else go to HH12 - STAYMIN.
HH13 - NEEDNURS
Display Provider Name for Home Health provider currently being asked about,
(PROVIDER NAME).
If someone works for this provider, display "someone from (PROVIDER
NAME)".
Else display "(PROVIDER NAME)".
If Home Health provider only visited the SP once during the specified reference
period, HH11- HELPUNIT = 1/NumberOfTimes and HH11 - HELPNUM = 1,
display "How long did".
Else if SP is deceased or institutionalized, display "Generally speaking, how
long did.."
Else display "Generally speaking, how long does".
HH14 - NEEDMEAL
Display Provider Name for Home Health provider currently being asked about,
(PROVIDER NAME).
If someone works for this provider, display "someone from (PROVIDER
NAME)".
Else display "(PROVIDER NAME)".
If Home Health provider only visited the SP once during the specified reference
period, HH11- HELPUNIT = 1/NumberOfTimes and HH11 - HELPNUM = 1,
display "How long did".
Else if SP is deceased or institutionalized, display "Generally speaking, how
long did.."
Else display "Generally speaking, how long does".
HH15 - NEEDCARE
Display Provider Name for Home Health provider currently being asked about,
(PROVIDER NAME).
If someone works for this provider, display "someone from (PROVIDER
NAME)".
Else display "(PROVIDER NAME)".
If Home Health provider only visited the SP once during the specified reference
period, HH11- HELPUNIT = 1/NumberOfTimes and HH11 - HELPNUM = 1,
display "How long did".
Else if SP is deceased or institutionalized, display "Generally speaking, how
long did.."
Else display "Generally speaking, how long does".
[Since (REFERENCE DATE)] - respondent is SP
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy,
SP deceased
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)]
respondent is proxy, SP institutionalized
If SP is deceased, display "was (SP)"
Else if proxy interview, display "has (SP) been".
Else display "have you been".
[since (REFERENCE DATE)] - respondent is SP
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy,
SP deceased
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)]
respondent is proxy, SP institutionalized
If SP is deceased, display "was (SP)"
Else if proxy interview, display "has (SP) been".
Else display "have you been".
BOX HH3
(01) HH2 - PROVIDER_HHP
(02) HH18 - HHPRFRND
(-8) HH18 - HHPRFRND
(-9) HH18 - HHPRFRND
(01) HH2 - PROVIDER_HHP
(02) HH18 - HHPRFRND
(-8) HH18 - HHPRFRND
(-9) HH18 - HHPRFRND
If SP reported a Home Health visit during the current round, display "Besides
what you have already talked about, [since (REFERENCE DATE/between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]".
SHOW CARD HH5
HHPRFRND
HH18
yes/no
(Besides what you have already talked about, [(Since/since) (REFERENCE
DATE)/(Between/between) (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], because of health problems
[have you/has (SP)/did (SP)] (received/receive) any personal care or help at
home with daily needs from (any other) persons who (do/did) not live with
(you/him/her), including home health aides, homemakers, friends, neighbors,
or relatives?
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP DO NOT DISPLAY. DATA
Else display "[Since (REFERENCE DATE)/Between (REFERENCE DATE)
EDITING ONLY.
and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]".
(-8) DON'T KNOW
(-9) REFUSED
If SP is alive and not institutionalized, display "received"
Else display "receive"
Who helped [you/(SP)]? What is the name of the person who helped
(you/him/her)?
ENTER NAME OF PERSON WHO HELPED. DO NOT ENTER THE NAME
OF THE PLACE OR ORGANIZATION.
PROVIDER_HHF
HH19
BOX HH3AA
HHFTYPE
HHFRELAT
HHFRELOS
HH20
HH21
roster
routing
code one
code one
(01) CONTINUOUS ANSWER
[SELECT OR ADD ONLY ONE PERSON. DO NOT ENTER A PERSON
WHO LIVES WITH THE SP. IF DIFFERENT PEOPLE COME FROM THE
SAME ORGANIZATION, PROBE FOR THE PERSON WHO USUALLY
COMES OR WHO COMES MOST OFTEN.]
IF (HOME HEALTH PROVIDER WAS ADDED AT HH19) OR (AN EXISTING
PROVIDER WAS SELECTED AT HH19 THAT WAS NOT ASSOCIATED
WITH A HOME HEALTH EVENT), GO TO HH20 - HHFTYPE.
ELSE GO TO BOX HH1BBB.
(01) FRIEND OR NEIGHBOR
(02) RELATIVE
Is (PROVIDER NAME) a friend or neighbor, a relative, or some other type of
(03) OTHER TYPE OF HOME HEALTH PROVIDER
home health provider?
(-8) DON'T KNOW
(-9) REFUSED
(01) SAMPLE PERSON
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
How is (PROVIDER NAME) related to [you/(SP)]?
(12) GRANDDAUGHTER
[CLASSIFY ANY “STEP” RELATIONSHIP WITH THE RELATED “NON-STEP”
(13) NEPHEW
RELATIONSHIP (E.G., STEP-DAUGHTER = DAUGHTER).]
(14) NIECE
(50) PARTNER/ROOMMATE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER RELATIVE
(92) OTHER NON-RELATIVE
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
HH21
text
BOX HH3A
routing
IF HH20 - HHFTYPE = 3/Other, DK, OR RF, GO TO HH3 - PROVSPEC.
ELSE GO TO BOX HH1AA.
routing
IF (HOME HEALTH PROVIDER IS A FRIEND OR RELATIVE) OR (HOME
HEALTH PROVIDER WORKS FOR SELF), GO TO HH28 - HHFMORE.
ELSE GO TO HH29 - HHFOMORE.
BOX HH6
[you] respondent is SP
[(SP)] respondent is proxy
Display Provider Name for Home Health provider currently being asked about,
(PROVIDER NAME).
Display Provider Name for Home Health provider currently being asked about,
(PROVIDER NAME).
[you] respondent is SP
[(SP)] respondent is proxy
(01) HH19 - PROVIDER_HHF
(02) BOX HH7
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX HH7
(-9) BOX HH7
BOX HH3AA
(01) BOX HH3A
(02) HH21 - HHFRELAT
(03) BOX HH3A
(-8) BOX HH3A
(-9) BOX HH3A
(01) BOX HH3A DO NOT DISPLAY
(02) BOX HH3A
(03) BOX HH3A
(04) BOX HH3A
(05) BOX HH3A
(06) BOX HH3A
(07) BOX HH3A
(08) BOX HH3A
(09) BOX HH3A
(10) BOX HH3A
(11) BOX HH3A
(12) BOX HH3A
(13) BOX HH3A
(14) BOX HH3A
(50) BOX HH3A DO NOT DISPLAY
(51) BOX HH3A
(52) BOX HH3A
(53) BOX HH3A
(54) BOX HH3A
(55) BOX HH3A
(56) BOX HH3A
(57) BOX HH3A
(91) HH21 - HHFRELOS
(92) HH21 - HHFRELOS
BOX HH3A
If SP is alive and not institutionalized, display "received". Else display
"receive".
Display " other" in "any o ther persons" in BOLD.
HHFMORE
HH28
yes/no
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], [have you/has (SP)/did (SP)]
(received/receive) personal care or help at home with daily needs from any
other persons who (do/did) not live with (you/him/her)?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[have you received] - respondent is SP
[has (SP) received] - respondent is proxy, SP alive
[did (SP) receive] - respondent is proxy, SP deceased
(01) HH19 - PROVIDER_HHF
(02) BOX HH7
(-8) BOX HH7
(-9) BOX HH7
[do] - SP is alive
[did] - SP is deceased
[you] - respondent is SP
[him] - respondent is proxy, SP male
Display Provider Name for Home Health provider currently being asked about,
(PROVIDER NAME).
HHFOMORE
HH29
yes/no
Other than the persons who have visited [you/(SP)] from (PROVIDER NAME)
[since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], [have you/has (SP)/did (SP)]
(received/receive) personal care or help at home with daily needs from any
other persons who (do/did) not live with (you/him/her)? [DON’T INCLUDE ANY
OTHER PERSONS COMING FROM THE SAME ORG/AGENCY LISTED
BELOW.]
If SP is alive and not institutionalized, display "received".
Else display "receive". Display " other" in "any other persons" in BOLD.
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[have you received] - respondent is SP
[has (SP) received] - respondent is proxy, SP alive
[did (SP) receive] - respondent is proxy, SP deceased
[do] - SP is alive
[did] - SP is deceased
[you] - respondent is SP
[him] - respondent is proxy, SP male
(01) HH19 - PROVIDER_HHF
(02) BOX HH7
(-8) BOX HH7
(-9) BOX HH7
Medical Provider Utilization (MPQ)
Variable Name
MR Screen Name
Question type
Question text/description)
Code list
(Besides what you have already mentioned), [(Since/since
(REFERENCE DATE)/(Between/between) (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION), [have
you/has (SP)/did (SP)] [seen/see] any medical doctors?
INCLUDE ANY VISITS FOR TESTS/X-RAYS.
SEE SHOWCARD AC1 FOR TYPES OF MEDICAL DOCTORS, IF
NECESSARY.
MPPRMDOC
MP1
yes/no
PROVIDER_MP
MP2
roster
PROVSPEC
PROVSPOS
VAPLACE
[DO NOT INCLUDE MEDICAL DOCTORS SEEN IN THE
EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT
THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]
Who did [you/(SP)] see?
SELECT OR ADD ONLY ONE PROVIDER.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
BOX MP1B
routing
MP2A
MP2A
code 1
verbatim text
IF (PROVIDER IS A MEDICAL PLACE) OR (PROVIDER SPECIALTY
HAS ALREADY BEEN COLLECTED), GO TO BOX MP1.
ELSE GO TO MP2A - PROVSPEC.
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
What kind of (health practitioner/mental health
(22) PSYCHOLOGIST
professional/therapist/medical person) is (PROVIDER NAME)?
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
[SELECT THE RESPONSE CATEGORY FOR A GIVEN SPECIALTY (25) SPEECH THERAPIST
ONLY IF THE RESPONDENT SPECIFICALLY NAMES THE LISTED (26) THERAPIST (MENTAL HEALTH)
SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN
(27) X-RAY TECHNICIAN
PARENTHESES FOLLOWING THAT PROVIDER SPECIALTY.]
(28) LICENSED PRACTICAL NURSE (LPN)
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
BOX MP1
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES
THROUGH V.A. IN THE CURRENT ROUND OR ANY PREVIOUS
ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS
UNKNOWN), GO TO MP3 - VAPLACE.
ELSE GO TO BOX MP2.
MP3
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans
Affairs, or V.A., facility?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Text Fill Logic
[Besides what you have already mentioned, since
(REFERENCE DATE)] respondent is SP, SP seen
doctor
[Besides what you have alread mentioned, between
(REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased, SP seen doctor
[Besides what you have alread mentioned, between
(REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, SP seen doctor
[Since (REFERENCE DATE)] SP has not seen doctor,
SP not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF
DEATH)] respondent is proxy, SP deceased, SP did
not see doctor
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, SP had not seen doctor
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[did (SP)] resondent is proxy, SP deceased
[seen] respondent is SP
[see] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
Input mask Routing
(01) MP2 - PROVIDER_MP
(02) MP18 - MPPRPRAC
(-8) MP18 - MPPRPRAC
(-9) MP18 - MPPRPRAC
BOX MP1B
(01) BOX MP1
(02) BOX MP1
(03) BOX MP1
(04) BOX MP1
(05) BOX MP1
(06) BOX MP1
(07) BOX MP1
(08) BOX MP1
(09) BOX MP1
(10) BOX MP1
(11) BOX MP1
(12) BOX MP1
(13) BOX MP1
(14) BOX MP1
(15) BOX MP1
(16) BOX MP1
(17) BOX MP1
(18) BOX MP1
(19) BOX MP1
(20) BOX MP1
(21) BOX MP1
(22) BOX MP1
(23) BOX MP1
(24) BOX MP1
(25) BOX MP1
(26) BOX MP1
(27) BOX MP1
(28) BOX MP1
BOX MP1
(01) MP6-EVENT
(02) BOX MP2
(-8) BOX MP2
(-9) BOX MP2
BOX MP2
HMOASSOC
MP4
routing
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING
THE CURRENT ROUND) AND (IF THIS PROVIDER IS
ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO
TO MP4 - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND) AND (THIS PROVIDER IS NOT
ASSOCIATED WITH A MANAGED CARE PLAN), GO TO MP5 HMOREFER.
ELSE GO TO MP6 - EVENT.
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ
MANAGED CARE PLAN NAME(S) BELOW] plan?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
(01) MP6 - EVENT
(02) MP5 - HMOREFER
(-8) MP5 - HMOREFER
(-9) MP5 - HMOREFER
[Were you] respondent is SP
[Was (SP)] respondent is proxy
MP6 - EVENT
[you] respondent is SP
[(SP)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or
proxy, SP not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF
DEATH)] respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
MP6_IN - NAVIGATOR
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ
MANAGED CARE PLAN NAME(S) BELOW]?
HMOREFER
MP5
yes/no
(01) YES
(02) NO
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE (-8) Don't Know
PHYSICIAN (PCP).]
(-9) Refused
When did [you/(SP)] see (PROVIDER NAME)? Please tell me all the
dates [since (REFERENCE DATE)/between (REFERENCE DATE)
and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)].
ENTER ALL DATES.
EVENT
NAVIGATOR
MP6
roster
MP6_IN
instance
navigator
BOX MP2AA
MPSDVIS
routing
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON
THE SAME DAY, ENTER THE DATE ONLY ONCE.]
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
MP6B
yes/no
BOX MP2B
routing
routing
IF PROVIDER SPECIALTY = Dentist, Medical Doctor, Optometrist,
Osteopath, Paramedic, PhysicianAssistant, Podiatrist, Other, DK or
RF, GO TO MP7 - ANYOPERS.
ELSE GO TO MP10 - SPECCOND.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Were any operations or other surgical procedures performed on
[you/(SP)] during [any of the/the] [VISIT ON EVENT DATE]?
ANYOPERS
SPECCOND
PRESMDCN
yes/no
(01) YES
(02) NO
[Operations include surgery and other surgical procedures like setting (-8) Don't Know
bones, stitching or removing growths, or any cutting of the skin.]
(-9) Refused
(01) YES
(02) NO
[Was this visit/Were any of these visits] to (PROVIDER NAME) for any (-8) Don't Know
specific condition?
(-9) Refused
BOX MP2D
routing
IF CURRENTLY ADMINISTERING ST, GO TO BOX ST23B.
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS23B.
ELSE GO TO MP12 - PRESMDCN.
MP12
yes/no
During [this visit/any of these visits] to (PROVIDER NAME), were any
medicines prescribed for [you/(SP)]?
MP7
MP10
yes/no
(01) BOX MP2AA
(02) BOX MP6AA
FOR FIRST/NEXT EVENT ENTERED AT MP6, IF (PROVIDER
SPECIALTY IS A MEDICAL DOCTOR) AND ((EVENT DATE
OVERLAPS AN EXISTING IP EVENT) OR (EVENT DATE MATCHES
AN EXISTING ER OR OP EVENT), GO TO MP6B - MPSDVIS.
ELSE GO TO BOX MP2C.
We have recorded that in (EVENT MONTH) [you were/(SP) was] also
in (READ EVENT(S) LISTED BELOW). Was this visit with
(PROVIDER NAME) a visit while [you were/(SP) was] in [the [READ
EVENT LISTED BELOW]/any of these places]?
UPDATE EVENT TYPE TO SEPARATELY BILLING DOCTOR AND
GO TO BOX MP6.
BOX MP2C
(01) [Continuous answer.]
(
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you were] respondent is SP
[(SP) was] respondent is proxy
[you were] respondent is SP
[(SP) was] respondent is proxy
[the (READ EVENT LISTED BELOW)] event listed
[any of these places] event not listed
(01) BOX MP2B
(02) BOX MP2C
(-8) BOX MP2C
(-9) BOX MP2C
[you] respondent is SP
[(SP)] respondent is proxy
[any of the] multiple visits
[the] one visit
(01) BOX MP2D
(02) MP10 - SPECCOND
(-8) MP10 - SPECCOND
(-9) MP10 - SPECCOND
[Was this visit] single visit reported
[Were any of these visits] multiple visits reported
BOX MP2D
[this visit] one visit reported
[any of these visits] multiple visits reported
[you] respondent is SP
[(SP)] respondent is proxy
(01) MP13 - PRESFILL
(02) BOX MP6
(-8) BOX MP6
(-9) BOX MP6
Were any of the prescriptions filled?
PRESFILL
MP13
yes/no
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO
OBTAINED IT FOR THE RESPONDENT, WHEN IT WAS
OBTAINED, WHETHER OR NOT THE PRESCRIPTION COST
ANYTHING, AND WHETHER OR NOT THE RESPONDENT
ACTUALLY TOOK THE MEDICINE.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX MP3A
(02) BOX MP6
(-8) BOX MP6
(-9) BOX MP6
BOX MP3A
routing
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS
NOT BEEN ASKED IN THE CURRENT ROUND, GO TO MP13A MPPMMEDS.
ELSE GO TO MP14 - MEDICINE_MP.
It would be helpful if I could look at any medicine bottle(s),
container(s), or bag(s) that you have so that I can spell the medicine
name correctly and enter the strength of the medicine. [Also, please
take out [your/(SP's)] (MEDICARE PRESCRIPTION DRUG PLAN
NAME) medicine statements, which should have that same
information on them.]
MPPMMEDS
MEDICINE_MP
MP13A
MP14
BOX MP6
BOX MP6AA
no entry
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same
information for all of the medicines [you/(SP)] obtained since the last
interview, if you’d like to get those bottles, too.
roster
routing
Please tell me the names of these medicines.
ENTER ALL MEDICINE NAMES.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
INCLUDE STRENGTH WITH NAME.
GO TO MP6_IN - NAVIGATOR.
routing
IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP1
PROBE, GO TO MP17 - MDOCMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED
FOLLOWING MP18 PROBE, GO TO MP25 - PRACMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED
FOLLOWING MP26 PROBE, GO TO MP33 - MENTMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED
FOLLOWING MP34 PROBE, GO TO MP41 - THERMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED
FOLLOWING MP42 PROBE, GO TO MP49 - PERSMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED
FOLLOWING MP50 PROBE, GO TO MP56 - MPPRMORE.
(01) CONTINUE
(-7) Empty
(01) [Continuous answer.]
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to this doctor or any other medical
doctor?
MDOCMORE
MP17
BOX MP6A
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
yes/no
(01) YES
[DO NOT INCLUDE MEDICAL DOCTORS SEEN IN THE
(02) NO
EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT (-8) Don't Know
THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.] (-9) Refused
routing
IF FALL ROUND AND (SP IS ALIVE AND NOT
INSTITUTIONALIZED) AND (SP REPORTED A MEDICAL
PROVIDER VISIT AT MP6 AND MP6B - MPSDVIS ^= 1/Yes AND
PROVIDER'S SPECIALTY IS A MEDICAL DOCTOR), GO TO AC20 MDSPCLTY.
ELSE GO TO MP18 - MPPRPRAC.
MP14 - MEDICINE_MP
BOX MP6
[Since (REFERENCE DATE)] respondent is SP or
proxy, SP not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF
DEATH)] respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
(01) MP2 - PROVIDER_MP
(02) BOX MP6A
(-8) BOX MP6A
(-9) BOX MP6A
[Besides what you have already mentioned, since
(REFERENCE DATE)] respondent is SP, SP seen
health practitioner
[Besides what you have alread mentioned, between
(REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased, SP seen health
practitioner
[Besides what you have already mentioned, between
(REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, SP seen health practitioner
[Since (REFERENCE DATE)] respondent is SP or
proxy, SP not seen health practittioner
[Between (REFERENCE DATE) and (DATE OF
DEATH)] respondent is proxy, SP deceased, SP not
seen health practitioner
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, SP not seen health practitioner
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[did (SP)] respondent is proxy, SP deceased
[seen] SP alive
[see] SP deceased
(01) MP2 - PROVIDER_MP
(02) MP26 - MPPRMENT
(-8) MP26 - MPPRMENT
(-9) MP26 - MPPRMENT
[Since (REFERENCE DATE)] respondent is SP or
proxy, SP not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF
DEATH)] respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
(01) MP2 - PROVIDER_MP
(02) MP26 - MPPRMENT
(-8) MP26 - MPPRMENT
(-9) MP26 - MPPRMENT
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Besides what you have already mentioned, since
(REFERENCE DATE)] respondent is SP, SP seen
mental health professional
[Besides what you have alread mentioned, between
(REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased, SP seen mental
health professional
[Besides what you have already mentioned, between
(REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, SP seen mental health professional
[Since (REFERENCE DATE)] respondent is SP or
proxy, SP not seen mental health professional
[Between (REFERENCE DATE) and (DATE OF
DEATH)] respondent is proxy, SP deceased, SP not
seen mental health professional
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, SP not seen mental health
professional
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[did (SP)] respondent is proxy, SP deceased
[seen] SP alive
[see] SP deceased
(01) MP2 - PROVIDER_MP
(02) MP34 - MPPRTHER
(-8) MP34 - MPPRTHER
(-9) MP34 - MPPRTHER
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Since (REFERENCE DATE)] respondent is SP or
proxy, SP not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF
DEATH)] respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
(01) MP2 - PROVIDER_MP
(02) MP34 - MPPRTHER
(-8) MP34 - MPPRTHER
(-9) MP34 - MPPRTHER
SHOW CARD MP1
(Besides what you have already mentioned), [(Since/since
(REFERENCE DATE)/(Between/between) (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION), [have
you/has (SP)/did (SP)] [seen/see] a health practitioner like any of the
ones listed on this card? [Health practitioners include acupuncturist,
audiologist, optometrist, chiropractor, podiatrist (foot doctor),
homeopath, naturopath, or any other kind of health provider who is not
a medical doctor.]
INCLUDE ANY VISITS FOR TESTS/X-RAYS.
MPPRPRAC
MP18
yes/no
(01) YES
[DO NOT INCLUDE MEDICAL PROVIDERS SEEN IN THE
(02) NO
EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT (-8) Don't Know
THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.] (-9) Refused
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to this practitioner or any other health
practitioner?
PRACMORE
MP25
yes/no
(01) YES
[DO NOT INCLUDE MEDICAL PROVIDERS SEEN IN THE
(02) NO
EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT (-8) Don't Know
THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.] (-9) Refused
SHOW CARD MP2
(Besides what you have already mentioned), [(Since/since
(REFERENCE DATE)/(Between/between) (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION), [have
you/has (SP)/did (SP)] (seen/see) a mental health professional like
any of the ones listed on this card? [Mental health professional
includes psychiatrist, psychologist, clinical social worker, and licensed
professional counselor.]
MPPRMENT
MP26
yes/no
[DO NOT INCLUDE PROVIDERS SEEN IN THE EMERGENCY
ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT THE
RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to this professional or any other mental
health professional?
MENTMORE
MP33
yes/no
[DO NOT INCLUDE PROVIDERS SEEN IN THE EMERGENCY
ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT THE
RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]
[Besides what you have already mentioned, since
(REFERENCE DATE)] respondent is SP, SP seen
therapist
[Besides what you have alread mentioned, between
(REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased, SP seen therapist
[Besides what you have already mentioned, between
(REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, SP seen therapist
[Since (REFERENCE DATE)] respondent is SP or
proxy, SP not seen therapist
[Between (REFERENCE DATE) and (DATE OF
DEATH)] respondent is proxy, SP deceased, SP not
seen therapist
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, SP not seen therapist
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[did (SP)] respondent is proxy, SP deceased
[seen] SP alive
[see] SP deceased
(01) MP2 - PROVIDER_MP
(02) MP42 - MPPRPERS.
(-8) MP42 - MPPRPERS
(-9) MP42 - MPPRPERS
(01) YES
[DO NOT INCLUDE MEDICAL PROVIDERS SEEN IN THE
(02) NO
EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT (-8) Don't Know
THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.] (-9) Refused
[Since (REFERENCE DATE)] respondent is SP or
proxy, SP not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF
DEATH)] respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
(01) MP2 - PROVIDER_MP
(02) MP42 - MPPRPERS
(-8) MP42 - MPPRPERS
(-9) MP42 - MPPRPERS
SHOW CARD MP4
(Besides what you have already mentioned), [(Since/since
(REFERENCE DATE)/(Between/between) (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION), [have
you/has (SP)/did (SP)] (seen/see) any other medical persons like the
ones listed on this card? [Other medical persons include nurse, nurse
practitioner, paramedic, and physician’s assistant.]
[INCLUDE ANY VISITS FOR TESTS/X-RAYS.
DO NOT INCLUDE PROVIDERS SEEN IN THE EMERGENCY
ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT THE
RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.
DO NOT INCLUDE PARAMEDIC IF ONLY AMBULANCE SERVICES
WERE PROVIDED.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Besides what you have already mentioned, since
(REFERENCE DATE)] respondent is SP, SP seen
other medical persons
[Besides what you have alread mentioned, between
(REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased, SP seen other
medical persons
[Besides what you have already mentioned, between
(REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, SP seen other medical persons
[Since (REFERENCE DATE)] respondent is SP or
proxy, SP not seen other medical persons
[Between (REFERENCE DATE) and (DATE OF
DEATH)] respondent is proxy, SP deceased, SP not
seen other medical persons
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, SP not seen other medical persons
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[did (SP)] respondent is proxy, SP deceased
[seen] SP alive
[see] SP deceased
(01) MP2 - PROVIDER_MP
(02) MP50 - MPPRPLAC
(-8) MP50 - MPPRPLAC
(-9) MP50 - MPPRPLAC
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Since (REFERENCE DATE)] respondent is SP or
proxy, SP not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF
DEATH)] respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
(01) MP2 - PROVIDER_MP
(02) MP50 - MPPRPLAC
(-8) MP50 - MPPRPLAC
(-9) MP50 - MPPRPLAC
SHOW CARD MP3
(Besides what you have already mentioned), [(Since/since
(REFERENCE DATE)/(Between/between) (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION), [have
you/has (SP)/did (SP)] (seen/see) a therapist like any of the ones
listed on this card? [Therapist includes physical therapist, speech
therapist, intravenous (IV) therapist, massage therapist, occupational
therapist, and respiratory therapist.]
MPPRTHER
MP34
yes/no
(01) YES
[DO NOT INCLUDE MEDICAL PROVIDERS SEEN IN THE
(02) NO
EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT (-8) Don't Know
THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.] (-9) Refused
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to this therapist or any other therapist?
THERMORE
MPPRPERS
MP41
MP42
yes/no
yes/no
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to this person or any other medical
person?
PERSMORE
MP49
yes/no
[DO NOT INCLUDE PROVIDERS SEEN IN THE EMERGENCY
ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT THE
RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Besides what you have already mentioned, since
(REFERENCE DATE)] respondent is SP, SP visted
other medical places
[Besides what you have alread mentioned, between
(REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased, SP visited other
medical places
[Besides what you have already mentioned, between
(REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, SP visited other medical places
[Since (REFERENCE DATE)] respondent is SP or
proxy, SP not visted other medical places
[Between (REFERENCE DATE) and (DATE OF
DEATH)] respondent is proxy, SP deceased, SP not
visted other medical places
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, SP not visited other medical places
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[did (SP)] respondent is proxy, SP deceased
[seen] SP alive
[see] SP deceased
(01) MP2 - PROVIDER_MP
(02) BOX MP22
(-8) BOX MP22
(-9) BOX MP22
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Since (REFERENCE DATE)] respondent is SP or
proxy, SP not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF
DEATH)] respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
(01) MP2 - PROVIDER_MP
(02) BOX MP22
(-8) BOX MP22
(-9) BOX MP22
SHOW CARD MP5
(Besides what you have already mentioned), [(Since/since
(REFERENCE DATE)/(Between/between) (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION), [have
you/has (SP)/did (SP)] (visited/visit) any other types of medical places
like the ones listed on this card? [Other types of medical places
include health clinic, neighborhood health center, rural health clinic,
infirmary, mental health clinic, urgent care center, or any other place.]
MPPRPLAC
MP50
yes/no
[DO NOT INCLUDE VISITS TO THE EMERGENCY ROOM,
OUTPATIENT DEPARTMENTS, INPATIENT STAYS, OR SENIOR
DAY CARE.]
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to this place or any other type of
medical place?
MPPRMORE
MP56
BOX MP22
yes/no
routing
[DO NOT INCLUDE VISITS TO THE EMERGENCY ROOM,
OUTPATIENT DEPARTMENTS, INPATIENT STAYS, OR SENIOR
DAY CARE.]
GO TO NEXT SECTION
Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
Question type
Question text/description
Code list
Next I’m going to ask you about other medical expenses that
[you/(SP)] may have had between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (today/(DATE OF DEATH/DATE OF
INSTITUTIONALIZATION).
OMPREYEG
OM1
yes/no
[Since (REFERENCE DATE/SURVEY REFERENCE DATE)/Between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF (01) YES
DEATH/DATE OF INSTITUTIONALIZATION)], did [you/(SP)] buy,
(02) NO
replace, or pay for repairs of eyeglasses or contact lenses?
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
(-9) Refused
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair glasses or contact lenses?
Please tell me all the dates [since (REFERENCE DATE/SURVEY
REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)].
EVENT_OMEYEG
NAVIGATOR
OM2
roster
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
BOX OM1AA
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR
PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND, GO TO OM2_IN - NAVIGATOR.
ELSE GO TO BOX OM1AA2.
OM2_IN
instance navigator
(01) continuous answer
(-8) Don't Know
(-9) Refused
Text Fill Logic
Input mask Routing
[you] respondent is SP
[(SP)] respondent is proxy
[(REFERENCE DATE)] SP completed previous round’s interview
[(SURVEY REFERENCE DATE)] SP skipped previous round’s interview
[today] respondent is SP or proxy, SP alive and not institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized
[Since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[Since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview, SP skipped
previous round’s interview
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s
interview
[Between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[Between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
(01) OM2 - EVENT_OMEYEG
(02) OM3 - OMPRHEAR
(03) DO NOT DISPLAY.
(-8) OM3 - OMPRHEAR
(-9) OM3 - OMPRHEAR
[you] respondent is SP
[(SP)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
BOX OM1AA
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) OM2A - OMSATHMO
(02) BOX OM1AA2
On (EVENT DATE), did [you/(SP)] buy or repair the glasses or
contact lenses at [READ MANAGED CARE PLAN NAME(S) BELOW]
or through a service or discount offered through [READ MANAGED
CARE PLAN NAME(S) BELOW]?
OMSATHMO
OM2A
BOX OM1AA1
BOX OM1AA2
OMPRHEAR
OM3
yes/no
routing
[PROBE: This could include buying or repairing the glasses or
lenses at a plan center; at an optician, optometrist or other place that
honors [your/(SP’s)] plan card; or through a place or service that the (01) YES
plan referred [you/(SP)] to.]
(02) NO
(-8) Don't Know
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
(-9) Refused
GO TO OM2_IN - NAVIGATOR.
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM3 - OMPRHEAR.
yes/no
[Since (REFERENCE DATE/SURVEY REFERENCE DATE)/Between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], did [you/(SP)] buy,
replace, or pay for repairs of a hearing aid, amplifier for a telephone,
or similar device to help [you/(SP)] hear or speak?
(01) YES
(02) NO
[INCLUDE RELATED EXPENSES SUCH AS BATTERIES FOR A
(03) INDICATED YES BY DATAPREP
HEARING AID OR SPEAKING DEVICE. DO NOT INCLUDE A
(-8) Don't Know
WARRANTY FOR A HEARING AID AS AN OM EVENT.]
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP)] respondent is proxy
BOX OM1AA1
[Since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[Since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s
interview
[Between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[Between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
[your] respondent is SP
[(SP)] respondent is proxy
(01) OM4 - EVENT_OMHEAR
(02) BOX OMA1
(03) DO NOT DISPLAY.
(-8) BOX OMA1
(-9) BOX OMA1
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair a hearing or speech device?
EVENT_OMHEAR
OM4
BOX OM1BB
NAVIGATOR
OM4_IN
roster
Please tell me the dates of each purchase or repair [since
(REFERENCE DATE/SURVEY REFERENCE DATE)/between
(01) continuous answer
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF (-8) Don't Know
DEATH/DATE OF INSTITUTIONALIZATION)].
(-9) Refused
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR
PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND, GO TO OM4_IN - NAVIGATOR.
ELSE GO TO BOX OM1BB2.
[you] respondent is SP
[(SP)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
instance navigator
BOX OM1BB
(01) OM4A - OMSATHMO
(02) BOX OM1BB2
On (EVENT DATE), did [you/(SP)] buy or repair the hearing or
speech device at [READ MANAGED CARE PLAN NAME(S) BELOW]
or through a service or discount offered through [READ MANAGED
CARE PLAN NAME(S) BELOW]?
yes/no
routing
[PROBE: This could include buying or repairing the hearing or
speech device at a plan center; from an audiologist, speech
pathologist, or other provider that honors [your/(SP’s)] plan card; or
through a place or service that the plan referred [you/(SP)] to.]
GO TO OM4_IN - NAVIGATOR.
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OMA1.
BOX OMA1
routing
IF SP WAS STILL RENTING AT LEAST ONE ORTHOPEDIC ITEM
AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO
OMS5INTR - ORTHINTRO.
ELSE GO TO OM5 - OMPRORTH.
ORTHINTRO
OMS5INTR
no entry
The next questions are about orthopedic items [you were/(SP) was]
renting as of (REFERENCE DATE).
NAVIGATOR
OMS5_IN
instance navigator
OMSATHMO
OM4A
BOX OM1BB1
BOX OM1BB2
OMS5
code one
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A
RENT-TO-BUY PROGRAM, SELECT "NO."]
SHOW CARD OM1
(Other than what we already talked about,) [(Since/since)
(REFERENCE DATE/SURVEY REFERENCE
DATE)/(Between/between) (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], did [you/(SP)] buy, repair or rent (other)
orthopedic items, such as any of those listed on this card?
OMPRORTH
OM5
yes/no
[you] respondent is SP
[(SP)] respondent is proxy
more?
[your] respondent is SP
[(SP)] respondent is proxy
BOX OM1BB1
(01) continuous answer
(-7) Empty
[you were] respondent is SP
[(SP) was] respondent is proxy
OMS5_IN - NAVIGATOR
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
At the time of the last interview, [you were/(SP) was] renting
(ORTHOPEDIC ITEM). As of (today/DATE OF DEATH/DATE OF
INSTITUTIONALIZATION), (was/were/is/are) the (ORTHOPEDIC
ITEM) being rented?
RENTSTIL
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Orthopedic items include crutches, canes, wheelchairs, walkers,
corrective shoes or inserts, support stockings, and braces or
supports.]
(01) OMS5 - RENTSTIL
(02) OM5 - OMPRORTH
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
[you were] respondent is SP
[(SP) was] respondent is proxy
[today] respondent is SP or proxy, SP alive and not institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized
[was] respondent is proxy, SP deceased, one orthopedic item
[were] respondent is proxy, SP deceased, two or more orthopedic items
[is] respondent is SP or proxy, SP alive and not institutionalized, one orthopedic item
[are] respondent is SP or proxy, SP alive and not institutionalized, two or more orthopedic items
(01) BOX OM1EE
(02) OM7C - EVENDMM
(03) BOX OM4
(-8) BOX OM4
(-9) BOX OM4
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
[Other than what we already talked about,] second or more loop
[] first loop
[Since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, respondent completed last round’s interview, first loop
[Since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, respondent skipped last round’s interview, first loop
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, respondent completed last round’s interview, second loop or more
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, respondent skipped last round’s interview, second loop
or more
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, respondent completed last round’s interview, first loop
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, respondent completed last round’s
interview, first loop
[Between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, respondent skipped last round’s interview, first loop
[Between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, respondent skipped last
round’s interview, first loop
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, respondent completed last round’s interview, second loop or
more
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, respondent completed last round’s
interview, second loop or more
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, respondent skipped last round’s interview, second
loop or more
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, respondent skipped last
round’s interview, second loop or more
[other] second loop or more
[] first loop
[you] respondent is SP
[(SP)] respondent is proxy
(01) OM6 - ORTHTYPE
(02) OM9 - OMPRDIAB
(03) DO NOT DISPLAY.
(-8) OM9 - OMPRDIAB
(-9) OM9 - OMPRDIAB
ORTHTYPE
EVOSTEXT
OM6
OM6
code one
verbatim text
What was the item?
OTHER (SPECIFY)
Did [you/(SP)] buy or repair the (ORTHOPEDIC ITEM), or did
[you/(SP)] rent (it/them)?
RENTPROB
EVENT_OMORTH
OM6A
OM7
BOX OM1CC
NAVIGATOR
OM7_IN
code one
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM
THROUGH A RENT-TO-BUY PROGRAM WITHIN THE SAME
ROUND, SELECT "RENT."]
roster
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy (or repair) the (ORTHOPEDIC ITEM)?
Please tell me all the dates [since (REFERENCE DATE/SURVEY
REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)].
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR
PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND, GO TO OM7_IN - NAVIGATOR.
ELSE GO TO BOX OM1EE1.
(01) BRACES/SUPPORTS
(02) CANE
(03) CORRECTIVE SHOES/INSERTS
(04) CRUTCHES
(05) WALKER
(06) WHEELCHAIR/CART
(07) STOCKINGS
(91) OTHER
(01) continuous answer
(01) OM7 - EVENT_OMORTH
(02) OM7 - EVENT_OMORTH
(03) OM7 - EVENT_OMORTH
(04) OM6A - RENTPROB
(05) OM6A - RENTPROB
(06) OM6A - RENTPROB
(07) OM7 - EVENT_OMORTH
(91) OM6 - EVOSTEXT
OM6A - RENTPROB
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
EQUIPMENT
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[it] one orthopedic item
[them] two or more orthopedic items
(01) OM7 - EVENT_OMORTH
(02) OM7A EVENT_OMORTHRENT
(03) DO NOT DISPLAY.
(-8) OM7 - EVENT_OMORTH
(-9) OM7 - EVENT_OMORTH
(01) continuous answer
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
BOX OM1CC
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
instance navigator
(01) OM7AA - OMSATHMO
(02) BOX OM1EE1
On (EVENT DATE), did [you/(SP)] buy (or repair) the (ORTHOPEDIC
ITEM) at [READ MANAGED CARE PLAN NAME(S) BELOW] or
through a service or discount offered through [READ MANAGED
CARE PLAN NAME(S) BELOW]?
OMSATHMO
EVENT_OMORTHRENT
RENTSTIL
OM7AA
BOX OM2A
OM7A
OM7B
yes/no
routing
yes/no
yes/no
[PROBE: This could include buying or repairing the (ORTHOPEDIC
ITEM) at a plan center; at a place or store that honors [your/(SP's)]
plan card; or through a place or store that the plan referred [you/(SP)]
to.]
GO TO OM7_IN - NAVIGATOR.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
ENTER ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY
REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) AND (DATE OF DEATH/DATE OF
(01) continuous answer
INSTITUTIONALIZATION] that [you/(SP)] rented the (ORTHOPEDIC (-8) Don't Know
ITEM).
(-9) Refused
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
[Are you/Is (SP)/Was (SP)] still renting the (ORTHOPEDIC ITEM)? (-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
BOX OM2A
[you] respondent is SP
[(SP)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
OM7B - RENTSTIL
(01) BOX OM1EE
(02) OM7C - EVENDMM
(03) DO NOT DISPLAY.
(-8) BOX OM1EE1
(-9) BOX OM1EE1
[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP alive
[Was (SP)] respondent is proxy, SP deceased
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?
EVENDMM
OM7C
date
(01) continuous answer
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF (-8) Don't Know
PURCHASE AS THE LAST DATE OF THE RENTAL PERIOD.]
(-9) Refused
[were] two or more orthopedic items
[was] one orthopedic item
MM
OM7C - EVENDDD
[were] two or more orthopedic items
[was] one orthopedic item
DD
OM7C - EVENDYY
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?
EVENDDD
OM7C
date
(01) continuous answer
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF (-8) Don't Know
PURCHASE AS THE LAST DATE OF THE RENTAL PERIOD.]
(-9) Refused
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?
EVENDYY
OM7C
BOX OM3A
date
(01) continuous answer
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF (-8) Don't Know
PURCHASE AS THE LAST DATE OF THE RENTAL PERIOD.]
(-9) Refused
routing
IF SP IS NOT DECEASED, GO TO OM7CC - RENT2BUY.
ELSE GO TO BOX OM1EE.
RENT2BUY
OM7CC
code one
REN2BVB
OM7CCVB
verbatim text
You said [you/(SP)] stopped renting the (ORTHOPEDIC ITEM). Is
this because (you/he/she) no longer (have/has) that item or because
(you/he/she) (have/has) purchased it through a rent-to-buy option?
BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE
(ORTHOPEDIC ITEM).
RECORD VERBATIM.
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR
PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND, GO TO OM7D - OMSATHMO.
ELSE GO TO BOX OM1EE1.
BOX OM1EE
(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused
[were] two or more orthopedic items
[was] one orthopedic item
[you] respondent is SP
[(SP)] respondent is proxy
[he] respondent is proxy, SP is male
[she] respondent is proxy, SP is female
[have] respondent is SP
[has] respodnent is proxy
(01) continuous answer
YY
BOX OM3A
(01) BOX OM1EE
(02) BOX OM1EE
(03) OM7CCVB - REN2BVB
(-8) BOX OM1EE
(-9) BOX OM1EE
BOX OM1EE
Did [you/(SP)] rent the (ORTHOPEDIC ITEM) at [READ MANAGED
CARE PLAN NAME(S) BELOW] or through a service or discount
offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
OMSATHMO
OM7D
BOX OM1EE1
BOX OM4
MOREORTH
OM8
yes/no
[PROBE: This could include renting the (ORTHOPEDIC ITEM) at a
plan center; at a place or store that honors [your/(SP’s)] plan card; or
through a place or service that the plan referred [you/(SP]] to.]
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM4.
routing
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS
ROUND, GO TO OMS5_IN - NAVIGATOR.
ELSE GO TO OM8 - MOREORTH.
yes/no
In addition to the orthopedic item(s) you just told me about, did
[you/(SP)] buy, repair, or rent any other orthopedic items [since
(REFERENCE DATE/SURVEY REFERENCE DATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)].?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
BOX OM1EE1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
(01) OM6 - ORTHTYPE
(02) OM9 - OMPRDIAB
(03) OM9 - OMPRDIAB
(04) OM9 - OMPRDIAB
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
[Since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[Since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s
interview
[Between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[Between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
[you] respondent is SP
[(SP)] respondent is proxy
(01) OM10 - EVENT_OMDIAB
(02) OM11 - OMPRAMBL
(03) DO NOT DISPLAY.
(-8) OM11 - OMPRAMBL
(-9) OM11 - OMPRAMBL
SHOW CARD OM2
[Since (REFERENCE DATE/SURVEY REFERENCE DATE)/Between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], did [you/(SP)] buy
diabetic equipment or supplies, such as those listed on this card?
[Diabetic equipment or supplies include syringes, test paper, test
strips, and blood monitoring kits.]
OMPRDIAB
OM9
yes/no
[DO NOT INCLUDE INSULIN.]
EVENT_OMDIAB
OM10
BOX OM1FF
NAVIGATOR
OM10_IN
roster
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy diabetic equipment or supplies? Please tell
me all the dates [since (REFERENCE DATE/SURVEY REFERENCE (01) continuous answer
DATE)/between (REFERENCE DATE/SURVEY REFERENCE
(-8) Don't Know
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]. (-9) Refused
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR
PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND, GO TO OM10_IN - NAVIGATOR.
ELSE GO TO BOX OM1FF2.
[you] respondent is SP
[(SP)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
instance navigator
BOX OM1FF
(01) OM10A - OMSATHMO
(02) BOX OM1FF2
On (EVENT DATE), did [you/(SP)] buy the diabetic equipment or
supplies at [READ MANAGED CARE PLAN NAME(S) BELOW] or
through a service or discount offered through [READ MANAGED
CARE PLAN NAME(S) BELOW]?
OMSATHMO
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
BOX OM1FF1
(01) YES
[Since (REFERENCE DATE/SURVEY REFERENCE DATE)/Between (02) NO
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF (03) INDICATED YES BY DATAPREP
DEATH/DATE OF INSTITUTIONALIZATION)], did [you/(SP)] use any (-8) Don't Know
ambulance or rescue squad service?
(-9) Refused
[Since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[Since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s
interview
[Between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[Between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
[you] respondent is SP
[(SP)] respondent is proxy
(01) OM12 - EVENT_OMAMBL
(02) OM13 - OMPRPROS
(03) DO NOT DISPLAY.
(-8) OM13 - OMPRPROS
(-9) OM13 - OMPRPROS
roster
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] use an ambulance? Please tell me all the dates
[since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (01) continuous answer
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF (-8) Don't Know
DEATH/DATE OF INSTITUTIONALIZATION)].
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
BOX OM1GG
BOX OM1GG
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR
PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND, GO TO OM12_IN - NAVIGATOR.
ELSE GO TO BOX OM1GG2.
OM12_IN
instance navigator
OM10A
BOX OM1FF1
BOX OM1FF2
OMPRAMBL
EVENT_OMAMBL
NAVIGATOR
OM11
OM12
yes/no
routing
[PROBE: This could include buying the diabetic equipment or
supplies at a plan center; at a place or store that honors [your/(SP’s)]
plan card; or through a place or store that the plan referred [you/(SP)]
to.]
GO TO OM10_IN - NAVIGATOR.
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM11 - OMPRAMBL.
yes/no
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) OM12A - OMSATHMO
(02) BOX OM1GG2
Was the ambulance on (EVENT DATE) provided by or approved by
[READ MANAGED CARE PLAN NAME(S) BELOW]?
OMSATHMO
OM12A
BOX OM1GG1
BOX OM1GG2
OMPRPROS
EVENT_OMPROS
OM13
OM14
BOX OM1HH
NAVIGATOR
OM14_IN
yes/no
routing
[PROBE: This could mean that the ambulance was sent by the plan,
or that [you/(SP)] or someone for [you/(SP)] contacted the plan for
them to authorize or approve the use of the ambulance. This
approval could have come after the use of the ambulance.]
GO TO OM12_IN - NAVIGATOR.
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM13 - OMPRPROS.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
BOX OM1GG1
SHOW CARD OM3
[Since (REFERENCE DATE/SURVEY REFERENCE DATE)/Between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], did [you/(SP)] buy or (01) YES
pay for repairs of any prostheses, such as those on the card?
(02) NO
(03) INDICATED YES BY DATAPREP
[Prostheses include artificial leg or arm, mastectomy prosthesis, and (-8) Don't Know
artificial or glass eye.]
(-9) Refused
[Since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[Since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s
interview
[Between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[Between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
[you] respondent is SP
[(SP)] respondent is proxy
(01) OM14 - EVENT_OMPROS
(02) BOX OMA4
(03) DO NOT DISPLAY.
(-8) BOX OMA4
(-9) BOX OMA4
roster
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair the prosthesis? Please tell me all
the dates [since (REFERENCE DATE/SURVEY REFERENCE
(01) continuous answer
DATE)/between (REFERENCE DATE/SURVEY REFERENCE
(-8) Don't Know
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]. (-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
BOX OM1HH
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR
PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND, GO TO OM14_IN - NAVIGATOR.
ELSE GO TO BOX OM1HH2.
yes/no
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
instance navigator
(01) OM14A - OMSATHMO
(02) BOX OM1HH2
On (EVENT DATE), did [you/(SP)] buy or repair the prosthesis at
[READ MANAGED CARE PLAN NAME(S) BELOW] or through a
service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?
OMSATHMO
OM14A
BOX OM1HH1
BOX OM1HH2
BOX OMA4
yes/no
routing
[PROBE: This could include buying or repairing the prosthesis at a
plan center; at a place or store that honors [your/(SP’s)] plan card; or
through a place or service that the plan referred [you/(SP)] to.]
GO TO OM14_IN - NAVIGATOR.
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OMA4.
routing
IF SP WAS STILL RENTING OXYGEN-RELATED EQUIPMENT AT
THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO
OMS19INTR - OXGNINTRO.
ELSE GO TO OM19 - OMPROXGN.
The next questions are about oxygen-related equipment [you
were/(SP) was] renting as of (REFERENCE DATE).
OXGNINTRO
OMS19INTR
no entry
NAVIGATOR
OMS19_IN
instance navigator
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
BOX OM1HH1
[you were] respondent is SP
[(SP) was] respondent is proxy
OMS19_IN - NAVIGATOR
(01) OMS19 - RENTSTIL
(02) OM19 - OMPROXGN
At the time of the last interview, [you were/(SP) was] renting oxygenrelated equipment. As of [today/(DATE OF DEATH)/(DATE OF
INSTITUTIONALIZATION)] (is/was) the oxygen-related equipment
being rented?
RENTSTIL
OMS19
code one
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A
RENT-TO-BUY PROGRAM, SELECT "NO."]
OMPROXGN
OM19
yes/no
(Other than what we already talked about,) [(Since/since)
(REFERENCE DATE/SURVEY REFERENCE
DATE)/(Between/between) (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], did [you/(SP)] have any (other) expenses
for oxygen or supplies or oxygen-related equipment?
OXGNTYPE
OM19A
code one
What was that?
Did [you/(SP)] buy or repair the oxygen-related equipment, or did
[you/(SP)] rent it?
RENTPROB
EVENT_OMOXGN
OM19B
OM20
BOX OM1II
NAVIGATOR
OM20_IN
code one
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM
THROUGH A RENT-TO-BUY PROGRAM WITHIN THE SAME
ROUND, SELECT "RENT."]
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
[you were] respondent is SP
[(SP) was] respondent is proxy
[today] respondent is SP or proxy, SP alive and not institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized
[is] respondent is SP or proxy, SP alive and not institutionalized
[was] respondent is proxy, SP institutionalized or deceased
(01) BOX OM1KK
(02) OM20C - EVENDMM
(03) BOX OM9
(-8) BOX OM9
(-9) BOX OM9
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
[Other than what we already talked about,] second or more loop
[] first loop
[Since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, respondent completed last round’s interview, first loop
[Since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, respondent skipped last round’s interview, first loop
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, respondent completed last round’s interview, second loop or more
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, respondent skipped last round’s interview, second loop
or more
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, respondent completed last round’s interview, first loop
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, respondent completed last round’s
interview, first loop
[Between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, respondent skipped last round’s interview, first loop
[Between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, respondent skipped last
round’s interview, first loop
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, respondent completed last round’s interview, second loop or
more
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, respondent completed last round’s
interview, second loop or more
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, respondent skipped last round’s interview, second
loop or more
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, respondent skipped last
round’s interview, second loop or more
[other] second loop or more
[] first loop
[you] respondent is SP
[(SP)] respondent is proxy
(01) OM19A - OXGNTYPE
(02) BOX OMA11
(03) DO NOT DISPLAY.
(-8) BOX OMA11
(-9) BOX OMA11
(01) OXYGEN/SUPPLIES
(02) OXYGEN-RELATED EQUIPMENT
(01) OM20 - EVENT_OMOXGN
(02) OM19B - RENTPROB
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
EQUIPMENT
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
(01) OM20 - EVENT_OMOXGN
(02) OM20A EVENT_OMOXGNRENT
(03) OM20 - EVENT_OMOXGN
(-8) OM20 - EVENT_OMOXGN
(-9) OM20 - EVENT_OMOXGN
[you] respondent is SP
[(SP)] respondent is proxy
[(oxygen or supplies)] EVNT.OXGNTYPE = supplies
[(oxygen-related equipment)] EVNT.OXGNTYPE = equipment
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
BOX OM1II
roster
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did (you/(SP)] purchase the [(oxygen or supplies)/(oxygenrelated equipment)]? Please tell me the dates of each purchase
[since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (01) continuous answer
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF (-8) Don't Know
DEATH/DATE OF INSTITUTIONALIZATION)].
(-9) Refused
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR
PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND, GO TO OM20_IN - NAVIGATOR.
ELSE GO TO BOX OM7.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
instance navigator
(01) OM20AA - OMSATHMO
(02) BOX OM7
On (EVENT DATE), did [you/(SP)] buy or repair the (OXYGEN ITEM)
at [READ MANAGED CARE PLAN NAME(S) BELOW] or through a
service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?
OMSATHMO
OM20AA
BOX OM1II1
yes/no
routing
BOX OM7
routing
(01) YES
[PROBE: This could include buying or repairing the (OXYGEN ITEM) (02) NO
at a plan center; at a place or store that honors [your/(SP’s)] plan
(-8) Don't Know
card; or through a place or store that the plan referred [you/(SP)] to.] (-9) Refused
GO TO OM20_IN - NAVIGATOR.
IF OM19B - RENTPROB = 3/BoughtAndRented, GO TO OM20A EVENT_OMOXGNRENT.
ELSE GO TO BOX OM1KK1.
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
BOX OM1II1
EVENT_OMOXGNRENT
RENTSTIL
OM20A
OM20B
roster
yes/no
SELECT OR ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY
REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] that [you/(SP)] rented the oxygen-related
equipment.
[Are you/Is (SP)/Was (SP)] still renting the oxygen-related
equipment?
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
OM20B - RENTSTIL
(01) BOX OM1KK
(02) OM20C - EVENDMM
(03) DO NOT DISPLAY.
(-8) BOX OM1KK1
(-9) BOX OM1KK1
[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP alive
[Was (SP)] respondent is proxy, SP deceased
What was the last date the equipment was rented?
EVENDMM
OM20C
date
(01) continuous answer
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF (02) Don't Know
PURCHASE AS THE LAST DATE OF THE RENTAL PERIOD.]
(03) Refused
MM
OM20C - EVENDDD
DD
OM20C - EVENDYY
YY
BOX OM8A
What was the last date the equipment was rented?
EVENDDD
OM20C
date
(01) continuous answer
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF (02) Don't Know
PURCHASE AS THE LAST DATE OF THE RENTAL PERIOD.]
(03) Refused
What was the last date the equipment was rented?
EVENDYY
OM20C
BOX OM8A
RENT2BUY
REN2BVB
OM20CC
OM20CCVB
BOX OM1KK
date
(01) continuous answer
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF (02) Don't Know
PURCHASE AS THE LAST DATE OF THE RENTAL PERIOD.]
(03) Refused
routing
IF SP IS NOT DECEASED, GO TO OM20CC - RENT2BUY.
ELSE GO TO BOX OM1KK.
code one
You said [you/(SP)] stopped renting the oxygen-related equipment. Is
this because (you/he/she) no longer (have/has) the equipment or
because (you/he/she) (have/has) purchased it through a rent-to-buy
option?
(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused
verbatim text
BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE OXYGENRELATED EQUIPMENT.
RECORD VERBATIM.
(01) continuous answer
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR
PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND, GO TO OM20D1 - OMSATHMO.
ELSE GO TO BOX OM1KK1.
[you] respodnent is SP
[(SP)] respondent is proxy
[he] respondent is proxy, SP is male
[she] respondent is proxy, SP is female
[have] respondent is SP
[has] respondent is proxy
(01) BOX OM1KK
(02) BOX OM1KK
(03) OM20CCVB - REN2BVB
(04) BOX OM1KK
(05) BOX OM1KK
BOX OM1KK
Did [you/(SP)] rent the oxygen equipment at [READ MANAGED
CARE PLAN NAME(S) BELOW] or through a service or discount
offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
OMSATHMO
OM20D1
BOX OM1KK1
BOX OM9
BOX OM10
MOREOXGN
OM20D
BOX OM11
BOXOMA11
yes/no
(01) YES
[PROBE: This could include renting the oxygen equipment at a plan (02) NO
center; at a place or store that honors [your/(SP’s)] plan card; or
(-8) Don't Know
through a place or service that the plan referred [you/(SP)] to.]
(-9) Refused
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM9.
routing
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS
ROUND, GO TO OMS19_IN - NAVIGATOR.
ELSE GO TO BOX OM10.
routing
IF OM20D HAS NOT BEEN ASKED, GO TO OM20D - MOREOXGN.
ELSE GO TO BOX OMA11.
yes/no
In addition to the [(oxygen or supplies)/(oxygen-related equipment)]
that you just told me about, did [you/(SP)] [(buy oxygen or
supplies)/(have any expenses for oxygen-related equipment)]?
routing
IF OM19A - OXYGTYPE = 1/Supplies, SET NEXT OXYGEN TYPE
TO EQUIPMENT AND GO TO OM19B - RENTPROB.
ELSE SET NEXT OXYGEN TYPE TO SUPPLIES AND GO TO
OM20 - EVENT_OMOXGN.
routing
IF SP WAS RENTING AT LEAST ONE KIDNEY DIALYSIS
EQUIPMENT AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO OMS21INTR - KDNYINTRO.
ELSE GO TO OM21 - OMPRKDNY.
The next questions are about kidney dialysis equipment [you
were/(SP) was] renting as of (REFERENCE DATE).
KDNYINTRO
OMS21INTR
no entry
NAVIGATOR
OMS21_IN
instance navigator
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
BOX OM1KK1
[(oxygen or supplies)] EVNT.OXGNTYPE = supplies
[(oxygen-related equipment)] EVNT.OXGNTYPE = equipment
[you] respondent is SP
[(SP)] respondent is proxy
[(buy oxygen or supplies)] if OXGNTYPE = supplies
[(have any expenses for oxygen-related equipment)] if OXGNTYPE = equipment
(01) BOX OM11
(02) BOX OMA11
(-8) BOX OMA11
(-9) BOX OMA11
[you were] respondent is SP
[(SP) was] respondent is proxy
OMS21_IN - NAVIGATOR
(01) OMS21 - RENTSTIL
(02) OM21 - OMPRKDNY
RENTSTIL
OMS21
code one
At the time of the last interview, [you were/(SP) was] renting
equipment for kidney dialysis. As of (today/DATE OF DEATH/DATE (01) YES
OF INSTITUTIONALIZATION), (is/was) the equipment being rented? (02) NO
(03) EVENT ENTERED IN ERROR
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A
(-8) Don't Know
RENT-TO-BUY PROGRAM, SELECT "NO."]
(-9) Refused
[you were] respondent is SP
[(SP) was] respondent is proxy
[today] respondent is SP or proxy, SP alive and not institutionalized
[DATE OF DEATH] respondent is proxy, SP deceased
[DATE OF INSTITUTIONALIZATION] respondent is proxy, SP institutionalized
[is] respondent is SP or proxy, SP alive and not institutionalized
[was] respondent is proxy, SP deceased or institutionalized
(01) BOX OM1NN
(02) OM22C - EVENDMM
(03) BOX OM16
(-8) BOX OM16
(-9) BOX OM16
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
[Other than what we already talked about,] second or more loop
[] first loop
[Since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, respondent completed last round’s interview, first loop
[Since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, respondent skipped last round’s interview, first loop
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, respondent completed last round’s interview, second loop or more
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, respondent skipped last round’s interview, second loop
or more
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, respondent completed last round’s interview, first loop
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, respondent completed last round’s
interview, first loop
[Between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, respondent skipped last round’s interview, first loop
[Between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, respondent skipped last
round’s interview, first loop
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, respondent completed last round’s interview, second loop or
more
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, respondent completed last round’s
interview, second loop or more
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, respondent skipped last round’s interview, second
loop or more
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, respondent skipped last
round’s interview, second loop or more
[other] second loop or more
[] first loop
[you] respondent is SP
[(SP)] respondent is proxy
(01) OM21A - KDNYTYPE
(02) BOX OMA18
(03) DO NOT DISPLAY.
(-8) BOX OMA18
(-9) BOX OMA18
(01) KIDNEY DIALYSIS SUPPLIES
(02) KIDNEY DIALYSIS EQUIPMENT
(01) OM22 - EVENT_OMKDNY
(02) OM21B - RENTPROB
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
EQUIPMENT
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
(01) OM22 - EVENT_OMKDNY
(02) OM22A EVENT_OMKDNYRENT
(03) DO NOT DISPLAY.
(-8) OM22 - EVENT_OMKDNY
(-9) OM22 - EVENT_OMKDNY
[you] respondent is SP
[(SP)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
BOX OM1LL
OMPRKDNY
OM21
yes/no
(Other than what we already talked about), [(Since/since)
(REFERENCE DATE/SURVEY REFERENCE
DATE)/(Between/between) (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], did [you/(SP)] buy any (other) kidney
dialysis supplies or buy, rent, or repair any related equipment?
KDNYTYPE
OM21A
code one
What was that?
Did [you/(SP)] buy or repair the dialysis equipment, or did [you/(SP)]
rent it?
RENTPROB
EVENT_OMKDNY
OM21B
OM22
BOX OM1LL
NAVIGATOR
OM22_IN
code one
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM
THROUGH A RENT-TO-BUY PROGRAM WITHIN THE SAME
ROUND, SELECT "RENT."]
roster
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] (purchase the kidney dialysis supplies)/(buy or
repair kidney dialysis equipment)? Please tell me all the dates [since
(REFERENCE DATE/SURVEY REFERENCE DATE)/between
(01) continuous answer
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF (-8) Don't Know
DEATH/DATE OF INSTITUTIONALIZATION)].
(-9) Refused
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR
PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND, GO TO OM22_IN - NAVIGATOR.
ELSE GO TO BOX OM1NN1.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
instance navigator
(01) OM22AA - OMSATHMO
(02) BOX OM1NN1
On (EVENT DATE), did [you/(SP)] buy (or repair) the (KIDNEY ITEM)
at [READ MANAGED CARE PLAN NAME(S) BELOW] or through a
service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?
OMSATHMO
OM22AA
BOX OM14
yes/no
routing
[PROBE: This could include buying (or repairing) the (KIDNEY
ITEM) at a plan center; at a place or store that honors [your/(SP’s)]
plan card; or through a place or store that the plan referred [you/(SP)]
to.]
GO TO OM22_IN - NAVIGATOR.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
BOX OM14
EVENT_OMKDNYRENT
RENTSTIL
OM22A
OM22B
roster
yes/no
SELECT OR ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY
REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] that [you/(SP)] rented the kidney dialysis
equipment.
[Are you/Is (SP)/Was (SP)] still renting the kidney dialysis
equipment?
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
[you] respondent is SP
[(SP)] respondent is proxy
OM22B - RENTSTIL
(01) BOX OM1NN
(02) OM22C - EVENDYY
(03) DO NOT DISPLAY.
(-8) BOX OM1NN1
(-9) BOX OM1NN1
[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP alive
[Was (SP)] respondent is proxy, SP deceased
What was the last date the equipment was rented?
EVENDMM
OM22C
date
(01) continuous answer
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF (-8) Don't Know
PURCHASE AS THE LAST DATE OF THE RENTAL PERIOD.]
(-9) Refused
MM
OM22C - EVENDDD
DD
OM22C - EVENDYY
YY
BOX OM15A
What was the last date the equipment was rented?
EVENDDD
OM22C
date
(01) continuous answer
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF (-8) Don't Know
PURCHASE AS THE LAST DATE OF THE RENTAL PERIOD.]
(-9) Refused
What was the last date the equipment was rented?
EVENDYY
OM22C
BOX OM15A
date
(01) continuous answer
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF (-8) Don't Know
PURCHASE AS THE LAST DATE OF THE RENTAL PERIOD.]
(-9) Refused
routing
IF SP IS NOT DECEASED, GO TO OM22CC - RENT2BUY.
ELSE GO TO BOX OM1NN.
RENT2BUY
OM22CC
code one
REN2BVB
OM22CCVB
verbatim text
(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
You said [you/(SP)] stopped renting the dialysis equipment. Is this
(03) OTHER
because (you/he/she) no longer (have/has) the equipment or because (-8) Don't Know
(you/he/she) (have/has) purchased it through a rent-to-buy option?
(-9) Refused
BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE DIALYSIS
EQUIPMENT.
RECORD VERBATIM.
(01) continuous answer
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR
PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND, GO TO OM22D1 - OMSATHMO.
ELSE GO TO BOX OM1NN1.
BOX OM1NN
[you] respondent is SP
[(SP)] respondent is proxy
[he] respondent is proxy, SP is male
[she] respondent is proxy, SP is female
[have] respondent is SP
[has] respodnent is proxy
(01) BOX OM1NN
(02) BOX OM1NN
(03) OM22CCVB - REN2BVB
(-8) BOX OM1NN
(-9) BOX OM1NN
BOX OM1NN
Did [you/(SP)] rent the kidney dialysis equipment at [READ
MANAGED CARE PLAN NAME(S) BELOW] or through a service or
discount offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?
OMSATHMO
OM22D1
BOX OM1NN1
BOX OM16
BOX OM17
MOREKDNY
OM22D
BOX OM18
BOX OMA18
yes/no
(01) YES
[PROBE: This could include renting the kidney dialysis equipment at (02) NO
a plan center; at a place or store that honors [your/(SP’s)] plan card; (-8) Don't Know
or through a place or service that the plan referred [you/(SP)] to.]
(-9) Refused
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM16.
routing
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS
ROUND, GO TO OMS21_IN - NAVIGATOR.
ELSE GO TO BOX OM17.
routing
IF OM22D HAS NOT BEEN ASKED, GO TO OM22D - MOREKDNY.
ELSE GO TO BOX OMA18.
yes/no
In addition to the [(kidney dialysis supplies)/(kidney dialysis
equipment)] that you just told me about, did [you/(SP)] [(obtain any
kidney dialysis equipment)/(buy any kidney dialysis supplies)]?
routing
IF OM21A - KDNYTYPE = 1/Supplies, SET NEXT KIDNEY TYPE TO
EQUIPMENT AND GO TO OM21B - RENTPROB.
ELSE SET NEXT KIDNEY TYPE TO SUPPLIES AND GO TO OM22 EVENT_OMKDNY.
routing
IF SP WAS STILL RENTING AT LEAST ONE OTHER MEDICAL
EQUIPMENT AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO OMS23INTR - OTHRINTRO.
ELSE GO TO OM23 - OMPROTHR.
The next questions are about other medical equipment [you
were/(SP) was] renting as of (REFERENCE DATE).
OTHRINTRO
OMS23INTR
no entry
NAVIGATOR
OMS23_IN
instance navigator
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
BOX OM1NN1
[(kidney dialysis supplies)] EVNT.KDNYTYPE = supplies
[(kidney dialysis equipment)] = equipment
[you] respondent is SP
[(SP)] respondent is proxy
[(obtain any kidney dialysis equipment)] if KDNYTYPE = equipment
[(buy any kidney dialysis supplies)] if KDNYTYPE = supplies
(01) BOX OM18
(02) BOX OMA18
(-8) BOX OMA18
(-9) BOX OMA18
[you were] respondent is SP
[(SP) was] respondent is proxy
OMS23_IN - NAVIGATOR
(01) OMS23 - RENTSTIL
(02) OM23 - OMPROTHR
RENTSTIL
OMS23
code one
At the time of the last interview, [you were/(SP) was] renting (OTHER
MEDICAL EXPENSE ITEM). As of (today/DATE OF DEATH/DATE
OF INSTITUTIONALIZATION), (is/was) the (OTHER MEDICAL
(01) YES
EXPENSE ITEM) being rented?
(02) NO
(03) EVENT ENTERED IN ERROR
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A
(-8) Don't Know
RENT-TO-BUY PROGRAM, SELECT "NO."]
(-9) Refused
SHOW CARD OM4
[Since (REFERENCE DATE/SURVEY REFERENCE DATE)/Between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], did [you/(SP)] buy,
rent, or repair any other medical equipment or buy any other medical
supplies besides what we have talked about?
OMPROTHR
OTHRTYPE
EVOSTEXT
OM23
OM24
OM24
yes/no
code one
verbatim text
[Other medical equipment and supplies include portable commodes
or raised toilet seats, portable tub seats, special chairs or cushions,
hospital beds, ostomy supplies, incontenence supplies such as
Depends, Serenity or other brands of disposable undergarments,
pads or briefs, bandages, dressings, tape supplies, pulmonary
equipment such as a Nebulizer or CPAP, and blood pressure
equipment such as cuffs or monitors, etc.]
What kind of equipment was the item?
OTHER (SPECIFY)
Did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE
ITEM), or did [you/(SP)] rent it?
RENTPROB
GETNUM
OM24A
code one
BOX OM18B
routing
OM25
numeric
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM
THROUGH A RENT-TO-BUY PROGRAM WITHIN THE SAME
ROUND, SELECT "RENT."]
IF NOT ADMINISTERING ST AND NOT ADMINISTERING NS, GO
TO OM25 - GETNUM.
ELSE GO TO BOX OM1QQ1.
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) PORTABLE COMMODE OR RAISED TOILET SEAT
(02) PORTABLE TUB SEAT
(03) SPECIAL CHAIR/CUSHION/MATTRESS
(04) HOSPITAL BED/BED SIDES
(05) OSTOMY SUPPLIES
(06) INCONTINENCE SUPPLIES (I.E. DEPENDS, SERENITY
DISPOSABLE DIAPERS OR PADS)
(07) BANDAGES, DRESSINGS, TAPE SUPPLIES
(08) PULMONARY EQUIPMENT
(09) BLOOD PRESSURE EQUIPMENT
(91) OTHER
(01) continuous answer
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
EQUIPMENT
(-8) Don't Know
(-9) Refused
THIS ITEM AND NUMBER OF PURCHASES HAS BEEN ENTERED
ALREADY FOR THIS ROUND. PLEASE CORRECT THE NUMBER
OF TIMES TO BE THE TOTAL NUMBER OF TIMES PURCHASED
SINCE (REFERENCE DATE).
How many times [since (REFERENCE DATE)/between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] [[have you/has (SP)] bought or
(01) continuous answer
obtained/did (SP) buy or obtain] (OTHER MEDICAL EXPENSE
(-8) Don't Know
ITEM)?
(-9) Refused
[you were] respondent is SP
[(SP) was] respondent is proxy
[today] respondent is SP or proxy, SP alive and not institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized
[is] respondent is SP or proxy, SP alive and not institutionalized
[was] respondent is proxy, SP deceased or institutionalized
(01) BOX OM1QQ
(02) OM26B - EVENDMM
(03) BOX OM23
(-8) BOX OM23
(-9) BOX OM23
[Since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[Since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview, SP skipped
previous round’s interview
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s
interview
[Between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[Between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
[you] respondent is SP
[(SP)] respondent is proxy
(01) OM24 - OTHRTYPE
(02) BOX OM24
(03) DO NOT DISPLAY.
(04) BOX OM24
(05) BOX OM24
(01) OM24A - RENTPROB
(02) OM24A - RENTPROB
(03) OM24A - RENTPROB
(04) OM24A - RENTPROB
(05) BOX OM18B
(06) BOX OM18B
(07) BOX OM18B
(08) OM24A - RENTPROB
(09) OM26 - EVENT_OMOTHR
(91) OM24 - EVOSTEXT
OM24A - RENTPROB
[you] respondent is SP
[(SP)] respondent is proxy
(01) OM26 - EVENT_OMOTHR
(02) OM26A EVENT_OMOTHRRENT
(03) DO NOT DISPLAY.
(-8) OM26 - EVENT_OMOTHR
(-9) OM26 - EVENT_OMOTHR
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
[have you] respondent is SP
[has (SP) bought or obtained] respondent is proxy, SP alive
[did (SP) buy or obtain] respondent is proxy, SP deceased
BOX OM1QQ1
EVENT_OMOTHR
OM26
BOX OM1OO
NAVIGATOR
OM26_IN
roster
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE
ITEM)? Please tell me all the dates [since (REFERENCE
DATE/SURVEY REFERENCE DATE)/between (REFERENCE
(01) continuous answer
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE (-8) Don't Know
OF INSTITUTIONALIZATION)]
(-9) Refused
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR
PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND, GO TO OM26_IN - NAVIGATOR.
ELSE GO TO BOX OM1QQ1.
[you] respondent is SP
[(SP)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
BOX OM1OO
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
instance navigator
(01) OM26AA - OMSATHMO
(02) BOX OM1QQ1
On (EVENT DATE), did [you/(SP)] buy or repair the (OTHER
MEDICAL EXPENSE ITEM) at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through
[READ MANAGED CARE PLAN NAME(S) BELOW]?
OMSATHMO
OM26AA
yes/no
[PROBE: This could include buying or repairing the (OTHER
MEDICAL EXPENSE ITEM) at a plan center; at a place or store that
honors [your/(SP’s)] plan card; or through a place or store that the
plan referred [you/(SP)] to.]
NAVIGATOR
BOX OM21
instance navigator
GO TO OM26_IN - NAVIGATOR.
EVENT_OMOTHRRENT
OM26A
roster
ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY
REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] that [you/(SP)] rented the (OTHER
MEDICAL EXPENSE ITEM).
RENTSTIL
OM26A1
yes/no
[Are you/Is (SP)] still renting the (OTHER MEDICAL EXPENSE
ITEM)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
BOX OM21
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
[you] respondent is SP
[(SP)] respondent is proxy
OM26A1 - RENTSTIL
(01) BOX OM1QQ
(02) OM26B - EVENDMM
(03) DO NOT DISPLAY.
(-8) BOX OM1QQ1
(-9) BOX OM1QQ1
[Are you] respondent is SP
[Is (SP)] respondent is proxy
What was the last date [you/(SP)] rented the (OTHER MEDICAL
EXPENSE ITEM)?
EVENDMM
OM26B
date
(01) continuous answer
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF (-8) Don't Know
PURCHASE AS THE LAST DATE OF THE RENTAL PERIOD.]
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
MM
OM26B - EVENDDD
[you] respondent is SP
[(SP)] respondent is proxy
DD
OM26B - EVENDYY
[you] respondent is SP
[(SP)] respondent is proxy
YY
BOX OM22A
What was the last date [you/(SP)] rented the (OTHER MEDICAL
EXPENSE ITEM)?
EVENDDD
OM26B
date
(01) continuous answer
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF (-8) Don't Know
PURCHASE AS THE LAST DATE OF THE RENTAL PERIOD.]
(-9) Refused
What was the last date [you/(SP)] rented the (OTHER MEDICAL
EXPENSE ITEM)?
EVENDYY
RENT2BUY
REN2BVB
OM26B
date
(01) continuous answer
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF (-8) Don't Know
PURCHASE AS THE LAST DATE OF THE RENTAL PERIOD.]
(-9) Refused
BOX OM22A
routing
IF SP IS NOT DECEASED, GO TO OM26BB - RENT2BUY.
ELSE GO TO BOX OM1QQ.
code one
(01) NO LONGER HAVE THE ITEM
You said [you/(SP)] stopped renting the (OTHER MEDICAL
(02) PURCHASED THROUGH RENT-TO-BUY
EXPENSE ITEM). Is this because (you/he/she) no longer (have/has) (03) OTHER
the item or because (you/he/she) (have/has) purchased it through a (-8) Don't Know
rent-to-buy option?
(-9) Refused
verbatim text
BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE (OTHER
MEDICAL EXPENSE ITEM).
RECORD VERBATIM.
OM26BB
OM26BBVB
(01) continuous answer
[you] respondent is SP
[(SP)] respondent is proxy
[he] respondent is proxy, SP is male
[she] respondent is proxy, SP is female
[have] respondent is SP
[has] respodnent is proxy
(01) BOX OM1QQ
(02) BOX OM1QQ
(03) OM26BBVB - REN2BVB
(-8) BOX OM1QQ
(-9) BOX OM1QQ
BOX OM1QQ
BOX OM1QQ
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR
PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND, GO TO OM26C - OMSATHMO.
ELSE GO TO BOX OM1QQ1.
Did [you/(SP)] rent the (OTHER MEDICAL EXPENSE ITEM) at
[READ MANAGED CARE PLAN NAME(S) BELOW] or through a
service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?
OMSATHMO
OM26C
BOX OM1QQ1
BOX OM23
MOREOTHR
OM27
BOX OM24
yes/no
[PROBE: This could include renting the (OTHER MEDICAL
EXPENSE ITEM) at a plan center; at a place or store that honors
[your/(SP’s)] plan card; or through a place or service that the plan
referred [you/(SP)] to.]
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM23.
routing
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS
ROUND, GO TO OMS23_IN - NAVIGATOR.
ELSE GO TO OM27 - MOREOTHR.
yes/no
In addition to the medical equipment you just told me about, did
[you/(SP)] buy, rent, or repair any other medical equipment [since
(REFERENCE DATE/SURVEY REFERENCE DATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?
routing
IF SP HAD AT LEAST ONE ALTERATION THAT WAS NOT
COMPLETE AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO OMS28INTR - ALTRINTRO.
ELSE GO TO OM28 - OMPRALTR.
The next questions are about an alteration [you were/(SP) was]
making as of (REFERENCE DATE).
ALTRINTRO
OMS28INTR
no entry
NAVIGATOR
OMS28_IN
instance navigator
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] resondent is proxy
BOX OM1QQ1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
(01) OM24 - OTHRTYPE
(02) BOX OM24
(-8) BOX OM24
(-9) BOX OM24
[you were] respondent is SP
[(SP) was] respondent is proxy
OMS28_IN - NAVIGATOR
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
Last time [you/(SP)] had started to make an alteration (ALTERATION)
that was not completed as of (REFERENCE DATE/SURVEY
REFERENCE DATE).
EVBEGMM
OMS28
date
On what date [since (REFERENCE DATE/SURVEY REFERENCE
DATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]
was this alteration completed?
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) OMS28 - EVBEGMM
(02) OM28 - OMPRALTR
[you] respondent is SP
[(SP)] respondent is proxy
[(REFERENCE DATE)] SP completed previous round's interview
[(SURVEY REFERENCE DATE)] SP skipped previous round's interview
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
MM
OMS28 - EVBEGDD
Last time [you/(SP)] had started to make an alteration (ALTERATION)
that was not completed as of (REFERENCE DATE/SURVEY
REFERENCE DATE).
EVBEGDD
OMS28
date
On what date [since (REFERENCE DATE/SURVEY REFERENCE
DATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]
was this alteration completed?
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
Last time [you/(SP)] had started to make an alteration (ALTERATION)
that was not completed as of (REFERENCE DATE/SURVEY
REFERENCE DATE).
EVBEGYY
OMS28
date
On what date [since (REFERENCE DATE/SURVEY REFERENCE
DATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]
was this alteration completed?
OMNOTDONE
OMS28
BOX OM25
code one
routing
GO TO OMS28_IN - NAVIGATOR.
OMPRALTR
ALTRTYPE
EVOSTEXT
OM28
OM29
OM29
yes/no
code one
verbatim text
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) ALTERATION NOT YET COMPLETED
(-7) Empty
SHOW CARD OM5
[Since (REFERENCE DATE/SURVEY REFERENCE DATE)/Between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], did [you/(SP)] make
any alterations or modify the inside or outside of (your/his/her) home
or car because of some illness or injury? This card lists some
(01) YES
examples.
(02) NO
(03) INDICATED YES BY DATAPREP
[Alterations include ramps, handrails, elevator or incline chair, tub
(-8) Don't Know
seats, tub handrails, and any car alterations.]
(-9)
(01) Refused
ELEVATOR OR INCLINE CHAIR
What was the alteration?
OTHER (SPECIFY)
(02) HANDRAILS (OTHER THAN TUB)
(03) RAMPS
(04) TUB HANDRAILS
(05) TUB SEAT
(06) ANY CAR ALTERATION
(91) OTHER
(01) continuous answer
[you] respondent is SP
[(SP)] respondent is proxy
[(REFERENCE DATE)] SP completed previous round's interview
[(SURVEY REFERENCE DATE)] SP skipped previous round's interview
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
DD
OMS28 - EVBEGYY
[you] respondent is SP
[(SP)] respondent is proxy
[(REFERENCE DATE)] SP completed previous round's interview
[(SURVEY REFERENCE DATE)] SP skipped previous round's interview
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
YY
OMS28 - OMNOTDONE
BOX OM25
[Since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[Since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s
interview
[Between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[Between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
[you] respondent is SP
[(SP) respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
(01) OM29 - ALTRTYPE
(02) BOX OM26
(03) DO NOT DISPLAY.
(-8) BOX OM26
(-9)
OM26
(01) BOX
OM30
- EVBEGMM
(02) OM30 - EVBEGMM
(03) OM30 - EVBEGMM
(04) OM30 - EVBEGMM
(05) OM30 - EVBEGMM
(06) OM30 - EVBEGMM
(91) OM29 - EVOSTEXT
OM30 - EVBEGMM
EVBEGMM
EVBEGDD
OM30
OM30
date
date
EVBEGYY
OM30
date
OMNOTDONE
OM30
code one
BOX OM25A
routing
On what date [since (REFERENCE DATE/SURVEY REFERENCE
DATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]
was this alteration completed?
On what date [since (REFERENCE DATE/SURVEY REFERENCE
DATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]
was this alteration completed?
On what date [since (REFERENCE DATE/SURVEY REFERENCE
DATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]
was this alteration completed?
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM31 - MOREALTR.
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
MM
OM30 - EVBEGDD
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
DD
OM30 - EVBEGYY
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
YY
OM30 - OMNOTDONE
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) ALTERATION NOT YET COMPLETED
(-7) Empty
BOX OM25A
MOREALTR
OM31
BOX OM26
yes/no
routing
In addition to the alteration(s) you just told me about, did [you/(SP)]
make any other alterations because of some illness or injury [since
(REFERENCE DATE/SURVEY REFERENCE DATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?
GO TO NEXT SECTION
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP] respondent is proxy
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP completed previous round’s interview
[since (SURVEY REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, SP skipped previous round’s interview
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP completed previous round’s interview
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP completed previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, SP skipped previous round’s interview
[between (SURVEY REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized, SP skipped previous round’s
interview
(01) OM29 - ALTRTYPE
(02) BOX OM26
(-8) BOX OM26
(-9) BOX OM26
Prescribed Medicine Summary (PMS)
Variable Name
MR Screen Name
BOX PMS1
Question type
Question text/description
routing
IF SP REPORTED PRESCRIPTION MEDICINE PURCHASES IN
THE PREVIOUS ROUND, GO TO PMSINTRA - PMSINTA.
ELSE GO TO BOX PMS12.
Code list
Text Fill Logic
Input mask
Routing
During the last interview, we recorded the names of medicines that
[you/(SP)] had obtained between (SUMMARY REFERENCE DATE)
and (REFERENCE DATE).
[HAND PM SUMMARY PAGE TO RESPONDENT.]
You may want to refer to the medicine names to help you recall any
medicines that [you/(SP)] may have obtained since that time, including
any refills of these medicines.
PMSINTA
PMSUPDATE
MEDICINE_PMSADD
PMSINTRA
PMSINTRB
PMS2
no entry
PRESS F12 AND SHOW THE PRESCRIPTION MEDICINE
SUMMARY TO THE RESPONDENT ON YOUR SCREEN
code one
REFER TO SUMMARY PAGE FOR PRESCRIBED MEDICINES TO
REVIEW PREVIOUS ROUND UTILIZATION.
CODE WITHOUT ASKING:
(01) NO CHANGES APPEAR TO BE NECESSARY
(02) NEED TO ADD A MEDICINE NAME
(03) NEED TO CORRECT A MEDICINE NAME
(04) NEED TO DROP A MEDICINE
(01) BOX PMS12
(02) PMS2 - MEDICINE_PMSADD
(03) PMS3 - MEDICINE_PMSEDIT
(04) PMS4 - MEDICINE_PMSDELETE
roster
What is the name of the medicine that needs to be added?
ADD ALL MEDICINES AT THIS ROSTER.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
INCLUDE STRENGTH WITH NAME.
(01) continuous answer
PMS6A - GETNUM
(01) continuous answer
PMSINTRB - PMSUPDATE
(01) continuous answer
PMSINTRB - PMSUPDATE
MEDICINE_PMSEDIT
PMS3
roster
EDIT ALL MEDICINES AT THIS ROSTER.
What is the name of the medicine that needs to be edited?
MEDICINE_PMSDELETE
PMS4
roster
What is the name of the medicine that needs to be deleted?
SELECT ALL MEDICINES FOR DELETION AT THIS ROSTER.
[you] respondent is SP
[(SP)] respondent is proxy
PMSINTRB - PMSUPDATE
IF ALL MEDICINES ARE NOT LISTED, USE "PREVIOUS PAGE"
AND ADD THE MEDICINE TO THE ROSTER. REFER TO
STATEMENTS OR RECEIPTS, IF AVAILABLE.
How many times between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE) did [you/(SP)] obtain (READ MEDICINE
NAME(S) BELOW)MEDICINE NAME)?
GETNUM
PMS6A
BOX PMS3
NAVIGATOR
PMS6A_IN
BOX PMS4
PMSATVA
PMS6A1
BOX PMS6
grid
[COUNT A MEDICINE AS OBTAINED REGARDLESS OF WHO
OBTAINED IT FOR THE RESPONDENT, WHEN IT WAS OBTAINED,
WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND (01) continuous answer
WHETHER OR NOT THE RESPONDENT ACTUALLY TOOK THE
(-8) Don't Know
MEDICINE.]
(-9) Refused
routing
IF AT LEAST ONE PRESCRIPTION MEDICINE DISPLAYED AT
PMS6A HAS NUMBER OF PURCHASES > 0 OR EQUAL TO DK OR
RF IN THE PREVIOUS ROUND, GO TO PMS6A_IN - NAVIGATOR.
ELSE GO TO PMSINTRB - PMSUPDATE.
[you] respondent is SP
[(SP)] respondent is proxy
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
instance navigator
routing
IF SP USED V.A. FACILITIES IN THE PREVIOUS ROUND, GO TO
PMS6A1 - PMSATVA.
ELSE GO TO BOX PMS6.
yes/no
Did [you/(SP)] obtain (this purchase/any of these purchases) of
(MEDICINE NAME) through the Department of Veterans Affairs or
V.A.?
routing
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR
PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
PREVIOUS ROUND, GO TO PMS6B - PMSATHMO.
ELSE GO TO PMSINTB1 - PMSINTB.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX PMS3
(01) BOX PMS4
(02) PMSINTRB - PMSUPDATE
[you] respondent is SP
[(SP)] respondent is proxy
[this purchase] one purchase
[any of these purchases] two or more
purchases
BOX PMS6
Did [you/(SP)] obtain (this purchase/any of these purchases) of
(MEDICINE NAME) at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ
MANAGED CARE PLAN NAME(S) BELOW]?
PMSATHMO
PMSINTB
PMBOTTLE
PMSINTC
PMFORM
PMFORMOS
PMS6B
PMSINTB1
BOX PMS8
PMS8
PMSINTRC
PMS9
PMS9
yes/no
(01) YES
[PROBE: This could include obtaining the purchases at a plan
(02) NO
pharmacy; at a pharmacy that honors [your/(SP’s)] plan card; or through (-8) Don't Know
a mail order service that the managed care plan referred [you/(SP)] to.] (-9) Refused
no entry
routing
[ASK R TO GET BOTTLES AND/OR STATEMENTS IF YOU HAVE
NOT ALREADY DONE SO.]
Now I need to ask you a few questions about the (MEDICINE NAME).
GO TO PMS8 - PMBOTTLE.
yes/no
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT,
BOTTLE OR BAG IS PRESENT.
Do you have the medicine bottle, container, or bag available?
IF R DOES NOT HAVE BOTTLE, PROBE TO DETERMINE IF R CAN
ANSWER QUESTIONS ABOUT THE FORM, STRENGTH, AND
QUANTITY OF THE MEDICINE.
no entry
COMPLETE PMS9 -- PMS16 USING INFORMATION FROM
STATEMENT, RECEIPT, MEDICINE BOTTLE OR CONTAINER. IF
THERE IS MORE THAN ONE FOR THE SAME MEDICINE, USE THE
MOST RECENT CONTAINER.
code one
verbatim text
STRNUNIT
STRNUNOS
PMS10
PMS10
code one
verbatim text
STRNNUM
PMS10
numeric
STRNPER
PMS10
verbatim text
STRNUNIT96
PMS10
verbatim text
BOX PMS8A
routing
STRNUNI2
STRNUNO2
PMS10B
PMS10B
code one
verbatim text
STRNNUM2
PMS10B
numeric
STRNPER2
PMS10B
verbatim text
PMSINTB1 - PMSINTB
BOX PMS8
(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) Don't Know
(-9) Refused
(01) PMSINTRC - PMSINTC
(02) BOX PMS11
(03) PMS9 - PMFORM
(-8) BOX PMS11
(-9) BOX PMS11
PMS9 - PMFORM
(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10) PATCHES
IN WHAT FORM WAS THE MEDICINE?
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
[IF THE CONTAINER INDICATES "PADS", SELECT THE
(91) OTHER
CATEGORY FOR "PATCHES'.]
(-8) Don't Know
OTHER (SPECIFY)
(01) MICROGRAMS
continuous answer
(01)
(mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
WHAT WAS THE STRENGTH OF [EACH PILL/EACH PATCH/EACH (08) UNITS (U)
SUPPOSITORY/THE (MEDICINE FORM)]?
(91) OTHER
(96) COMPOUND/MORE THAN ONE MEDICINE
IF COMPOUND MEDICINE: ENTER STRENGTH OF 1ST MEDICINE, COMBINED
THEN CHECK THE BOX BELOW.
(-8) Don't Know
OTHER (SPECIFY)
(01) continuous answer
(01) continuous answer
(-8) Don't Know
(01) continuous answer
(-8) Don't Know
(01) COMPOUND/MORE THAN ONE MEDICINE
COMBINED
(-7) Empty
IF PMS10 - STRNUNIT96 = 1/Compound, GO TO PMS10B STRNUNI2.
ELSE GO TO BOX PMS9.
(01) MICROGRAMS (mcg, mc)
WHAT WAS THE STRENGTH OF THE 2ND MEDICINE IN THE
COMPOUND?
OTHER (SPECIFY)
[you] respondent is SP
[(SP)] respondent is proxy
[this purchase] one purchase
[any of these purchases] two or more
purchases
[your] respondent is SP
[(SP's)] respondent is proxy
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(96) COMPOUND/MORE THAN ONE MEDICINE
COMBINED
(-8) Don't Know
(01) continuous answer
(01) continuous answer
(-8) Don't Know
(01) continuous answer
(-8) Don't Know
(01) PMS10 - STRNUNIT
(02) PMS10 - STRNUNIT
(03) PMS10 - STRNUNIT
(04) PMS10 - STRNUNIT
(05) PMS10 - STRNUNIT
(06) PMS10 - STRNUNIT
(07) PMS10 - STRNUNIT
(08) PMS10 - STRNUNIT
(09) PMS10 - STRNUNIT
(10) PMS10 - STRNUNIT
(11) PMS10 - STRNUNIT
(12) PMS10 - STRNUNIT
(91) PMS9 - PMFORMOS
(-8) BOX PMS9
PMS10 - STRNUNIT
[EACH PILL] (MEDICINE FORM) = 01
[EACH PATCH] (MEDICINE FORM) = 10
[EACH SUPPOSITORY] (MEDICINE FORM)
= 05
[THE (MEDICINE FORM)] (MEDICINE
FORM) NOT EQUAL 01,10,05
(01) PMS10 - STRNNUM
(02) PMS10 - STRNNUM
(03) PMS10 - STRNNUM
(04) PMS10 - STRNNUM
(05) PMS10 - STRNNUM
(06) PMS10 - STRNPER
(07) PMS10 - STRNNUM
(08) PMS10 - STRNNUM
(91) PMS10 - STRNUNOS
(96) PMS10 - STRNUNIT96
(-8) PMS10 - STRNUNIT96
PMS10 - STRNNUM
PMS10 - STRNUNIT96
PMS10 - STRNUNIT96
BOX PMS8A
(01) PMS10B - STRNNUM2
(02) PMS10B - STRNNUM2
(03) PMS10B - STRNNUM2
(04) PMS10B - STRNNUM2
(05) PMS10B - STRNNUM2
(06) PMS10B - STRNPER2
(07) PMS10B - STRNNUM2
(08) PMS10B - STRNNUM2
(91) PMS10B - STRNUNO2
(96) DO NOT DISPLAY.
(-8) BOX PMS9
PM10B - STRNNUM2
BOX PMS9
BOX PMS9
BOX PMS9
TABNUM
PMS11
BOX PMS10
routing
IF THE PRESCRIPTION MEDICINE FORM IS PILLS,
SUPPOSITORIES OR PATCHES IN THE PREVIOUS ROUND, GO
TO PMS11 - TABNUM.
ELSE GO TO PMS16 - AMTUNIT.
numeric
HOW MANY (PILLS/SUPPOSITORIES/PATCHES) WERE IN THE
CONTAINER WHEN IT WAS OBTAINED?
routing
IF PRESCRIPTION MEDICINE FORM IS PILLS OR
SUPPOSITORIES IN THE PREVIOUS ROUND AND PMS11 TABNUM=DK, GO TO PMS12 - TABSADAY.
ELSE GO TO BOX PMS11.
TABSADAY
PMS12
numeric
TABSADAY95
PMS12
code one
HOW MANY (PILLS/SUPPOSITORIES) WERE TO BE TAKEN IN A
DAY?
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-7) Empty
(-8) Don't Know
(01) LESS THAN WHOLE
(02) TAKE AS NEEDED
(-7) Empty
[PILL] (MEDICINE FORM) = 01
[SUPPOSITORY] (MEDICINE FORM) = 05
[PATCH] (MEDICINE FORM) = 10
BOX PMS10
[PILL] (MEDICINE FORM) = 01
[SUPPOSITORY] (MEDICINE FORM) = 05
PMS12 - TABSADAY95
BOX PMS10A
IF PMS12 - TABSADAY = DK, GO TO BOX PMS11.
ELSE IF PMS12 - TABSADAY95 = 2/TakeAsNeeded, GO TO PMS13 TABTAKE.
ELSE GO TO PMS14 - TAKEUNIT.
BOX PMS10A
routing
TABTAKE
PMS13
numeric
TABTAKE96
PMS13
code one
BOX PMS10B
routing
TAKEUNIT
TAKENUM
PMS14
PMS14
code one
numeric
AMTUNIT
AMTUNOS
PMS16
PMS16
code one
verbatim text
AMTNUM
PMS16
BOX PMS11
BOX PMS12
numeric
routing
routing
How many (pills/suppositories) did [you/(SP)] usually take in a day?
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) DON'T TAKE EVERY DAY
(-7) Empty
[pills] (MEDICINE FORM) = 01
[suppositories] (MEDICINE FORM) = 05
[you] respondent is SP
[(SP)] respondent is proxy
PMS13 - TABTAKE96
BOX PMS10B
IF PMS13 - TABTAKE96 = 1/DontTakeEveryDay, GO TO BOX
PMS11.
ELSE GO TO PMS14 - TAKEUNIT.
(01) DAYS
HOW MANY DAYS OR WEEKS WAS THE MEDICINE TO BE
(02) WEEKS
TAKEN?
(03) TAKE UNTIL GONE
(04) TAKE AS NEEDED
[IF THE BOTTLE SAYS TO TAKE A CERTAIN DOSE OF THE
(05) TAKE EVERY DAY
MEDICINE DAILY WITHOUT GIVING A TIME FRAME (E.G., “TAKE 2 (-8) Don't Know
PILLS DAILY”), SELECT “TAKE EVERY DAY”.]
(-9) Refused
(01) continuous answer
(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS (06) MICROGRAMS (mcg)
OBTAINED?
(07) PUFFS, DOSES, BLISTERS
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE
(91) OTHER
STRENGTH OF THE MEDICINE.]
(-8) Don't Know
(01) continuous answer
(01) continuous answer
(-8) Don't Know
GO TO PMS6A_IN - NAVIGATOR.
GO TO NEXT SECTION
BOX PMS11
(01) PMS16 - AMTNUM
(02) PMS16 - AMTNUM
(03) PMS16 - AMTNUM
(04) PMS16 - AMTNUM
(05) PMS16 - AMTNUM
(06) PMS16 - AMTNUM
(07) PMS16 - AMTNUM
(91) PMS16 - AMTUNOS
(-8) BOX PMS11
PMS16 - AMTNUM
BOX PMS11
Prescribed Medicine Utilization (PMQ)
Variable Name
MR Screen
Name
Question type
Question text/description
Code list
Text Fill Logic
Input mask Routing
[Now let’s talk about prescribed medicines [you have/(SP) has] obtained since (REFERENCE DATE).] SP
reported PM purchases in the previous round
[] SP did not report PM purchases in the second round
[you have] respondent is SP
[(SP) has] respondent is proxy
[Now let’s talk about prescribed medicines [you have/(SP) has] obtained since (REFERENCE DATE).]
PMINTA
PMINTROA
no entry
[While talking about medical visits, you mentioned some medicine(s): [READ MEDICINE NAME(S)
BELOW.]] SP reported PM's in the current round utilization
[] SP did not report PM's in the current round utilization
[While talking about medical visits, you mentioned some medicine(s): [READ MEDICINE NAME(S) BELOW.]]
[Now I’d like to talk about prescribed medicines.]
PM1 - PMFILLED
[Now I’d like to talk about prescribed medicines.] (SP did not report PM purchases in the previous round)
and (SP
did not report PM's in the current round utilization)
[] (SP reported PM purchases in the previous round) or (SP reported PM's in the current round utilization)
Else do not display.
[Besides that medicine, ] only one PM reported during the current round utilization
[Besides those medicines, ] more than one PM reported during the current round utilization
[] no PM’s reported during current round utilization
[Since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, no PM’s
reported during the current round utilization
[since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not institutionalized, one or more
PM's reported during the current round utilization
[Besides that medicine, /Besides those medicines, ] [(Since/since) (REFERENCE DATE)/(Between/between)
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)] [have you had/has (SP)
had/did (SP) have] any (other) prescriptions filled?
PMFILLED
PM1
yes/no
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHEN IT WAS OBTAINED, WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND
WHETHER OR NOT THE RESPONDENT ACTUALLY TOOK THE MEDICINE.]
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP DO NOT
DISPLAY.DATA EDITING ONLY.
(-8) DON'T KNOW
(-9) REFUSED
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, no PM’s
reported during the current round utilization
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, no PM’s reported during the current round utilization
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased, one or more
PM's reported during the current round utilization
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, one or more PM's reported during the current round utilization
(01) BOX PMA1
(02) PM3 - PMREFILL
(03) DO NOT DISPLAY.
DATA EDITING ONLY.
(-8) PM3 - PMREFILL
(-9) PM3 - PMREFILL
[other] one or more PM's reported during the current round utilization
[] no PM's reported during the current round utilization
[have you had] respondent is SP
[has (SP) had] respondent is proxy, SP alive and not institutionalized
[did (SP) have] respondent is proxy, SP deceased/institutionalized
BOX PMA1
PM1PMMEDS
PM1A
routing
no entry
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO PM1A - PM1PMMEDS.
ELSE GO TO PM2 - MEDICINE_PM1.
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can
spell the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)]
(MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same
information on them.]
[Also, please take out [your/(SP's)] (MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine
statements, which should have that same information on them.] - SP has a "current" Medicare Prescription
Drug plan or there was
a Medicare Prescription Drug plan "current" at the time of the
previous round interview.
Else do not display.
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles, too.
MEDICINE_PM1
PMREFILL
PM2
PM3
BOX PMA2
PM2PMMEDS
PM3A
roster
What is the name of the medicine?
SELECT OR ADD ALL MEDICINES AT THIS ROSTER.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
INCLUDE STRENGTH WITH NAME.
yes/no
People sometimes forget to mention refills of earlier prescriptions. (In addition to what you’ve told me about,
did/Did) [you/(SP)] have any prescriptions refilled [since (REFERENCE DATE)/between (REFERENCE DATE)
(01) YES
and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
(02) NO
(-8) DON'T KNOW
[COUNT A MEDICINE AS "REFILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
(-9) REFUSED
WHEN IT WAS OBTAINED, WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND
WHETHER OR NOT THE RESPONDENT ACTUALLY TOOK THE MEDICINE.]
routing
no entry
(01) CONTINUOUS ANSWER
PM4
roster
[In addition to what you’ve told me about, did] SP reported one or more PM's in the current round utilization
[Did] SP did not report PM's in the current round utilization
[you] respondent is SP
[(SP)] respondent is proxy
[since (REFERENCE DATE)] respondent is SP
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
(01) BOX PMA2
(02) PM5 - PMDRPHON
(-8) PM5 - PMDRPHON
(-9) PM5 - PMDRPHON
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO PM3A - PM2PMMEDS.
ELSE GO TO PM4 - MEDICINE_PM2.
[your] respondent is SP
[(SP)'s] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can
spell the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)]
(MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same
information on them.]
[Also, please take out [your/(SP's)] (MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine
statements, which should have that same information on them.] - SP has a "current" Medicare Prescription
Drug plan or there was
a Medicare Prescription Drug plan "current" at the time of the
previous round interview
[] SP does not have a "current" Medicare Prescription Drug plan or there was not
a Medicare Prescription Drug plan "current" at the time of the
previous round interview
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles, too.
MEDICINE_PM2
PM3 - PMREFILL
Please tell me all the names of these medicines.
SELECT OR ADD ALL MEDICINES AT THIS ROSTER.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
INCLUDE STRENGTH WITH NAME.
(01) CONTINUOUS ANSWER
PM4 - MEDICINE_PM2
PM5 - PMDRPHON
PMDRPHON
PM5
BOX PMA3
PM3PMMEDS
PM5A
yes/no
routing
no entry
People sometimes forget to mention prescriptions that were phoned in by a doctor. (In addition to what you’ve
told me about, did/Did) [you/(SP)] get any medicine prescribed by a doctor in a telephone call to a drugstore or
pharmacy [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) YES
INSTITUTIONALIZATION)]?
(02) NO
(-8) DON'T KNOW
[INLCUDE ALL PRESCRIBED MEDICINES REGARDLESS OF WHO OBTAINED IT FOR THE
(-9) REFUSED
RESPONDENT, WHEN IT WAS OBTAINED, WHETHER OR NOT THE PRESCRIPTION COST ANYTHING,
AND WHETHER OR NOT THE RESPONDENT ACTUALLY TOOK THE MEDICINE.]
GETNUM
PM6
roster
BOX PM1
routing
PM6A
grid
BOX PM1A
routing
BOX PM1AB
routing
RXNOFILL
PM6AB
list
RXDELAY
PM6AB
list
RXSKIP
PM6AB
list
RXDOSE
PM6AB
list
NAVIGATOR
PM6A_IN
instance navigator
BOX PM1A-1
PMSATVA
PMSATHMO
routing
PM6A1
yes/no
BOX PM1AA
routing
PM6B
yes/no
PMINTROB
BOX PM1B
no entry
[since (REFERENCE DATE)] respondent is SP
[between (REFERENCE DATE) and (DATE OF DEATH)] respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[Also, please
take out [your/(SP's)] (MEDICARE PRESCRIPTION DRUG PLAN
NAME) medicine statements, which should have that same
information on them.] SP has a "current" Medicare Prescription Drug plan or there was
a Medicare Prescription Drug plan "current" at the time of the
previous round interview
[] SP does not have a "current" Medicare Prescription Drug plan or there was not
a Medicare Prescription Drug plan "current" at the time of the
previous round interview
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can
spell the medicine name correctly and enter the strength of the medicine. [Also, please
take out [your/(SP's)] (MEDICARE PRESCRIPTION DRUG PLAN
NAME) medicine statements, which should have that same
information on them.]
(01) BOX PMA3
(02) BOX PM1
(-8) BOX PM1
(-9) BOX PM1
PM6 - MEDICINE_PM3
[your] respondent is SP
[(SP)'s] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
Please tell me the names of these medicines.
SELECT OR ADD ALL MEDICINES AT THIS ROSTER.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
INCLUDE STRENGTH WITH NAME.
(01) CONTINUOUS ANSWER
BOX PM1
IF SP REPORTED AT LEAST ONE PRESCRIPTION MEDICINE IN THE CURRENT ROUND UTILIZATION
THAT DOES NOT HAVE NUMBER OF PURCHASES ENTERED, GO TO PM6A - GETNUM.
ELSE GO TO PM17 - PMMORE.
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX PM1A
IF AT LEAST ONE PRESCRIPTION MEDICINE DISPLAYED AT PM6A HAS NUMBER OF PURCHASES > 0
OR EQUAL TO DK OR RF, GO TO RXNOFILL
ELSE GO TO PM17 - PMMORE.
IF THIS IS ROUND 70 AND PM6AB - RXNOFILL HAS NOT BEEN ASKED IN THE CURRENT ROUND, GO
TO PM6AB - RXNOFILL.
ELSE GO TO PM6A_IN - NAVIGATOR.
SHOW CARD PM1
(01) OFTEN
Please think about the medicines you have obtained since (REFERENCE DATE), including [READ MEDICINE
(02) SOMETIMES
NAME(S) BELOW.] Since (REFERENCE DATE), how often did [you/(SP)] do any of the following things for
(03) NEVER
these medicines. Did [you/(SP)] often, sometimes, or never…
(-8) DON'T KNOW
(-9) REFUSED
decide not to fill or refill a prescription because the medicine cost too much?
(01) OFTEN
(02) SOMETIMES
delay getting a prescription filled or refilled because the medicine cost too much?
(03) NEVER
(-8) DON'T KNOW
(-9) REFUSED
(01) OFTEN
(02) SOMETIMES
skip doses to make the medicine last longer?
(03) NEVER
(-8) DON'T KNOW
(-9) REFUSED
(01) OFTEN
(02) SOMETIMES
take smaller doses to make the medicine last longer?
(03) NEVER
(-8) DON'T KNOW
(-9) REFUSED
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
[you] respondent is SP
[(SP)] respondent is proxy
PM6AB - RXDELAY
PM6AB - RXSKIP
PM6AB - RXDOSE
PM6A_IN - NAVIGATOR
(01) BOX PM1A-1
(02) BOX PM3A
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND
OR ANY PREVIOUS ROUND), GO TO PM6A1 - PMSATVA.
ELSE GO TO BOX PM1AA.
(01) YES
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of (02) NO
Veterans Affairs or V.A.?
(-8) DON'T KNOW
(-9) REFUSED
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO PM6B - PMSATHMO.
ELSE GO TO PMINTROB - PMINTB.
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED
CARE PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE
PLAN NAME(S) BELOW]?
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]
PMINTB
[you] respondent is SP
[(SP)] respondent is proxy
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO PM5A - PM3PMMEDS.
ELSE GO TO PM6 - MEDICINE_PM3.
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles, too.
MEDICINE_PM3
[In addition to what you’ve told me about, did] SP reported one or more PM's in the current round utilization
[Did] SP did not report PM's in the current round utilization
[ASK R TO GET BOTTLES AND/OR STATEMENTS IF YOU HAVE NOT ALREADY DONE SO.]
[Now] I need to ask you a few [more] questions about the (MEDICINE NAME).
GO TO PM8 - PMBOTTLE.
[you] respondent is SP
[(SP)] respondent is proxy
[this purchse] PMRO.GETNUM = 1
[any of these purchases] PMRO.GETNUM is not equal to 1
BOX PM1AA
[you] respondent is SP
[(SP)] respondent is proxy
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[this purchse] PMRO.GETNUM = 1
[any of these purchases]
PMRO.GETNUM is not equal 1
[your] respondent is SP
[(SP)'s]
respondent
is proxyby a Medicare managed care plan or a private managed care plan anytime
[Now] SP
was not covered
during the current round
[] SP was covered by a Medicare managed care plan or a private managed care plan anytime during the
current round
[more] SP was covered by a Medicare managed care plan or a private managed care plan anytime during
the current round
[] SP was not covered by a Medicare managed care plan or a private managed care plan anytime during the
current round
PMINTROB - PMINTB
PMBOTTLE
PM8
BOX PM1B-1
code one
CODE “YES” WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT.
Do you have the medicine bottle, container, or bag available?
IF R DOES NOT HAVE BOTTLE, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS ABOUT THE
FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
routing
IF (SP REPORTED THE PRESCRIPTION MEDICINE IN THE PREVIOUS ROUND AND THE PREVIOUS
ROUND FORM WAS ASKED AND DID NOT EQUAL DK) AND (SP REPORTED THE PRESCRIPTION
MEDICINE IN THE PREVIOUS ROUND AND THE PREVIOUS ROUND STRENGTH WAS ASKED AND DID
NOT EQUAL DK) AND ((SP REPORTED THE PRESCRIPTION MEDICINE IN THE PREVIOUS ROUND
AND THE PREVIOUS ROUND NUMBER WAS ASKED AND DID NOT EQUAL DK) OR (SP REPORTED
THE PRESCRIPTION MEDICINE IN THE PREVIOUS ROUND AND THE PREVIOUS ROUND AMOUNT
WAS ASKED AND DID NOT EQUAL DK)), GO TO PM8AA - SAMEFSAM.
IF SP REPORTED THE PRESCRIPTION MEDICINE IN THE PREVIOUS ROUND AND THE PREVIOUS
ROUND FORM WAS ASKED AND DID NOT EQUAL DK, GO TO PM8A - SAMEFORM.
ELSE GO TO BOX PM1B-2A.
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
[you] respondent is SP
[(SP)] respondent is proxy
The strength of [each pill/each suppository/each patch/the (STRENGTH MEDICINE FORM)] was [READ
STRENGTH BELOW].
SAMEFSAM
PM8AA
yes/no
(STRENGTH 1)
(STRENGTH 2)
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[The amount of the (MEDICINE FORM) in the container when it was obtained was (PREVIOUS ROUND
MEDICINE AMOUNT)./The number of (MEDICINE FORM) in the container when it was obtained was
(PREVIOUS ROUND NUMBER).]
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS STRENGTH, FORM AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.
SAMEFORM
PM8A
BOX PM1B-2
yes/no
routing
BOX PM1B-2A routing
PMINTROC
no entry
CODE “YES” WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM
IS SAME AS PREVIOUS INTERVIEW.
(I would like to record what is different about this medicine.)
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
Is this medicine in the same form?
IF SP REPORTED THE PRESCRIPTION MEDICINE IN THE PREVIOUS ROUND AND THE PREVIOUS
ROUND STRENGTH WAS ASKED AND DID NOT EQUAL DK, GO TO PM9A - SAMESTRN.
ELSE GO TO PM10 - STRNUNIT.
IF PM8 - PMBOTTLE=1/Yes, GO TO PMINTROC - PMINTC.
ELSE GO TO PM9 - PMFORM.
COMPLETE PM9 -- PM16 USING INFORMATION FROM STATEMENT, RECEIPT, MEDICINE BOTTLE OR
CONTAINER. IF THERE IS MORE THAN ONE FOR THE SAME MEDICINE, USE THE MOST RECENT
CONTAINER.
IN WHAT FORM IS THE MEDICINE?
PMFORM
PM9
code one
[IF THE CONTAINER INDICATES "PADS", SELECT THE CATEGORY FOR "PATCHES'.]
PMFORMOS
SAMESTRN
PM9
PM9A
text
yes/no
WHAT IS THE STRENGTH OF [EACH PILL/EACH SUPPOSITORY/EACH PATCH/THE (MEDICINE
FORM)]?
STRNUNIT
PM10
quantity unit
IF COMPOUND MEDICINE: ENTER STRENGTH OF 1ST MEDICINE, THEN CHECK THE BOX BELOW.
STRNUNOS
STRNNUM
STRNPER
PM10
PM10
PM10
STRNUNIT96
PM10
BOX PM1B-3
text
numeric
numeric
routing
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
IF PM10 - STRNUNIT96 = 1/Compound, GO TO PM10B - STRNUNI2.
ELSE GO TO BOX PM1B-4.
[each pill] previous round PMRO.PMFORM = 1/Pill
[each suppository] previous round PMRO.PMFORM = 5/Suppository
[each patch] previous round PMRO.PMFORM = 10/Patch
Else display [the (STRENGTH MEDICINE FORM)]
[The amount of the (MEDICINE FORM) in the container when it was obtained was (PREVIOUS ROUND
MEDICINE AMOUNT)] SP reported the prescription medicine in the previous round and the previous round
amount was asked
[The number of (MEDICINE FORM) in the container when it was obtained was (PREVIOUS ROUND
NUMBER).] SP reported the prescription medicine in the previous round and the previous round medicine
number was asked
[you] respondent is SP
[(SP)] respondent is proxy
(01) BOX PM2
(02) PM8A - SAMEFORM
(-8) PM8A - SAMEFORM
(-9) PM8A - SAMEFORM
(01) BOX PM1B-2
(02) BOX PM1B-2A
(-8) BOX PM1B-2A
(-9) BOX PM1B-2A
PM9 - PMFORM
(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
(01) CONTINUOUS ANSWER
OTHER (SPECIFY)
CODE “YES” WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND
STRENGTH IS SAME AS PREVIOUS INTERVIEW.
At the time of the last interview, the strength of [each pill/each suppository/each patch/the (MEDICINE FORM)]
(01) YES
was [READ STRENGTH BELOW].
(02) NO
(-8) DON'T KNOW
(STRENGTH 1)
(-9) REFUSED
(STRENGTH 2)
Is this medicine in the same strength?
(01) BOX PM1B-1
(02) BOX PM2
(03) BOX PM1B-1
(-8) BOX PM2
(-9) BOX PM2
(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED
(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(96) COMPOUND/MORE THAN ONE MEDICINE
COMBINED DO NOT DISPLAY.
(-8) Don't Know
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(01) COMPOUND/MORE THAN ONE MEDICINE
COMBINED
(-7) EMPTY
(01) PM10 - STRNUNIT
(02) PM10 - STRNUNIT
(03) PM10 - STRNUNIT
(04) PM10 - STRNUNIT
(05) PM10 - STRNUNIT
(06) PM10 - STRNUNIT
(07) PM10 - STRNUNIT
(08) PM10 - STRNUNIT
(09) PM10 - STRNUNIT
(10) PM10 - STRNUNIT
(11) PM10 - STRNUNIT
(12) PM10 - STRNUNIT
(91) PM9 - PMFORMOS
(-8) BOX PM1B-4
PM10 - STRNUNIT
[you] respondent is SP
[(SP)] respondent is proxy
[each pill] previous round PMRO.PMFORM = 1/Pill
[each suppository] previous round PMRO.PMFORM = 5/Suppository
[each patch] previous round PMRO.PMFORM = 10/Patch
Else display [the (MEDICINE FORM)]
[EACH PILL] current round PMFORM = 1/Pill
[EACH SUPPOSITORY] current round PMFORM = 5/Suppository
[EACH PATCH] current round PMFORM = 10/Patch
Else display [THE (MEDICINE FORM)]
(01) BOX PM1B-4
(02) PM10 - STRNUNIT
(-8) PM10 - STRNUNIT
(-9) PM10 - STRNUNIT
(01) PM10 - STRNNUM
(02)) PM10 - STRNNUM
(03) PM10 - STRNNUM
(04) PM10 - STRNNUM
(05) PM10 - STRNNUM
(06) PM10 - STRNPER
(07) PM10 - STRNNUM
(08) PM10 - STRNNUM
(91) PM10 - STRNUNOS
(96) DO NOT DISPLAY.
(-8) PM10 - STRNUNIT96
PM10 - STRNNUM
PM10 - STRNUNIT96
PM10 - STRNUNIT96
BOX PM1B-3
STRNUNI2
PM10B
quantity unit
WHAT WAS THE STRENGTH OF THE 2ND MEDICINE IN THE COMPOUND?
STRNUNO2
STRNNUM2
STRNPER2
PM10B
PM10B
PM10B
text
numeric
numeric
OTHER (SPECIFY)
BOX PM1B-4
routing
TABNUM
TABSADAY
TABSADAY95
TABTAKE
TABTAKE96
PERCENT?
IF PM9A - SAMESTRN = 1/Yes AND SP REPORTED THE PRESCRIPTION MEDICINE IN THE PREVIOUS
ROUND AND THE PREVIOUS ROUND AMOUNT WAS ASKED AND DID NOT EQUAL DK, GO TO PM15A SAMEAMNT.
ELSE IF THE PRESCRIPTION MEDICINE FORM IS PILLS, SUPPOSITORIES OR PATCHES, GO TO PM11 TABNUM.
ELSE GO TO PM16 - AMTUNIT.
HOW MANY [PILLS/SUPPOSITORIES/PATCHES] WERE IN THE CONTAINER WHEN IT WAS
(01) CONTINUOUS ANSWER
OBTAINED?
(-8) DON'T KNOW
PM11
numeric
BOX PM1C
routing
IF PRESCRIPTION MEDICINE FORM IS PILLS OR SUPPOSITORIES AND PM11 - TABNUM = DK, GO TO
PM12 - TABSADAY.
ELSE GO TO BOX PM2.
PM12
numeric
HOW MANY [PILLS/SUPPOSITORIES] ARE TO BE TAKEN IN A DAY?
PM12
code one
BOX PM1D
routing
PM13
numeric
PM13
code one
BOX PM1E
routing
TAKEUNIT
PM14
quantity unit
TAKENUM
PM14
numeric
IF PM12 - TABSADAY = DK, GO TO BOX PM2.
ELSE IF PM12 - TABSADAY95 = 2/TakeAsNeeded, GO TO PM13 - TABTAKE.
ELSE GO TO PM14 - TAKEUNIT.
How many (pills/suppositories) (do/did/does) [you/(SP)] usually take in a day?
PM16
quantity unit
HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]
AMTUNOS
AMTNUM
PM16
PM16
text
numeric
DELAYFIL
PM16A
code one
SKIPDOSE
PM16B
code one
BOX PM1C
[PILLS] current round, PMFORM = 1/Pill
[SUPPOSITORIES] current round, PMFORM = 5/Suppository
PM12 - TABSADAY95
(01) LESS THAN WHOLE
(02) TAKE AS NEEDED
(-7) Empty
BOX PM1D
[pills] current round PMFORM = 1/Pill
[suppositories] current round PMFORM = 5/Suppository
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
[do] respondent is SP
[did] respondent is proxy, SP deceased
[does] respondent is proxy, SP alive
PM13 - TABTAKE96
[you] respondent is SP
[(SP)] respondent is proxy
BOX PM1E
(01) BOX PM2
(02) PM16 - AMTUNIT
(-8) PM16 - AMTUNIT
(-9) PM16 - AMTUNIT
(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM2
PM16 - AMTNUM
BOX PM2
AMTUNIT
code one
[PILLS] current round PMFORM = 1/Pill
[SUPPOSITORIES] current round PMFORM = 5/Suppository
[PATCHES] current round PMFORM = 10/Patch
(01) PM14 - TAKENUM
(02) PM14 - TAKENUM
(03) BOX PM2
(04) BOX PM2
(05) BOX PM2
(-8) BOX PM2
BOX PM2
yes/no
PM16A1
PM10B - STRNNUM2
BOX PM1B-4
BOX PM1B-4
(01) DAYS
HOW MANY DAYS OR WEEKS WAS THE MEDICINE TO BE TAKEN?
(02) WEEKS
(03) TAKE UNTIL GONE
[IF THE BOTTLE SAYS TO TAKE A CERTAIN DOSE OF THE MEDICINE DAILY WITHOUT GIVING A TIME (04) TAKE AS NEEDED
FRAME (E.G., “TAKE 2 PILLS DAILY”), SELECT “TAKE EVERY DAY”.]
(05) TAKE EVERY DAY
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
PM15A
NOFILLED
(01) PM10B - STRNNUM2
(02)) PM10B - STRNNUM2
(03) PM10B - STRNNUM2
(04) PM10B - STRNNUM2
(05) PM10B - STRNNUM2
(06) PM10B - STRNPER2
(07) PM10B - STRNNUM2
(08) PM10B - STRNNUM2
(91) PM10B - STRNUNO2
(96) DO NOT DISPLAY.
(-8) BOX PM1B-4
IF PM13 - TABTAKE96 = 1/DontTakeEveryDay, GO TO BOX PM2.
ELSE GO TO PM14 - TAKEUNIT.
SAMEAMNT
routing
(01) CONTINUOUS ANSWER
(01) DON'T TAKE EVERY DAY
(-7) EMPTY
CODE “YES” WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND
AMOUNT IS SAME AS PREVIOUS INTERVIEW.
At the time of the last interview, the amount of the (PREVIOUS ROUND MEDICINE FORM) was (PREVIOUS
ROUND MEDICINE AMOUNT). Is this medicine in the same amount?
BOX PM2
(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(96) COMPOUND/MORE THAN ONE MEDICINE
COMBINED DO NOT DISPLAY.
(-8) Don't Know
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
OTHER (SPECIFY)
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
IF (NOT ADMINISTERING ST AND NOT ADMINISTERING NS) AND (SP IS ALIVE AND NOT
INSTITUTIONALIZED) AND (UTILIZATION IS NOT BEING COLLECTED FOR THE FIRST TIME FOR THIS
SP) AND (THIS IS ROUND 70) AND (AT LEAST ONE RESPONSE AT PM6AB = 1/OFTEN OR
2/SOMETIMES) AND (AT LEAST TWO PRESCRIPTION MEDICINES DISPLAYED AT PM6A HAVE
NUMBER OF PURCHASES > 0 OR EQUAL TO DK OR RF) AND (THIS IS ONE OF THE FIRST 15
MEDICINES BEING ASKED ABOUT IN PM), GO TO PM16A1 - NOFILLED.
ELSE GO TO BOX PM3.
(01) OFTEN
SHOW CARD PM1
(02) SOMETIMES
Since (REFERENCE DATE), how often did [you/(SP)] decide not to fill or refill (MEDICINE) because it cost too (03) NEVER
much?
(-8) DON'T KNOW
(-9) REFUSED
(01) OFTEN
SHOW CARD PM1
(02) SOMETIMES
Since (REFERENCE DATE), how often did [you/(SP)] delay filling or refilling a prescription for (MEDICINE
(03) NEVER
NAME) because it cost too much?
(-8) DON'T KNOW
(-9) REFUSED
SHOW CARD PM1
(01) OFTEN
Since (REFERENCE DATE), how often did [you/(SP)] skip doses of (MEDICINE NAME) to make the medicine (02) SOMETIMES
last longer?
(03) NEVER
(04) NEVER TOOK THE MEDICINE AT ALL
[IF THE RESPONSE IS "NEVER", PROBE: Do you mean that [you/(SP)] never skipped doses of the medicine (-8) DON'T KNOW
to make it last longer, or that (you/he/she) never took the medicine at all?]
(-9) REFUSED
[you] respondent is SP
[(SP)] respondent is proxy
PM16A - DELAYFIL
[you] respondent is SP
[(SP)] respondent is proxy
PM16B - SKIPDOSE
[you] respondent is SP
[(SP)] respondent is proxy
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
(01) PM16C - CUTDOSE
(02) PM16C - CUTDOSE
(03) PM16C - CUTDOSE
(04) BOX PM3
(-8) PM16C - CUTDOSE
(-9) PM16C - CUTDOSE
CUTDOSE
PM16C
code one
BOX PM3
routing
BOX PM3A
routing
SHOW CARD PM1
Since (REFERENCE DATE), how often did [you/(SP)] take smaller doses of (MEDICINE NAME) to make the
medicine last longer?
[IF THE RESPONSE IS "NEVER", PROBE: Do you mean that [you/(SP)] never took smaller doses of the
medicine to make it last longer, or that (you/he/she) never took the medicine at all?]
GO TO PM6A_IN - NAVIGATOR.
IF CURRENTLY ADMINISTERING ST, GO TO BOX ST43.
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS43.
ELSE GO TO PM17 - PMMORE.
(01) OFTEN
(02) SOMETIMES
(03) NEVER
(04) NEVER TOOK THE MEDICINE AT ALL
(-8) DON'T KNOW
(-9) REFUSED
([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE
NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.])
PMMORE
PM17
BOX PMEND
yes/no
routing
(01) YES
REVIEW THIS INFORMATION WITH THE RESPONDENT.
(02) NO
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF
R ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE) that we haven't talked
about?]
GO TO NEXT SECTION
[you] respondent is SP
[(SP)] respondent is proxy
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[THE NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE
DISPLAYED BELOW.] SP reported any Prescription Medicine purchases during the current round
[NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD.] SP
did not report any Prescription Medicine purchases during the current round
[MORE] Display if SP reported any Prescription Medicine purchases during the current round.
Else do not display.
BOX PM3
(01) PM6 - MEDICINE_PM3
(02) BOX PMEND
Statement Charge Series (STQ)
Variable Name
MR Screen
Name
Question type
BOX STBEG routing
Question text/description
Code list
Text Fills
Input mask
Routing
IF ((SP WAS COVERED BY A MEDICARE MANAGED CARE PLAN WITHOUT RX
COVERAGE ANYTIME DURING THE CURRENT ROUND) OR (SP WAS
COVERED BY A PRIVATE MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND)) AND (SP WAS NOT COVERED BY A MEDICARE
PRESCRIPTION DRUG PLAN ANYTIME DURING THE CURRENT ROUND), GO
TO ST1 - MHMOSTMT.
ELSE GO TO ST2 - MCSAVAIL.
[your] respondent is SP
[(SP)'s] respondent is proxy
[Do you usually receive any statements or papers from Medicare, insurance, such as (MANAGED CARE PLAN NAME), or TRICARE
that show the charges for medical visits or equipment?] respondent is SP, previous round HRND.MHMOSTMT = DK, RF or EMPTY
[Does (SP) usually receive any statements or papers from Medicare, insurance, such as (MANAGED CARE PLAN NAME), or
TRICARE that show the charges for medical visits or equipment?] respondent is proxy, previous round HRND.MHMOSTMT = DK,
RF or EMPTY
Now that we have finished talking about medical visits and prescribed medicines, let’s
talk about [your/(SP’s)] medical costs. We should start by looking at any paperwork or
written explanations of what was paid by Medicare, any insurance company, or
TRICARE.
MHMOSTMT
ST1
code one
[Do you/Does (SP)] usually receive any statements or papers from Medicare,
insurance, such as (MANAGED CARE PLAN NAME), or TRICARE that show the
charges for medical visits or equipment?/Last time, we recorded that [you/(SP)]
(always/sometimes/never) received statements or papers from Medicare, insurance, or
TRICARE that show the charges for medical visits or equipment.]
(01) ALWAYS
(02) SOMETIMES
(03) NEVER
(-8) DON'T KNOW
(-9) REFUSED
Please tell me if (currently) [you always receive statements, sometimes receive
statements, or never receive statements/(SP) always receives statements, sometimes
receives statements, or never receives statements].
[Last time, we recorded that you always received statements or papers from Medicare, insurance, or TRICARE that show the charges
for medical visits or equipment.] respondent is SP, previous round HRND.MHMOSTMT = 1/Always
[Last time, we recorded that you sometimes received statements or papers from Medicare, insurance, or TRICARE that show the
charges for medical visits or equipment.] respondent is SP, previous round HRND.MHMOSTMT = 2/Sometimes
[Last time, we recorded that you never received statements or papers from Medicare, insurance, or TRICARE that show the charges
for medical visits or equipment.] respondent is SP, previous round HRND.MHMOSTMT = 3/Never
[Last time, we recorded that [(SP)] always received statements or papers from Medicare, insurance, or TRICARE that show the
charges for medical visits or equipment.] respondent is proxy, previous round HRND.MHMOSTMT = 1/Always
[Last time, we recorded that [(SP)] sometimes received statements or papers from Medicare, insurance, or TRICARE that show the
charges for medical visits or equipment.] respondent is proxy, previous round HRND.MHMOSTMT = 2/Sometimes
[Last time, we recorded that [(SP)] never received statements or papers from Medicare, insurance, or TRICARE that show the
charges for medical visits or equipment.] respondent is proxy, previous round HRND.MHMOSTMT = 3/Never
(01) ST2 - MCSAVAIL
(02) ST2 - MCSAVAIL
(03) BOX STEND
(-8) ST2 - MCSAVAIL
(-9) ST2 - MCSAVAIL
[currently] previous round HRND.MHMOSTMT ^= empty
Else do not display [currently]
[you always receive statements, sometimes receive statements, or never receive statements] respondent is SP
[(SP) always receives statements, sometimes receives statements, or never receives statements] respondent is proxy
[Now that we have finished talking about medical visits and prescribed medicines, let’s talk about [your/(SP’s)] medical costs. We
should start by looking at any paperwork or written explanations of what costs were paid by Medicare, any insurance company, or
TRICARE.] ST1 - MHMOSTMT = empty
[] ST1 - MHMOSTMT is not equal to empty
MCSAVAIL
ST2
yes/no
[Now that we have finished talking about medical visits and prescribed medicines, let’s
talk about [your/(SP’s)] medical costs. We should start by looking at any paperwork or
written explanations of what costs were paid by Medicare, any insurance company, or
TRICARE.]
[PROBE IF NECESSARY: Do you have any statements or paper from Medicare,
insurance, or TRICARE [that [you/(SP)] received since the last interview]? (Please
include any statements received about [your/(SP's)] prescription drug benefit.)]
STHIREP
MATCHST
ST_CHARGEBUNDLE
PDPTYPE
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[your] respondent is SP
[(SP)'s] respondent is proxy
[that you received since the last interview] respondent is SP, this is SP's second or more community interview
[that (SP) received since the last interview] respondent is proxy, this is SP's second or more community interview
[] this is SP's first community interview
(01)
(02)
(-8)
(-9)
ST3 - STHIREP
BOX STEND
BOX STEND
BOX STEND
[Please include any statements received about [your/(SP's)] prescription drug benefit.] - SP has a "current" (MHMO, TRICARE, or
Medicare Prescription Drug plan) or there was a (MHMO, TRICARE, or Medicare Prescription Drug plan) "current" at the time of the
previous round interview
[] SP does not have a "current" (MHMO, TRICARE, or Medicare Prescription Drug plan) or there was not a (MHMO, TRICARE, or
Medicare Prescription Drug plan) "current" at the time of the previous round interview
no entry
BASED ON THE INFORMATION RECORDED IN THE HEALTH INSURANCE
SECTION FOR RECENT ROUNDS, THE PLAN(S) LISTED BELOW ARE THE
SOURCES OF STATEMENTS YOU MIGHT EXPECT TO FIND FOR THIS SP.
ST4 - MATCHST
no entry
[MATCH UP MEDICARE, INSURANCE, TRICARE, AND MEDICARE
PRESCRIPTION BENEFIT STATEMENTS BY PROVIDER AND DATE OF
SERVICE./PRESS ENTER TO CONTINUE TO THE NEXT
(STATEMENT/BUNDLE).]
[SELECT "MPDP STATEMENT OR MA/TRICARE PRESCRIPTION DRUG
BUNDLE" AT THE NEXT SCREEN FOR ALL STATEMENTS FROM THE SP’S
"(MPDP)" PLAN, "(MHMO)" PLAN OR TRICARE PLAN THAT REPORTS
PRESCRIPTION DRUG CLAIMS.]
ST5 - ST_CHARGEBUNDLE
ST5
roster
ADD THE SOURCE(S) AND TYPE OF STATEMENT(S) FOR THE (FIRST/NEXT)
BUNDLE OF EVENTS.
ADD ONE CHARGE BUNDLE AT THIS ROSTER.
BOX ST5A
BOX ST5A
routing
IF ST5 – STTYPE = 8/MPDPorMAorTricare THEN GO TO ST5A - PDPTYPE.
ELSE GO TO BOX ST5B.
ST3
ST4
ST5A
code one
BOX ST5B
routing
BOX ST5
routing
SELECT THE TYPE OF PRESCRIPTION DRUG STATEMENT FOR THIS
BUNDLE.
SET STATEMENT TYPE.
GO TO BOX ST5.
IF TYPE OF STATEMENT = 1/Medicare, 3/MedicareAndInsurance,
5/MedicareAndTricare, OR 7/MedicareAndTricareAndInsurance, GO TO ST7 MSNCLNUM.
ELSE IF TYPE OF STATEMENT = 2/Insurance OR 6/TricareAndInsurance, GO TO
ST10 - INSCLNUM.
ELSE IF TYPE OF STATEMENT = 4/Tricare AND ST5 - STTYPE = 4/Tricare, GO
TO ST11 - TRICLNUM.
ELSE GO TO ST11B - PDPBEGMM.
(01) MEDICARE PRESCRIPTION DRUG BENEFIT
STATEMENT
(02) MEDICARE ADVANTAGE STATEMENT
(03) TRICARE STATEMENT
BOX ST5B
ENTER UP TO FIVE CLAIM CONTROL NUMBERS FROM THE MEDICARE
SUMMARY NOTICE (MSN) ASSOCIATED WITH ONE CLAIM TOTAL.
MSNCLNUM
ST7
text
IF NO CLAIM CONTROL NUMBER(S) LISTED, ENTER "DON'T KNOW".
DO NOT ENTER ANY CLAIM CONTROL NUMBERS IN COMMENTS.
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
MSNCLNM2
ST7
text
MSNCLNM3
ST7
text
MSNCLNM4
ST7
text
MSNCLNM5
ST7
text
BOX ST7
routing
IF ST7 - MSNCLNUM = DK, GO TO BOX ST9.
ELSE GO TO ST8 - MSCLVER1.
ST8
text
PLEASE ENTER THE FIRST CLAIM CONTROL NUMBER FROM THE MEDICARE
(01) CONTINUOUS ANSWER
SUMMARY NOTICE (MSN) AGAIN.
routing
IF ST8 - MSCLVER1 MATCHES ST7 - MSNCLNUM, GO TO BOX ST9.
ELSE GO TO ST9 - WHICHNUM.
MSCLVER1
BOX ST8
WHICHNUM
ST9
code one
ST7 - MSNCLNM2
ST7 - MSNCLNM3
ST7 - MSNCLNM4
ST7 - MSNCLNM5
BOX ST7
BOX ST8
IF ST8 - MSCLVER1 MATCHES ST7 - MSNCLNUM, GO TO
BOX ST9.
ELSE GO TO ST9 - WHICHNUM.
YOU HAVE ENTERED THE CLAIM CONTROL NUMBERS FROM THE MEDICARE
SUMMARY NOTICE (MSN) DIFFERENTLY.
FIRST TIME: (FIRST MSN CLAIM CONTROL NUMBER)
(01) FIRST
(02) SECOND
SECOND TIME: (SECOND MSN CLAIM CONTROL NUMBER)
(03) NEITHER
(01) BOX ST9
(02) BOX ST9
(03) ST9 - NEWCLNUM
WHICH IS CORRECT?
NEWCLNUM
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
text
ENTER CORRECT MSN CLAIM CONTROL NUMBER:
BOX ST9
routing
IF TYPE OF STATEMENT = 3/MedicareAndInsurance OR
7/MedicareAndTricareAndInsurance, GO TO ST10 - INSCLNUM.
ELSE IF TYPE OF STATEMENT = 5/MedicareAndTricare, GO TO ST11 TRICLNUM.
ELSE GO TO ST12 - INCTYPE.
ST10
text
ENTER THE CLAIM CONTROL NUMBER FROM THE INSURANCE STATEMENT. (01) CONTINUOUS ANSWER
IF NO CLAIM CONTROL NUMBER LISTED, ENTER "DON'T KNOW".
(-8) DON'T KNOW
BOX ST10
routing
IF TYPE OF STATEMENT = 6/TricareAndInsurance OR
7/MedicareAndTricareAndInsurance, GO TO ST11 - TRICLNUM.
ELSE GO TO ST12 - INCTYPE.
TRICLNUM
ST11
text
ENTER THE CLAIM CONTROL NUMBER FROM THE TRICARE STATEMENT. IF (01) CONTINUOUS ANSWER
NO CLAIM CONTROL NUMBER LISTED, ENTER "DON'T KNOW".
(-8) DON'T KNOW
PDPBEGMM
ST11B
date
ENTER THE BEGINNING AND ENDING DATES OF SERVICE FROM THE
PRESCRIPTION DRUG BENEFIT STATEMENT.
BEGINNING DATE:
INSCLNUM
ST9
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) PROVIDER SERVICE DATES
(02) HOME HEALTH VISITS
(03) OTHER MEDICAL EXPENSES
(04) PRESCRIBED MEDICINES
BOX ST9
BOX ST10
ST12 - INCTYPE
MM
ST11B - PDPBEGDD
DD
ST11B - PDPBEGYY
YY
ST11B - PDPENDMM
MM
ST11B - PDPENDDD
DD
ST11B - PDPENDYY
YY
ST12 - INCTYPE
PDPBEGDD
ST11B
date
PDPBEGYY
ST11B
date
PDPENDMM
ST11B
date
PDPENDDD
ST11B
date
PDPENDYY
ST11B
date
INCTYPE
ST12
code all
WHAT TYPE(S) OF EVENT(S) ARE INCLUDED IN THIS CHARGE BUNDLE ON
THE (TYPE OF STATEMENT)?
CHECK ALL THAT APPLY.
BOX ST12
routing
IF THE RESPONSE TO ST12 - INCTYPE INCLUDES 1/ProvDates, GO TO ST13 PROVIDER_STDATE.
ELSE GO TO BOX ST26.
ST13
roster
WHICH MEDICAL PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.
(01) ST24 - EVENT_STDATE
(02) EVENT DATE ST16 EVENT_STDATEADD
(03) ST15 - EVENT_STDATEDIT
PROVIDER_STDATE
ENDING DATE:
(01) CONTINUOUS ANSWER
BOX ST12
ST14 - STDATEUPD
STDATEUPD
ST14
code one
THE FOLLOWING EVENT DATES HAVE BEEN ENTERED FOR THIS PROVIDER. (01) NO, DO NOT NEED TO ADD OR EDIT EVENT DATES
DO YOU NEED TO ADD OR EDIT AN EVENT DATE FOR THIS CHARGE
(02) YES, NEED TO ADD EVENT DATE
BUNDLE?
(03) YES, NEED TO EDIT EVENT DATE
EVENT_STDATEDIT
ST15
roster
SELECT AND EDIT THE EVENT DATE THAT NEEDS CORRECTION.
(01) CONTINUOUS ANSWER
ST14 - STDATEUPD
EVENT_STDATEADD
ST16
roster
ADD THE MISSING EVENT DATE(S) IN THIS CHARGE BUNDLE.
ADD ALL EVENT DATES FOR THIS PROVIDER.
(01) CONTINUOUS ANSWER
BOX ST16A
BOX ST16A
routing
IF AT LEAST ONE EVENT DATE ADDED AT ST16 IS NOT OUTSIDE THE
SURVEY REFERENCE PERIOD, GO TO BOX ST16B.
ELSE GO TO ST14 - STDATEUPD.
BOX ST16B
routing
IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'IP', 'OP', OR 'MP' EVENT
TYPE, GO TO ST17 - STDATEINTRO.
ELSE GO TO BOX ST17.
ST17
no entry
BOX ST17
routing
STDATEINTRO
Before we continue with this statement, I would like to ask you a few questions about
the visit(s) I just added.
IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU' OR 'MP' EVENT TYPE AND
THE PROVIDER SPECIALTY HAS NOT BEEN COLLECTED, GO TO ST18 PROVSPEC.
ELSE GO TO BOX ST18.
BOX ST17
PROVSPEC
ST18
code one
What kind of medical person is (PROVIDER NAME)?
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
PROVSPOS
ST18
text
OTHER MEDICAL PROVIDER (SPECIFY)
(01) CONTINUOUS ANSWER
BOX ST18
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX ST19
BOX ST18
routing
(01)-(34), (-8), (-9) BOX ST18
(91) - ST18 - PROVSPOS
IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'ER', 'IP', 'OP', 'IU', OR 'MP'
EVENT TYPE) AND (SP REPORTED RECEIVING HEALTH CARE SERVICES
THROUGH V.A. IN THE CURRENT ROUND OR ANY PREVIOUS ROUND) AND
(IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO ST19 VAPLACE.
ELSE GO TO BOX ST19.
VAPLACE
ST19
BOX ST19
HMOASSOC
ST20
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A.
facility?
routing
IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'ER', 'IP', 'OP', OR 'MP'
EVENT TYPE) AND (SP COVERED BY A MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND) AND (IF THIS PROVIDER IS ASSOCIATED
WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO ST20 - HMOASSOC.
ELSE IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'ER', 'IP', 'OP', OR
'MP' EVENT TYPE) AND (SP COVERED BY A MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND) AND (THIS PROVIDER IS NOT ASSOCIATED
WITH A MANAGED CARE PLAN), GO TO ST21 - HMOREFER.
ELSE GO TO ST22A_IN - NAVIGATOR.
yes/no
(01) YES
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN (02) NO
NAME(S) BELOW] plan?
(-8) DON'T KNOW
(-9) REFUSED
HMOREFER
ST21
yes/no
NAVIGATOR
ST22A_IN
instance
navigator
BOX ST22A
BOX ST22B
MPSDVIS
EVENT_STDATE
RVLINKS
ST23
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE
PLAN NAME(S) BELOW]?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[your] respondent is SP
[(SP)'s] respondent is proxy
[Were you] respondent is SP
[Was (SP)] respondent is proxy
(PROVIDER NAME)
[READ MANAGED CARE PLAN NAME(S) BELOW]
(01) ITEM SELECTED IN INSTANCE NAVIGATOR BOX ST22A
(02) CONTINUE INTERVIEW SELECTED ST14 - STDATEUPD
routing
FOR THIS EVENT ADDED AT ST16,
IF TYPE OF EVENT = 'IP', GO TO IP7 - ANYOPERS.
ELSE IF TYPE OF EVENT = 'OP', GO TO OP5 - ANYOPERS.
ELSE IF TYPE OF EVENT = 'MP', GO TO BOX ST22B.
ELSE GO TO BOX ST23B.
routing
IF (PROVIDER SPECIALTY IS A MEDICAL DOCTOR) AND ((EVENT DATE
OVERLAPS AN EXISTING IP EVENT) OR (EVENT DATE MATCHES AN EXISTING
ER OR OP EVENT) GO TO ST23 - MPSDVIS.
ELSE GO TO BOX ST23A.
yes/no
(01) YES
We have recorded that in (EVENT MONTH) [you were/(SP) was] also in [READ
(02) NO
EVENT(S) LISTED BELOW]. Was this visit with (PROVIDER NAME) a visit while [you
(-8) DON'T KNOW
were/(SP) was] in [the [READ EVENT LISTED BELOW]/any of these places]?
(-9) REFUSED
BOX ST23A
routing
IF ST23 ASKED AND ST23 - MPSDVIS = 1/Yes, GO TO BOX ST23B.
ELSE GO TO BOX MP2C.
BOX ST23B
routing
GO TO ST22A_IN - NAVIGATOR.
ST24
roster
BOX ST24
routing
ST24A
numeric
SELECT THE EVENT DATE(S) THAT ARE INCLUDED IN THIS CHARGE
BUNDLE.
IF AT LEAST ONE EVENT SELECTED AT ST24 IS A REPEAT VISIT, GO TO
ST24A - RVLINKS.
ELSE GO TO ST25 - STDATEMTCH.
ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT MONTH, YEAR)
THAT ARE COVERED BY THIS CHARGE.
(01) ST22A_IN - NAVIGATOR
(02) ST21 - HMOREFER
(-8) ST21 - HMOREFER
(-9) ST21 - HMOREFER
ST22A_IN - NAVIGATOR
(01) BOX ST22A
(02) ST14 - STDATEUPD
[you were] respondent is SP
[(SP) was] respondent is proxy
BOX ST23A
[the (READ EVENT LISTED BELOW)] event does not overlap more than one existing ER, IP, or OP event
[any of these places] event overlaps more than one existing ER, IP, or OP event
(01) CONTINUOUS ANSWER
BOX ST24
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST24A
BOX ST24A
routing
IF ANOTHER EVENT SELECTED AT ST24 IS A REPEAT VISIT, GO TO ST24A RVLINKS.
ELSE GO TO ST25 - STDATEMTCH.
(01) BOX ST26
(02) ST13 - PROVIDER_STDATE
(03) ST26 EVENT_STDATEDEL
(01) CONTINUOUS ANSWER
ST25 - STDATEMTCH
(01) CONTINUOUS ANSWER
ST28 - COSTBEGM
STDATEMTCH
ST25
code one
(01) YES
ARE ALL THE PROVIDER EVENTS FROM THE CHARGE BUNDLE ON (TYPE OF
(02) NO, NEED TO ADD A PROVIDER EVENT
STATEMENT) SHOWN BELOW?
(03) NO, NEED TO REMOVE A PROVIDER EVENT
EVENT_STDATEDEL
ST26
roster
SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE
CHARGE BUNDLE.
BOX ST26
routing
IF ST12 – INCTYPE INCLUDES 2/HHVisits, GO TO ST27 - PROVIDER_STHH.
ELSE GO TO BOX ST33.
ST27
roster
WHICH HOME HEALTH PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.
PROVIDER_STHH
COSTBEGM
ST28
numeric
ENTER THE START DATE AND STOP DATE COVERED BY THE CHARGE
BUNDLE.
START DATE:
COSTBEGD
ST28
numeric
COSTBEGY
ST28
numeric
COSTENDM
ST28
numeric
COSTENDD
ST28
numeric
COSTENDY
ST28
numeric
STOP DATE:
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST28A
routing
IF (HOME HEALTH PROVIDER WAS ADDED AT ST27) OR (AN EXISTING
PROVIDER WAS SELECTED AT ST27 THAT WAS NOT ASSOCIATED WITH A
HOME HEALTH EVENT), GO TO ST30 - HHEVNTTYPE.
ELSE GO TO BOX ST31B.
HHEVNTTYPE
ST30
code one
IS THE PROVIDER A HOME HEALTH PROFESSIONAL OR SOME OTHER TYPE
OF HOME HEALTH PROVIDER (HOME HEALTH AIDE, HOMEMAKER, ETC.)?
(01) HOME HEALTH PROFESSIONAL
(02) OTHER HOME HEALTH PROVIDER
STHHINTRO
ST31
no entry
Before we continue with this statement, I would like to ask you a few questions about
the home health provider I just added.
BOX ST31A
BOX ST31A
routing
IF ST30 - HHEVNTTYPE = 1/HP, GO TO HH3 - PROVSPEC.
ELSE GO TO HH20 - HHFTYPE.
BOX ST31B
routing
LINK HOME HEALTH PROVIDER TO CHARGE BUNDLE
GO TO ST32 - STHHMTCH.
MM
ST28 - COSTBEGD
DD
ST28 - COSTBEGY
YY
ST28 - COSTENDM
MM
ST28 - COSTENDD
DD
ST28 - COSTENDY
YY
BOX ST28A
ST31 - STHHINTRO
THE FOLLOWING HOME HEALTH PROVIDER EVENT HAS BEEN ADDED TO
THIS CHARGE BUNDLE.
STHHMTCH
ST32
code one
BOX ST33
routing
IF ST12 – INCTYPE INCLUDES 3/OMExpenses, GO TO ST34 - STOMUPD.
ELSE GO TO BOX ST40.
THE FOLLOWING OME EVENTS HAVE BEEN ENTERED.
STOMUPD
ST34
code one
EVENT_STOMEDIT
ST35
roster
STOMADD
DO YOU NEED TO ADD OR EDIT AN OME EVENT FOR THIS CHARGE
BUNDLE?
code one
WHAT TYPE OF OTHER MEDICAL EXPENSE NEEDS TO BE ADDED?
BOX ST36
routing
GO TO ST34 - STOMUPD.
ST37
roster
SELECT OTHER MEDICAL EXPENSES THAT ARE IN THIS CHARGE BUNDLE
ON THE (TYPE OF STATEMENT).
BOX ST37
routing
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT ST37 IS RENTED,
GO TO ST38 - MONTHCOV.
ELSE GO TO BOX ST38B.
ST38
MONCOV96
ST38
BOX ST38A
numeric
routing
(01) NO, DO NOT NEED TO ADD OR EDIT OM EVENT
(02) YES, NEED TO ADD AN OME EVENT
(03) YES, NEED TO EDIT AN OME EVENT
(01) ST37 - EVENT_STOM
(02) ST36 - STOMADD
(03) ST35 - EVENT_STOMEDIT
(01) GLASSES/CONTACTS
(02) HEARING/SPEECH DEVICE
(03) ORTHOPEDIC ITEM
(04) DIABETIC SUPPLIES
(05) AMBULANCE/RESCUE
(06 PROSTHESIS
(07) ALTERATIONS (HOME/CAR)
(08) OXYGEN
(09) KIDNEY DIALYSIS
(10) ALL OTHER MEDICAL SUPPLIES
(01) OM2 - EVENT_OMEYEG
(02) OM4 - EVENT_OMHEAR
(03) OM6 - ORTHTYPE
(04) OM10 - EVENT_OMDIAB
(05) OM12 - EVENT_OMAMBL
(06) OM14 - EVENT_OMPROS
(07) OM29 - ALTRTYPE
(08) OM19A - OXGNTYPE
(09) OM21A - KDNYTYPE
(10) OM24 - OTHRTYPE
SELECT AND EDIT THE OTHER MEDICAL EXPENSE EVENT THAT NEEDS
CORRECTION.
ST36
MONTHCOV
BOX ST33
PLEASE ENTER A COMMENT IF THIS EVENT WAS ENTERED IN ERROR OR IF
ANOTHER HOME HEALTH EVENT SHOULD BE INCLUDED IN THIS CHARGE
BUNDLE.
HOW MANY MONTHS ARE COVERED BY THIS CHARGE BUNDLE?
IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT ST37 IS RENTED, GO
TO ST38 - MONTHCOV.
ELSE GO TO BOX ST38B.
BOX ST37
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED
(01) LESS THAN 1 MONTH
(-7) EMPTY
ST38 - MONCOV96
BOX ST38A
BOX ST38B
NUMLINKS
ST38A
routing
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT ST37 IS OSTOMY
SUPPLIES, INCONTINENCE SUPPLIES OR BANDAGES, GO TO ST38A NUMLINKS.
ELSE GO TO ST39 - STOMMTCH.
numeric
HOW MANY PURCHASES OF (NAME OF OME ITEM) ARE COVERED BY THIS
CHARGE BUNDLE?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST38AA
(01) BOX ST40
(02) ST34 - STOMUPD
(03) ST40 - EVENT_STOMDEL
BOX ST38AA routing
IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT ST37 IS OSTOMY
SUPPLIES, INCONTINENCE SUPPLIES OR BANDAGES, GO TO ST38A NUMLINKS.
ELSE GO TO ST39 - STOMMTCH.
STOMMTCH
ST39
code one
ARE ALL THE OTHER MEDICAL EXPENSES FROM THE CHARGE BUNDLE ON
THE (TYPE OF STATEMENT) SHOWN BELOW?
(01) YES
(02) NO, NEED TO ADD AN OME EVENT
(03) NO, NEED TO REMOVE AN OME EVENT
EVENT_STOMDEL
ST40
roster
SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE
CHARGE BUNDLE.
(01) CONTINUOUS ANSWER
BOX ST40
routing
IF ST12 – INCTYPE INCLUDES 4/PMS, GO TO ST41 - EVENT_STPM.
ELSE GO TO BOX ST45.
ST41
roster
SELECT OR ADD ALL PRESCRIPTION MEDICINES THAT ARE IN THIS CHARGE
(01) CONTINUOUS ANSWER
BUNDLE ON THE (TYPE OF STATEMENT).
EVENT_STPM
ST42 - NUMLINKS
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST42
grid
HOW MANY PURCHASES OF EACH MEDICINE SHOWN BELOW ARE
COVERED BY THIS CHARGE BUNDLE?
BOX ST42
routing
IF AT LEAST ONE PRESCRIPTION MEDICINE WAS ADDED AT ST41, GO TO
ST43 - STPMINTRO.
ELSE GO TO ST44 - STPMMTCH.
ST43
no entry
Before we continue with this statement, I would like to ask you a few questions about
the prescribed medicine(s) I just added. [It would be very helpful for the following
questions if we could look at the bottle(s) or container(s) for the medicine(s).]
BOX ST43
routing
GO TO ST44 - STPMMTCH.
STPMMTCH
ST44
code one
(01) YES
ARE ALL THE PRESCRIBED MEDICINES FROM THE CHARGE BUNDLE ON THE
(02) NO, NEED TO ADD A MEDICINE NAME
(TYPE OF STATEMENT) SHOWN BELOW?
(03) NO, NEED TO REMOVE A MEDICINE NAME
(01) BOX ST45
(02) ST41 - EVENT_STPM
(03) ST45 - EVENT_STPMDEL
EVENT_STPMDEL
ST45
roster
SELECT THE PRESCRIBED MEDICINE(S) THAT YOU WOULD LIKE TO REMOVE
(01) CONTINUOUS ANSWER
FROM THE CHARGE BUNDLE.
ST44 - STPMMTCH
routing
IF ALL EVENT DATES SELECTED FOR THIS CHARGE BUNDLE ARE OUTSIDE
THE SURVEY REFERENCE PERIOD, GO TO ST46 - ORPMESSAGE.
ELSE GO TO BOX ST46.
no entry
SINCE ALL EVENTS IN THIS BUNDLE ARE OUTSIDE THE SURVEY
REFERENCE PERIOD, WE DO NOT NEED ANY CHARGE INFORMATION
ABOUT THE BUNDLE.
BOX ST46
routing
IF (TYPE OF STATEMENT = 2/Insurance OR 6/TricareAndInsurance) OR (TYPE OF
STATEMENT = 4/Tricare AND ST5 – STTTYPE = 4/Tricare) OR (ST5 - MCARTYPE
= 4/MSNPartB), GO TO ST47 - ASGNTAKE.
ELSE GO TO BOX ST47.
ST47
code one
WAS ASSIGNMENT TAKEN FOR THIS CHARGE BUNDLE?
routing
IF ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF STATEMENT =
4/Tricare and ST5 - STTYPE = 8/MPDPorMAorTricare)), GO TO ST47A TOTALCHG.
ELSE IF (TYPE OF STATEMENT = 2/Insurance) OR (TYPE OF STATEMENT =
4/Tricare AND ST5 - STTYPE = 4/Tricare) OR (TYPE OF STATEMENT =
6/TricareAndInsurance), GO TO ST48 - TOTALCHG.
ELSE IF ST5 - MCARTYPE = 4/MSNPartB, GO TO ST52 - TOTALCHG.
ELSE IF ST5 - MCARTYPE = 6/MSNPartAInpatient, GO TO ST56 - DAYSUSED.
ELSE GO TO ST60 - TOTALCHG.
NUMLINKS
STPMINTRO
BOX ST45
ORPMESSAGE
ASGNTAKE
ST46
BOX ST47
TOTALCHG
ST47A
dollar
ENTER THE TOTAL COST OF PRESCRIPTION(S) FROM THE PRESCRIPTION
DRUG BENEFIT STATEMENT. IF A TOTAL COST IS NOT LISTED, IT MAY BE
NECESSARY TO CALCULATE A TOTAL BY ADDING THE COSTS OF
INDIVIDUAL ITEMS LISTED ON THE STATEMENT.
TOTALCHG
ST48
numeric
ENTER THE FOLLOWING AMOUNTS FROM THE (TYPE OF STATEMENT). IF
AMOUNT NOT AVAILABLE, ENTER "DON'T KNOW".
MCAPPAMT
ST48
numeric
MCPAYAMT
ST48
numeric
BOX ST48
routing
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST51.
ELSE IF (AMOUNT REMAINING < $1.00) OR ((ST48 - MCAPPAMT ^= DK OR RF)
AND (AMOUNT REMAINING < .02 * ST48 - MCAPPAMT)), GO TO BOX ST80.
ELSE GO TO ST49 - STTCHGPAID1.
BOX ST42
PM6A_IN - NAVIGATOR
BOX ST80
(01) YES
(02) NO
(03) CAN'T TELL
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST47
$$$$.cc??
ST64 - STTCHGPAID2
ST48 - MCAPPAMT
ST48 - MCPAYAMT
BOX ST48
STTCHGPAID1
ST49
code one
REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH RESPONDENT IF
YOU HAVEN'T ALREADY DONE SO. POINT OUT PROVIDER NAME, DATE(S),
AND TYPE OF SERVICE. THEN ASK:
So, I have an amount remaining of $(AMOUNT REMAINING) that Medicare didn't pay.
[Have you/Has (SP)] or any other source, [such as (TRICARE/an insurance
plan/TRICARE or an insurance plan)], paid any of this amount?
[Have you] respondent is SP
[Has (SP)] respondent is proxy
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) DON'T KNOW
(-9) REFUSED
[such as an insurance plan] SP was not covered by TRICARE and was covered by any other insurance plan besides Medicare during
the current round
[such as TRICARE] SP was covered by TRICARE and is not covered by any other insurance plan besides Medicare during the
current round
[such as TRICARE or an insurance plan] SP was covered by TRICARE and any other insurance plan besides Medicare during the
current round
(01) BOX ST64A
(02) BOX ST64A
(03) ST50 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A
THESE AMOUNTS WERE ENTERED FROM THE (TYPE OF STATEMENT)
STATEMENT:
TOTAL CHARGE/BILLED AMOUNT: (TOTAL CHARGE AMOUNT)
CHANGAMT
ST50
yes/no
TOTAL MEDICARE APPROVED AMOUNT: (MEDICARE APPROVED AMOUNT)
(01) ST51 - TOTALCHG
(02) BOX ST51
(01) YES
(02) NO
TOTAL MEDICARE PAYMENT: (MEDICARE PAYMENT)
AMOUNT REMAINING AFTER MEDICARE PAYMENT: (AMOUNT REMAINING)
DO YOU WANT TO MAKE ANY CHANGES?
TOTALCHG
ST51
numeric
MCAPPAMT
ST51
numeric
MCPAYAMT
ST51
numeric
BOX ST51
routing
TOTALCHG
ST52
numeric
MCAPPAMT
ST52
numeric
MCPAYAMT
ST52
numeric
MAYBBILL
ST52
numeric
STTCHGPAID1
ST53
code one
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE
ENTERED FROM THE (TYPE OF STATEMENT).
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST51 - MCAPPAMT
ST51 - MCPAYAMT
BOX ST51
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND
((AMOUNT REMAINING < $1.00) OR ((ST51 - MCAPPAMT ^= DK AND ST51 MCAPPAMT ^= RF) AND (AMOUNT REMAINING < .02 * ST51 - MCAPPAMT))), GO
TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
ENTER THE FOLLOWING AMOUNTS FROM THE MSN:
REVIEW CHARGE BUNDLE ON THE (TYPE OF STATEMENT) WITH
RESPONDENT IF YOU HAVEN'T ALREADY DONE SO. POINT OUT PROVIDER
NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
So, I have an amount remaining of $(AMOUNT REMAINING) that Medicare didn't pay.
[Have you/Has (SP)] or any other source, [such as (TRICARE/an insurance
plan/TRICARE or an insurance plan)], paid any of this amount?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
ST52 - MCAPPAMT
ST52 - MCPAYAMT
ST52 - MAYBBILL
BOX ST52
[Have you] respondent is SP
[Has (SP)] respondent is proxy
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) DON'T KNOW
(-9) REFUSED
[such as TRICARE] SP was covered by TRICARE and is not covered by any other insurance plan besides Medicare during the
current round
[such as an insurance plan] SP was not covered by TRICARE and was covered by any other insurance plan besides Medicare during
the current round
[such as TRICARE or an insurance plan] SP was covered by TRICARE and any other insurance plan besides Medicare during the
current round
(01) BOX ST64A
(02) BOX ST64A
(03) ST54 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A
THESE AMOUNTS WERE ENTERED FROM THE (TYPE OF STATEMENT) :
AMOUNT CHARGED: (TOTAL CHARGE AMOUNT)
MEDICARE APPROVED: (MEDICARE APPROVED AMOUNT)
CHANGAMT
ST54
yes/no
MEDICARE PAID: (MEDICARE PAYMENT)
(01) YES
(02) NO
(01) ST55 - TOTALCHG
(02) BOX ST55
YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
TOTALCHG
ST55
numeric
MCAPPAMT
ST55
numeric
MCPAYAMT
ST55
numeric
MAYBBILL
ST55
numeric
DAYSUSED
NONCOVRD
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE
ENTERED FROM THE (TYPE OF STATEMENT).
BOX ST55
routing
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND
(AMOUNT REMAINING < $1.00), GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
ST56
numeric
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.
DISREGARD "AMOUNT CHARGED" IF IT APPEARS ON THE STATEMENT.
ST56
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
ST55 - MCAPPAMT
ST55 - MCPAYAMT
ST55 - MAYBBILL
BOX ST55
(01) CONTINUOUS ANSWER
ST56 - NONCOVRD
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST56 - COINSUR MCPAYAMT
COINSUR MCPAYAMT
ST56
numeric
MAYBBILL
ST56
numeric
BOX ST56
routing
STTCHGPAID1
ST57
code one
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
ST56 - MAYBBILL
BOX ST56
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST59.
ELSE IF AMOUNT REMAINING < $1.00, GO TO BOX ST80.
ELSE GO TO ST57 - STTCHGPAID1.
REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH RESPONDENT IF
YOU HAVEN'T ALREADY DONE SO. POINT OUT PROVIDER NAME, DATE(S),
AND TYPE OF SERVICE. THEN ASK:
So, I have an amount remaining $(AMOUNT REMAINING) that Medicare didn't pay.
[Have you/Has (SP)] or any other source, [such as (TRICARE/an insurance
plan/TRICARE or an insurance plan)], paid any of this amount?
[Have you] respondent is SP
[Has (SP)] respondent is proxy
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) DON'T KNOW
(-9) REFUSED
[such as TRICARE] SP was covered by TRICARE and is not covered by any other insurance plan besides Medicare during the
current round
[such as an insurance plan] SP was not covered by TRICARE and was covered by any other insurance plan besides Medicare during
the current round
[such as TRICARE or an insurance plan] SP was covered by TRICARE and any other insurance plan besides Medicare during the
current round
(01) BOX ST64A
(02) BOX ST64A
(03) ST58 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A
THESE AMOUNTS WERE ENTERED FROM THE MSN:
BENEFITS DAYS USED: (DAYS USED)
NON-COVERED CHARGES: (NON COVERED CHARGES)
CHANGAMT
ST58
yes/no
DEDUCTIBLE AND COINSURANCE: (COINSURANCE)
(01) YES
(02) NO
(01) ST59 - DAYSUSED
(02) BOX ST59
AMOUNT MEDICARE PAID: (MEDICARE PAYMENT)
MAXIMUM YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
DAYSUSED
ST59
numeric
NONCOVRD
ST59
numeric
COINSUR MCPAYAMT
ST59
numeric
MAYBBILL
ST59
numeric
BOX ST59
routing
TOTALCHG
ST60
numeric
NONCOVRD MCAPPAMT
ST60
numeric
COINSUR MCPAYAMT
ST60
numeric
MAYBBILL
ST60
numeric
ST61
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND
(AMOUNT REMAINING < $1.00), GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST59 - COINSUR MCPAYAMT
ST59 - MAYBBILL
BOX ST59
ST60 - NONCOVRD
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST60 - NONCOVRD MCAPPAMT
ST60 - COINSUR MCPAYAMT
ST60 - MAYBBILL
BOX ST60
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST63.
ELSE IF AMOUNT REMAINING < $1.00, GO TO BOX ST80.
ELSE GO TO ST61 - STTCHGPAID1.
BOX ST60
STTCHGPAID1
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE
ENTERED FROM THE (TYPE OF STATEMENT).
code one
REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH RESPONDENT IF
YOU HAVEN'T ALREADY DONE SO. POINT OUT PROVIDER NAME, DATE(S),
AND TYPE OF SERVICE. THEN ASK:
So, I have an amount remaining (AMOUNT REMAINING) that Medicare didn't pay.
[Have you/Has (SP)] or any other source, [such as (TRICARE/an insurance
plan/TRICARE or an insurance plan)], paid any of this amount?
[Have you] respondent is SP
[Has (SP)] respondent is proxy
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) DON'T KNOW
(-9) REFUSED
[such as TRICARE] SP was covered by TRICARE and is not covered by any other insurance plan besides Medicare during the
current round
[such as an insurance plan] SP was not covered by TRICARE and was covered by any other insurance plan besides Medicare during
the current round
[such as TRICARE or an insurance plan] SP was covered by TRICARE and any other insurance plan besides Medicare during the
current round
(01) BOX ST64A
(02) BOX ST64A
(03) ST62 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A
THESE AMOUNTS WERE ENTERED FROM THE MSN:
AMOUNT CHARGED: (TOTAL CHARGE AMOUNT)
MEDICARE APPROVED AMOUNT: (MEDICARE APPROVED AMOUNT)
CHANGAMT
ST62
yes/no
AMOUNT MEDICARE PAID: (MEDICARE PAYMENT)
(01) YES
(02) NO
(01) ST63 - TOTALCHG
(02) BOX ST63
MAXIMUM YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
TOTALCHG
ST63
numeric
NONCOVRD MCAPPAMT
ST63
numeric
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST63 - NONCOVRD MCAPPAMT
ST63 - COINSUR MCPAYAMT
COINSUR MCPAYAMT
ST63
numeric
MAYBBILL
ST63
numeric
BOX ST63
routing
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST63 - MAYBBILL
BOX ST63
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND
(AMOUNT REMAINING < $1.00), GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
[(PROVIDER NAME)] ST5 - STTYPE ^= 8/MPDPorMAorTricare.
[] ST5 - STTYPE ^ is not equal to 8/MPDPorMAorTricare.
[THEN ASK:] ST5 - STTYPE ^= 8/MPDPorMAorTricare
[SELECT "SP OR ANY SOURCE PAID" IF ALREADY KNOWN. OTHERWISE ASK:] ST5 - STTYPE ^ is not equal to
8/MPDPorMAorTricare.
STTCHGPAID2
ST64
code one
REVIEW CHARGE BUNDLE ON [TYPE OF STATEMENT] WITH RESPONDENT IF
YOU HAVEN'T ALREADY DONE SO. POINT OUT (PROVIDER NAME), DATE(S),
AND TYPE OF SERVICE(S). (THEN ASK:/SELECT "SP OR ANY SOURCE PAID"
IF ALREADY KNOWN. OTHERWISE ASK:)
[The total cost of prescriptions reported on this statement is (TOTAL CHARGE
TEXT).] [[Have you/Has (SP)]/Besides Medicare, [have you/has (SP)]] or any other
source [, such as (an insurance plan/TRICARE/TRICARE or an insurance plan),] paid
anything for this?
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(-8) DON'T KNOW
(-9) REFUSED
[The total cost of prescriptions reported on this statement is (TOTAL CHARGE TEXT).] ST5 - STTYPE = 8/MPDPorMAorTricare
[] ST5 - STTYPE is not equal to 8/MPDPorMAorTricare
[Have you] ST5 - STTYPE = 8/MPDPorMAorTricare, respondent is SP, only "DU" event types included in this charge bundle
[Has (SP)] ST5 - STTYPE = 8/MPDPorMAorTricare, respondent is proxy, only "DU" event types included in this charge bundle
[Besides Medicare, have you] event types other than “DU” included in the charge bundle, respondent is SP
[Besides Medicare, has (SP)] event types other than “DU” included in the charge bundle, respondent is proxy
BOX ST64A
[, such as an insurance plan,] SP was not covered by TRICARE and was covered by any other insurance plan besides Medicare
during the current round
[, such as TRICARE,] SP was covered by TRICARE and is not covered by any other insurance plan besides Medicare during the
current round
[, such as TRICARE or an insurance plan,] SP was covered by TRICARE and any other insurance plan besides Medicare during the
current round
[] SP was not covered by TRICARE or any other insurance plan besides Medicare during the current round
BOX ST64A
BOX ST64B
routing
routing
IF SP OR ANY SOURCE HAS PAID, GO TO BOX ST64B.
ELSE IF (NOTHING HAS BEEN PAID) OR (RESPONDENT DOES NOT KNOW IF
ANYTHING HAS BEEN PAID), GO TO BOX ST78B.
ELSE GO TO BOX ST80.
CREATE SOURCE OF PAYMENT ROSTER
IF ADMINISTERING ST AND (ONE OR MORE CHARGE BUNDLES ENTERED IN
ST SECTION) AND (ST65 – STADDSOP1 HAS BEEN ASKED IN THE CURRENT
ROUND) AND (PAYMENTS HAVE BEEN COLLECTED AT ST67), GO TO ST67 TSOPAMT.
STADDSOP1
ST65
yes/no
ARE ALL OF THE SOURCES OF PAYMENT NECESSARY FOR COMPLETING
THE STATEMENT SECTION LISTED BELOW?
SELECT "NO" TO ADD A SOURCE OF PAYMENT.
SOP_ST1
ST66
roster
ADD ALL ADDITIONAL SOURCES OF PAYMENT.
TSOPAMT
ST67
grid
BOX
ST67HE
routing
(REFER TO INSURANCE STATEMENT/REFER TO TRICARE
STATEMENT/REFER TO INSURANCE AND TRICARE STATEMENTS/REFER TO
MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENT).
Who (else) paid besides Medicare? How much did (SOURCE) pay?
ENTER ALL PAYMENT AMOUNTS. CORRECT PAYMENT AMOUNTS AS
NECESSARY.
(01) YES
(02) NO
(01) CONTINUOUS ANSWER
(01) ST67 - TSOPAMT
(02) ST66 - SOP_ST1
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED
BOX ST67HE
(01) CONTINUOUS ANSWER
ST67HE-PAYMHE
(01) CONTINUOUS ANSWER
ST67B_IN - NAVIGATOR
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) BOX ST67C
(02)BOX ST69E
IF AT LEAST ONE TSOPAMT = DK OR RF OR THE SUM OF ALL TSOPAMT
VALUES FOR THIS COST > 0.00, GO TO BOX ST67A.
ELSE GO TO ST67HE - PAYMHE.
THE SUM OF ALL PAYMENT AMOUNTS MUST BE GREATER THAN $0.00 OR AT
LEAST ONE PAYMENT AMOUNT MUST BE 'DON'T KNOW' OR 'REFUSED'.
PAYMHE
ST67HE
no entry
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID AND MAKE
CORRECTIONS.
BOXST67A
routing
BOX ST67B
routing
PLANINTRO
ST67BINT
no entry
NAVIGATOR
ST67B_IN
instance
navigator
IF AT LEAST ONE SOURCE OF PAYMENT WAS ADDED AT ST66, GO TO BOX
ST67B.
ELSE GO TO BOX ST69F.
IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT ST66 IS A HEALTH
INSURANCE PLAN, GO TO ST67BINT - PLANINTRO.
ELSE GO TO BOX ST69E.
Before we continue, I would like to ask you a few questions about the health insurance
plan(s) you just added.
BOX ST67C
STMHMOCHNG1
ST68
routing
CREATE A NEW HEALTH INSURANCE PLAN FOR FIRST/NEXT SOURCE OF
PAYMENT ADDED AT ST66
IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP HAS
A MEDICARE MANAGED CARE PLAN THAT IS CURRENT, GO TO ST68 STMHMOCHNG1.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND
SP DOES NOT HAVE A MEDICARE MANAGED CARE PLAN THAT IS CURRENT,
GO TO ST69 - STSOPCURR1.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE PRESCRIPTION DRUG PLAN
AND SP HAS A MEDICARE PRESCRIPTION DRUG PLAN THAT IS CURRENT,
GO TO ST69A - STMPDPCHNG.
ELSE IF SOURCE OF PAYMENT IS MEDICARE PRESCRIPTION DRUG PLAN
AND SP DOES NOT HAVE A MEDICARE PRESCRIPTION DRUG PLAN THAT IS
CURRENT, GO TO ST69B - STSOPCURR2.
ELSE IF SOURCE OF PAYMENT IS MEDICAID, GO TO HI6 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PUBLIC PLAN, GO TO HI13 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PRIVATE PLAN, GO TO HI21 - COVTIME.
ELSE GO TO HIT2 - COVTIME.
yes/no
I recorded previously that (CURRENT MEDICARE MANAGED CARE PLAN NAME)
was [your/(SP's)] current Medicare Managed Care Plan. Has this information
changed?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[your] respondent is SP
[(SP)'s] respondent is proxy
(01) ST69 - STSOPCURR1
(02) BOX ST69A
(-8) BOX ST69A
(-9) BOX ST69A
[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP is alive
[Was (SP)] respondent is proxy, SP is deceased
STSOPCURR1
ST69
yes/no
[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (ST66 SOP MEDICARE
MANAGED CARE PLAN NAME) [on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[currently] SP alive
[] SP deceased
(01) HIMC6A - MHMORXTM
(02) BOX ST69A
(-8) BOX ST69A
(-9) BOX ST69A
[on (DATE OF DEATH)] respondent is proxy, SP deceased
[on (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized
[] respondent is SP
STMPDPCHNG
ST69A
yes/no
I recorded previously that (CURRENT MEDICARE PRESCRIPTION DRUG PLAN)
was [your/(SP's)] current Medicare Prescription Drug Care Plan.
Has this information changed?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[your] respondent is SP
[(SP)'s] respondent is proxy
(01) ST69B - STSOPCURR2
(02) BOX ST69A
(-8) BOX ST69A
(-9) BOX ST69A
[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP is alive
[Was (SP)] respondent is proxy, SP is deceased
STSOPCURR2
ST69B
yes/no
[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (ST66 SOP MEDICARE
PRESCRIPTION DRUG PLAN) [on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[currently] SP alive
[] SP deceased
BOX ST69A
[on (DATE OF DEATH)] respondent is proxy, SP deceased
[on (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized
[] respondent is SP
BOX ST69A
BOX ST69E
BOX ST69F
AMTSCORR
ST70
routing
GO TO ST67B_IN - NAVIGATOR.
routing
IF AN "OTHER SOURCE OF PAYMENT" ADDED AT ST66, CREATE AN OSOP
FOR EACH SOURCE OF PAYMENT ADDED AT ST66 THAT IS AN "OTHER
SOURCE OF PAYMENT"
GO TO BOX ST69F.
routing
IF ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF STATEMENT =
4/Tricare and ST5 - STTYPE = 8/MPDPorMAorTricare)) and ((TOTAL CHARGE ^=
DK and TOTAL CHARGE ^= RF) and (ALL PAYMENTS ENTERED AT ST67 ^= DK
AND ^= RF)) AND ((TOTAL CHARGE IS > TOTAL PAYMENTS ENTERED AT
ST67) AND (THE DIFFERENCE BETWEEN TOTAL CHARGE AND TOTAL
PAYMENTS ENTERED AT ST67 IS > $1.00)), GO TO ST73 - AMTSCORR.
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AT
LEAST ONE PAYMENT ENTERED AT ST67 = DK OR RF) AND (AT LEAST ONE
PAYMENT ENTERED AT ST67 ^= DK AND ^= RF) AND (TOTAL OF ALL NONMISSING PAYMENTS ENTERED AT ST67 IS >= AMOUNT REMAINING), GO TO
ST71 - AMTSCORR.
ELSE IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY)
AND (ALL PAYMENTS ENTERED AT ST67 ^= DK AND ^= RF) AND (THE
ABSOLUTE VALUE OF THE DIFFERENCE BETWEEN THE TOTAL PAYMENTS
ENTERED AT ST67 AND AMOUNT REMAINING IS > $1.00), GO TO ST70 AMTSCORR.
ELSE GO TO BOX ST77C.
code one
There seems to be (some amount still unpaid/more payments than the amount left after
Medicare paid). The total of non-Medicare payments is $(TOTAL PAYMENTS). The
amount (unpaid/overpaid) is $(DIFFERENCE BETWEEN PAYMENTS AND AMOUNT
REMAINING). Is that correct?
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE
"PREVIOUS PAGE" TO RETURN TO THE SOP GRID.
(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION DO NOT
DISPLAY.
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8)
(-9) REFUSED
[some amount still unpaid] Total Payments < Amount Remaining
[more payments than the amount left after Medicare paid] Total Payments > Amount Remaining
[unpaid] Total Payments < Amount Remaining
[overpaid] Total Payments > Amount Remaining
(01) BOX ST77C
(02) DO NOT DISPLAY.
(03) ST72 - ENTERCOM
(-8) BOX ST77C
(-9) BOX ST77C
AMTSCORR
ST71
code one
THE AMOUNTS ENTERED FOR THE SOURCES OF PAYMENT EQUAL OR
EXCEED THE (TOTAL CHARGE/AMOUNT REMAINING), WITH AT LEAST ONE
SOP BEING A MISSING AMOUNT. VERIFY ALL AMOUNTS AS ENTERED.
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE
"PREVIOUS PAGE" TO RETURN TO THE SOP GRID.
ENTERCOM
ST72
no entry
[THE TOTAL OF NON-MEDICARE PAYMENTS IS $(TOTAL PAYMENTS). THE
AMOUNT (UNPAID/OVERPAID) IS $(DIFFERENCE BETWEEN PAYMENTS AND
AMOUNT REMAINING).]
(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION DO NOT
DISPLAY.
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8)
(-9) REFUSED
(01) CONTINUOUS ANSWER
(01) BOX ST77C
(02) DO NOT DISPLAY.
(03) ST72 - ENTERCOM
(-8) BOX ST77C
(-9) BOX ST77C
[UNPAID] Total Payments < Amount Remaining
[OVERPAID] Total Payments > Amount Remaining
BOX ST77C
USE COMMENTS TO EXPLAIN WHY THE AMOUNT REMAINING SEEMS
INCORRECT.
AMTSCORR
ST73
yes/no
There seems to be some amount still unpaid. The total of non-Medicare payments is
$(TOTAL PAYMENTS). The amount unpaid is $(DIFFERENCE BETWEEN TOTAL
CHARGE AND PAYMENTS). Is that correct?
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE
"PREVIOUS PAGE" TO RETURN TO THE SOP GRID.
INFOEXPLAIN
ST74
yes/no
IS THERE ADDITIONAL INFORMATION ON THE DRUG BENEFIT STATEMENT
THAT EXPLAINS THE AMOUNT STILL UNPAID?
ENTERCOM2
ST75
no entry
USE COMMENTS TO ENTER ANY INFORMATION THAT EXPLAINS THE
AMOUNT STILL UNPAID.
BOX ST77C
routing
CREATE PAYMENTS FOR AMOUNTS ENTERED AT ST67
GO TO BOX ST77D.
routing
IF THE SP OR FAMILY MADE A PAYMENT AND PAYMENT IS GREATER THAN
$5.00, GO TO ST78 - EXPPAYBK.
ELSE GO TO BOX ST80.
BOX ST77D
EXPPAYBK
ST78
BOX ST78A
BOX ST78B
yes/no
I have recorded that [you have/(SP) has] paid $(SP/FAMILY PAYMENT). Do you
expect any source to pay [you/(SP)] back any or all of that amount?
routing
IF ST78 - EXPPAYBK = 1/Yes AND ((CURRENTLY ADMINISTERING CPS AND
CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO CURRENT
ROUND) OR (SP IS IN THE EXIT SAMPLE)), GO TO ST80 - EXPAYUNT.
ELSE GO TO BOX ST80.
routing
IF (CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST
COLLECTED 2 ROUNDS PREVIOUS TO CURRENT ROUND) OR (SP IS IN THE
EXIT SAMPLE), GO TO ST79 - EXPAYOUT.
ELSE GO TO BOX ST80.
EXPAYOUT
ST79
yes/no
Do you expect anyone to pay any of this amount?
EXPAYUNT
ST80
quantity unit
How much do you expect will be paid?
EXPAYPCT
EXPAYAMT
ST80
ST80
numeric
numeric
BOX ST80
routing
IF CURRENTLY ADMINISTERING NS, GO TO BOX NSBEG.
ELSE IF CURRENTLY ADMINISTERING CPS, GO TO BOX CPSBEG.
ELSE IF ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF STATEMENT =
4/Tricare and ST5 - STTYPE = 8/MPDPorMAorTricare)), GO TO ST82 ASTATEMENT.
ELSE GO TO ST81 - ABUNDLE.
ABUNDLE
ST81
yes/no
IS THERE ANOTHER CHARGE BUNDLE TO ENTER FROM THIS (TYPE OF
STATEMENT)?
ASTATEMENT
ST82
yes/no
IS THERE ANOTHER MSN, INSURANCE, TRICARE, OR MEDICARE
PRESCRIPTION DRUG BENEFIT STATEMENT TO ENTER?
BOX STEND routing
GO TO NEXT SECTION.
(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION DO NOT
DISPLAY.
(03) AMOUNT REMAINING SEEMS INCORRECT DO NOT
DISPLAY.
(-8)
(-9) REFUSED
(01) ST74 - INFOEXPLAIN
(02) DO NOT DISPLAY.
(03) DO NOT DISPLAY.
(-8) BOX ST77C
(-9) BOX ST77C
(01) YES
(02) NO
(01) ST75 - ENTERCOM2
(02) BOX ST77C
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) PERCENTAGE
(02) DOLLARS
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(01) YES
(02) NO
(01) YES
(02) NO
[you have] respondent is SP
[(SP) has] respondent is proxy
BOX ST78A
[you] respondent is SP
[(SP)] respondent is proxy
(01) ST80 - EXPAYUNT
(02) BOX ST80
(-8) BOX ST80
(-9) BOX ST80
(01) ST80 - EXPAYPCT
(02) ST80 - EXPAYAMT
(-8) BOX ST80
(-9) BOX ST80
BOX ST80
BOX ST80
(01) ST4 - MATCHST
(02) ST82 - ASTATEMENT
(01) ST4 - MATCHST
(02) BOX STEND
Post Statement Charge (PSQ)
Variable Name
MR Screen Name
Question type
Question text/description
Code list
Text Fill Logic
Input mask Routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[SP] respondent is proxy
PS2 - EXPPYMNT
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Do you] respondent is SP
[Does (SP)] respondent is proxy
BOX PS3
IF THE SP STILL EXPECTS CHARGES FOR AT LEAST ONE
RENTAL ITEM ENTERED IN A PREVIOUS ROUND THAT IS NOT
ALREADY INCLUDED IN A CURRENT ROUND CHARGE
BUNDLE, GO TO PS1A - HADPYMNT.
BOX PS1
routing
ELSE GO TO BOX PSEND.
(Now/Next), let’s look at the costs for the (OME ITEM TYPE)
[you/(SP)] [rented and then bought/stopped renting/stopped renting
on (EVENT END DATE)].
Since (REFERENCE DATE), were any payments made for the
(OME ITEM TYPE)?
HADPYMNT
PS1A
yes/no
THIS INCLUDES PAYMENTS MADE BY SP, MEDICARE,
INSURANCE, TRICARE, OR ANY OTHER SOURCE OF
PAYMENT.
[Do you/Does (SP)] expect any more rental or installment payments
to be made for the (OME ITEM TYPE)?
EXPPYMNT
PS2
yes/no
THIS INCLUDES PAYMENTS MADE BY SP, MEDICARE,
INSURANCE, TRICARE, OR ANY OTHER SOURCE OF
PAYMENT.
IF THE SP STILL EXPECTS CHARGES FOR ANOTHER RENTAL
ITEM ENTERED IN A PREVIOUS ROUND THAT IS NOT
ALREADY INCLUDED IN A CURRENT ROUND CHARGE
BUNDLE, GO TO PS1A - HADPYMNT.
BOX PS3
BOX PSEND
routing
routing
ELSE GO TO BOX PSEND.
GO TO NEXT SECTION
Address Verification (AVQ)
Variable Name
VERIFY
MR Screen Name
BOX AVBEG
AV1
Question type
routing
yes/no
Question text/description)
GO TO AV1 - VERIFY.
Next, I would like to verify [your/(SP's)] home address. I have it
listed as..[READ ADDRESS LISTED BELOW].
Code list
Text Fill Logic
Input mask Routing
(01) YES
(02) NO
[your] respondent is SP
[(SP)] respondent is proxy
(01) BOX AV3
(02) AV2 - STADDR1
Is this correct?
[IF ANY INFORMATION IS MISSING (E.G., AN APARTMENT
NUMBER), SELECT “NO” TO ENTER THE MISSING DATA.]
NAME: (SP)
STREET ADDRESS 1: (STREET ADDRESS LINE 1)
STREET ADDRESS 2: (STREET ADDRESS LINE 2)
CITY: (CITY) STATE: (STATE) ZIPCODE: (ZIPCODE)
STADDR1
AV2
addresses
ENTER CORRECT ADDRESS.
What is [your/(SP's)] home address?
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
[PROBE FOR ANY MISSING INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
AV2 - STADDR2
STADDR2
AV2
addresses
ENTER CORRECT ADDRESS.
What is [your/(SP's)] home address?
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
[PROBE FOR ANY MISSING INFORMATION.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
AV2 - CITY
CITY
AV2
addresses
ENTER CORRECT ADDRESS.
What is [your/(SP's)] home address?
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
[PROBE FOR ANY MISSING INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
AV2 - STATE
STATE
AV2
addresses
ENTER CORRECT ADDRESS.
What is [your/(SP's)] home address?
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
[PROBE FOR ANY MISSING INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
AV2 - ZIPCODE
ZIPCODE
AV2
addresses
ENTER CORRECT ADDRESS.
What is [your/(SP's)] home address?
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
[PROBE FOR ANY MISSING INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
AV3 - SPMOVED
SPMOVED
AV3
yes/no
BOX AV3
routing
WAS CHANGE MADE TO SP'S ADDRESS BECAUSE SP MOVED? (01) YES
(02) NO
(-8) Don't Know
(-9) Refused
IF A PRIMARY PHONE NUMBER HAS BEEN COLLECTED FOR
THE SP, GO TO AV4 - VERIFY.
ELSE GO TO AV5 - PHONAREA.
AV4
yes/no
VERIFY
Next, I would like to verify [your/(SP's)] phone [number/numbers]. I
have [it/them] listed as …
[READ PHONE NUMBER(S) LISTED BELOW].
(01) YES
(02) NO
[your] respondent is SP
[(SP's)] respondent is proxy
[number] Only one telephone number for SP
[numbers] More than one telephone number for SP
[it] Only one telephone number for SP
[them] More than one telephone number for SP
(01) BOX AV6
(02) AV5 - PHONAREA
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) PERSON DOES NOT HAVE PHONE
(-7) Empty
[your] respondent is SP
[(SP's)] respondent is proxy
AV5 - PHONEXCH
[your] respondent is SP
[(SP's)] respondent is proxy
AV5 - PHONLOCL
[your] respondent is SP
[(SP's)] respondent is proxy
AV5 - NOPHONE
[your] respondent is SP
[(SP's)] respondent is proxy
BOX AV5
Are these correct?
PHONE 1: (PRIMARY PHONE NUMBER)
PHONE 2: [(SECONDARY PHONE NUMBER)/NONE)
[IF ANY PART OF THE PHONE NUMBER(S) IS NOT CORRECT,
SELECT “NO”. PROBE FOR A SECOND PHONE NUMBER IF ONE
IS NOT PRESENT. IF THERE IS A SECOND NUMBER TO ADD,
SELECT “NO” TO ENTER THE MISSING NUMBER.]
PHONAREA
AV5
phone
What is [your/(SP's)] phone number?
PHONEXCH
AV5
phone
What is [your/(SP's)] phone number?
PHONLOCL
AV5
phone
What is [your/(SP's)] phone number?
NOPHONE
AV5
phone
What is [your/(SP's)] phone number?
BOX AV3
PHONAREA
BOX AV5
routing
AV6
phone
IF AV5 - NOPHONE = 1/NotHavePhone OR AV5 - PHONAREA =
RF, GO TO BOX AV6.
ELSE GO TO AV6 - PHONAREA.
[Do you/Does (SP)] have a second phone number?
[PROBE: What is that number?]
PHONEXCH
AV6
phone
[Do you/Does (SP)] have a second phone number?
[PROBE: What is that number?]
PHONLOCL
AV6
phone
[Do you/Does (SP)] have a second phone number?
[PROBE: What is that number?]
NOPHONE
AV6
phone
[Do you/Does (SP)] have a second phone number?
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) PERSON DOES NOT HAVE PHONE
(-7) Empty
[Do you] respondent is SP
[Does (SP)] respondent is proxy
AV6 - PHONEXCH
[Do you] respondent is SP
[Does (SP)] respondent is proxy
AV6 - PHONLOCL
[Do you] respondent is SP
[Does (SP)] respondent is proxy
AV6 - NOPHONE
[Do you] respondent is SP
[Does (SP)] respondent is proxy
BOX AV6
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
(01) BOX AVEND
(02) AV8 - STADDR1
(-8) BOX AVEND
(-9) BOX AVEND
[PROBE: What is that number?]
VERIFY
BOX AV6
routing
CHECK FOR SP'S PREVIOUS ROUND MAILING ADDRESS. IF
SP'S MAILING ADDRESS WAS NOT COLLECTED IN THE
PREVIOUS ROUND, COPY SP'S CURRENT ROUND ADDRESS
TO SP'S MAILING ADDRESS
GO TO AV7 - VERIFY.
AV7
yes/no
I would also like to verify [your/(SP's)] mailing address. I have it
listed as ... [READ ADDRESS LISTED BELOW.]
Is this the correct mailing address for [you/(SP)]?
NAME: (SP)
MAILING ADDRESS 1: (MAILING ADDRESS LINE 1)
MAILING ADDRESS 2: (MAILING ADDRESS LINE 2)
CITY: (MAILING CITY) STATE: (MAILING STATE) ZIPCODE:
(MAILING ZIPCODE)
[IF ANY INFORMATION IS MISSING (E.G., AN APARTMENT
NUMBER), SELECT “NO” TO ENTER THE MISSING DATA.]
STADDR1
AV8
address
ENTER CORRECT ADDRESS.
What is [your/(SP's)] mailing address?
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
[PROBE FOR ANY MISSING INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
AV8 - STADDR2
STADDR2
AV8
address
ENTER CORRECT ADDRESS.
What is [your/(SP's)] mailing address?
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
[PROBE FOR ANY MISSING INFORMATION.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
AV8 - CITY
CITY
AV8
address
ENTER CORRECT ADDRESS.
What is [your/(SP's)] mailing address?
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
[PROBE FOR ANY MISSING INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
AV8 - STATE
STATE
AV8
address
ENTER CORRECT ADDRESS.
What is [your/(SP's)] mailing address?
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
[PROBE FOR ANY MISSING INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
AV8 - ZIPCODE
ZIPCODE
AV8
address
ENTER CORRECT ADDRESS.
What is [your/(SP's)] mailing address?
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
[PROBE FOR ANY MISSING INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
BOX AVEND
BOX AVEND
routing
GO TO NEXT SECTION
No Statement Charge (NSQ)
Variable Name
MR Screen Name
Question type Question text/description
NS1_IN
Text fills
Input mask Routing
CREATE LIST OF EVENTS ENTERED IN THE CURRENT ROUND THAT ARE NOT ASSOCIATED WITH CHARGE DATA ALREADY
ENTERED
IF AT LEAST ONE EVENT ENTERED IN THE CURRENT ROUND IS NOT ASSOCIATED WITH CHARGE DATA ALREADY ENTERED, GO
TO NS1_IN - NAVIGATOR.
ELSE GO TO NS81 - NSTATEMENT.
BOX NSBEG
NAVIGATOR
Code list
instance
navigator
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) NS1 - NSINT
(02) BOX NSBEG
[Now that we're done with [your/(SP's)] statements, let's]
one or more charge bundles entered in ST section
[Let's] talk about the medical services and costs for
which [you/(SP)] did not have a statement.] no charge
bundles entered in ST section
[REMAINING] NS1 - NSINT has already been asked in
the current round
[]NS1 - NSINT has not been asked in the current round
[Now that we're done with [your/(SP's)] statements, let's/Let's] talk about the medical services and costs for which [you/(SP)] did not have a
statement.]
NSINT
NS1
no entry
[Next let’s look at] NS1 - NSINT has already been asked
in the current round
[Let’s start with] NS1 - NSINT has not been asked in the
current round
THERE ARE (TOTAL NUMBER OF NS EVENTS) EVENTS (REMAINING) TO ASK ABOUT.
BOX NS1
(Let's start with/Next let's look at) (the/[your/(SP's)]) costs for the (EVENT).
[your/(SP's)] event is associated with a Managed Care
Plan
[the] event is not associated with a Managed Care Plan
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP)'s] respondent is proxy
BOX NS1
NSEXMCMAIL
NS2
routing
code one
IF (ST1 - MHMOSTMT = 3/Never AND ((SP HAS A MEDICARE MANAGED CARE PLAN THAT DOES NOT HAVE RX COVERAGE ANYTIME
IN THE CURRENT ROUND) OR (SP HAS A PRIVATE PLAN THAT IS A MANAGED CARE PLAN ANYTIME IN THE CURRENT ROUND) OR
(SP IS IN THE EXIT SAMPLE) OR (EVENT IS ASSOCIATED WITH A MANAGED CARE PLAN))) OR (EVENT TYPE = 'OM' AND EVENT IS A
RENTAL ITEM AND PS1 - HADPYMNT = 1/Yes) OR ((EVNTTYPE = 'DU' OR 'PM') AND SP DOES NOT HAVE ANY OTHER HEALTH
INSURANCE PLAN BESIDES MEDICARE IN THE CURRENT ROUND) , GO TO BOX NS4.
ELSE IF (SP IS IN THE EXIT SAMPLE), GO TO NS4 - NSRECDSTAT.
ELSE GO TO NS2 - NSEXMCMAIL.
As far as you know, is anything expected in the mail from (Medicare, Insurance, and Tricare/Medicare and Tricare/Medicare and
Insurance/Medicare) about [READ EVENT ABOVE]?
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(04) HAVE STATEMENT FOR EVENT
(09) FLAG COST FOR CPS DO NOT DISPLAY.
(-8) DON'T KNOW
(-9) REFUSED
[Medicare, Insurance, and Tricare] SP was covered by
TRICARE and any other insurance plan besides
Medicare during the current round
[Medicare and Tricare] SP was covered by TRICARE
and is not covered by any other insurance plan besides
Medicare during the current round
[Medicare and Insurance] SP was not covered by
TRICARE and was covered by any other insurance plan
besides Medicare during the current round
[Medicare] SP was not covered by TRICARE or any
other insurance plan besides Medicare during the
current round
(01) BOX NS4
(02) BOX NS4
(03) NS3 - EVERRVB
(04) ST4 - MATCHST
(09) DO NOT DISPLAY
(-8) BOX NS4
(-9) BOX NS4
REMINDER: "EVENT ENTERED IN ERROR" INSTRUCTS THE HOME OFFICE TO DELETE THIS EVENT.
EVERRVB
NSRECDSTAT
NS3
NS4
verbatim text
code one
IF YOU HAVE ENTERED THIS CODE IN ERROR, SELECT PREVIOUS PAGE AND ENTER THE CORRECT CODE AT NS2. OTHERWISE,
EXPLAIN WHY YOU SELECTED "EVENT ENTERED IN ERROR" FOR THIS EVENT.
[Have you/Has (SP)] received a statement for the [READ EVENT ABOVE]?
(01) CONTINUOUS ANSWER
(01) STATEMENT RECEIVED AND AVAILABLE
(02) STATEMENT RECEIVED, NOT AVAILABLE
(03) STATEMENT NOT RECEIVED
(-8) DON'T KNOW
(-9) REFUSED
BOX NS4
[Have you] respondent is SP
[Has (SP)] respondent is proxy
(01) ST4 - MATCHST
(02) BOX NS4
(03) BOX NS4
(-8) BOX NS4
(-9) BOX NS4
BOX NS4
BOX NS4A
TOTALCHG
NS5
routing
CREATE A NEW CHARGE BUNDLE FOR THIS EVENT
IF NS2 - NSEXMCMAIL = 1/Yes or 3/EventEnteredInError, GO TO BOX NS80.
ELSE GO TO BOX NS4A.
routing
F (EVENT TYPE IS NOT AN OTHER MEDICAL EXPENSE) AND (EVENT IS ASSOCIATED WITH A MANAGED CARE PLAN), GO TO NS6 TOTALCHG.
ELSE GO TO NS5 - TOTALCHG.
dollar
Including any amounts that may be paid by Medicare or anyone else, what [was the charge for the (OME ITEM TYPE) rented (with the option to
buy) for the time period between (REFERENCE DATE) and (TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/was the total
charge (that is, the total amount billed)]?
IF CHARGE REPORTED AS HOURLY RATE, CALCULATE AND ENTER THE TOTAL CHARGE FOR THE ENTIRE ROUND.
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
[PROBE FOR TOTAL BILLED AMOUNT, REGARDLESS OF WHO PAID (OR WILL PAY) ANY PORTION OF THE CHARGE. IF THE
RESPONDENT RECEIVES A DISCOUNT, RECORD THE TOTAL CHARGE BEFORE THE DISCOUNT IS APPLIED.]
[was the charge for the (OME ITEM TYPE) rented (with
the option to buy) for the time period between
(REFERENCE DATE) and (TODAY/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]
statement is for other medical item that was rented,
EVNT.EVNTTYPE = 'OM' and EVNT.RENTPROB =
2/Rent
[was the total charge (that is, the total amount billed)]
statement is for purchase (not rental)
$$$$.cc?
BOX NS5
$$$$.cc?
BOX NS6
[with the option to buy] statement is for other medical
item that was rented, EVNT.RENT2BUY =
2/PurchasedRentToBuy
Else do not display.
[TODAY] SP alive
[DATE OF DEATH] SP deceased
[DATE OF INSTITUTIONALIZATION] SP
institutionalized
BOX NS5
routing
IF TOTALCHG = 0 AND SP CURRENTLY COVERED BY MEDICAID, GO TO BOX NS80.
ELSE IF EVENT TYPE = 'OM' AND EVENT IS A RENTAL ITEM, GO TO NS7 - MONTHCOV.
ELSE IF (EVENT TYPE = 'PM' OR 'OM') AND NUMBER OF PURCHASES BEING ASKED ABOUT IN NS IS > 1, GO TO NS8 - NUMLINKS.
ELSE IF (EVENT WAS ENTERED AS A REPEAT VISIT), GO TO NS9 - RVLINKS.
ELSE GO TO BOX NS9.
What was the copayment amount for the [READ EVENT ABOVE]?
TOTALCHG
NS6
BOX NS6
dollar
routing
[EXPLAIN IF NECESSARY: Managed care plans commonly charge a fixed amount, or copayment, each time health services are provided. For
example, the person may pay $20 for each office visit and $10 for each drug prescription.]
ENTER 0 IF NO COPAYMENT FOR THE EVENT.
IF TOTALCHG = 0 AND SP CURRENTLY COVERED BY MEDICAID, GO TO BOX NS80.
IF EVENT TYPE = 'PM' AND THE TOTAL OF NUMBER OF PURCHASES BEING ASKED ABOUT IN NS IS > 1, GO TO NS8 - NUMLINKS.
ELSE IF (EVENT WAS ENTERED AS A REPEAT VISIT), GO TO NS9 - RVLINKS.
ELSE GO TO BOX NS9.
How many months are covered by the charge for the period of time [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?
MONTHCOV
NS7
numeric
[IF THE RESPONDENT DOES NOT REPORT THE NUMBER OF MONTHS AS A WHOLE NUMBER, ROUND UP. (E.G., FOR 2 ½ MONTHS,
ENTER “3”.)]
MONCOV96
NS7
code one
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED
(01) LESS THAN 1 MONTH
(-7) EMPTY
[since (REFERENCE DATE)] respondent is SP
[between (REFERENCE DATE) and (DATE OF
DEATH)] respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
NS7 - MONCOV96
BOX NS9
[you] respondent is SP
[(SP)] respondent is proxy
NUMLINKS
NS8
numeric
(01) CONTINUOUS ANSWER
How many of the times [you/(SP)] obtained [READ EVENT ABOVE] since (REFERENCE DATE) [were covered by the total charge/was there no
(-8) DON'T KNOW
charge/were covered by the (TOTAL CHARGE)/were covered by the copayment/was there no copayment/were covered by the (COPAYMENT)]?
(-9) REFUSED
[were covered by the total charge] total charge collected
for charge bundle, (NS5 – TOTALCHG) = (DK or RF)
[was there no charge] total charge collected for charge
bundle, (NS5 – TOTALCHG) = 0
[were covered by the (TOTAL CHARGE)] total charge
collected for charge bundle, (NS5 – TOTALCHG) is not
equal to DK, RF, or 0
BOX NS9
[were covered by the copayment] copayment collected
for charge bundle, (NS6 – TOTALCHG = DK or RF)
[was there no copayment] copayment collected for
charge bundle, (NS6 – TOTALCHG = 0)
[were covered by the (COPAYMENT)] copayment
collected for charge bundle, (NS6 – TOTALCHG) is not
equal to DK, RF, or 0
[visits to the OPD at] EVNT.EVNTTYPE = 'OP'
[lab services provided by] EVNT.EVNTTYPE = 'SL'
[visits to] EVNT.EVNTTYPE is not equal to 'SL' or ‘OP’
RVLINKS
NS9
numeric
How many of the (NUMBER OF VISITS) (visits to the OPD at/lab services provided by/visits to) (PROVIDER NAME) during the month of (EVENT
MONTH) [were covered by the total charge/was there no charge/were covered by the (TOTAL CHARGE)/were covered by the copayment/was
there no copayment/were covered by the (COPAYMENT)]?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
[were covered by the total charge] total charge collected
for charge bundle, (NS5 – TOTALCHG = DK or RF)
[was there no charge] total charge collected for charge
bundle, (NS5 – TOTALCHG = 0)
[were covered by the (TOTAL CHARGE)] total charge
collected for charge bundle, (NS5 – TOTALCHG) is not
equal to DK, RF, or 0
BOX NS9
[were covered by the copayment] copayment collected
for charge bundle, (NS6 – TOTALCHG = DK or RF)
[was there no copayment] copayment collected for
charge bundle, (NS6 – TOTALCHG = 0)
[were covered by the (COPAYMENT)] copayment
collected for charge bundle, (NS6 – TOTALCHG) is not
equal to DK, RF, or 0
BOX NS9
INCOTHER
INCTYPE
PROVIDER_NSDATE
NS10
routing
code one
IF (COPAYMENT WAS COLLECTED FOR CHARGE BUNDLE INSTEAD OF A TOTAL CHARGE), GO TO BOX NS45.
ELSE GO TO NS10 - INCOTHER.
[READ IF NECESSARY: Does [the total charge/TOTAL CHARGE)] cover this (medicine/item/event) only or does it include other
(medicine/item/event)s.]
(01) ONLY THIS EVENT/ITEM/MEDICINE
(02) OTHER EVENTS/ITEMS/MEDICINES
(03) CAN'T TELL
(01) PROVIDER SERVICE DATES
(02) HOME HEALTH VISITS
(03) OTHER MEDICAL EXPENSES
(04) PRESCRIBED MEDICINES
[the total charge] NS5 - TOTALCHG = DK or RF
[(TOTAL CHARGE)] NS5 - TOTALCHG is not equal to
DK or RF
[medicine] EVNT.EVNTTYPE = 'PM'
[item] EVNT.EVNTTYPE = 'OM'
[event] EVNT.EVNTTYPE is not equal to 'OM' or 'PM'
(01) BOX NS45
(02) NS12 - INCTYPE
(03) BOX NS45
NS12
code all
What else was included?
CHECK ALL THAT APPLY.
BOX NS12
routing
IF THE RESPONSE TO NS12 - INCTYPE INCLUDES 1/ProvDates, GO TO NS13 - PROVIDER_NSDATE.
ELSE GO TO BOX NS26.
NS13
roster
WHICH MEDICAL PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.
(01) CONTINUOUS ANSWER
(01) NO, DO NOT NEED TO ADD OR EDIT EVENT
DATES
(02) YES, NEED TO ADD EVENT DATE
(03) YES, NEED TO EDIT EVENT DATE
(01) NS24 - EVENT_NSDATE
(02) NS16 - EVENT_NSDATEADD
(03) NS15 - EVENT_NSDATEDIT
BOX NS12
NSDATEUPD
NS14
code one
THE FOLLOWING EVENT DATES HAVE BEEN ENTERED FOR THIS PROVIDER.
DO YOU NEED TO ADD OR EDIT AN EVENT DATE FOR THIS CHARGE BUNDLE?
EVENT_NSDATEDIT
NS15
roster
SELECT AND EDIT THE EVENT DATE THAT NEEDS CORRECTION.
(01) CONTINUOUS ANSWER
NS14 - NSDATEUPD
EVENT_NSDATEADD
NS16
roster
ADD THE MISSING EVENT DATE(S) IN THIS CHARGE BUNDLE.
ADD ALL EVENT DATES FOR THIS PROVIDER.
(01) CONTINUOUS ANSWER
BOX NS16A
BOX NS16A
routing
IF AT LEAST ONE EVENT DATE ADDED AT NS16 IS NOT OUTSIDE THE SURVEY REFERENCE PERIOD, GO TO BOX NS16B.
ELSE GO TO NS14 - NSDATEUPD.
BOX NS16B
routing
IF AT LEAST ONE EVENT ADDED AT NS16 IS A 'DU', 'IP', 'OP', OR 'MP' EVENT TYPE, GO TO NS17 - NSDATEINTRO.
ELSE GO TO BOX NS17.
NSDATEINTRO
NS17
no entry
Before we continue with this statement, I would like to ask you a few questions about the visit(s) I just added.
BOX NS17
routing
IF AT LEAST ONE EVENT ADDED AT NS16 IS A 'DU' OR 'MP' EVENT TYPE AND THE PROVIDER SPECIALTY HAS NOT BEEN
COLLECTED, GO TO NS18 - PROVSPEC.
ELSE GO TO BOX NS18.
What kind of medical person is (PROVIDER NAME)?
PROVSPEC
NS18
code one
PROVSPOS
NS18
text
OTHER MEDICAL PROVIDER (SPECIFY)
routing
IF (AT LEAST ONE EVENT ADDED AT NS16 IS A 'DU', 'ER', 'IP', 'OP', 'IU', OR 'MP' EVENT TYPE) AND (SP REPORTED RECEIVING
HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY PREVIOUS ROUND) AND (IF THIS PROVIDER IS
ASSOCIATED WITH V.A. IS UNKNOWN), GO TO NS19 - VAPLACE.
ELSE GO TO BOX NS19.
BOX NS18
VAPLACE
NS19
BOX NS19
HMOASSOC
NS20
yes/no
routing
yes/no
[SELECT THE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT SPECIFICALLY NAMES THE LISTED SPECIALTY OR
MENTIONS THE WORDS OR INITIALS IN PARENTHESES FOLLOWING THAT PROVIDER SPECIALTY.]
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A. facility?
NS21
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
yes/no
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]
NAVIGATOR
NS22A_IN
BOX NS22A
BOX NS22B
MPSDVIS
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(01) CONTINUOUS ANSWER
(01)-(34), (-8), (-9) BOX NS18
(91) - NS18 - PROVSPOS
BOX NS18
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX NS19
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[your] respondent is SP
[(SP)'s] respondent is proxy
(01) NS22A_IN - NAVIGATOR
(02) NS21 - HMOREFER
(-8) NS21 - HMOREFER
(-9) NS21 - HMOREFER
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[Were you] respondent is SP
[Was (SP)] respondent is proxy
NS22A_IN - NAVIGATOR
IF (AT LEAST ONE EVENT ADDED AT NS16 IS A 'DU', 'ER', 'IP', 'OP', OR 'MP' EVENT TYPE) AND (SP COVERED BY A MANAGED CARE
PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS
UNKNOWN), GO TO NS20 - HMOASSOC.
IF (AT LEAST ONE EVENT ADDED AT NS16 IS A 'DU', 'ER', 'IP', 'OP', OR 'MP' EVENT TYPE) AND (SP COVERED BY A MANAGED CARE
PLAN ANYTIME DURING THE CURRENT ROUND) AND (THIS PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO
NS21 - HMOREFER.
ELSE GO TO NS22A_IN - NAVIGATOR.
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
HMOREFER
BOX NS17
instance
navigator
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
routing
FOR THE EVENT ADDED AT NS16,
IF TYPE OF EVENT = 'IP', GO TO IP7 - ANYOPERS.
ELSE IF TYPE OF EVENT = 'OP', GO TO OP5 - ANYOPERS.
ELSE IF TYPE OF EVENT = 'MP', GO TO BOX NS22B.
ELSE GO TO BOX NS23B.
routing
IF (PROVIDER SPECIALTY IS A MEDICAL DOCTOR) AND ((EVENT DATE OVERLAPS AN EXISTING IP EVENT) OR (EVENT DATE
MATCHES AN EXISTING ER OR OP EVENT) GO TO NS23 - MPSDVIS.
ELSE GO TO BOX NS23A
NS23
yes/no
We have recorded that in (EVENT MONTH) [you were/(SP) was] also in [READ EVENT(S) LISTED BELOW]. Was this visit with (PROVIDER
NAME) a visit while [you were/(SP) was] in [the [READ EVENT LISTED BELOW]/any of these places]?
BOX NS23A
routing
IF NS23 ASKED AND NS23 - MPSDVIS = 1/Yes, GO TO BOX NS23B.
ELSE GO TO BOX MP2C.
BOX NS23B
routing
GO TO NS22A_IN - NAVIGATOR.
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX NS22A
(02) NS14 - NSDATEUPD
[you were] - respondent is SP
[SP) was] - respondent is proxy
[READ EVENT LISTED BELOW] event does not
overlap more than one existing ER, IP, or OP event
[any of these places] event overlaps more than one
existing ER, IP, or OP event
BOX NS23A
EVENT_NSDATE
NS24
roster
SELECT THE EVENT DATE(S) THAT ARE INCLUDED IN THIS CHARGE BUNDLE.
BOX NS24
routing
IF AT LEAST ONE EVENT SELECTED AT NS24 IS A REPEAT VISIT, GO TO NS24A - RVLINKS.
ELSE GO TO NS25 - NSDATEMTCH.
(01) CONTINUOUS ANSWER
BOX NS24
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX NS24A
(01) BOX NS26
(02) NS13 - PROVIDER_NSDATE
(03) NS26 - EVENT_NSDATEDEL
ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT MONTH, YEAR) THAT ARE COVERED BY THIS CHARGE.
RVLINKS
NS24A
numeric
BOX NS24A
routing
[A REPEAT VISIT MEANS THAT THE RESPONDNT HAD AT LEAST 5 VISITS TO THE PROVIDER DURING THE CURRENT ROUND
REFERENCE PERIOD.]
IF ANOTHER EVENT SELECTED AT NS24 IS A REPEAT VISIT, GO TO NS24A - RVLINKS.
ELSE GO TO NS25 - NSDATEMTCH.
NSDATEMTCH
NS25
code one
ARE ALL THE PROVIDER EVENTS FROM THE CHARGE BUNDLE SHOWN BELOW?
(01) YES
(02) NO, NEED TO ADD A PROVIDER EVENT
(03) NO, NEED TO REMOVE A PROVIDER
EVENT
EVENT_NSDATEDEL
NS26
roster
SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
(01) CONTINUOUS ANSWER
NS25 - NSDATEMTCH
BOX NS26
routing
IF NS12 – INCTYPE INCLUDES 2/HHVisits, GO TO NS27 - PROVIDER_HH.
ELSE GO TO BOX NS33.
NS27
roster
WHICH HOME HEALTH PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.
(01) CONTINUOUS ANSWER
BOX NS28A
BOX NS28A
routing
IF (HOME HEALTH PROVIDER WAS ADDED AT NS27) OR (AN EXISTING PROVIDER WAS SELECTED AT NS27 THAT WAS NOT
ASSOCIATED WITH A HOME HEALTH EVENT), GO TO NS30 - HHEVNTTYPE.
ELSE GO TO BOX NS31B.
HHEVNTTYPE
NS30
code one
IS THE PROVIDER A HOME HEALTH PROFESSIONAL OR SOME OTHER TYPE OF HOME HEALTH PROVIDER (HOME HEALTH AIDE,
HOMEMAKER, ETC.)?
(01) HOME HEALTH PROFESSIONAL
(02) OTHER HOME HEALTH PROVIDER
NS31 - NSHHINTRO
NSHHINTRO
NS31
no entry
Before we continue with this statement, I would like to ask you a few questions about the home health provider I just added.
BOX NS31A
routing
BOX NS31B
routing
NS32
no entry
THE FOLLOWING HOME HEALTH PROVIDER EVENT HAS BEEN ADDED TO THIS CHARGE BUNDLE.
PLEASE ENTER A COMMENT IF THIS EVENT WAS ENTERED IN ERROR OR IF ANOTHER HOME HEALTH EVENT SHOULD BE
INCLUDED IN THIS CHARGE BUNDLE.
BOX NS33
routing
IF NS12 – INCTYPE INCLUDES 3/OMExpenses, GO TO NS34 - NSOMUPD.
ELSE GO TO BOX NS40.
PROVIDER_HH
NSHHMTCH
IF NS30 - HHEVNTTYPE = 1/HP, GO TO HH3 - PROVSPEC.
ELSE GO TO HH20 - HHFTYPE.
LINK HOME HEALTH PROVIDER TO CHARGE BUNDLE
GO TO NS32 - NSHHMTCH.
NSOMUPD
NS34
code one
THE FOLLOWING OME EVENTS HAVE BEEN ENTERED.
DO YOU NEED TO ADD OR EDIT AN OME EVENT FOR THIS CHARGE BUNDLE?
EVENT_NSOMEDIT
NS35
roster
SELECT AND EDIT THE OTHER MEDICAL EXPENSE EVENT THAT NEEDS CORRECTION.
NSOMADD
EVENT_NSOM
BOX NS31A
NS36
code one
WHAT TYPE OF OTHER MEDICAL EXPENSE NEEDS TO BE ADDED?
BOX NS36
routing
GO TO NS34 - NSOMUPD.
NS37
roster
SELECT OTHER MEDICAL EXPENSES THAT ARE IN THIS CHARGE BUNDLE.
BOX NS37
routing
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT NS37 IS RENTED, GO TO NS38 - MONTHCOV.
ELSE GO TO BOX NS38B.
HOW MANY MONTHS ARE COVERED BY THIS CHARGE BUNDLE?
MONTHCOV
NS38
numeric
MONCOV96
NS38
code one
BOX NS38A
routing
IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT NS37 IS RENTED, GO TO NS38 - MONTHCOV.
ELSE GO TO BOX NS38B.
BOX NS38B
routing
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT NS37 IS OSTOMY SUPPLIES, INCONTINENCE SUPPLIES OR BANDAGES,
GO TO NS38A - NUMLINKS.
ELSE GO TO NS39 - NSOMMTCH.
[IF THE RESPONDENT DOES NOT REPORT THE NUMBER OF MONTHS AS A WHOLE NUMBER, ROUND UP. (E.G., FOR 2 ½ MONTHS,
ENTER “3”.)]
(01) CONTINUE
(-7) EMPTY
BOX NS33
(01) NO, DO NOT NEED TO ADD OR EDIT OM
EVENT
(02) YES, NEED TO ADD AN OME EVENT
(03) YES, NEED TO EDIT AN OME EVENT
(01) NS37 - EVENT_NSOM
(02) NS36 - NSOMADD
(03) NS35 - EVENT_NSOMEDIT
(01) CONTINUOUS ANSWER
(01) GLASSES/CONTACTS
(02) HEARING/SPEECH DEVICE
(03) ORTHOPEDIC ITEM
(04) DIABETIC SUPPLIES
(05) AMBULANCE/RESCUE
(06 PROSTHESIS
(07) ALTERATIONS (HOME/CAR)
(08) OXYGEN
(09) KIDNEY DIALYSIS
(10) ALL OTHER MEDICAL SUPPLIES
(01) OM2 - EVENT_OMEYEG
(02) OM4 - EVENT_OMHEAR
(03) ITEM OM6 - ORTHTYPE
(04) OM10 - EVENT_OMDIAB
(05) OM12 - EVENT_OMAMBL
(06) OM14 - EVENT_OMPROS
(07) OM29 - ALTRTYPE
(08) OM19A - OXGNTYPE
(09) OM21A - KDNYTYPE
(10) OM24 - OTHRTYPE
(01) CONTINUOUS ANSWER
BOX NS37
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED
NS38 - MONCOV96
(01) LESS THAN 1 MONTH
(-7) EMPTY
BOX NS38A
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX NS38AA
ARE ALL THE OTHER MEDICAL EXPENSES FROM THE CHARGE BUNDLE SHOWN BELOW?
(01) YES
(02) NO, NEED TO ADD AN OME EVENT
(03) NO, NEED TO REMOVE AN OME EVENT
(01) BOX NS40
(02) NS34 - NSOMUPD
(03) NS40 - EVENT_NSOMDEL
roster
SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
(01) CONTINUOUS ANSWER
NS39 - NSOMMTCH
BOX NS40
routing
IF NS12 – INCTYPE INCLUDES 4/PMS, GO TO NS41 - EVENT_NSPM.
ELSE GO TO BOX NS45.
EVENT_NSPM
NS41
roster
SELECT OR ADD ALL PRESCRIPTION MEDICINES THAT ARE IN THIS CHARGE BUNDLE.
(01) CONTINUOUS ANSWER
NS42 - NUMLINKS
NUMLINKS
NS42
grid
HOW MANY PURCHASES OF EACH MEDICINE SHOWN BELOW ARE COVERED BY THIS CHARGE BUNDLE?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX NS42
BOX NS42
routing
IF AT LEAST ONE PRESCRIPTION MEDICINE WAS ADDED AT NS41, GO TO NS43 - NSPMINTRO.
ELSE GO TO NS44 - NSPMMTCH.
NS43
no entry
Before we continue with this statement, I would like to ask you a few questions about the prescribed medicine(s) I just added. [It would be very
helpful for the following questions if we could look at the bottle(s) or container(s) for the medicine(s).]
BOX NS43
routing
GO TO NS44 - NSPMMTCH.
NSPMMTCH
NS44
code one
ARE ALL THE PRESCRIBED MEDICINES FROM THE CHARGE BUNDLE SHOWN BELOW?
(01) YES
(02) NO, NEED TO ADD A MEDICINE NAME
(03) NO, NEED TO REMOVE A MEDICINE NAME
(01) BOX NS45
(02) NS41 - EVENT_NSPM
(03) NS45 - EVENT_NSPMDEL
EVENT_NSPMDEL
NS45
roster
SELECT THE PRESCRIBED MEDICINE(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
(01) CONTINUOUS ANSWER
NS44 - NSPMMTCH
BOX NS45
routing
IF TOTAL CHARGE OR COPAY COLLECTED > 0, DK OR RF, GO TO NS64 - NSTCHGPAID.
ELSE GO TO BOX NS64B.
NUMLINKS
numeric
HOW MANY PURCHASES OF (NAME OF OME ITEM) ARE COVERED BY THIS CHARGE BUNDLE?
BOX NS38AA
routing
IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT NS37 IS OSTOMY SUPPLIES, INCONTINENCE SUPPLIES OR BANDAGES, GO
TO NS38A - NUMLINKS.
ELSE GO TO NS39 - NSOMMTCH.
NSOMMTCH
NS39
code one
EVENT_NSOMDEL
NS40
NSPMINTRO
NS38A
PM6A_IN - NAVIGATOR
[Have you] respondent is SP
[Has (SP)] respondent is proxy
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(-8) DON'T KNOW
(-9) REFUSED
[, such as an insurance plan,] SP was not covered by
TRICARE and was covered by any other insurance plan
besides Medicare during the current round
[, such as TRICARE,] SP was covered by TRICARE and
is not covered by any other insurance plan besides
Medicare during the current round
[, such as TRICARE or an insurance plan,] SP was
covered by TRICARE and any other insurance plan
besides Medicare during the current round
code one
[[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance plan),] already paid any of [the
charge/the total charge/the copayment amount/this (TOTAL CHARGE)]?
BOX NS64A
routing
IF SP OR ANY SOURCE HAS PAID, GO TO BOX NS64B.
ELSE IF (NOTHING HAS BEEN PAID) OR (RESPONDENT DOES NOT KNOW IF ANYTHING HAS BEEN PAID), GO TO BOX NS78B.
ELSE GO TO BOX NS80.
BOX NS64B
routing
CREATE SOURCE OF PAYMENT ROSTER
GO TO NS65 - NSADDSOP1.
NSADDSOP1
NS65
yes/no
ARE ALL OF THE SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE LISTED BELOW?
SELECT "NO" TO ADD A SOURCE OF PAYMENT.
(01) YES
(02) NO
(01) NS67 - TSOPAMT
(02) NS66 - SOP_NS1
SOP_NS1
NS66
roster
ADD ALL ADDITIONAL SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE.
(01) CONTINUOUS ANSWER
NS67 - TSOPAMT
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED
BOX NS67HE
NSTCHGPAID
TSOPAMT
PAYMHE
NS64
NS67
grid
Who (else) paid? How much did (SOURCE) pay?
ENTER ALL PAYMENT AMOUNTS. CORRECT PAYMENT AMOUNTS AS NECESSARY.
BOX NS67HE
routing
IF AT LEAST ONE TSOPAMT = DK OR RF OR THE SUM OF ALL TSOPAMT VALUES FOR THIS COST > 0.00, GO TO BOX NS67A.
ELSE GO TO NS67HE - PAYMHE.
NS67HE
BOX NS67A
no entry
routing
THE SUM OF ALL PAYMENT AMOUNTS MUST BE GREATER
THAN $0.00 OR AT LEAST ONE PAYMENT AMOUNT MUST BE
'DON'T KNOW' OR 'REFUSED'.
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID AND
MAKE CORRECTIONS.
IF AT LEAST ONE SOURCE OF PAYMENT WAS ADDED AT NS66, GO TO BOX NS67B.
ELSE GO TO BOX NS69F.
[the charge] total charge was collected for charge
bundle, (NS5 - TOTALCHG = DK or RF), event is a
rental
[the total charge] total charge was collected for charge
bundle, (NS5 - TOTALCHG = DK or RF), event is not a
rental
[this (NS5 - TOTALCHG)] total charge was collected for
charge bundle, NS5 – TOTALCHG is not equal to DK or
RF
[the copayment amount] copayment was collected for
charge bundle, (NS6 - TOTALCHG = DK or RF)
[this (NS6 – TOTALCHG)] copayment was collected for
charge bundle, NS6 – TOTALCHG is not equal to DK or
RF
BOX NS64A
NS67HE - PAYMHE
BOX NS67B
routing
IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT NS66 IS A HEALTH INSURANCE PLAN, GO TO NS67BINT - PLANINTRO_NS.
ELSE GO TO BOX NS69E.
PLANINTRO_NS
NS67BINT
no entry
Before we continue, I would like to ask you a few questions about the health insurance plan(s) you just added.
NAVIGATOR
NS67B_IN
instance
navigator
BOX NS67C
NSMHMOCHNG1
NS68
NS67B_IN - NAVIGATOR
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
routing
CREATE A NEW HEALTH INSURANCE PLAN FOR FIRST/NEXT SOURCE OF PAYMENT ADDED AT NS66
IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP HAS A MEDICARE MANAGED CARE PLAN THAT IS
CURRENT, GO TO NS68 - NSMHMOCHNG1.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP DOES NOT HAVE A MEDICARE MANAGED CARE
PLAN THAT IS CURRENT, GO TO NS69 - NSSOPCURR1.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE PRESCRIPTION DRUG PLAN AND SP HAS A MEDICARE PRESCRIPTION DRUG PLAN
THAT IS CURRENT, GO TO NS69A - NSMPDPCHNG.
ELSE IF SOURCE OF PAYMENT IS MEDICARE PRESCRIPTION DRUG PLAN AND SP DOES NOT HAVE A MEDICARE PRESCRIPTION
DRUG PLAN THAT IS CURRENT, GO TO NS69B - NSSOPCURR2.
ELSE IF SOURCE OF PAYMENT IS MEDICAID, GO TO HI6 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PUBLIC PLAN, GO TO HI13 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PRIVATE PLAN, GO TO HI21 - COVTIME.
ELSE GO TO HIT2 - COVTIME.
yes/no
(01) YES
I recorded previously that (CURRENT MEDICARE MANAGED CARE PLAN NAME) was [your/(SP's)] current Medicare Managed Care Plan. Has (02) NO
this information changed?
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX NS67C
(02) BOX NS69E
[your] respondent is SP
[(SP)'s] respondent is proxy
(01) NS69 - NSSOPCURR1
(02) BOX NS69A
(-8) BOX NS69A
(-9) BOX NS69A
[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP is alive
[Was (SP)] respondent is proxy, SP is deceased
NSSOPCURR1
NSMPDPCHNG
NS69
NS69A
yes/no
yes/no
[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (NS66 SOP MEDICARE MANAGED CARE PLAN NAME) [on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?
I recorded previously that (CURRENT MEDICARE PRESCRIPTION
DRUG PLAN) was [your/(SP's)] current Medicare Prescription Drug
Care Plan.
Has this information changed?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[currently] - SP alive
[] SP deceased
[on (DATE OF DEATH)] respondent is proxy, SP
deceased
[on (DATE OF INSTITUTIONALIZATION)] respondent is
proxy, SP institutionalized
[] respondent is SP
[your] respondent is SP
[(SP)'s] respondent is proxy
(01) HIMC6A - MHMORXTM
(02) BOX NS69A
(-8) BOX NS69A
(-9) BOX NS69A
(01) NS69B - NSSOPCURR2
(02) BOX NS69A
(-8) BOX NS69A
(-9) BOX NS69A
[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP is alive
[Was (SP)] respondent is proxy, SP is deceased
NSSOPCURR2
NS69B
yes/no
[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (NS66 SOP MEDICARE PRESCRIPTION DRUG PLAN) [on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?
BOX NS69A
routing
GO TO NS67B_IN - NAVIGATOR.
BOX NS69E
routing
IF AN "OTHER SOURCE OF PAYMENT" ADDED AT NS66, CREATE AN OSOP FOR EACH SOURCE OF PAYMENT ADDED AT NS66 THAT
IS AN "OTHER SOURCE OF PAYMENT" .
GO TO BOX NS69F.
routing
IF (TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (AT LEAST ONE PAYMENT ENTERED AT NS67 = DK OR RF) AND (AT
LEAST ONE PAYMENT ENTERED AT NS67 ^= DK AND ^= RF AND ^= 0) AND (TOTAL OF ALL NON-MISSING PAYMENTS ENTERED AT
NS67 >= TOTAL CHARGE), GO TO NS71 - AMTSCORR.
ELSE IF (TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (ALL PAYMENTS ENTERED AT NS67 ^= DK AND ^= RF) AND (THE
ABSOLUTE VALUE OF THE DIFFERENCE BETWEEN THE TOTAL PAYMENTS ENTERED AT NS67 AND TOTAL CHARGE IS > $1.00), GO
TO NS70 - AMTSCORR.
ELSE GO TO BOX NS77C.
BOX NS69F
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[currently] - SP alive
[] SP deceased
[on (DATE OF DEATH)] respondent is proxy, SP
deceased
[on (DATE OF INSTITUTIONALIZATION)] respondent is
proxy, SP institutionalized
[] respondent is SP
BOX NS69A
There seems to be [some amount still unpaid/more payments than the charge].
AMTSCORR
NS70
code one
[REVIEW WITH RESPONDENT.] The total of all payments is $(TOTAL PAYMENTS). The amount [unpaid/overpaid] is $(DIFFERENCE
BETWEEN PAYMENTS AND TOTAL CHARGE). Is that correct?
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION,
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID.
THE AMOUNTS ENTERED FOR THE SOURCES OF PAYMENT EQUAL OR EXCEED THE [TOTAL CHARGE/COPAYMENT], WITH AT
LEAST ONE SOP BEING A MISSING AMOUNT. VERIFY ALL AMOUNTS AS ENTERED.
AMTSCORR
NS71
code one
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION,
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID.
ENTERCOM
NS72
no entry
(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR
CORRECTION
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8) DON'T KNOW
(-9) REFUSED
(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR
CORRECTION
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8) DON'T KNOW
(-9) REFUSED
[THE TOTAL OF PAYMENTS IS $(TOTAL PAYMENTS). THE AMOUNT [UNPAID/OVERPAID] IS $(DIFFERENCE BETWEEN PAYMENTS
AND TOTAL CHARGE).]
[some amount still unpaid] total amounts paid < total
charge
[more payments than the charge] total amounts paid >
total charge
[unpaid] total amount paid < total charge
[overpaid] total amount paid > total charge
(01) BOX NS77C
(02) DO NOT DISPLAY.
(03) NS72 - ENTERCOM
(-8) BOX NS77C
(-9) BOX NS77C
[(TOTAL CHARGE)] total charge was collected for
charge bundle
[(COPAYMENT)] copayment collected for charge bundle
(01) BOX NS77C
(02) DO NOT DISPLAY.
(03) NS72 - ENTERCOM
(-8) BOX NS77C
(-9) BOX NS77C
[UNPAID] - total amount paid < total charge
[OVEPAID] - total amount paid > total charge
BOX NS77C
[you have] -respondent is SP
[(SP) has] - respondent is proxy
[you] -respondent is SP
[(SP)] - respondent is proxy
BOX NS78A
USE COMMENTS TO EXPLAIN WHY THE AMOUNT REMAINING SEEMS INCORRECT.
EXPPAYBK
BOX NS77C
routing
CREATE PAYMENTS FOR AMOUNTS ENTERED AT NS67
GO TO BOX NS77D.
BOX NS77D
routing
IF THE SP OR FAMILY MADE A PAYMENT AND PAYMENT IS GREATER THAN $5.00, GO TO NS78 - EXPPAYBK.
ELSE GO TO BOX NS80.
NS78
BOX NS78A
BOX NS78B
yes/no
I have recorded that [you have/(SP) has] paid $(SP/FAMILY PAYMENT). Do you expect any source to pay [you/(SP)] back any or all of that
amount?
routing
IF NS78 - EXPPAYBK = 1/Yes AND ((CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST COLLECTED 2 ROUNDS
PREVIOUS TO CURRENT ROUND) OR (SP IS IN THE EXIT SAMPLE)), GO TO NS80 - EXPAYUNT.
ELSE GO TO BOX NS80.
routing
IF (CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO CURRENT ROUND) OR
(SP IS IN THE EXIT SAMPLE), GO TO NS79 - EXPAYOUT.
ELSE GO TO BOX NS80.
EXPAYOUT
NS79
yes/no
Do you expect anyone to pay any of this amount?
EXPAYUNT
NS80
quantity unit
How much do you expect will be paid?
EXPAYPCT
EXPAYAMT
NS80
NS80
numeric
numeric
BOX NS80
routing
IF CURRENTLY ADMINISTERING CPS, GO TO BOX CPSBEG.
ELSE GO TO BOX NSL1.
IF (CHARGE DATA WAS COLLECTED IN NS FOR THIS NS CHARGE BUNDLE) AND (NS CHARGE BUNDLE IS LINKED TO ONLY ONE
EVENT) AND (SP OR ANY OTHER SOURCE HAS PAID) AND
BOX NSL1
routing
((EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'PM' AND (THE TOTAL CHARGE ^= RF) AND (PM WAS
PURCHASED THROUGH AN HMO) AND (THERE ARE OTHER CURRENT ROUND PRESCRIPTION MEDICINE EVENTS NOT LINKED TO A
CURRENT ROUND CHARGE BUNDLE THAT WERE PURCHASED THROUGH AN HMO))
OR
(EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'PM' AND (TOTAL CHARGE ^= RF) AND (PM WAS NOT PURCHASED
THROUGH AN HMO OR HAD AN UNKNOWN PURCHASE LOCATION) AND (THERE ARE OTHER CURRENT ROUND PRESCRIPTION
MEDICINE EVENTS NOT LINKED TO A CURRENT ROUND CHARGE BUNDLE THAT WERE NOT PURCHASED THROUGH AN HMO OR
HAD AN UNKNOWN PURCHASE LOCATION))
OR
(EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'DU', 'ER', 'OP', 'MP', 'SD', OR 'SL' AND (THE TOTAL CHARGE ^= DK
AND TOTAL CHARGE ^= RF) AND (SP REFERRED TO PROVIDER BY HMO FOR THIS EVENT) AND (THERE ARE OTHER CURRENT
ROUND EVENTS WITH THE SAME EVENT TYPE FOR THIS PROVIDER WHERE THE SP WAS REFERRED TO THE PROVIDER BY THE
HIMO THAT ARE NOT LINKED TO A CURRENT ROUND CHARGE BUNDLE))
OR
(EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'DU', 'ER', 'OP', 'MP', 'SD', OR 'SL' AND (THE TOTAL CHARGE ^= DK
AND TOTAL CHARGE ^= RF) AND (SP WAS NOT REFERRED TO PROVIDER BY HMO OR REFERRAL IS UNKNOWN FOR THE EVENT)
AND (THERE ARE OTHER CURRENT ROUND EVENTS WITH THE SAME EVENT TYPE FOR THIS PROVIDER WHERE THE SP WAS NOT
REFERRED TO PROVIDER BY HMO OR REFERRAL IS UNKNOWN FOR THE EVENT THAT ARE NOT LINKED TO A CURRENT ROUND
CHARGE BUNDLE)),
), GO TO NSL1 - NSEVSAME.
ELSE GO TO BOX NSBEG.
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) PERCENTAGE NS80 - EXPAYPCT
(02) DOLLARS NS80 - EXPAYAMT
(-8) DON'T KNOW
(-9) REFUSED
(01) NS80 - EXPAYUNT
(02) BOX NS80
(-8) BOX NS80
(-9) BOX NS80
(01) NS80 - EXPAYPCT
(02) NS80 - EXPAYAMT
(-8) BOX NS80
(-9) BOX NS80
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
BOX NS80
BOX NS80
[you] respondent is SP
[(SP)] respondent is proxy
You told me earlier that [you/(SP)] had other [visits to (PROVIDER NAME)/prescribed medicine purchases].
NSEVSAME
NSL1
code one
Are any other [visits to (PROVIDER NAME)/prescribed medicine purchases] the same -- where the [total charge was (TOTAL CHARGE
TEXT)/copayment was (TOTAL CHARGE TEXT)] per (visit/purchase) and payments were: [READ PAYMENTS LISTED ABOVE]?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[prescribed medicine purchases] event linked to NS
charge bundle is a PM event (there will only be one
event)
[visits to (PROVIDER NAME)] event linked to NS charge
bundle is not a PM event
[total charge was (TOTAL CHARGE TEXT)] total charge
was collected for charge bundle
[copayment was (TOTAL CHARGE TEXT)] copayment
was collected for charge bundle
(01) BOX NSL2
(02) BOX NSBEG
(-8) BOX NSBEG
(-9) BOX NSBEG
[purchase] event linked to NS charge bundle is a PM
event
[visit] event linked to NS charge bundle is not a PM event
BOX NSL2
NSL3
routing
roster
IF EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'PM', GO TO NSL3 - EVENT_PMSAME.
ELSE GO TO NSL5 - EVENT_VISITSAME.
Which ones are the same?
REVIEW LIST WITH RESPONDENT AND SELECT ALL PRESCRIPTION MEDICINES WHERE THE COSTS AND PAYMENTS ARE THE
SAME.
(01) CONTINUOUS ANSWER
BOX NSL3
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX NSBEG
(01) CONTINUOUS ANSWER
BOX NSL5
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX NSL6
IF NO PRESCRIPTION MEDICINES HAD THE SAME COST AND PAYMENTS, PRESS ENTER WITHOUT SELECTING ANY MEDICINES.
BOX NSL3
NUMLINKS
EVENT_VISITSAME
NSL4
NSL5
routing
IF AT LEAST ONE PRESCRIBED MEDICINE SELECTED AT NSL3 HAS NUMBER OF PURCHASES BEING ASKED ABOUT IN NS > 1, GO
TO NSL4 - NUMLINKS.
ELSE GO TO BOX NSBEG.
grid
How many times are the same?
ENTER THE NUMBER OF PURCHASES OF EACH MEDICINE SHOWN BELOW THAT ARE THE SAME.
roster
Which ones are the same?
REVIEW LIST WITH THE RESPONDENT AND SELECT ALL PROVIDER EVENTS WHERE THE COST AND PAYMENTS ARE THE SAME.
IF NO PROVIDER EVENTS HAD THE SAME COST AND PAYMENTS, PRESS ENTER WITHOUT SELECTING ANY EVENTS.
RVLINKS
BOX NSL5
routing
IF AT LEAST ONE EVENT SELECTED AT NSL5 IS A REPEAT VISIT, GO TO NSL6 - RVLINKS.
ELSE GO TO BOX NSBEG.
NSL6
numeric
How many times are the same for (EVENT)?
ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT
MONTH, YEAR) THAT ARE THE SAME.
BOX NSL6
routing
IF ANOTHER EVENT SELECTED AT NSL5 IS A REPEAT VISIT, GO TO NSL6 - RVLINKS.
ELSE GO TO BOX NSBEG.
YOU HAVE ENTERED ALL CHARGE/PAYMENT DATA FOR ALL EVENTS REPORTED.
NSTATEMENT
NS81
yes/no
BOX NSEND
routing
(01) YES
DO YOU HAVE ANY MSN, INSURANCE, TRICARE, OR MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENTS THAT YOU HAVE NOT (02) NO
YET ENTERED?
GO TO NEXT SECTION
(01) ST5 - ST_CHARGEBUNDLE
(02) BOX NSEND
Charge Payment Summary (CPS)
Variable Name
MR Screen Name
Question type
Question text/description
CPS REASON HAS ALREADY BEEN ASSIGNED TO ALL CHARGE BUNDLES ENTERED IN THE PAST 2 ROUNDS THAT HAVE MISSING CHARGE DATA.
Code list
Text Fill Logic
Input mask Routing
CPS REASON 1 = NO STATEMENT CHARGE BUNDLE, SP EXPECTED TO RECEIVE A STATEMENT
CPS REASON 2 = NO STATEMENT CHARGE BUNDLE, NO PAYMENTS HAVE BEEN MADE.
CPS REASON 3 = STATEMENT CHARGE BUNDLE, NO PAYMENTS HAVE BEEN MADE.
CPS REASON 4 = NO STATEMENT CHARGE BUNDLE, TOTAL PAYMENTS LESS THAN TOTAL CHARGE.
CPS REASON 5 = STATEMENT CHARGE BUNDLE, TOTAL PAYMENTS LESS THAN AMOUNT REMAINING.
CPS REASON 6 = SP MADE PAYMENT AND EXPECTED REIMBURSEMENT.
CPS REASON 7 = SP MADE PAYMENT AND DID NOT KNOW IF REIMBURSEMENT EXPECTED.
CPS REASON 8 = NO STATEMENT CHARGE BUNDLE ENTERED AT HOME OFFICE, SP EXPECTED TO RECEIVE A STATEMENT.
IN CPS, WE WILL REVIEW THIS LIST OF CHARGE BUNDLES AND WILL EXCLUDE ANY CHARGE BUNDLE WITH AN EVENT THAT HAS BEEN DELETED, HAS BEEN LINKED TO A STATEMENT
CHARGE BUNDLE IN THE CURRENT ROUND, OR WAS ASKED ABOUT IN THE CURRENT ROUND NO STATEMENT SECTION AND THE SP IS NOT EXPECTING TO RECEIVE A STATEMENT FOR
THIS EVENT.
THE REMAINING LIST OF CHARGE BUNDLES WILL BE ELIGIBLE FOR CPS. WE WILL SORT THIS LIST BY CPS REASON. WE WILL THEN COLLECT CPS DETAILS FOR THE FIRST CHARGE
BUNDLE IN THIS LIST.
NAVIGATOR
BOX CPSBEG
routing
CPS1_IN
instance navigator
AFTER COMPLETING THE CPS DETAILS FOR THIS CHARGE BUNDLE, WE WILL RETURN TO BOX CPSBEG. BECAUSE THE DATA THAT DETERMINES IF A CHARGE BUNDLE IS ELIGIBLE
FOR CPS MAY BE UPDATED WHILE ADMINISTERING CPS, THE LIST OF ELIGIBLE CHARGE BUNDLES WILL BE RECREATED AT THE BEGINNING OF EACH LOOP IN CPS
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) CPS1 - CPSINT
(02) BOX CPSBEG
[Next, I will ask about some medical care that we talked about in a previous interview.] CPS1 - CPSINT has not
been asked in the current round
[] CPS1 - CPSINT has been asked in the current round
[Next, I will ask about some medical care that we talked about in a previous interview.]
[REMAINING] CPS1 - CPSINT has already been asked in the current round
[] CPS1 - CPSINT has not already been asked in the current round
THERE ARE (TOTAL NUMBER OF CPS EVENTS) EVENTS OR BUNDLES [REMAINING] FOR SUMMARY.
CPSINT
CPS1
BOX CPS1A
BOX CPS1B
no entry
[First/Next], I want to ask about [READ EVENT(S) ABOVE].
routing
IF CPS REASON = 1 OR 8, GO TO CPS2 - RECDSTAT.
ELSE GO TO BOX CPS1B.
routing
CREATE SOURCE OF PAYMENT ROSTER
IF CPS REASON = 2, 6 OR 7, GO TO BOX CPS2.
ELSE IF CPS REASON = 3, GO TO CPS11 - CPTCHGPAID2.
ELSE IF CPS REASON = 4, GO TO CPS13 - CPTCHGPAID3.
ELSE IF CPS REASON = 5, GO TO CPS15 - CPTCHGPAID4.
[First] CPS1 - CPSINT has not been asked in the current round
[Next] CPS1 - CPSINT has not been asked in the current round
BOX CPS1A
[At the last interview, [you were/(SP) was] expecting to receive a statement or paper from (Medicare, Insurance,
and TRICARE/Medicare and TRICARE/Medicare and Insurance/Medicare).] CPS Reason = 1
[] CPS Reason not equal to 1
[since then] CPS Reason = 1
[since the last interview] CPS Reason not equal to 1
[Medicare,
Insurance, and TRICARE] SP was covered by TRICARE and any other insurance plan
besides Medicare during the current round
[Medicare and TRICARE] SP was covered by TRICARE and is not covered by any
other insurance plan besides Medicare during the current round
[Medicare and Insurance] SP was not covered by TRICARE and was covered by any
other insurance plan besides Medicare during the current round
[Medicare] SP was not covered by TRICARE or any other insurance plan
besides Medicare during the current round
[PROBE IF NECESSARY: Please include any statements received about (your/(SP's)] Medicare prescription
drug benefit.] - PM event is linked to the charge bundle and ((SP has reported a
Medicare Prescription Drug Plan) or (SP has reported having a
Medicare Managed Care plan with RX coverage in the past year))
Else do not display sentence.
[At the last interview, [you were/(SP) was] expecting to receive a statement or paper from [Medicare, Insurance, and TRICARE/Medicare and TRICARE/Medicare and Insurance/Medicare).] [Have you/Has
(SP)] received a statement for the [READ EVENT(S) ABOVE] (since then/since the last interview)?
RECDSTAT
CPS2
BOX CPS2
KNOWTOTL
CPS3
BOX CPS3
TOTALCHG
CPS4
code one
[PROBE IF NECESSARY: Please include any statements received about (your/(SP's)] Medicare prescription drug benefit.]
routing
IF TOTAL CHARGE = DK OR RF AND ((ASKING ABOUT A NO STATEMENT CHARGE BUNDLE) OR (ASKING ABOUT A STATEMENT CHARGE BUNDLE AND TYPE OF STATEMENT IS NOT A
MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENT)), GO TO CPS3 - KNOWTOTL.
ELSE IF CPS REASON = 2, GO TO CPS9 - CPTCHGPAID1.
ELSE IF CPS REASON = 6 OR 7, GO TO CPS19 - CPSREIMINT.
yes/no
Do you happen to know the (total charge/copayment amount) for the [READ EVENT(S) ABOVE]?
routing
IF CPS3 - KNOWTOTL = 1/Yes AND (TOTAL CHARGE WAS COLLECTED FOR CHARGE BUNDLE), GO TO CPS4 - TOTALCHG.
ELSE IF CPS3 - KNOWTOTL = 1/Yes AND (COPAYMENT WAS COLLECTED FOR CHARGE BUNDLE), GO TO CPS5 - TOTALCHG.
ELSE IF (CPS3 - KNOWTOTL = 2/No OR RF) AND (CPS REASON = 2), GO TO CPS9 - CPTCHGPAID1.
ELSE IF CPS REASON = 6 OR 7, GO TO CPS19 - CPSREIMINT.
numeric
Including any amounts that may be paid by Medicare or anyone else, what was the total charge (that is, the amount billed)?
ENTER 0 IF NO CHARGE FOR THE EVENT.
[PROBE FOR TOTAL BILLED AMOUNT, REGARDLESS OF WHO PAID (OR WILL PAY) ANY PORTION OF THE CHARGE. IF THE RESPONDENT RECEIVES A DISCOUNT, RECORD THE TOTAL
CHARGE BEFORE THE DISCOUNT IS APPLIED.]
(01) STATEMENT RECEIVED AND AVAILABLE
(02) STATEMENT RECEIVED, NOT AVAILABLE
(03) STATEMENT NOT RECEIVED
(-8) Don't Know
(-9) Refused
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is SP
(01) ST4 - MATCHST
(02) BOX NS4A
(03) BOX NS4A
(-8) BOX NS4A
(-9) BOX CPS32
(01) YES
(02) NO
(-9) Refused
[total charge] total charge was collected for charge bundle
[copayment amount] copayment was collected for charge bundle
BOX CPS3
(01) continuous answer
(-8) Don't Know
(-9) Refused
BOX CPS5A
What was the copayment amount for the [READ EVENT(S) ABOVE]?
TOTALCHG
CPS5
BOX CPS5A
BOX CPS5B
MONTHCOV
CPS6
numeric
[EXPLAIN IF NECESSARY: Managed care plans commonly charge a fixed amount, or copayment, each time health services are provided. For example, the person may pay $20 for each office visit and $10
for each drug prescription.]
(01) continuous answer
(-8) Don't Know
ENTER 0 IF NO COPAYMENT FOR THE EVENT.
(-9) Refused
routing
IF (CPS REASON = 2) AND (TOTAL CHARGE = 0) AND (SP IS CURRENTLY COVERED BY MEDICAID), GO TO BOX CPS32.
ELSE IF (CPS REASON = 6 OR 7) AND (TOTAL CHARGE = RF), GO TO CPS19 - CPSREIMINT.
ELSE GO TO BOX CPS5B.
routing
FOR THE FIRST/NEXT EVENT INCLUDED IN THE CHARGE BUNDLE, IF EVENT TYPE = 'OM' AND EVENT IS A RENTAL ITEM, GO TO CPS6 - MONTHCOV.
ELSE FOR THE FIRST/NEXT EVENT INCLUDED IN THE CHARGE BUNDLE, IF (EVENT TYPE = 'PM') OR (EVENT TYPE = 'OM' AND (OTHER MEDICAL EXPENSE IS OSTOMY SUPPLIES,
INCONTINENCE SUPPLIES OR BANDAGES)), GO TO CPS7 - NUMLINKS.
ELSE FOR THE FIRST/NEXT EVENT INCLUDED IN THE CHARGE BUNDLE, IF (EVENT WAS ENTERED AS A REPEAT VISIT), GO TO CPS8 - RVLINKS.
ELSE GO TO BOX CPS8A.
numeric
For the [READ OME ITEM ABOVE], how many months are covered by the charge for the period of time between (CHARGE BUNDLE REFERENCE PERIOD)?
[IF THE RESPONDENT DOES NOT REPORT THE NUMBER OF MONTHS AS A WHOLE NUMBER, ROUND UP. (E.G., FOR 2 ½ MONTHS, ENTER “3”.)]
BOX CPS5A
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
CPS6 - MONCOV96
[you] respondent is SP
[(SP)] respondent is proxy
[(MEDICINE NAME)] EVENT TYPE = 'PM'
[(OME ITEM TYPE)] EVENT TYPE = 'OM'
[were covered by the total charge] total charge was collected for charge bundle, CPS4 - TOTALCHG = DK or RF
[was there no charge] total charge was collected for charge bundle, CPS4-TOTALCHG = 0
[were covered by the (CPS4 - TOTAL CHARGE)] total charge was collected for charge bundle, CPS4 TOTALCHG is not equal to DK, RF, or 0
NUMLINKS
CPS7
numeric
(01) continuous answer
How many of the times [you/(SP)] obtained (MEDICINE NAME/OME ITEM TYPE) for the period between (CHARGE BUNDLE REFERENCE PERIOD) [were covered by the total charge/were covered by the (-8) Don't Know
(CPS4 - TOTAL CHARGE)/was there no charge/were covered by the copayment/were covered by the (CPS5 - COPAYMENT)/was there no copayment]?
(-9) Refused
[were covered by the copayment] copayment was collected for charge bundle, CPS5 - TOTALCHG = DK or RF
[was there no copayment] copayment was collected for charge bundle, CPS5 - TOTALCHG = 0
[were covered by the (CPS5 - COPAYMENT)] copayment was collected for charge bundle, CPS5 - TOTALCHG
is not equal to DK, RF, or 0
BOX CPS8A
[were covered by the total charge] total charge was collected for charge bundle, CPS4 - TOTALCHG = DK or RF
[was there no charge] CPS4-TOTALCHG = 0
Else display [were covered by the (CPS4 - TOTAL CHARGE)]
RVLINKS
CPS8
BOX CPS8A
BOX CPS8B
numeric
(01) continuous answer
How many of the [READ EVENT ABOVE] [were covered by the total charge/were covered by the (CPS4 - TOTAL CHARGE)/was there no charge/were covered by the copayment/were covered by the (CPS5 - (-8) Don't Know
COPAYMENT)/was there no copayment]?
(-9) Refused
routing
IF ANOTHER EVENT IS INCLUDED IN THE CHARGE BUNDLE, GO TO BOX CPS5B.
ELSE GO TO BOX CPS8B.
routing
IF CPS REASON = 2 AND TOTAL CHARGE ^= 0, GO TO CPS9 - CPTCHGPAID1.
ELSE IF CPS REASON = 2 AND TOTAL CHARGE = 0, GO TO BOX CPS10.
ELSE IF CPS REASON = 6 OR 7, GO TO CPS19 - CPSREIMINT.
[were covered by the copayment] copayment was collected for charge bundle, CPS5 - TOTALCHG = DK or RF
[was there no copayment] CPS5 - TOTALCHG = 0
Else display [were covered by the (CPS5 - COPAYMENT)]
BOX CPS8B
[Last time, we recorded that the (total charge/copayment amount) for the [READ EVENT(S) ABOVE] was
(TOTAL CHARGE)), and that no payment had been made.] CPS3 - KNOWTOTL was not asked for this charge
bundle
[] CPS3 - KNOWTOTL was already asked for this charge bundle
[total charge] total charge was collected for charge bundle
[copayment amount] copayment was collected for charge bundle
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[, such as an insurance plan,] SP was not covered by TRICARE and was covered by any other insurance plan
besides Medicare during the current round
[, such as TRICARE,] SP was covered by TRICARE and is not covered by any other insurance plan besides
Medicare during the current round
[, such as TRICARE or an insurance plan,] SP was covered by TRICARE and any other insurance plan besides
Medicare during the current round
[] SP was not covered by TRICARE or any other insurance plan besides Medicare during the current round
CPTCHGPAID1
CPS9
code one
[Last time, we recorded that the (total charge/copayment amount) for the [READ EVENT(S) ABOVE] was (TOTAL CHARGE)), and that no payment had been made.] [Have you/Has (SP)] or any other
source[, such as (an insurance plan/TRICARE/TRICARE or an insurance plan),] now paid any of [the total charge/the copayment amount/this (TOTAL CHARGE)]?
TCHGWRONG
CPS10
no entry
YOU CANNOT CORRECT THE TOTAL CHARGE HERE. THE ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO” AS APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID ANY PORTION
OF THE CHARGE.
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) (TOTAL CHARGE/COPAYMENT AMOUNT) IS
WRONG
(-8) Don't Know
(-9) Refused
[the total charge] total charge was collected for charge bundle, CPS3 - KNOWTOTL was not asked for this
charge bundle
[the copayment amount] copayment was collected for charge bundle, CPS3 - KNOWTOTL was not asked for
this charge bundle
Else display [this (TOTAL CHARGE)]
(01) BOX CPS10
(02) BOX CPS10
(03) CPS10 - TCHGWRON
(-8) BOX CPS10
(-9) BOX CPS10
CPS9 - CPTCHGPAID1
BOX CPS10
routing
DESIGN NOTES
Calls NS SOP roster.
IF (CPS9 - CPTCHGPAID1 = 1/SomeonePaid) OR (TOTAL CHARGE = 0), GO TO NS65 - NSADDSOP1.
ELSE IF (CPS9 - CPTCHGPAID1 = 2/NothingPaid), GO TO CPS17 - EXPAYOUT.
ELSE GO TO BOX CPS32.
NS returns to CPS at BOX
[Medicare had paid [nothing and/(MEDICARE PAYMENT AMOUNT) and after Medicare paid,]]
COST.MCPAYAMT ^= EMPTY & Medicare Payment Amount, COST.MCPAYAMT >=0
Else do not display phrase.
[Medicare had paid nothing and] COST.MCPAYAMT = 0
[Medicare had paid (MEDICARE PAYMENT AMOUNT) and after Medicare paid] COST.MCPAYAMT is not equal
to 0
[Have you] respondent is SP
[Has (SP)] respondent is proxy
Last time, we recorded that [Medicare had paid [nothing and/(MEDICARE PAYMENT AMOUNT) and after Medicare paid,]] there was an amount remaining of (CPS AMOUNT REMAINING) for the [READ
EVENT(S) ABOVE.]
CPTCHGPAID2
CPS11
code one
[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance plan),] now paid any of this (AMOUNT REMAINING)?
TCHGWRONG
CPS12
no entry
YOU CANNOT CORRECT THE AMOUNT REMAINING HERE. THE ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO” AS APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID.
routing
IF (CPS11 - CPTCHGPAID2 = 1/SomeonePaid), GO TO ST65 - STADDSOP1.
ELSE IF (CPS11 - CPTCHGPAID2 = 2/NothingPaid), GO TO CPS17 - EXPAYOUT.
ELSE IF (CPS11 - CPTCHGPAID2 = DK), GO TO CPS23 - RRDETAIL.
ELSE GO TO BOX CPS32.
BOX CPS12
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) Don't Know
(-9) Refused
[, such as an insurance plan,] SP was not covered by TRICARE and was covered by any other insurance plan
besides Medicare during the current round
[, such as TRICARE,] SP was covered by TRICARE and is not covered by any other insurance plan besides
Medicare during the current round
[, such as TRICARE or an insurance plan,] SP was covered by TRICARE and any other insurance plan besides
Medicare during the current round
[] SP was not covered by TRICARE or any other insurance plan besides Medicare during the current round
(01) BOX CPS12
(02) BOX CPS12
(03) CPS12 - TCHGWRON
(-8) BOX CPS12
(-9) BOX CPS12
CPS11 - CPTCHGPAID2
[Have you] respondent is SP
[Has (SP)] respondent is proxy
Let me review what we recorded last time.
[REVIEW WITH RESPONDENT.] The total of all payments is $(TOTAL PAYMENTS). The amount unpaid is $(DIFFERENCE BETWEEN PAYMENTS AND TOTAL CHARGE).
CPTCHGPAID3
CPS13
code one
[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance plan),] paid any additional amount?
TCHGWRONG
CPS14
no entry
YOU CANNOT CORRECT THE TOTAL CHARGE HERE. THE ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO” AS APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID ANY
ADDITIONAL AMOUNT.
routing
IF CPS13 - CPTCHGPAID3 = 1/Yes OR 4/PaymentsWrong, GO TO NS65 - NSADDSOP1.
ELSE IF CPS13 - CPTCHGPAID3 = 2/NothingPaid, GO TO CPS17 - EXPAYOUT.
ELSE IF (CPS13 - CPTCHGPAID3 = DK), GO TO CPS23 - RRDETAIL.
ELSE GO TO BOX CPS32.
BOX CPS14
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) TOTAL CHARGE SEEMS WRONG
(04) PAYMENT AMOUNTS WRONG
(-8) Don't Know
(-9) Refused
[, such as an insurance plan,] SP was not covered by TRICARE and was covered by any other insurance plan
besides Medicare during the current round
[, such as TRICARE,] SP was covered by TRICARE and is not covered by any other insurance plan besides
Medicare during the current round
[, such as TRICARE or an insurance plan,] SP was covered by TRICARE and any other insurance plan besides
Medicare during the current round
[] SP was not covered by TRICARE or any other insurance plan besides Medicare during the current round
(01) BOX CPS14
(02) BOX CPS14
(03) CPS14 - TCHGWRON
(04) BOX CPS14
(-8) BOX CPS14
(-9) BOX CPS14
CPS13 - CPTCHGPAID3
[Have you] respondent is SP
[Has (SP)] respondent is proxy
Let me review what we recorded last time.
CPTCHGPAID4
CPS15
code one
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
[REVIEW ABOVE WITH RESPONDENT.] There seems to be some amount still unpaid. The total of non-Medicare payments is $(TOTAL PAYMENTS). The amount unpaid is $(DIFFERENCE BETWEEN (03) AMOUNT REMAINING SEEMS WRONG
PAYMENTS AND CPS AMOUNT REMAINING).
(04) PAYMENT AMOUNTS WRONG
(-8) Don't Know
[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance plan),] paid any additional amount?
(-9) Refused
TCHGWRONG
CPS16
no entry
YOU CANNOT CORRECT THE AMOUNT REMAINING HERE. THE ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO” AS APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID ANY
ADDITIONAL AMOUNT.
routing
IF CPS15 - CPTCHGPAID4 = 1/Yes OR 4/PaymentsWrong, GO TO ST65 - STADDSOP1.
ELSE IF CPS15 - CPTCHGPAID4 = 2/NothingPaid, GO TO CPS17 - EXPAYOUT.
ELSE IF (CPS15 - CPTCHGPAID4 = DK), GO TO CPS23 - RRDETAIL.
ELSE GO TO BOX CPS32.
BOX CPS16
EXPAYOUT
CPS17
yes/no
Do you expect that [you/(SP)] or any other source will pay any [of this amount/additional amount for [READ EVENT(S) ABOVE]]?
[, such as an insurance plan,] SP was not covered by TRICARE and was covered by any other insurance plan
besides Medicare during the current round
[, such as TRICARE,] SP was covered by TRICARE and is not covered by any other insurance plan besides
Medicare during the current round
[, such as TRICARE or an insurance plan,] SP was covered by TRICARE and any other insurance plan besides
Medicare during the current round
[] SP was not covered by TRICARE or any other insurance plan besides Medicare during the current round
(01) BOX CPS16
(02) BOX CPS16
(03) CPS16 - TCHGWRON
(04) BOX CPS16
(-8) BOX CPS16
(-9) BOX CPS16
CPS15 - CPTCHGPAID4
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[of this amount] CPS REASON = 2 or 3
[additional amount for [READ EVENT(S) ABOVE]] CPS REASON is not equal to 2 or 3
(01) BOX CPS17
(02) BOX CPS32
(-8) BOX CPS32
(-9) BOX CPS32
EXPAYUNT
EXPAYPCT
EXPAYAMT
BOX CPS17
routing
IF (CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO CURRENT ROUND) OR (SP IS IN THE EXIT SAMPLE), GO TO CPS18 - EXPAYUNT.
ELSE GO TO BOX CPS32.
CPS18
CPS18
CPS18
code one
numeric
numeric
How much do you expect will be paid?
How much do you expect will be paid?
How much do you expect will be paid?
(91) PERCENTAGE
(02) DOLLARS
(-8) Don't Know
(-9) Refused
(01) continuous answer
(01) continuous answer
(01) CPS18 - EXPAYAMT
(02) CPS18 - EXPAYPCT
(-8) BOX CPS32
(-9) BOX CPS32
BOX CPS32
BOX CPS32
[you] respondent is SP
[(SP)] respondent is proxy
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
CPSREIMINT
CPS19
no entry
[expected some source to pay] CPS Reason = 6
[weren't sure whether some source would pay you back] CPS reason not equal to 6, respondent is SP
[wasn’t sure whether some source would pay (SP) back] CPS reason not equal to 6, respondent is proxy
Last time, [you/(SP)] [expected some source to pay/ (weren’t/wasn't) sure whether some source would pay [you/(SP)] back] some or all of the (SP/FAMILY PAYMENT) [you/he/she] had paid for [READ
EVENT(S) ABOVE].
CPS20 - GOTPAYBK
[, such as an insurance plan,] SP was not covered by TRICARE and was covered by any other insurance plan
besides Medicare during the current round
[, such as TRICARE,] SP was covered by TRICARE and is not covered by any other insurance plan besides
Medicare during the current round
[, such as TRICARE or an insurance plan,] SP was covered by TRICARE and any other insurance plan besides
Medicare during the current round
[] SP was not covered by TRICARE or any other insurance plan besides Medicare during the current round
[you] respondent is SP
[(SP)] respondent is SP
Has any source [, such as (an insurance plan/TRICARE/TRICARE or an insurance plan),] paid [you/(SP)] back any of that amount?
GOTPAYBK
EXPPAYBK
EXPAYUNT
EXPAYPCT
EXPAYAMT
CPS20
yes/no
([PROBE IF NECESSARY: Please include any payments received from (your/(SP's)] Medicare prescription drug benefit.])
BOX CPS20
routing
IF (CPS20 - GOTPAYBK = 2/No) AND (SP PREVIOUSLY EXPECTED A SOURCE TO PAY BACK ANY AMOUNT), GO TO CPS21 - EXPPAYBK.
ELSE IF CPS20 - GOTPAYBK = DK, GO TO CPS23 - RRDETAIL.
ELSE GO TO BOX CPS32.
CPS21
yes/no
Do you still expect any source to pay [you/(SP)] back any amount for [READ EVENT(S) ABOVE]?
BOX CPS21
routing
IF (CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO CURRENT ROUND) OR (SP IS IN THE EXIT SAMPLE), GO TO CPS22 - EXPAYUNT.
ELSE GO TO BOX CPS32.
CPS22
CPS22
CPS22
code one
numeric
numeric
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[PROBE IF NECESSARY: Please include any payments received from (your/(SP's)] Medicare prescription drug
benefit.] PM event is linked to the charge bundle that has Number of Purchases >0 and ^= DK and ^= RF, and
((SP was covered by a Medicare Prescription Drug Plan anytime during the current round) or (SP had a
Medicare Managed Care plan with RX coverage anytime during the current round))
Else do not display sentence.
[your] respondent is SP
[(SP's)] respondent is proxy
(01) CPS25 - CPADDSOP
(02) BOX CPS20
(-8) BOX CPS20
(-9) BOX CPS20
[you] respondent is SP
[(SP)] respondent is proxy
(01) BOX CPS21
(02) BOX CPS32
(-8) BOX CPS32
(-9) BOX CPS32
How much do you expect will be paid?
How much do you expect will be paid?
How much do you expect will be paid?
(01) PERCENTAGE
(02) DOLLARS
(-8) Don't Know
(-9) Refused
(01) continuous answer
(01) continuous answer
(01) CPS22 - EXPAYPCT
(02) CPS22 - EXPAYAMT
(-8) BOX CPS32
(-9) BOX CPS32
BOX CPS32
BOX CPS32
(01) CPS24 - RRADD
(02) BOX CPS32
(-8) BOX CPS32
RRDETAIL
CPS23
yes/no
DID RESPONDENT MENTION (AN INSURANCE/A) REFUND OR REIMBURSEMENT ABOUT WHICH HE/SHE IS NOT SURE OF THE DETAILS?
[DO NOT ENTER A COMMENT HERE TO EXPLAIN THE SITUATION.]
(01) YES
(02) NO
(-8) Don't Know
RRADD
CPS24
yes/no
DO YOU WANT TO ADD A REFUND OR REIMBURSEMENT?
[DO NOT SELECT “YES” IF THE RESPONDENT KNOWS A REIMBURSEMENT AMOUNT, BUT DOES NOT KNOW WHO PAID IT.]
(01) YES
(02) NO
(01) CPS25 - CPADDSOP
(02) BOX CPS32
CPADDSOP
CPS25
yes/no
ARE ALL OF THE SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE LISTED BELOW?
SELECT "NO" TO ADD A SOURCE OF PAYMENT.
(01) YES
(02) NO
(01) CPS27 - TSOPREIM
(02) CPS26 - SOP_CP
SOP_CP
CPS26
roster
ADD ALL ADDITIONAL SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE.
(01) continuous answer
CPS27 - TSOPREIM
Who (else) paid (besides Medicare)? How much did (SOURCE) pay?
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
BOX CPS27A
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
BOX CPS27A
TSOPREIM_NAME
CPS27
grid
REIMBURSEMENT AMOUNT: (REIMBURSEMENT AMOUNT)
ENTER ALL REIMBURESMENT AMOUNTS.
How much did (SOURCE) pay?
CPS27
grid
REIMBURSEMENT AMOUNT: (REIMBURSEMENT AMOUNT)
ENTER ALL REIMBURESMENT AMOUNTS.
BOX CPS27A
routing
IF AT LEAST ONE SOURCE OF PAYMENT WAS ADDED AT CPS26, GO TO BOX CPS27B.
ELSE GO TO BOX CPS29F.
BOX CPS27B
routing
IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT CPS26 IS A HEALTH INSURANCE PLAN, GO TO CPS27BINT - PLANINTRO_CPS.
ELSE GO TO BOX CPS29E.
PLANINTRO_CPS
CPS27BINT
no entry
Before we continue, I would like to ask you a few questions about the health insurance plan(s) you just added.
NAVIGATOR
CPS27B_IN
instance navigator
TSOPREIM_AMT
[A] CPS REASON = 1 or 6
[AN INSURANCE] CPS REASON not equal to 1 or 6
CPS27B_IN - NAVIGATOR
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) BOX CPS27C
(02) BOX CPS29E
CPMHMOCHNG
BOX CPS27C
routing
CREATE A NEW HEALTH INSURANCE PLAN FOR FIRST/NEXT SOURCE OF PAYMENT ADDED AT CPS26
IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP HAS A MEDICARE MANAGED CARE PLAN THAT IS CURRENT, GO TO CPS28 - CPMHMOCHNG.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP DOES NOT HAVE A MEDICARE MANAGED CARE PLAN THAT IS CURRENT, GO TO CPS29 - CPSOPCURR.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE PRESCRIPTION DRUG PLAN AND SP HAS A MEDICARE PRESCRIPTION DRUG PLAN THAT IS CURRENT, GO TO CPS29A - CPMPDPCHNG.
ELSE IF SOURCE OF PAYMENT IS MEDICARE PRESCRIPTION DRUG PLAN AND SP DOES NOT HAVE A MEDICARE PRESCRIPTION DRUG PLAN THAT IS CURRENT, GO TO CPS29B CPSOPCURR2.
ELSE IF SOURCE OF PAYMENT IS MEDICAID, GO TO HI6 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PUBLIC PLAN, GO TO HI13 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PRIVATE PLAN, GO TO HI21 - COVTIME.
ELSE GO TO HIT2 - COVTIME.
CPS28
yes/no
I recorded previously that (CURRENT MEDICARE MANAGED CARE PLAN NAME) was [your/(SP's)] current Medicare Managed Care Plan. Has this information changed?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
(01) CPS29 - CPSOPCUR
(02) BOX CPS29A
(-8) BOX CPS29A
(-9) BOX CPS29A
[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP alive
[Was (SP)] respondet is proxy, SP deceased
[currently] respondent is SP or proxy, SP alive
[] respondent is proxy, SP deceased
CPSOPCURR
CPS29
yes/no
[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (CPS26 SOP MEDICARE MANAGED CARE PLAN NAME) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
I recorded previously that (CURRENT MEDICARE PRESCRIPTION DRUG PLAN) was [your/(SP's)] current Medicare Prescription Drug Care Plan.
CPMPDPCHNG
CPS29A
yes/no
Has this information changed?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[on (DATE OF DEATH)] respondent is proxy, SP deceased
[on (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized
[] respondent is SP
(01) HIMC6A - MHMORXT
(02) BOX CPS29A
(-8) BOX CPS29A
(-9) BOX CPS29A
[your] respondent is SP
[(SP's)] respondent is proxy
(01) CPS29B - CPSOPCU
(02) BOX CPS29A
(-8) BOX CPS29A
(-9) BOX CPS29A
[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP alive
[Was (SP)] respondet is proxy, SP deceased
[currently] respondent is SP or proxy, SP alive
[] respondent is proxy, SP deceased
CPSOPCURR2
REIMBCOV
CPS29B
BOX CPS29A
yes/no
routing
[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (CPS26 SOP MEDICARE PRESCRIPTION DRUG PLAN) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
GO TO CPS27B_IN - NAVIGATOR.
BOX CPS29E
routing
IF AN "OTHER SOURCE OF PAYMENT" ADDED AT CPS26, CREATE AN OSOP FOR EACH SOURCE OF PAYMENT ADDED AT CPS26 THAT IS AN "OTHER SOURCE OF PAYMENT"
GO TO BOX CPS29F.
BOX CPS29F
routing
CREATE REIMBURSEMENTS FOR AMOUNTS ENTERED AT CPS27
GO TO CPS30 - REIMBCOV.
CPS30
yes/no
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[on (DATE OF DEATH)] respondent is proxy, SP deceased
[on (DATE OF INSTITUTIONALIZATION)] respondent is proxy, SP institutionalized
[] respondent is SP
BOX CPS29A
DOES THIS REIMBURSEMENT AMOUNT COVER ANY OTHER EVENTS BESIDES THOSE SHOWN ABOVE?
(01) YES
(02) NO
(-8) Don't Know
(01) CPS31 - REIMCODE
(02) BOX CPS32
(-8) BOX CPS32
(01) SEPARATELY BILLING LAB (SL)
(02) SEPARATELY BILLING DOCTOR (SD)
(03) DENTAL (DU)
(04) HOSPITAL EMERGENCY ROOM (ER)
(05) HOSPITAL INPATIENT STAY (IP)
(06) HOSPITAL OUTPATIENT VISIT (OP)
(07) INSTITUTIONAL STAY (IU)
(08) HOME HEALTH PROFESSIONAL (HP)
(09) OTHER HOME HEALTH (HF)
(10) OTHER VISITS TO MEDICAL PROVIDERS (MP)
(11) OTHER MEDICAL EXPENSES (OM)
(12) PRESCRIBED MEDICINES (PM)
(-8) Don't Know
CPS32 - REIMCOMMENT
REIMCODE
CPS31
code all
WHAT OTHER TYPE(S) OF EVENT(S) ARE COVERD BY THIS REIMBURSEMENT?
CHECK ALL THAT APPLY.
REIMCOMMENT
CPS32
BOX CPS32
BOX CPSEND
no entry
routing
routing
PLEASE ENTER A COMMENT TO RECORD ANYTHING ELSE YOU KNOW ABOUT THIS REFUND (PROVIDER(S), DATE(S), ETC.)
GO TO BOX CPSBEG.
GO TO NEXT SECTION.
BOX CPS32
Mobility of Beneficiaries (MBQ)
Variable Name
MR Screen Name
BOX MBBEG
Question type
routing
Question text/description)
GO TO MB1 - MTBLGTPL.
Code list
My next questions are about [your/(SP)’s] travel activities and
[your/his/her] health.
Because of a health or physical problem, [have you/has (SP)]...
MTBLGTPL
MB1
yes/no
(01) YES
(02) NO
had trouble getting places, like the doctor’s office, a supermarket, or a (-8) Don't Know
friend’s house since (REFERENCE DATE)?
(-9) Refused
Because of a health or physical problem, [have you/has (SP)]…
MREDTRAV
MB2
yes/no
reduced [your/his/her] day-to-day travel since [March (CURRENT
YEAR)/(REFERENCE DATE)]?
Because of a health or physical problem, [have you/has (SP)]...
MASKRIDE
MB3
yes/no
asked others for rides since [March (CURRENT
YEAR)/(REFERENCE DATE)]?
Because of a health or physical problem, [have you/has (SP)]…
MLIMDRIV
MB4
yes/no
limited driving to daytime since [March (CURRENT
YEAR)/(REFERENCE DATE)]?
Because of a health or physical problem, [have you/has (SP)]...
MGIVUPDR
MB5
yes/no
given up driving altogether since [March (CURRENT
YEAR)/(REFERENCE DATE)]?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DRIVE
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DRIVE
(-8) Don't Know
(-9) Refused
Text Fill Logic
Input mask
Routing
[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[have you] respondent is SP
[has (SP)] respondent is proxy
MB2 - MREDTRAV
[have you] respondent is SP
[has (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
MB3 - MASKRIDE
[have you] respondent is SP
[has (SP)] respondent is proxy
MB4 - MLIMDRIV
[have you] respondent is SP
[has (SP)] respondent is proxy
MB5 - MGIVUPDR
[have you] respondent is SP
[has (SP)] respondent is proxy
MB6 - MUSETRNS
[have you] respondent is SP
[has (SP)] respondent is proxy
BOX MBEND
Because of a health or physical problem, [have you/has (SP)]...
MUSETRNS
MB6
BOX MBEND
yes/no
routing
used a taxi or special transportation service since [March (CURRENT
YEAR)/(REFERENCE DATE)]?
(01) YES
(02) NO
[EXPLAIN IF NECESSARY: A special transportation service may
(-8) Don't Know
include a van or shuttle service for seniors or people with disabilities.] (-9) Refused
GO TO NEXT SECTION
Access to Care (ACQ)
Variable Name
ACINT
ERVISIT
EWAITUNT
EWAITHRS
EWAITMIN
ERADMT
OPDVISIT
MR Screen Name
Question type
Question text/description
BOX AC1AA
routing
IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO ACINTRO ACINT.
ELSE IF (SP HAD AN ER VISIT IN THE CURRENT ROUND OR
ANY OF THE 2 PREVIOUS ROUNDS) AND (AC6A NOT ALREADY
ASKED), GO TO AC6A - EWAITUNT.
ELSE GO TO BOX AC1C.
ACINTRO
no entry
The next questions are about health care services [you/(SP)] may
have used since (REFERENCE DATE).
yes/no
Since (REFERENCE DATE), did [you/(SP)] go to a hospital
emergency room?
AC1
AC6A
AC6A
code one
numeric
Think about the most recent time [you/(SP)] went to the hospital
emergency room. How long did [you/(SP)] have to wait during
(your/his/her) visit before (you/he/she) saw a doctor or some other
medical person? Please include the time spent in the waiting room
and exam room.
Think about the most recent time [you/(SP)] went to the hospital
emergency room. How long did [you/(SP)] have to wait during
(your/his/her) visit before (you/he/she) saw a doctor or some other
medical person? Please include the time spent in the waiting room
and exam room.
AC6A
numeric
BOX AC1B
routing
Think about the most recent time [you/(SP)] went to the hospital
emergency room. How long did [you/(SP)] have to wait during
(your/his/her) visit before (you/he/she) saw a doctor or some other
medical person? Please include the time spent in the waiting room
and exam room.
IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO AC7 ERADMT.
ELSE GO TO BOX AC1C.
yes/no
[Were you/Was (SP)] admitted to the hospital from the emergency
room?
[PROBE IF NECESSARY TO DETERMINE IF THE RESPONDENT
WAS ACTUALLY ADMITTED OR ASK TO SEE THE HOSPITAL
BILL TO MAKE THE DETERMINATION.]
BOX AC1C
routing
IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO AC8 OPDVISIT.
ELSE IF AC6A ASKED WHILE ADMINISTERING ER, GO TO BOX
ER6.
ELSE IF (SP HAD AN OP VISIT IN THE CURRENT ROUND OR
ANY OF THE 2 PREVIOUS ROUNDS) AND (AC9-AC16A NOT
ALREADY ASKED), GO TO AC9 - OPDREAS.
ELSE GO TO BOX AC1E.
AC8
yes/no
AC7
Code list
Text Fill Logic
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
AC1 - ERVISIT
(01) AC6A - EWAITUNT
(02) AC8 - OPDVISIT
(-8) AC8 - OPDVISIT
(-9) AC8 - OPDVISIT
(00) DID NOT HAVE TO WAIT
(01) HOURS ONLY
(02) MINUTES ONLY
(03) HOURS AND MINUTES
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is SP, SP male
[her] respondent is SP, SP female
[he] respondent is SP, SP male
[she] respondent is SP, SP female
(00) BOX AC1B
(01) AC6A - EWAITHRS
(02) AC6A - EWAITMIN
(03) AC6A - EWAITHRS
(-8) BOX AC1B
(-9) BOX AC1B
(01) continuous answer
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is SP, SP male
[her] respondent is SP, SP female
[he] respondent is SP, SP male
[she] respondent is SP, SP female
If AC6A - EWAITUNT =
3/HoursAndMinutes, go to AC6A EWAITMIN.
Else go to BOX AC1B.
(01) continuous answer
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is SP, SP male
[her] respondent is SP, SP female
[he] respondent is SP, SP male
[she] respondent is SP, SP female
BOX AC1B
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Were you] respondent is SP
[Was (SP)] respondent is proxy
BOX AC1C
[you] respondent is SP
[(SP)] respondent is proxy
(01) AC9 - OPDREAS
(02) AC17 - NHRESEVR
(-8) AC17 - NHRESEVR
(-9) AC17 - NHRESEVR
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
Since (REFERENCE DATE), did [you/(SP)] go to a hospital clinic or (02) NO
outpatient department?
(-8) Don't Know
DO NOT INCLUDE HOSPITAL INPATIENT STAYS.
(-9) Refused
[I have a few more questions about visits that [you/(SP)] had in the
past.]
OPDREAS
OPDOTHOS
AC9
AC9
code all
verbatim text
Input mask Routing
(01) MEDICAL CONDITION NAMED
(02) TESTS
(03) FOLLOW-UP
Think about the most recent time [you/(SP)] went to a hospital clinic (04) CHECKUP
or outpatient department. What was the reason [you/(SP)] went to
(05) REFERRAL
the hospital clinic or outpatient department?
(06) SURGERY
[PROBE FOR THE MOST RECENT VISIT IF RESPONDENT
(07) PREVENTIVE SHOT
MENTIONS MORE THAN ONE. IF NEEDED, PROBE WITH ‘What (08) TREATMENT SHOT
did you have done during your most recent visit to the hospital clinic (09) TO GET OR REFILL PRESCRIPTION
or outpatient department?’ SELECT ALL THAT APPLY.]
(91) OTHER
[PROBE: Any other reason?]
(-8) Don't Know
CHECK ALL THAT APPLY.
(-9) Refused
OTHER (SPECIFY)
(01) continuous answer
[you] respondent is SP
[(SP)] respondent is proxy
(01) BOX AC1D
(02) BOX AC1D
(03) BOX AC1D
(04) BOX AC1D
(05) BOX AC1D
(06) BOX AC1D
(07) BOX AC1D
(08) BOX AC1D
(09) BOX AC1D
(91) AC9 - OPDOTHOS
(-8) BOX AC1D
(-9) BOX AC1D
BOX AC1D
OPDSCOND
OPDAPPT
BOX AC1D
routing
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) AND (RESPONSE
TO AC9 - OPDREAS INCLUDES 1/MedCondNamed OR
6/Surgery), GO TO AC12 - OPDAPPT.
ELSE IF (SP IS IN THE SUPPLEMENTAL SAMPLE) AND
(RESPONSE TO AC9 - OPDREAS DOES NOT INCLUDE
1/MedCondNamed AND DOES NOT INCLUDE 6/Surgery), GO TO
AC10 - OPDSCOND.
ELSE GO TO AC12 - OPDAPPT.
AC10
yes/no
Was that for a specific condition?
code one
(01) APPOINTMENT
(02) WALKED IN
Did [you/(SP)] have an appointment for this visit to the hospital clinic (-8) Don't Know
or outpatient department, or did (you/he/she) just walk in?
(-9) Refused
AC12
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
AC12 - OPDAPPT
[you] respondent is SP
[(SP)] respondent is proxy
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
(01) AC13 - OPDDRTEL
(02) AC16A - OWAITUNT
(-8) AC16A - OWAITUNT
(-9) AC16A - OWAITUNT
OPDAWUNT
AC14
code one
We are interested in knowing how the appointment was made for the
visit to the hospital clinic or outpatient department you just told me
(01) SOMEONE MADE APPOINTMENT DURING
about.
EARLIER VISIT
(02) SP CONTACTED OFFICE TO SET UP
Did someone make this appointment during an earlier visit, or did
APPOINTMENT
[you/(SP)] contact the hospital clinic or outpatient department to set (-8) Don't Know
up the appointment ?
(-9) Refused
(00) DID NOT HAVE TO WAIT
(01) DAYS
(02) WEEKS
(03) MONTHS
How long did [you/(SP)] have to wait for the appointment -- about
(-8) Don't Know
how many days, weeks, or months?
(-9) Refused
OPDAWDAY
AC14
numeric
How long did [you/(SP)] have to wait for the appointment -- about
how many days, weeks, or months?
(01) continuous answer
[you] respondent is SP
[(SP)] respondent is proxy
AC16A - OWAITUNT
OPDAWWKS
AC14
numeric
How long did [you/(SP)] have to wait for the appointment -- about
how many days, weeks, or months?
(01) continuous answer
[you] respondent is SP
[(SP)] respondent is proxy
AC16A - OWAITUNT
numeric
How long did [you/(SP)] have to wait for the appointment -- about
how many days, weeks, or months?
(01) continuous answer
[you] respondent is SP
[(SP)] respondent is proxy
AC16A - OWAITUNT
code one
[Think about the most recent time [you/(SP)] went to a hospital clinic
or outpatient department.]
(00) DID NOT HAVE TO WAIT
(01) HOURS ONLY
How long did [you/(SP)] have to wait during (your/his/her) most
(02) MINUTES ONLY
recent visit before (you/he/she) saw a doctor or some other medical (03) HOURS AND MINUTES
person? Please include the time spent in the waiting room and
(-8) Don't Know
exam room.
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is SP, SP male
[her] respondent is SP, SP female
[he] respondent is SP, SP male
[she] respondent is SP, SP female
(00) BOX AC1E
(01) AC16A - OWAITHRS
(02) AC16A - OWAITMIN
(03) AC16A - OWAITHRS
(-8) BOX AC1E
(-9) BOX AC1E
[Think about the most recent time [you/(SP)] went to a hospital clinic
or outpatient department.]
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is SP, SP male
[her] respondent is SP, SP female
[he] respondent is SP, SP male
[she] respondent is SP, SP female
If AC16A - OWAITUNT =
3/HoursAndMinutes, go to AC16A OWAITMIN.
Else go to BOX AC1E.
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is SP, SP male
[her] respondent is SP, SP female
[he] respondent is SP, SP male
[she] respondent is SP, SP female
BOX AC1E
[Have you] respondent is SP
[Has (SP)] respondent is proxy
(01) AC18 - NHLRESMM
(02) AC19 - MDVISIT
(03) AC19 - MDVISIT
(04) AC19 - MDVISIT
OPDDRTEL
OPDAWMOS
OWAITUNT
OWAITHRS
AC13
AC14
AC16A
AC16A
code one
numeric
How long did [you/(SP)] have to wait during (your/his/her) most
recent visit before (you/he/she) saw a doctor or some other medical
person? Please include the time spent in the waiting room and
exam room.
(01) continuous answer
[Think about the most recent time [you/(SP)] went to a hospital clinic
or outpatient department.]
OWAITMIN
NHRESEVR
NHLRESMM
numeric
How long did [you/(SP)] have to wait during (your/his/her) most
recent visit before (you/he/she) saw a doctor or some other medical
person? Please include the time spent in the waiting room and
exam room.
(01) continuous answer
BOX AC1E
routing
IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO AC17 NHRESEVR.
ELSE IF AC9-AC16A ASKED WHILE ADMINISTERING OP, GO TO
BOX OP7.
ELSE IF (SP HAD AN MP VISIT IN THE CURRENT ROUND OR
ANY OF THE 2 PREVIOUS ROUNDS) AND (AC20-AC28A1 NOT
ALREADY ASKED), GO TO AC20 - MDSPCLTY.
ELSE GO TO BOX AC1G.
AC17
yes/no
[Have you/Has (SP)] ever been a resident or patient in a nursing
home or similar place?
date
When [were you/was (SP)] last a resident or patient in a nursing
home or similar place?
AC16A
AC18
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
(01) AC16A - OWAITUNT
(02) AC14 - OPDAWUNT
(-8) AC16A - OWAITUNT
(-9) AC16A - OWAITUNT
(00) AC16A - OWAITUNT
(01) AC14 - OPDAWDAY
(02) AC14 - OPDAWWKS
(03) AC14 - OPDAWMOS
(-8) AC16A - OWAITUNT
(-9) AC16A - OWAITUNT
[were you] respondent is SP
[was (SP)] respondent is proxy
MM
AC18 - NHLRESYY
NHLRESYY
MDVISIT
AC18
AC19
date
When [were you/was (SP)] last a resident or patient in a nursing
home or similar place?
(01) continuous answer
(-8) Don't Know
(-9) Refused
yes/no
Next, I want to ask about [your/(SP)’s] visits to doctors since
(REFERENCE DATE). [Have you/Has (SP)] seen a medical doctor
since (REFERENCE DATE)? Please do not include a doctor seen
at home, at an emergency room or outpatient department, or while
an inpatient at a hospital.
[IF NECESSARY, SAY, ‘Please look at show card AC1 for examples
of types of medical doctors.’]
(01) YES
(02) NO
(-8) Don't Know
(-9)
(01) Refused
ALLERGY/IMMUNOLOGY
MDSPCLTY
MDSPCLOS
AC20
AC20
code one
verbatim text
MDREAS
MDREAS
AC21
AC21
code all
verbatim text
(02) ANESTHESIOLOGY
(03) CARDIOLOGY (HEART)
(05) DERMATOLOGY (SKIN)
(07) ENDOCRINOLOGY/METABOLISM
(DIABETES,THYROID)
(08) FAMILY PRACTICE
(09) GASTROENTEROLOGY
(10) GENERAL PRACTICE
(11) GENERAL SURGERY
(12) GERIATRICS (ELDERLY)
(13) GYNECOLOGY - OBSTETRICS
(14) HEMATOLOGY (BLOOD)
SHOW CARD AC1
(15) HOSPITAL RESIDENCE
[I have a few more questions about visits that [you/(SP)] had in the (16) INTERNAL MEDICINE (INTERNIST)
past.]
(17) NEPHROLOGY (KIDNEYS)
(18) NEUROLOGY
Think about the most recent time [you/(SP)] saw a medical doctor
(19) NUCLEAR MEDICINE
somewhere other than at home or at a hospital. What was the
(20) ONCOLOGY (TUMORS, CANCER)
doctor’s specialty?
(21) OPHTHALMOLOGY (EYES)
[PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE (22) ORTHOPEDICS
CARD IF THEY MENTION A 'GENERIC' SPECIALITY LIKE ‘HEART (24) OSTEOPATHY (DO)
DOCTOR.’ IF RESPONDENT ONLY GIVES A 'GENERIC'
(25) OTORHINOLARYNGOLOGY (EAR, NOSE,
SPECIALTY AND THE GENERIC WORD IS SHOWN IN
THROAT)
PARENTHESES FOLLOWING ONE OF THE RESPONSES,
(26) PATHOLOGY
SELECT THE RESPONSE CATEGORY FOR THAT SPECIALTY
(27) PHYS MED/REHAB
(E.G., 'CARDIOLOGY'). OTHERWISE SELECT 'OTHER DR
(28) PLASTIC SURGERY
SPECIALTY'.]
(29) PROCTOLOGY
OTHER DR SPECIALTY (SPECIFY)
(01) continuous answer
(01) MEDICAL CONDITION NAMED
(02) TESTS
(03) FOLLOW-UP
(04) CHECKUP
(05) REFERRAL
(06) SURGERY
What was the reason [you/(SP)] saw the doctor?
(07) PREVENTIVE SHOT
(08) TREATMENT SHOT
[PROBE: ‘What did you have done during the visit?’ IF
(09) TO GET OR REFILL PRESCRIPTION
RESPONDENT DOES NOT UNDERSTAND WHAT IS BEING
(91) OTHER
ASKED. PROBE: ‘Any other reason?’ TO OBTAIN ALL REASONS.] (-8) Don't Know
CHECK ALL THAT APPLY.
(-9) Refused
OTHER (SPECIFY)
(01) continuous answer
BOX AC1F
routing
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) AND (RESPONSE
TO AC21- MDREAS INCLUDES 1/MedCondNamed OR 6/Surgery),
GO TO AC24 - MDAPPT.
ELSE IF (SP IS IN THE SUPPLEMENTAL SAMPLE) AND
(RESPONSE TO AC21- MDREAS DOES NOT INCLUDE
1/MedCondNamed AND DOES NOT INCLUDE 6/Surgery), GO TO
AC22 - MDSCOND.
ELSE GO TO AC24 - MDAPPT.
AC22
yes/no
Was that for a specific condition?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
code one
Did [you/(SP)] have an appointment for this visit with the doctor, or
did (you/he/she) just walk in?
(01) APPOINTMENT
(02) WALKED IN
(-8) Don't Know
(-9) Refused
code one
(01) SOMEONE MADE APPOINTMENT DURING
We are interested in knowing how the appointment was made for the EARLIER VISIT
visit to the doctor’s office you just told me about.
(02) SP CONTACTED OFFICE TO SET UP
APPOINTMENT
Did someone make this appointment during an earlier visit, or did
(-8) Don't Know
[you/(SP)] contact the doctor’s office to set up the appointment?
(-9) Refused
MDSCOND
MDAPPT
MDDRTEL
AC24
AC25
[were you] respondent is SP
[was (SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[SP) respondent is proxy
YY
AC19- MDVISIT
(01) AC20 - MDSPCLTY
(02) BOX AC1G
(-8) BOX AC1G
(-9)
(01) BOX
AC21AC1G
- MDREAS
(02) AC21 - MDREAS
(03) AC21 - MDREAS
(05) AC21 - MDREAS
(07) AC21 - MDREAS
(08) AC21 - MDREAS
(09) AC21 - MDREAS
(10) AC21 - MDREAS
(11) AC21 - MDREAS
(12) AC21 - MDREAS
(13) AC21 - MDREAS
(14) AC21 - MDREAS
(15) AC21 - MDREAS
(16) AC21 - MDREAS
(17) AC21 - MDREAS
(18) AC21 - MDREAS
(19) AC21 - MDREAS
(20) AC21 - MDREAS
(21) AC21 - MDREAS
(22) AC21 - MDREAS
(24) AC21 - MDREAS
(25) AC21 - MDREAS
(26) AC21 - MDREAS
(27) AC21 - MDREAS
(28) AC21 - MDREAS
(29) AC21 - MDREAS
(30) AC21 - MDREAS
(31) AC21 - MDREAS
AC21 - MDREAS
(01) BOX AC1F
(02) BOX AC1F
(03) BOX AC1F
(04) BOX AC1F
(05) BOX AC1F
(06) BOX AC1F
(07) BOX AC1F
(08) BOX AC1F
(09) BOX AC1F
(91) AC21 - MDOTHOS
(-8) BOX AC1F
(-9) BOX AC1F
BOX AC1F
AC24 - MDAPPT
[you] respondent is SP
[(SP)] respondent is proxy
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
(01) AC25 - MDDRTEL
(02) AC28A1 - MWAITUNT
(-8) AC28A1 - MWAITUNT
(-9) AC28A1 - MWAITUNT
[you] respondent is SP
[(SP)] respondent is proxy
(01) AC28A1 - MWAITUNT
(02) AC26 - MDAWUNT
(-8) AC28A1 - MWAITUNT
(-9) AC28A1 - MWAITUNT
MDAWUNT
AC26
(00) DID NOT HAVE TO WAIT
(01) DAYS
(02) WEEKS
(03) MONTHS
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
(00) AC28A1 - MWAITUNT
(01) AC26 - MDAWDAY
(02) AC26 - MDAWWKS
(03) AC26 - MDAWMOS
(-8) AC28A1 - MWAITUNT
(-9) AC28A1 - MWAITUNT
AC28A1 - MWAITUNT
code one
How long did [you/(SP)] have to wait for the appointment with the
medical doctor -- about how many days, weeks, or months?
(01) continuous answer
[you] respondent is SP
[(SP)] respondent is proxy
MDAWDAY
AC26
numeric
How long did [you/(SP)] have to wait for the appointment with the
medical doctor -- about how many days, weeks, or months?
MDAWWKS
AC26
numeric
How long did [you/(SP)] have to wait for the appointment with the
medical doctor -- about how many days, weeks, or months?
(01) continuous answer
[you] respondent is SP
[(SP)] respondent is proxy
AC28A1 - MWAITUNT
MDAWMOS
AC26
numeric
How long did [you/(SP)] have to wait for the appointment with the
medical doctor -- about how many days, weeks, or months?
(01) continuous answer
[you] respondent is SP
[(SP)] respondent is proxy
AC28A1 - MWAITUNT
code one
(00) DID NOT HAVE TO WAIT
[Think about the most recent time [you/(SP)] saw a medical doctor
(01) HOURS ONLY
somewhere other than at home or at a hospital.] How long did
(02) MINUTES ONLY
[you/(SP)] have to wait during (your/his/her) most recent visit before (03) HOURS AND MINUTES
(you/he/she) saw a doctor or some other medical person? Please
(-8) Don't Know
include the time spent in the waiting room and exam room.
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is SP, SP male
[her] respondent is SP, SP female
[he] respondent is SP, SP male
[she] respondent is SP, SP female
(00) BOX AC1G
(01) AC28A1 - MWAITHRS
(02) AC28A1 - MWAITMIN
(03) AC28A1 - MWAITHRS
(-8) BOX AC1G
(-9) BOX AC1G
[Think about the most recent time [you/(SP)] saw a medical doctor
somewhere other than at home or at a hospital.] How long did
[you/(SP)] have to wait during (your/his/her) most recent visit before
(you/he/she) saw a doctor or some other medical person? Please
include the time spent in the waiting room and exam room.
(01) continuous answer
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is SP, SP male
[her] respondent is SP, SP female
[he] respondent is SP, SP male
[she] respondent is SP, SP female
If AC28A1 - MWAITUNT =
3/HoursAndMinutes, go to AC28A1 MWAITMIN.
Else go to BOX AC1G.
numeric
[Think about the most recent time [you/(SP)] saw a medical doctor
somewhere other than at home or at a hospital.] How long did
[you/(SP)] have to wait during (your/his/her) most recent visit before
(you/he/she) saw a doctor or some other medical person? Please
include the time spent in the waiting room and exam room.
(01) continuous answer
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is SP, SP male
[her] respondent is SP, SP female
[he] respondent is SP, SP male
[she] respondent is SP, SP female
BOX AC1G
routing
IF AC20-AC28A1 ASKED WHILE ADMINISTERING MP, GO TO
MP18 - MPPRPRAC.
ELSE IF SP HAS A CURRENT MEDICARE MANAGED CARE
PLAN, GO TO AC33 - MHREFDIF.
ELSE GO TO BOX AC3.
[you] respondent is SP
[(SP)] respondent is proxy
[have you] respondent is SP
[has (SP)] respondent is proxy
(01) AC34A - MHSPCLTY
(02) AC36 - MHREFPAY
(03) AC36 - MHREFPAY
(-8) AC36 - MHREFPAY
(-9) AC36 - MHREFPAY
MWAITUNT
MWAITHRS
MWAITMIN
AC28A1
AC28A1
AC28A1
BOX AC1G
numeric
The following questions are about health care that [you/(SP)]
received through (CURRENT MEDICARE MANAGED CARE PLAN
NAME).
MHREFDIF
AC33
code one
While a member of (CURRENT MEDICARE MANAGED CARE
PLAN NAME), [have you/has (SP)] had difficulty in obtaining
referrals for the services of a specialist or other medical person
within (CURRENT MEDICARE MANAGED CARE PLAN NAME) that
[you/(SP)] thought were necessary?
[IF NECESSARY, SAY: ‘The referral must have been for services
provided by a specialist or medical provider who is associated with
your Medicare Managed Care plan, not a specialist or medical
provider who is "outside" of the plan.’]
(01) YES
(02) NO
(03) N/A, HAVEN'T TRIED TO OBTAIN REFERRAL
(-8) Don't Know
(-9) Refused
MHSPCLTY
MHSPCLOS
AC34A
AC34A
code one
verbatim text
(01) ALLERGY/IMMUNOLOGY
(03) CARDIOLOGY (HEART)
(05) DERMATOLOGY (SKIN)
(07) ENDOCRINOLOGY/METABOLISM
(DIABETES,THYROID)
(09) GASTROENTEROLOGY
(11) GENERAL SURGERY
(12) GERIATRICS (ELDERLY)
(13) GYNECOLOGY - OBSTETRICS
(14) HEMATOLOGY (BLOOD)
(16) INTERNAL MEDICINE (INTERNIST)
(17) NEPHROLOGY (KIDNEYS)
(18) NEUROLOGY
(20) ONCOLOGY (TUMORS, CANCER)
(21) OPHTHALMOLOGY (EYES)
(22) ORTHOPEDICS
(24) OSTEOPATHY (DO)
(25) OTORHINOLARYNGOLOGY (EAR, NOSE,
SHOW CARD AC1
THROAT)
What kind of specialist or medical person was this?
(26) PATHOLOGY
[PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE (27) PHYS MED/REHAB
CARD IF THEY MENTION A 'GENERIC' SPECIALITY LIKE ‘HEART (28) PLASTIC SURGERY
DOCTOR.’ IF RESPONDENT ONLY GIVES A 'GENERIC'
(29) PROCTOLOGY
SPECIALTY AND THE GENERIC WORD IS SHOWN IN
(30) PSYCHIATRY/PSYCHIATRIST
PARENTHESES FOLLOWING ONE OF THE RESPONSES,
(31) PULMONARY (LUNGS)
SELECT THE RESPONSE CATEGORY FOR THAT SPECIALTY
(33) RHEUMATOLOGY (ARTHRITIS)
(E.G., 'CARDIOLOGY'). OTHERWISE SELECT 'OTHER DR
(35) UROLOGY
SPECIALTY'.]
(36) AUDIOLOGIST
OTHER (SPECIFY)
(01) continuous answer
What kind of difficulty did [you/(SP)] have?
MHDIFCLT
MHOTHOS
MHREFPAY
AC35
AC35
AC36
BOX AC3
code all
verbatim text
[PROBE: Any other difficulty?]
CHECK ALL THAT APPLY.
OTHER (SPECIFY)
code one
routing
Has (CURRENT MEDICARE MANAGED CARE PLAN NAME) ever
refused to pay for emergency treatment that [you/(SP)] felt was
necessary?
[‘EMERGENCY TREATMENT’ REFERS TO URGENTLY NEEDED
MEDICAL CARE THAT IS REQUIRED WHEN THE BENEFICIARY
IS OUTSIDE OF THE PLAN'S SERVICE AREA OR WHEN THE
CARE IS REQUIRED DURING A TIME THAT IS OUTSIDE THE
PLAN'S NORMAL OPERATING HOURS.]
GO TO NEXT SECTION
(01) AC35 - MHDIFCLT
(03) AC35 - MHDIFCLT
(05) AC35 - MHDIFCLT
(07) AC35 - MHDIFCLT
(09) AC35 - MHDIFCLT
(11) AC35 - MHDIFCLT
(12) AC35 - MHDIFCLT
(13) AC35 - MHDIFCLT
(14) AC35 - MHDIFCLT
(16) AC35 - MHDIFCLT
(17) AC35 - MHDIFCLT
(18) AC35 - MHDIFCLT
(20) AC35 - MHDIFCLT
(21) AC35 - MHDIFCLT
(22) AC35 - MHDIFCLT
(24) AC35 - MHDIFCLT
(25) AC35 - MHDIFCLT
(26) AC35 - MHDIFCLT
(27) AC35 - MHDIFCLT
(28) AC35 - MHDIFCLT
(29) AC35 - MHDIFCLT
(30) AC35 - MHDIFCLT
(31) AC35 - MHDIFCLT
(33) AC35 - MHDIFCLT
(35) AC35 - MHDIFCLT
(36) AC35 - MHDIFCLT
(37) AC35 - MHDIFCLT
(38) AC35 - MHDIFCLT
AC35 - MHDIFCLT
(01) PLAN WOULDN’T AUTHORIZE SERVICE
(02) THE WAIT FOR APPOINTMENT WAS TOO LONG
(03) PROVIDER’S LOCATION WAS NOT
CONVENIENT
(04) DOCTOR/PLAN WOULDN'T GIVE SP REFERRAL
TO SEE PROVIDER SP WANTED TO SEE
(05) SP DIDN'T LIKE/NOT CONFIDENT IN PROVIDER
PLAN REFERRED SP TO
(06) PROVIDER’S OFFICE HOURS WERE NOT
CONVENIENT
(91) OTHER
(-8) Don't Know
[you] respodnent is SP
(-9) Refused
[(SP)] respondent is proxy
(01) continuous answer
(01) AC36 - MHREFPAY
(02) AC36 - MHREFPAY
(03) AC36 - MHREFPAY
(04) AC36 - MHREFPAY
(05) AC36 - MHREFPAY
(06) AC36 - MHREFPAY
(91) AC35 - MHOTHOS
(-8) AC36 - MHREFPAY
(-9) AC36 - MHREFPAY
AC36 - MHREFPAY
(01) YES
(02) NO
(03) N/A, HAVEN'T NEEDED EMERGENCY
TREATMENT
(-8) Don't Know
(-9) Refused
BOX AC3
[you] respodnent is SP
[(SP)] respondent is proxy
Health Functioning and Status (HFQ)
Variable Name
MR Screen Name Question type Question text/description
GO TO HFA1 - GENHELTH
BOX HFBEG
routing
Now, I would like to ask you about [your/(SP's)] health.
GENHELTH
HFA1
code one
In general, compared to other people [your/(SP's)] age, would you say that
(your/his/her) health is . . .
SHOW CARD HFX HF1
Compared to one year ago, how would you rate [your/(SP's)] health in general
now?
COMPHLTH
HFA2
code one
Would you say [your/(SP's)] health is . . .
SHOW CARD HFX HF2
FUTRHLTH
HFA2B
code one
In the next 6 months, what do you think will happen to [your/(SP's)] overall
health?
Now, I would like to ask you about [your/(SP's)] health.
DISHEAR
DISSEE
DIS1
DIS2
yes/no
[Are you/is (SP)] deaf or [do you/does (SP)] have serious difficulty hearing?
yes/no
[Are you/is (SP)] blind or [do you/does (SP)] have serious difficulty seeing, even
when wearing glasses?
DISDECISION
DIS3
yes/no
Because of a physical, mental, or emotional condition, [do you/does (SP)] have
serious difficulty concentrating, remembering, or making decisions?
DISWALK
DIS4
yes/no
[Do you/Does (SP)] have serious difficulty walking or climbing stairs?
DISBATH
DIS5
yes/no
[Do you/Does (SP)] have difficulty dressing or bathing?
yes/no
Because of a physical, mental, or emotional condition, [do you/does (SP)] have
difficulty doing errands alone such as visiting a doctor's office or shopping?
DISERRANDS
DIS6
How much of the time during the past month has [your/(SP's)] health limited
[your/(SP's)] social activities, like visiting with friends or close relatives?
HELMTACT
ECHELP
ECTROUB
HFA3
code one
BOX HFA1
routing
HFB1
HFB2
yes/no
code one
Would you say . . .
IF THIS IS ROUND 73 AND SP IS NOT IN THE SUPPLEMENTAL SAMPLE GO TO BOX
HFF1.
ELSE GO TO HFB1 - ECHELP.
EDOCEXAM
HFB2A
HFB6
(01) excellent,
(02) very good,
(03) good,
(04) fair, or
(05) poor?
(-8) DON'T KNOW
(-9) REFUSED
(01) much better now than one year ago,
(02) somewhat better now than one year ago,
(03) about the same,
(04) somewhat worse now than one year ago, or
(05) much worse now than one year ago?
(-8) DON'T KNOW
(-9) REFUSED
(01) it will get much better
(02) it will get somewhat better
(03) it will not change
(04) it will get somewhat worse
(05) it will get much worse
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) none of the time,
(02) some of the time,
(03) most of the time, or
(04) all of the time?
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(03) SP IS BLIND
(-8) DON'T KNOW
[Do you/Does (SP)] wear eyeglasses or contact lenses?
(-9) REFUSED
(01) NO TROUBLE SEEING
(02) A LITTLE TROUBLE SEEING
(03) A LOT OF TROUBLE SEEING
Which statement best describes [your/(SP's)] vision [while wearing glasses or
(04) NO USABLE VISION
contact lenses]... no trouble seeing, a little trouble, a lot of trouble, or no usable (-8) DON'T KNOW
vision?
(-9) REFUSED
[Have you/Has (SP)] been told that (you are/he is/she is) legally blind?
ECLEGBLI
Code list
yes/no
[EXPLAIN IF NECESSARY: Informally, a person is legally blind when, even with
corrective lenses, they cannot see well enough to drive.]
yes/no
[Have you/Has (SP)] had an eye examination by an eye doctor since (LAST HF
MONTH YEAR)?
INCLUDE OPHTHALMOLOGISTS AND OPTOMETRISTS.
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
Text Fill Logic
Input mask
Routing
[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
HFA2 - COMPHLTH
[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
HFA3 - HELMTACT HFA2B- FUTRHLTH
[your] respondent is SP
[(SP's)] respondent is proxy
[Are you] respondent is SP
[is (SP)] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
[Are you] respondent is SP
[is (SP)] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
DIS1
DIS2
DIS3
[do you] respondent is SP
[does (SP)] respondent is proxy
DIS4
[Do you] respondent is SP
[Does (SP)] respondent is proxy
DIS5
[Do you] respondent is SP
[Does (SP)] respondent is proxy
DIS6
[do you] respondent is SP
[does (SP)] respondent is proxy
HFA3 - HELMTACT
[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
HFB1-ECHELP BOX HFA1
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[while wearing glasses or contact lenses] SP wears glasses or
contact lenses
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[you are] respondent is SP
[he is] respondent is proxy, SP male
[she is] respondent is proxy, SP female
[Have you] respondent is SP
[Has (SP)] respondent is proxy
(01) HFB2 - ECTROUB
(02) HFB2 - ECTROUB
(03) HFB6 - EDOCEXAM
(-8) HFB6 - EDOCEXAM
(-9) HFB6 - EDOCEXAM
(01) HFB6 - EDOCEXAM
(02) HFB6 - EDOCEXAM
(03) HFB2A - ECLEGBLI
(04) HFB6 - EDOCEXAM
(-8) HFB6 - EDOCEXAM
(-9) HFB6 - EDOCEXAM
HFB6 - EDOCEXAM
(01) HFB7A - EDOCTYPE
(02) HFB7 - EDOCLAST
(-8) BOX HFB1
(-9) BOX HFB1
EDOCLAST
HFB7
code one
How long has it been since [your/(SP's)] last eye examination by an eye doctor?
I have a couple of questions about [your/(SP’s)] last eye examination.
Was the eye examination given by an optometrist, ophthalmologist or some
other type of doctor or eye care professional?
EDOCTYPE
EDOCTYOS
EDOCDLAT
HFB7A
HFB7A
HFB7B
code one
verbatim text
yes/no
[EXPLAIN IF NECESSARY: An optometrist is a doctor of optometry (O.D.) who
diagnoses and treats visual health problems. An ophthalmologist is a doctor of
medicine (M.D.) who specializes in surgery and diseases of the eye.]
OTHER (SPECIFY)
Again, thinking about [your/(SP’s)] last eye examination, were dilating drops
used in [your/(SP)’s] eyes?
[EXPLAIN IF NECESSARY: Dilating drops are used to enlarge the pupil for eye
examinations. The drops often make your eyes more sensitive to bright light
and may cause temporary blurry vision.]
I am going to read a list of eye conditions. Please tell me if [you have/(SP) has]
ever been told by a doctor that (you/he/she) had any of these conditions.
ECATARAC
HFB7C
yes/no
[Have you/Has (SP)] ever been told by a doctor that (you/he/she)
had…Cataracts?
EGLAUCOM
HFB7C
yes/no
Glaucoma?
ERETINOP
HFB7C
yes/no
Diabetic retinopathy?
EMACULAR
ECCATOP
ELASRSUR
HCHELP
HCTROUB
HFB7C
BOX HFB1A
yes/no
routing
HFB10
yes/no
BOX HFB1
routing
HFB11
HFC1
HFC2
yes/no
yes/no
code one
Macular degeneration or age-related macular degeneration, also called AMD?
IF ECATARAC=02/NO, GO TO BOX HFB1. ELSE GO TO HFB10 - ECCATOP.
[Have you/Has (SP)] ever had an operation for cataracts?
IF HFB7C - ERETINOP = 1/Yes OR HFB7C - EMACULAR = 1/Yes, GO TO HFB11 ELASRSUR.
ELSE GO TO HFC1 - HCHELP.
Laser surgery to the back of the eye, or retina, is a commonly used treatment for
diabetic retinopathy and macular degeneration.
(01) NEVER HAD EYE EXAM BY EYE DOCTOR
(02) 1 YEAR TO LESS THAN 2 YEARS
(03) 2 YEARS TO LESS THAN 5 YEARS
(04) 5 YEARS OR MORE
(-8) DON'T KNOW
(-9) REFUSED
(01) OPTOMETRIST
(02) OPTHAMOLOGIST
(91) OTHER DOCTOR SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
Have [you/(SP)] [Have you/Has (SP)] ever had laser surgery to the back of
(01) YES
either eye for one of these conditions?
(02) NO
[EXPLAIN IF NECESSARY: This does not include "Lasik" surgery to the (-8) DON'T KNOW
front of the eye used to correct vision.]
(-9) REFUSED
(01) YES
(02) NO
(03) SP IS DEAF
(-8) DON'T KNOW
[Do you/Does (SP)] use a hearing aid?
(-9) REFUSED
(01) NO TROUBLE HEARING
(02) A LITTLE TROUBLE HEARING
(03) A LOT OF TROUBLE HEARING
(04) DEAF
Which statement best describes [your/(SP's)] hearing (with a hearing aid): no
(-8) DON'T KNOW
trouble hearing, a little trouble, a lot of trouble, or deaf?
(-9) REFUSED
[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[you have] respondent is SP
[(SP) has] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
(01) BOX HFB1
(02) HFB7A - EDOCTYPE
(03) HFB7A - EDOCTYPE
(04) HFB7A - EDOCTYPE
(-8) BOX HFB1
(-9) BOX HFB1
(01) H7B7B - EDOCDLAT
(02) H7B7B - EDOCDLAT
(91) HFB7 - EDOCTYOS
(-8) BOX HFB1
(-9) BOX HFB1
H7B7B - EDOCDLAT
HFB7C - ECATARAC
HFB7C - EGLAUCOM
HFB7C - ERETINOP
HFB7C - EMACULAR
HFB10 - ECCATOP
BOX HFB1A
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
BOX HFB1
HFC1 - HCHELP
(01) HFC2 - HCTROUB
(02) HFC2 - HCTROUB
(03) HFC3 - HCKNOWMC
(-8) HFD1A - FOODTRBL
(-9) HFD1A - FOODTRBL
(01) HFD1A - FOODTRBL
(02) HFC3 - HCKNOWMC
(03) HFC3 - HCKNOWMC
(04) HFC3 - HCKNOWMC
(-8) HFD1A - FOODTRBL
(-9) HFD1A - FOODTRBL
HCKNOWMC
HCCOMDOC
FOODTRBL
HEIGHTFT
HFC3
HFC4
HFD1A
HFE1
code one
code one
code one
numeric
WEIGHT
HFE1
numeric
PREVHLTHINTRO
HFFINTRO
no entry
BPTAKEN
BCTAKEN
MAMMOGRM
HFF1
code one
HFF2
code one
BOX HFF1
routing
HFF3
yes/no
BOX HFF1A
routing
How much trouble [do you/does (SP)] have finding out things (you need/he
needs/she needs) to know about Medicare because [of (your/his/her) difficulty
hearing/(you are/he is/she is) deaf]? Would you say (you have/she has/he has)
no trouble, a little trouble, or a lot of trouble?
(01) NO TROUBLE
(02) A LITTLE TROUBLE
(03) A LOT OF TROUBLE
(-8) DON'T KNOW
(-9) REFUSED
How much trouble [do you/does (SP)] have communicating with (your/his/her)
doctor or other medical personnel because [of (your/his/her) difficulty
hearing/(you are/he is/she is) deaf]? Would you say (you have/she has/he has)
no trouble, a little trouble, or a lot of trouble?
(01) NO TROUBLE
(02) A LITTLE TROUBLE
(03) A LOT OF TROUBLE
(-8) DON'T KNOW
(-9) REFUSED
(01) NO TROUBLE
(02) A LITTLE TROUBLE
How much trouble [do you/does (SP)] have eating solid foods because of
(03) A LOT OF TROUBLE
problems with (your/his/her) mouth or teeth? Would you say (you have/she
(-8) DON'T KNOW
has/he has) no trouble, a little trouble, or a lot of trouble?
(-9) REFUSED
(01) continuous answer
(-8) DON'T KNOW
How tall [are you/is (SP)]?
(-9) REFUSED
(01) continuous answer
(-8) DON'T KNOW
How much [do you/does (SP)] weigh?
(-9) REFUSED
These next few questions are about preventive health care measures some
(01) CONTINUE
people take.
(-7) EMPTY
(01) LESS THAN 6 MONTHS AGO
(02) 6 MONTHS TO LESS THAN 1 YEAR AGO
(03) 1 YEAR TO LESS THAN 2 YEARS AGO
(04) 2 YEARS AGO TO LESS THAN 5 YEARS AGO
(05) 5 OR MORE YEARS AGO
(06) NEVER HAD BLOOD PRESSURE TAKEN
When was the most recent time [you/(SP)] had (your/his/her) blood pressure
(-8) DON'T KNOW
taken by a doctor or other health professional?
(-9) REFUSED
(01) LESS THAN 6 MONTHS AGO
(02) 6 MONTHS TO LESS THAN 1 YEAR AGO
(03) 1 YEAR TO LESS THAN 2 YEARS AGO
(04) 2 YEARS AGO TO LESS THAN 5 YEARS AGO
(05) 5 OR MORE YEARS AGO
(06) NEVER HAD CHOLESTEROL CHECKED
When was the most recent time [you/(SP)] had (your/his/her) blood cholesterol (-8) DON'T KNOW
checked?
(-9) REFUSED
IF SP IS FEMALE, GO TO HFF3 - MAMMOGRM.
ELSE GO TO BOX HFF3.
(01) YES
(These next few questions are about preventive health care measures some
(02) NO
people take). [Have you/Has (SP)] had a mammogram or a breast X-ray since
(-8) DON'T KNOW
(LAST HF MONTH YEAR)?
(-9) REFUSED
IF THIS IS ROUND 73 AND SP IS NOT IN THE SUPPLEMENTAL SAMPLE GO TO HFF6
- PAPSMEAR.
ELSE GO TO HFF5 - MAMCODE.
[do you] respondent is SP
[does (SP)] respondent is proxy
[you need] respondent is SP
[he needs] respondent is proxy, SP male
[she needs] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you are] respondent is SP
[he is] respondent is proxy, SP male
[she is] respondent is proxy, SP female
[you have] respondent is SP
[she has] respondent is proxy, SP female
[he has] respondent is proxy, SP male
[do you] respondent is SP
[does (SP)] respondent is proxy
[you need] respondent is SP
[he needs] respondent is proxy, SP male
[she needs] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you are] respondent is SP
[he is] respondent is proxy, SP male
[she is] respondent is proxy, SP female
[you have] respondent is SP
[she has] respondent is proxy, SP female
[he has] respondent is proxy, SP male
[do you] respondent is SP
[does (SP)] respondent is proxy
[you need] respondent is SP
[he needs] respondent is proxy, SP male
[she needs] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you are] respondent is SP
[he is] respondent is proxy, SP male
[she is] respondent is proxy, SP female
[you have] respondent is SP
[she has] respondent is proxy, SP female
[he has] respondent is proxy, SP male
HFC4 - HCCOMDOC
HFD1A - FOODTRBL
HFE1 - HEIGHTFT
[are you] respondent is SP
[is (SP)] respondent is proxy
HFE1 - HEIGHTIN
[do you] respondent is SP
[does (SP)] respondent is proxy
HFFINTRO - PREVHLTHINTRO
HFF1 - BPTAKEN
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
HFF2 - BCTAKEN
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
BOX HFF1
[Have you] respondent is SP
[Has (SP)] respondent is proxy
(01) HFF6 - PAPSMEAR
(02) BOX HFF1A HFF5 - MAMCODE
(-8) HFF6 - PAPSMEAR
(-9) HFF6 - PAPSMEAR
MAMCODE
MAMNOTHS
PAPSMEAR
PAPCODE
PAPNOTHS
HYSTEREC
HFF5
HFF5
code all
verbatim text
HFF6
yes/no
BOX HFF1B
routing
HFF8
HFF8
code all
verbatim text
BOX HFF2
routing
HFF9
yes/no
BOX HFF3
routing
What is the reason that [you have/(SP) has] not had a mammogram since (LAST
HF MONTH YEAR)?
CHECK ALL THAT APPLY.
OTHER (SPECIFY)
[Have you/Has (SP)] had a Pap smear test since (LAST HF MONTH YEAR)?
IF THIS IS ROUND 73 AND SP IS NOT IN THE SUPPLEMENTAL SAMPLE GO TO BOX
HFF2.
ELSE GO TO HFF8 - PAPCODE.
(01) DIDN’T KNOW IT WAS NEEDED/NO
NEED/NOTHING WRONG
(02) NOT RECOMMENDED EVERY YEAR/ON A
DIFFERENT SCREENING SCHEDULE
(03) DIDN’T THINK IT WOULD PREVENT BREAST
CANCER/COULD GET BREAST CANCER ANYWAY/TEST IS
USELESS
(04) NOT AT RISK FOR BREAST CANCER
(05) DOCTOR DID NOT PRESCRIBE OR RECOMMEND IT
(06) DOCTOR RECOMMENDED AGAINST GETTING IT
(07) DON’T LIKE MAMMOGRAMS/PAIN, SORENESS,
DISCOMFORT OR REACTIONS
(08) INCONVENIENT/UNABLE TO GET TO
LOCATION/TRANSPORTATION DIFFICULTY
(09) DIDN’T THINK ABOUT IT/FORGOT/MISSED
IT/PROCRASTINATED
(10) COST OF MAMMOGRAM/INSURANCE DOESN’T
COVER COST/NOT WORTH THE MONEY
(11) AFRAID OF RESULTS/DON’T WANT TO KNOW
(12) MAMMOGRAM RADIATION COULD CAUSE
CANCER/ILL EFFECTS
(13) NEVER HEARD OF MAMMOGRAM
(14) APPOINTMENT SCHEDULED FOR FUTURE DATE
(15) MASTECTOMY/BREASTS REMOVED
(16) TOO ILL, PHYSICALLY/MENTALLY
(91) OTHER
(-8) DON'T KNOW
[you have] respondent is SP
(-9) REFUSED
[(SP) has] respondent is proxy
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[Have you] respondent is SP
[Has (SP)] respondent is proxy
(01) DIDN’T KNOW IT WAS NEEDED/NO
NEED/NOTHING WRONG
(02) NOT RECOMMENDED EVERY YEAR/ON A
DIFFERENT SCREENING SCHEDULE
(03) DIDN’T THINK IT WOULD PREVENT CANCER/COULD
GET CANCER ANYWAY/TEST IS USELESS
(04) NOT AT RISK FOR CANCER
(05) DOCTOR DID NOT PRESCRIBE OR RECOMMEND IT
(06) DOCTOR RECOMMENDED AGAINST GETTING IT
(07) DON’T LIKE PAP SMEAR/PAIN, SORENESS,
DISCOMFORT OR REACTIONS
(08) INCONVENIENT/UNABLE TO GET TO
LOCATION/TRANSPORTATION DIFFICULTY
(09) DIDN’T THINK ABOUT IT/FORGOT/MISSED
IT/PROCRASTINATED
(10) COST OF PAP SMEAR/INSURANCE DOESN’T COVER
COST/NOT WORTH THE MONEY
(11) AFRAID OF RESULTS/DON’T WANT TO KNOW
(12) NEVER HEARD OF PAP SMEAR
(13) APPOINTMENT SCHEDULED FOR FUTURE DATE
(14) HAD HYSTERECTOMY/NO UTERUS, OVARIES
(15) TOO ILL, PHYSICALLY/MENTALLY
(91) OTHER
What is the reason that [you have/(SP) has] not had a Pap smear test since (LAST (-8) DON'T KNOW
HF MONTH YEAR)?
(-9) REFUSED
[you have] respondent is SP
CHECK ALL THAT APPLY.
[(SP) has] respondent is proxy
OTHER (SPECIFY)
IF SP IS IN THE SUPPLEMENTAL SAMPLE AND RESPONSE TO HHF8 – PAPCODE
DOES NOT INCLUDE 14/HadHysterectomy, GO TO HFF9 - HYSTEREC.
ELSE GO TO BOX HFF3.
(01) YES
(02) NO
(-8) DON'T KNOW
[Have you] respondent is SP
[Have you/Has (SP)] ever had a hysterectomy?
(-9) REFUSED
[Has (SP)] respondent is proxy
IF SP HAS EVER REPORTED HAVING PROSTATE SURGERY IN A PREVIOUS ROUND,
GO TO HFF11 - DIGTEXAM.
ELSE GO TO HFF10 - PROSSURG.
(01) HFF6 - PAPSMEAR
(02) HFF6 - PAPSMEAR
(03) HFF6 - PAPSMEAR
(04) HFF6 - PAPSMEAR
(05) HFF6 - PAPSMEAR
(06) HFF6 - PAPSMEAR
(07) HFF6 - PAPSMEAR
(08) HFF6 - PAPSMEAR
(09) HFF6 - PAPSMEAR
(10) HFF6 - PAPSMEAR
(11) HFF6 - PAPSMEAR
(12) HFF6 - PAPSMEAR
(13) HFF6 - PAPSMEAR
(14) HFF6 - PAPSMEAR
(15) HFF6 - PAPSMEAR
(16) HFF6 - PAPSMEAR
(91) HFF5 - MAMNOTHS
(-8) HFF6 - PAPSMEAR
(-9) HFF6 - PAPSMEAR
HFF6 - PAPSMEAR
(01) BOX HFF2
(02) BOX HFF1B HFF8 - PAPCODE
(-8) BOX HFF2
(-9) BOX HFF2
(01) BOX HFF2
(02) BOX HFF2
(03) BOX HFF2
(04) BOX HFF2
(05) BOX HFF2
(06) BOX HFF2
(07) BOX HFF2
(08) BOX HFF2
(09) BOX HFF2
(10) BOX HFF2
(11) BOX HFF2
(12) BOX HFF2
(13) BOX HFF2
(14) BOX HFF2
(15) BOX HFF2
(91) HFF8 - PAPNOTHS
(-8) BOX HFF2
(-9) BOX HFF2
BOX HFF2
HFF15 - FLUSHOT
[Since (LAST HF MONTH YEAR), [have you/has (SP)/[Have you/has (SP)] ever] had
surgery on (your/his) prostate?
PROSSURG
HFF10
yes/no
[EXPLAIN IF NECESSARY: Surgery on the prostate gland is typically used as a
treatment for prostate cancer or to correct urinary problems. Surgery can
include complete or partial removal of the prostate.]
These next few questions are about [preventive health care measures some
people take/follow-up care sometimes prescribed after prostate surgery].
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[Have you/Has (SP)] had a digital rectal examination (of the prostate) since (LAST
HF MONTH YEAR)?
DIGTEXAM
HFF11
yes/no
(01) YES
[EXPLAIN IF NECESSARY: The exam may be used to detect prostate cancer, to
(02) NO
determine whether cancer has spread beyond the prostate, and as part of follow- (-8) DON'T KNOW
up care after prostate surgery.]
(-9) REFUSED
[Have you/Has (SP)] had a blood test for detection of prostate cancer, known as
a PSA, since (LAST HF MONTH YEAR)?
[Since (LAST HF MONTH YEAR)] second or more time through
loop
[have you] respondent is SP, second or more time through
loop
[has (SP)] respondent is proxy, second or more time through
loop
[Have you ever] respondent is SP, first time through loop
[Has (SP) ever] respondent is proxy, first time through loop
[your] respondent is SP
[his] respondent is proxy
[Since (LAST HF MONTH YEAR), have you] HFQ has been
completed before in a previous round and the respondent is
SP
[Since (LAST HF MONTH YEAR), has (SP)] HFQ has been
completed before in a previous round and the respondent is
proxy
[Have you ever] respondent is SP, first time through the HFQ
section ever
[Has (SP) ever] respondent is proxy, first time through the HFQ
section ever
[your] respondent is SP
[his] respondent is proxy
HFF11 - DIGTEXAM
[preventive health care measures some people take]
PROSSURG in(02,-8,-9)
[follow-up care sometimes prescribed after prostate surgery]
PROSSURG = 01 or P_PROSSURG=1
[Have you] respondent is SP
[Has (SP)] respondent is proxy
HFF12 - BLOODTST
[Have you] respondent is SP
[Has (SP)] respondent is proxy
(01) HFF15 - FLUSHOT
(02) BOX HFF3B HFF14 - PRONCODE
(-8) HFF15 - FLUSHOT
(-9) HFF15 - FLUSHOT
PSA = PROSTATE-SPECIFIC ANTIGEN
BLOODTST
PRONCODE
PRONOTHS
FLUSHOT
HFF12
yes/no
BOX HFF3B
routing
HFF14
HFF14
HFF15
code all
verbatim text
yes/no
(01) YES
[EXPLAIN IF NECESSARY: The test may be used to detect prostate cancer, to
(02) NO
determine whether cancer has spread beyond the prostate, and as part of follow- (-8) DON'T KNOW
up care after prostate surgery.]
(-9) REFUSED
IF THIS IS ROUND 73 AND SP IS NOT IN THE SUPPLEMENTAL SAMPLE GO TO
HFF15 - FLUSHOT.
ELSE GO TO HFF14 - PRONCODE.
(01) DIDN’T KNOW IT WAS NEEDED/NO
NEED/NOTHING WRONG
(02) NOT RECOMMENDED EVERY YEAR/ON A
DIFFERENT SCREENING SCHEDULE
(03) DIDN’T THINK IT WOULD PREVENT CANCER/COULD
GET CANCER ANYWAY/TEST IS USELESS
(04) NOT AT RISK FOR CANCER
(05) DOCTOR DID NOT PRESCRIBE OR RECOMMEND IT
(06) DOCTOR RECOMMENDED AGAINST GETTING IT
(07) DON’T LIKE BLOOD TESTS/PAIN, SORENESS,
DISCOMFORT OR REACTIONS
(08) INCONVENIENT/UNABLE TO GET TO
LOCATION/TRANSPORTATION DIFFICULTY
(09) DIDN’T THINK ABOUT IT/FORGOT/MISSED
IT/PROCRASTINATED
(10) COST OF TEST/INSURANCE DOESN’T COVER
COST/NOT WORTH THE MONEY
(11) AFRAID OF RESULTS/DON’T WANT TO KNOW
(12) NEVER HEARD OF PSA
(13) APPOINTMENT SCHEDULED FOR FUTURE DATE
(14) PROSTATECTOMY/PROSTATE REMOVED
What is the reason that [you have/(SP) has] not had a prostate blood test or PSA (91) OTHER
since (LAST HF MONTH YEAR)?
(-8) DON'T KNOW
[you have] respondent is SP
CHECK ALL THAT APPLY.
(-9) REFUSED
[(SP) has] respondent is proxy
OTHER (SPECIFY)
Did [you/(SP)] have a seasonal flu shot for last winter?
(01) YES
[you] respondent is SP
[EXPLAIN IF NECESSARY: Did [you/(SP)] have a seasonal flu shot any time during (02) NO
[(SP)] respondent is proxy
the period from September (PREVIOUS YEAR) through December (PREVIOUS
(-8) DON'T KNOW
[you] respondent is SP
YEAR)?]
(-9) REFUSED
[(SP)] respondent is proxy
(01) HFF15 - FLUSHOT
(02) HFF15 - FLUSHOT
(03) HFF15 - FLUSHOT
(04) HFF15 - FLUSHOT
(05) HFF15 - FLUSHOT
(06) HFF15 - FLUSHOT
(07) HFF15 - FLUSHOT
(08) HFF15 - FLUSHOT
(09) HFF15 - FLUSHOT
(10) HFF15 - FLUSHOT
(11) HFF15 - FLUSHOT
(12) HFF15 - FLUSHOT
(13) HFF15 - FLUSHOT
(14) HFF15 - FLUSHOT
(91) HFF14 - PRONOTHS
(-8) HFF15 - FLUSHOT
(-9) HFF15 - FLUSHOT
HFF15 - FLUSHOT
(01) HFF18 - FLUSITE
(02) HFF17 - FLUCODE
(-8) BOX HFF5
(-9) BOX HFF5
Why didn't [you/(SP)] get a seasonal flu shot last winter?
FLUCODE
FLUOTHOS
FLUSITE
FLUSITOS
VACPAID
VACSUPLY
NOVACINE
PNEUSHOT
HFF17
HFF17
code all
verbatim text
BOX HFF4
routing
HFF18
HFF18
HFF18A
HFF20
code all
verbatim text
yes/no
yes/no
HFF21
yes/no
BOX HFF5
routing
HFF22
yes/no
BOX HFF5B
routing
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.
OTHER (SPECIFY)
IF RESPONSE TO HFF17 – FLUCODE DOES NOT INCLUDE 13/VaccineUnavailable,
GO TO HFF21 - NOVACINE.
ELSE GO TO BOX HFF5.
(01) DIDN’T KNOW IT WAS NEEDED
(02) SHOT COULD CAUSE FLU
(03) SHOT COULD HAVE SIDE EFFECTS OR CAUSE
DISEASE
(04) DIDN’T THINK IT WOULD PREVENT THE FLU/COULD
GET THE FLU ANYWAY
(05) FLU NOT SERIOUS/WOULD NOT GET FLU
ANYWAY/NOT AT RISK
(06) DOCTOR DID NOT RECOMMEND THE SHOT
(07) DOCTOR RECOMMENDED AGAINST GETTING
SHOT/ALLERGIC TO SHOT/MEDICAL REASONS
(08) DON’T LIKE SHOTS OR NEEDLES/CONCERNS ABOUT
SORENESS OR RASH/LOCAL REACTIONS
(09) INCONVENIENT TO GET SHOT/UNABLE TO GET TO
LOCATION
(10) DIDN’T THINK ABOUT IT/FORGOT/MISSED IT
(11) COST OF SHOT/NOT WORTH THE MONEY
(12) HAD SHOT BEFORE/DIDN’T NEED IT AGAIN
(13) VACCINE UNAVAILABLE/VACCINE SHORTAGE
(91) OTHER
(-8) DON'T KNOW
[you] respondent is SP
(-9) REFUSED
[(SP)] respondent is proxy
(01) DOCTORS OFFICE OR GROUP PRACTICE
(02) MEDICAL CLINIC
(03) MANAGED CARE PLAN CENTER/HMO
(04) NEIGHBORHOOD/FAMILY HEALTH CENTER
(05) FREESTANDING SURGICAL CENTER
(06) RURAL HEALTH CLINIC
(07) COMPANY CLINIC
(08) OTHER CLINIC
(09) WALK-IN URGENT CENTER
(10) HOSPITAL EMERGENCY ROOM
(11) HOSPITAL OUTPATIENT DEPARTMENT/CLINIC
(12) VA FACILITY
(13) HEALTH FAIR
(14) SHOPPING MALL/OTHER STORE
(15) SENIOR CENTER
(16) AT HOME
(17) CHURCH/SCHOOL
Where did [you/(SP)] go for (your/his/her) most recent seasonal flu shot, was
(18) LIBRARY
that a managed care plan or HMO center, a clinic, a doctor’s office, a hospital, a (19) HOSPITAL INPATIENT
health fair, shopping mall, or some other place?
(91) OTHER
(-8) DON'T KNOW
[IF CLINIC, ASK: Was it a hospital outpatient clinic, or some other kind of clinic? (-9) REFUSED
IF SOME OTHER PLACE, ASK: Where was this?]
OTHER (SPECIFY)
Did [you/(SP)] pay some or all of the cost of the flu shot?
(01) YES
(02) NO
Please include any monetary donations that you may have made to cover the
(-8) DON'T KNOW
cost of the flu shot.
(-9) REFUSED
Did [you/(SP)] have any trouble getting a seasonal flu shot when (you/he/she)
wanted to because the vaccine was in short supply or unavailable?
Was one reason that [you/(SP)] did not get a seasonal flu shot last winter
because the vaccine was in short supply or unavailable?
IF SP HAS EVER REPORTED HAVING A PNEUMONIA SHOT IN A PREVIOUS ROUND,
GO TO BOX HFG1.
ELSE GO TO HFF22 - PNEUSHOT.
[Have you/Has (SP)] ever had a shot for pneumonia?
IF THIS IS ROUND 73 AND SP IS NOT IN THE SUPPLEMENTAL SAMPLE GO TO BOX
HFG1.
ELSE GO TO HFF23 - PNUCODE.
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
(01) BOX HFF4
(02) BOX HFF4
(03) BOX HFF4
(04) BOX HFF4
(05) BOX HFF4
(06) BOX HFF4
(07) BOX HFF4
(08) BOX HFF4
(09) BOX HFF4
(10) BOX HFF4
(11) BOX HFF4
(12) BOX HFF4
(13) BOX HFF4
(91) HFF17 - FLUOTHOS
(-8) BOX HFF4
(-9) BOX HFF4
BOX HFF4
(01) HFF18A - VACPAID
(02) HFF18A - VACPAID
(03) HFF18A - VACPAID
(04) HFF18A - VACPAID
(05) HFF18A - VACPAID
(06) HFF18A - VACPAID
(07) HFF18A - VACPAID
(08) HFF18A - VACPAID
(09) HFF18A - VACPAID
(10) HFF18A - VACPAID
(11) HFF18A - VACPAID
(12) HFF18A - VACPAID
(13) HFF18A - VACPAID
(14) HFF18A - VACPAID
(15) HFF18A - VACPAID
(16) HFF18A - VACPAID
(17) HFF18A - VACPAID
(18) HFF18A - VACPAID
(19) HFF18A - VACPAID
(91) HFF18 - FLUSITOS
(-8) HFF18A - VACPAID
(-9) HFF18A - VACPAID
HFF18A - VACPAID
HFF20 - VACSUPLY
BOX HFF5
[you] respondent is SP
[(SP)] respondent is proxy
BOX HFF5
[Have you] respondent is SP
[Has (SP)] respondent is proxy
(01) BOX HFG1
(02) BOX HFF5B HFF23 PNUCODE
(-8) BOX HFG1
(-9) BOX HFG1
Why [haven't you/hasn't (SP)] ever had a shot for pneumonia?
PNUCODE
PNUOTHOS
EVERSMOK
SMOKNOW
HFF23
HFF23
code all
verbatim text
BOX HFG1
routing
HFG1
yes/no
HFG2
yes/no
BOX HFG1A
routing
DIDSMOKE
HFG3
numeric
LASTSMOK
HFG4
code 1
HAVSMOKE
HFG5
numeric
HAVSMOKE_LESSONE
HFG5
numeric
DRQTSMOK
QUITSMOK
DRINKDAY
HFG5A
yes/no
BOX HFG1B
routing
HFG6
yes/no
BOX HFG1C
routing
HFG7
numeric
BOX HFG2
routing
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.
OTHER (SPECIFY)
IF SP WAS ASKED IF HE/SHE NOW SMOKES CIGARETTES, CIGARS, OR PIPE
TOBACCO IN A PREVIOUS ROUND, GO TO HFG2 - SMOKNOW.
ELSE GO TO HFG1 - EVERSMOK.
[Have you/Has (SP)] ever smoked cigarettes, cigars, or pipe tobacco?
[Do you/Does (SP)] smoke cigarettes, cigars, or pipe tobacco now?
IF THIS IS ROUND 73 THEN
IF HFG2-SMOKNOW = 2/No, GO TO HFG3 - DIDSMOKE.
ELSE GO TO HFG5 - HAVSMOKE.
ELSE IF THIS IS NOT ROUND 73 THEN
IF HFG2-SMOKNOW = 2/No, GO TO BOX HFG1C.
ELSE GO TO HFG5A - DRQTSMOK.
(01) DIDN'T KNOW IT WAS NEEDED
(02) SHOT COULD CAUSE PNEUMONIA
(03) SHOT COULD HAVE SIDE EFFECTS OR CAUSE
DISEASE
(04) DIDN'T THINK IT WOULD PREVENT
PNEUMONIA/COULD GET PNEUMONIA ANYWAY
(05) PNEUMONIA NOT SERIOUS/WOULD NOT GET
PNEUMONIA ANYWAY/NOT AT RISK
(06) DOCTOR DID NOT RECOMMEND THE SHOT
(07) DOCTOR RECOMMENDED AGAINST GETTING
SHOT/ALLERGIC TO SHOT/MEDICAL REASONS
(08) DON'T LIKE SHOTS OR NEEDLES/CONCERNS ABOUT
SORENESS OR RASH/LOCAL REACTIONS
(09) INCONVENIENT TO GET SHOT/UNABLE TO GET TO
LOCATION
(10) DIDN'T THINK ABOUT IT/FORGOT/MISSED IT
(11) COST OF SHOT/NOT WORTH THE MONEY
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[Have you] respondent is SP
[Has (SP)] respondent is proxy
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[Do you] respondent is SP
[Does (SP)] respondent is proxy
(01) HFG2 - SMOKNOW
(02) BOX HFG1C
(-8) BOX HFG1C
(-9) BOX HFG1C
(01) BOX HFG1A
(02) BOX HFG1A
(03) BOX HFG1C
(-8) BOX HFG1C
(-9) BOX HFG1C
[you] respondent is SP
[(SP)] respondent is proxy
HFG3 - DIDSMOKE_LESSONE
[you] respondent is SP
[(SP)] respondent is proxy
BOX HFG1C
(01) continuous answer
How many years did [you/(SP)] smoke?
(-7) EMPTY
[EXCLUDE BREAKS WHEN THE RESPONDENT DID NOT SMOKE BETWEEN YEARS (-8) DON'T KNOW
OF SMOKING.]
(-9) REFUSED
(01) WITHIN THE LAST MONTH
(02) 1 MONTH TO LESS THAN 6 MONTHS AGO
(03) 6 MONTHS TO LESS THAN 1 YEAR AGO
(04) 1 YEAR TO LESS THAN 5 YEARS AGO
(05) 5 YEARS TO LESS THAN 10 YEARS AGO
(06) 10 OR MORE YEARS AGO
(-8) Don't Know
About how long has it been since [you/(SP)] last smoked regularly?
(-9) Refused
(01) [Continuous answer.]
How many years [have you/has (SP)] smoked?
(-7) Empty
[EXCLUDE BREAKS WHEN THE RESPONDENT DID NOT SMOKE BETWEEN YEARS (-8) Don't Know
OF SMOKING.]
(-9) Refused
How many years [have you/has (SP)] smoked? [EXCLUDE BREAKS WHEN THE
(01) LESS THAN ONE YEAR
RESPONDENT DID NOT SMOKE BETWEEN YEARS OF SMOKING.]
(-7) Empty
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), has a doctor or other health professional advised (-8) Don't Know
[you/(SP)] to quit smoking?
(-9) Refused
IF THIS IS ROUND 67 73, GO TO HFG6 - QUITSMOK.
ELSE GO TO BOX HFG1C
(01) YES
(02) NO
During the past 12 months, [have you/has (SP)] stopped smoking for one day or (-8) Don't Know
longer because (you were/he was/she was) trying to quit smoking?
(-9) Refused
IF THIS IS ROUND 73, GO TO HFG7 - DRINKDAY.
ELSE GO TO HFHINTRO - DIFINTRO.
The next questions are about drinking alcoholic beverages. Included are liquor
such as whiskey or gin, mixed drinks, wine, beer, and any other type of alcoholic
beverage.
Please think about a typical month in the past year. On how many days did
[you/(SP)] drink any type of alcoholic beverage?
ENTER "0" FOR "NEVER DRANK" OR "NONE".
IF HFG7 - DRINKDAY = 0, GO TO HFHINTRO - DIFINTRO.
ELSE GO TO HFG8 - DRINKSPD.
[you] respondent is SP
[(SP)] respondent is proxy
[haven't you] respondent is SP
[hasn't (SP)] respondent is proxy
(01) BOX HFG1
(02) BOX HFG1
(03) BOX HFG1
(04) BOX HFG1
(05) BOX HFG1
(06) BOX HFG1
(07) BOX HFG1
(08) BOX HFG1
(09) IBOX HFG1
(10) BOX HFG1
(11) BOX HFG1
(91) HFF23 - PNUOTHOS
(-8) BOX HFG1
(-9) BOX HFG1
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
[have you] respondent is SP
[(SP)] respondent is proxy
[have you] respondent is SP
[(SP)] respondent is proxy
HFG5 - HAVSMOKE_LESSONE
HFG5A - DRQTSMOK
[you] respondent is SP
[(SP)] respondent is proxy
BOX HFG1B
[have you] respondent is SP
[has (SP)] respondent is proxy
[you were] respondent is SP
[he was] respondent is proxy, SP male
[she was] respondent is proxy, SP female
BOX HFG1C HFG7 - DRINKDAY
[you] respondent is SP
[(SP)] respondent is proxy
BOX HFG2
DRINKSPD
FOURDRNK
HFG8
HFG9
numeric
[Please think about a typical month in the past year.] On those days that
[you/(SP)] drank alcohol, how many drinks did (you/he/she) have?
[Please think about a typical month in the past year.] On how many days did
[you/(SP)] have 4 or more drinks in a single day?
ENTER "0" FOR "NEVER" OR "NONE".
no entry
Now, I'm going to ask about how difficult it is, on the average, for [you/(SP)] to
do certain kinds of activities. Please tell me for each activity whether [you
have/(SP) has] no difficulty at all, a little difficulty, some difficulty, a lot of
difficulty, or (is/are) not able to do it.
numeric
(01) [Continuous answer.]
(-7) LESS THAN ONE
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
HFH5
code 1
BOX HFH1
routing
PHYSACTINTRO
HFH10INT
no entry
VIGUNIT
HFH10
quantity unit
(01) CONTINUE
(-7) Empty
(01) NO DIFFICULTY AT ALL
(02) A LITTLE DIFFICULTY
(03) SOME DIFFICULTY
SHOW CARD HF1 HF3
(04) A LOT OF DIFFICULTY
How much difficulty, if any, [do you/does (SP)] have stooping, crouching, or
(05) NOT ABLE TO DO IT
kneeling? Would you say [you have/(SP) has] no difficulty at all, a little difficulty, (-8) Don't Know
some difficulty, a lot of difficulty, or (is/are) not able to do it?
(-9) Refused
(01) NO DIFFICULTY AT ALL
SHOW CARD HF1 HF3
(02) A LITTLE DIFFICULTY
How much difficulty, if any, [do you/does (SP)] have lifting or carrying objects as (03) SOME DIFFICULTY
heavy as 10 pounds, like a sack of potatoes?
(04) A LOT OF DIFFICULTY
(05) NOT ABLE TO DO IT
[PROBE IF NECESSARY: Would you say [you have/(SP) has] no difficulty at all, a (-8) Don't Know
little difficulty, some difficulty, a lot of difficulty, or (is/are) not able to do it?]
(-9) Refused
(01) NO DIFFICULTY AT ALL
(02) A LITTLE DIFFICULTY
SHOW CARD HF1 HF3
(03) SOME DIFFICULTY
What about reaching or extending arms above shoulder level?
(04) A LOT OF DIFFICULTY
(05) NOT ABLE TO DO IT
[PROBE IF NECESSARY: Would you say [you have/(SP) has] no difficulty at all, a (-8) Don't Know
little difficulty, some difficulty, a lot of difficulty, or (is/are) not able to do it?]
(-9) Refused
(01) NO DIFFICULTY AT ALL
SHOW CARD HF1 HF3
(02) A LITTLE DIFFICULTY
How much difficulty, if any, [do you/does (SP)] have either writing or handling
(03) SOME DIFFICULTY
and grasping small objects?
(04) A LOT OF DIFFICULTY
(05) NOT ABLE TO DO IT
[PROBE IF NECESSARY: Would you say [you have/(SP) has] no difficulty at all, a (-8) Don't Know
little difficulty, some difficulty, a lot of difficulty, or (is/are) not able to do it?]
(-9) Refused
(01) NO DIFFICULTY AT ALL
SHOW CARD HF1 HF3
(02) A LITTLE DIFFICULTY
What about walking a quarter of a mile - that is, about 2 or 3 blocks?
(03) SOME DIFFICULTY
(04) A LOT OF DIFFICULTY
(05) NOT ABLE TO DO IT
[PROBE IF NECESSARY: Would you say [you have/(SP) has] no difficulty at all, a (-8) Don't Know
little difficulty, some difficulty, a lot of difficulty, or (is/are) not able to do it?]
(-9) Refused
IF THIS IS ROUND 73, GO TO HFH10INT - PHYSACTINTRO.
ELSE GO TO HFJINTRO - MEDCONDINTRO.
We are interested in two types of physical activity - vigorous and moderate.
Vigorous activities cause large increases in breathing or heart rate. Moderate
activities cause small increases in breathing or heart rate. First I will ask about
(01) CONTINUE
the vigorous activities that [you do/(SP) does].
(-7) Empty
(01) NUMBER OF MINUTES PER DAY
(02) NUMBER OF HOURS PER DAY
(03) NUMBER OF HOURS PER WEEK
In a typical week, how much time [do you/does (SP)] spend doing vigorous
(04) NUMBER OF HOURS PER MONTH
activities, such as team sports, running, aerobics, heavy house or yard work, or (96) NONE
anything else that causes large increases in breathing or heart rate?
(-8) Don't Know
IF TIME REPORTED IN BOTH MINUTES AND HOURS, ROUND TO NEAREST HOUR. (-9) Refused
quantity unit
In a typical week, how much time [do you/does (SP)] spend doing vigorous
activities, such as team sports, running, aerobics, heavy house or yard work, or
anything else that causes large increases in breathing or heart rate?
IF TIME REPORTED IN BOTH MINUTES AND HOURS, ROUND TO NEAREST HOUR.
DIFINTRO
DIFSTOOP
DIFLIFT
DIFREACH
DIFWRITE
DIFWALK
VIGNUM
HFHINTRO
HFH1
HFH2
HFH3
HFH4
HFH10
code 1
code 1
code 1
code 1
MODUNIT
HFH11
quantity unit
MODNUM
HFH11
numeric
In a typical week, how much time [do you/does (SP)] spend doing moderate
activities, such as brisk walking, bicycling, gardening, golf, swimming, or
vacuuming?
IF TIME REPORTED IN BOTH MINUTES AND HOURS, ROUND TO NEAREST HOUR.
In a typical week, how much time [do you/does (SP)] spend doing moderate
activities, such as brisk walking, bicycling, gardening, golf, swimming, or
vacuuming?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) NUMBER OF MINUTES PER DAY
(02) NUMBER OF HOURS PER DAY
(03) NUMBER OF HOURS PER WEEK
(04) NUMBER OF HOURS PER MONTH
(96) NONE
(-8) Don't Know
(-9) Refused
(01)continous answer
[you] respondent is SP
[(SP)] respondent is proxy
[you] reespondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[you have] respondent is SP
[(SP) has] respondent is proxy
[is] respondent is proxy
[are] respondent is SP
HFG9 - FOURDRNK
HFHINTRO - DIFINTRO
HFH1 - DIFSTOOP
[ do you] respondent is SP
[does (SP)] respondent is proxy
[you have] respondent is SP
[(SP) has] respondent is proxy
[is] respondent is proxy
[are] respondent is SP
HFH2 - DIFLIFT
[ do you] respondent is SP
[does (SP)] respondent is proxy
[you have] respondent is SP
[(SP) has] respondent is proxy
[is] respondent is proxy
[are] respondent is SP
HFH3 - DIFREACH
[you have] respondent is SP
[(SP) has] respondent is proxy
[is] respondent is proxy
[are] respondent is SP
HFH4 - DIFWRITE
[ do you] respondent is SP
[does (SP)] respondent is proxy
[you have] respondent is SP
[(SP) has] respondent is proxy
[is] respondent is proxy
[are] respondent is SP
HFH5 - DIFWALK
[you have] respondent is SP
[(SP) has] respondent is proxy
[is] respondent is proxy
[are] respondent is SP
BOX HFH1
[you do] respondent is SP
[(SP) does] respondent is proxy
[ do you] respondent is SP
[does (SP)] respondent is proxy
[ do you] respondent is SP
[does (SP)] respondent is proxy
[ do you] respondent is SP
[does (SP)] respondent is proxy
HFH10 - VIGUNIT
(01) HFH10 - VIGNUM
(02) HFH10 - VIGNUM
(03) HFH10 - VIGNUM
(04) HFH10 - VIGNUM
(96) HFH11 - MODUNIT
(-8) HFH11 - MODUNIT
(-9) HFH11 - MODUNIT
HFH11 - MODUNIT
(01) HFH11 - MODNUM
(02) HFH11 - MODNUM
(03) HFH11 - MODNUM
(04) HFH11 - MODNUM
(96) HFH12 - MUSUNIT
(-8) HFH12 - MUSUNIT
(-9) HFH12 - MUSUNIT
(01) HFH12 - MUSUNIT
MUSUNIT
HFH12
quantity unit
IF TIME REPORTED IN BOTH MINUTES AND HOURS, ROUND TO NEAREST HOUR.
(01) NUMBER OF MINUTES PER DAY
(02) NUMBER OF HOURS PER DAY
(03) NUMBER OF HOURS PER WEEK
(04) NUMBER OF HOURS PER MONTH
(96) NONE
(-8) Don't Know
(-9) Refused
MUSNUM
HFH12
numeric
IF TIME REPORTED IN BOTH MINUTES AND HOURS, ROUND TO NEAREST HOUR.
(01) Continunous answer
Next, I'm going to read a list of medical conditions. [Since (LAST HF MONTH
YEAR) has/Has] a doctor (ever) told [you/(SP)] that (you/he/she) had any of
these conditions?
MEDCONDINTRO
HFJINTRO
no entry
BOX HFJ1
routing
[INTERVIEWER: IF THE SP IS CURRENTLY TAKING MEDICATION TO CONTROL A
CONDITION, THE RESPONSE RECORDED SHOULD BE "YES" TO INDICATE THAT
(01) CONTINUE
THE SP HAS THE CONDITION.]
(-7) Empty
IF SP HAS EVER REPORTED HAVING HARDENING OF THE ARTERIES IN A PREVIOUS
ROUND, GO TO HFJ2 - OCHBP.
ELSE GO TO HFJ1 - OCARTERY.
[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...
OCARTERY
HFJ1
yes/no
hardening of the arteries or arteriosclerosis?
[[Since (LAST HF MONTH YEAR) has/Has] a doctor [ever] told [you/(SP)] that
[you/he/she] (still have/[still has/still have/had/has/have)...]
OCHBP
YRHBP
HFJ2
yes/no
BOX HFJ2
routing
HFJ3
yes/no
hypertension, sometimes called high blood pressure?
IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO HFJ3 - YRHBP.
ELSE GO TO HFJ4 - OCMYOCAR.
YRMYOCAR
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) still (-8) Don't Know
had hypertension or high blood pressure?
(-9) Refused
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCMYOCAR
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFJ4
yes/no
BOX HFJ3
routing
a myocardial infarction or heart attack?
IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO HFJ5 - YRMYOCAR.
ELSE GO TO HFJ6 - OCCHD.
yes/no
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) had (-8) Don't Know
a myocardial infarction or heart attack?
(-9) Refused
HFJ5
[ do you] respondent is SP
[does (SP)] respondent is proxy
(01) HFH12 - MUSNUM
(02) HFH12 - MUSNUM
(03) HFH12 - MUSNUM
(04) HFH12 - MUSNUM
(96) HFJINTRO - MEDCONDINTRO
(-8) HFJINTRO - MEDCONDINTRO
(-9) HFJINTRO - MEDCONDINTRO
HFJINTRO - MEDCONDINTRO
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[still has] respondent is proxy, SP is alive, P_OCHBP = 1
[still have] respondent is SP, P_OCHBP = 1
[had] respondent is proxy, SP is deceased, P_OCHBP = 1
[has] respondent is proxy, SP is alive, P_OCHBP = 0
[have] respondent is SP, P_OCHBP = 0
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[you] reespondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
BOX HFJ1
HFJ2 - OCHBP
(01) BOX HFJ2
(02) HFJ4 - OCMYOCAR
(-8) HFJ4 - OCMYOCAR
(-9) HFJ4 - OCMYOCAR
HFJ4 - OCMYOCAR
(01) BOX HFJ3
(02) HFJ6 - OCCHD
(-8) HFJ6 - OCCHD
(-9) HFJ6 - OCCHD
HFJ6 - OCCHD
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCCHD
YRCHD
HFJ6
yes/no
BOX HFJ4
routing
HFJ7
yes/no
([a new episode of]) angina pectoris or coronary heart disease?
IF SP IS IN THE SUPPLMENTAL SAMPLE, GO TO HFJ7 - YRCHD.
ELSE GO TO HFJ8 - OCCFAIL.
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) had (-8) Don't Know
an episode of angina pectoris or coronary heart disease?
(-9) Refused
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCCFAIL
YRCFAIL
HFJ8
yes/no
BOX HFJ5
routing
HFJ9
yes/no
[(a new episode of)] congestive heart failure?
IF SP IS IN THE SUPPLMENTAL SAMPLE, GO TO HFJ9 - YRCFAIL.
ELSE GO TO HFJ10 - OCCVALVE.
YRVALVE
YRRHYTHM
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFJ10
yes/no
BOX HFJ6
routing
([a new episode of]) problems with the valves of the heart, such as aortic
stenosis?
IF SP IS IN THE SUPPLMENTAL SAMPLE, GO TO HFJ11 - YRVALVE.
ELSE GO TO HFJ12 - OCRHYTHM.
yes/no
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) had (-8) Don't Know
an episode of problems with the valves of the heart, such as aortic stenosis?
(-9) Refused
HFJ11
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCRHYTHM
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) had (-8) Don't Know
an episode of congestive heart failure?
(-9) Refused
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCCVALVE
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFJ12
yes/no
BOX HFJ7
routing
HFJ13
yes/no
(a new episode of) problems with the rhythm of (your/his/her) heartbeat, such
as atrial fibrillation?
IF SP IS IN THE SUPPLMENTAL SAMPLE, GO TO HFJ13 - YRRHYTHM.
ELSE GO TO HFJ14 - OCOTHHRT.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) had (02) NO
an episode of problems with the rhythm of (your/his/her) heart, such as atrial
(-8) Don't Know
fibrillation?
(-9) Refused
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[a new episode of] P_OCCHD = 1
[you] respondent is SP
[(SP)] respondent is proxy
[you] reespondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[a new episode of] P_OCCFAIL = 1
[you] respondent is SP
[(SP)] respondent is proxy
[you] reespondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[a new episode of] P_OCCVALVE = 1
[you] respondent is SP
[(SP)] respondent is proxy
[you] reespondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[you] reespondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
(01) BOX HFJ4
(02) HFJ8 - OCCFAIL
(-8) HFJ8 - OCCFAIL
(-9) HFJ8 - OCCFAIL
HFJ8 - OCCFAIL
(01) BOX HFJ5
(02) HFJ10 - OCCVALVE
(-8) HFJ10 - OCCVALVE
(-9) HFJ10 - OCCVALVE
HFJ10 - OCCVALVE
(01) BOX HFJ6
(02) HFJ12 - OCRHYTHM
(-8) HFJ12 - OCRHYTHM
(-9) HFJ12 - OCRHYTHM
HFJ12 - OCRHYTHM
(01) BOX HFJ7
(02) HFJ14 - OCOTHHRT
(-8) HFJ14 - OCOTHHRT
(-9) HFJ14 - OCOTHHRT
HFJ14 - OCOTHHRT
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCOTHHRT
YROTHHRT
HFJ14
yes/no
BOX HFJ8
routing
HFJ15
yes/no
(a new episode of) any other heart condition?
[DO NOT RECORD THE NAME OF THE CONDITION AT THIS QUESTION.]
IF SP IS IN THE SUPPLMENTAL SAMPLE, GO TO HFJ15 - YROTHHRT.
ELSE GO TO HFJ16 - OCSTROKE.
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) had (-8) Don't Know
an episode of any other heart condition?
(-9) Refused
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCSTROKE
YRSTROKE
OCCHOLES
YRCHOLES
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFJ16
yes/no
BOX HFJ9
routing
a stroke, a brain hemorrhage, or a cerebrovascular accident?
IF SP IS IN THE SUPPLMENTAL SAMPLE, GO TO HFJ17 - YRSTROKE.
ELSE GO TO HFJ17A - OCCHOLES.
yes/no
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) had (-8) Don't Know
a stroke, a brain hemorrhage, or a cerebrovascular accident?
(-9) Refused
yes/no
Has a doctor ever told [you/(SP)] that (you/he/she) had high cholesterol?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
yes/no
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) had (-8) Don't Know
high cholesterol?
(-9) Refused
HFJ17
HFJ17A
HFJ17B
[I've recorded that [you/(SP)] previously reported having had skin cancer.]
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCCSKIN
YRCSKIN
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFJ18
yes/no
BOX HFJ10
routing
(a new occurrence of) skin cancer?
IF SP IS IN THE SUPPLMENTAL SAMPLE, GO TO HFJ19 - YRCSKIN.
ELSE GO TO HFJ20 - OCCANCER.
yes/no
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) had (-8) Don't Know
an occurrence of skin cancer?
(-9) Refused
HFJ19
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[you] reespondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[you] reespondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[you] reespondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[you] reespondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[I've recorded that [you] previously reported having had skin
cancer] OCCSKIN = 1 in a previous round for SP, respondent is
SP. second or more time through loop
[I've recorded that [(SP)] previously reported having had skin
cancer] OCCSKIN = 1 in a previous round for SP, respondent is
proxy, second or more time through loop
[Since (LAST HF MONTH YEAR) has] HFQ has been completed
in a previous round for this respondent second or more time
through loop
[Has] HFQ has not been completed in a previous round for
this respondent first time through loop
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[a new occurrence] second or more time through loop
[you] respondent is SP
[(SP)] respondent is proxy
[you] reespondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
(01) BOX HFJ8
(02) HFJ16 - OCSTROKE
(-8) HFJ16 - OCSTROKE
(-9) HFJ16 - OCSTROKE
HFJ16 - OCSTROKE
(01) BOX HFJ9
(02) HFJ17A - OCCHOLES
(-8) HFJ17A - OCCHOLES
(-9) HFJ17A - OCCHOLES
HFJ17A - OCCHOLES
(01) HFJ17B - YRCHOLES
(02) HFJ18 - OCCSKIN
(-8) HFJ18 - OCCSKIN
(-9) HFJ18 - OCCSKIN
HFJ18 - OCCSKIN
(01) BOX HFJ10
(02) HFJ20 - OCCANCER
(-8) HFJ20 - OCCANCER
(-9) HFJ20 - OCCANCER
HFJ20 - OCCANCER
[I've recorded that [you/(SP)] previously reported having had a tumor, growth,
or cancer of the [READ RESPONSES BELOW].]
OCCANCER
HFJ20
yes/no
BOX HFJ11
routing
YRCANCER
HFJ21
yes/no
OCCCODE
OCCOS
HFJ22
HFJ22
code all
verbatim text
BOX HFJ13
routing
[Has a doctor (ever) told [you/(SP)] that (you/he/she) had/Since (LAST HF
MONTH YEAR), has a doctor told [you/(SP)] that (you/he/she) had] any (other)
kind of cancer, malignancy, or tumor other than skin cancer?
INCLUDE BENIGN OR NON-MALIGNANT TUMORS OR GROWTHS.
IF SP IS IN THE SUPPLMENTAL SAMPLE, GO TO HFJ21 - YRCANCER.
ELSE GO TO HFJ22 - OCCCODE.
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) had (-8) Don't Know
any kind of cancer, malignancy, or tumor other than skin cancer?
(-9) Refused
(01) LUNG
(02) COLON, RECTUM, OR BOWEL
(03) BREAST
(04) UTERUS
(05) PROSTATE
(06) BLADDER
(07) OVARY
(08) STOMACH
(09) CERVIX
(10) BRAIN
(11) KIDNEY
(12) THROAT
[Since the first time a doctor told [you/(SP)] that (you/he/she) had a cancer,
(13) HEAD
malignancy, or tumor, on/On] what part or parts of [your/(SP's)] body was the
(14) BACK
cancer or tumor other than skin cancer found?
(15) OTHER FEMALE REPRODUCTIVE ORGANS
(91) OTHER
[PROBE: Any other part?]
(-8) Don't Know
CHECK ALL THAT APPLY
(-9) Refused
OTHER (SPECIFY)
(01) [Continuous answer.]
IF SP HAS EVER REPORTED HAVING RHEUMATOID ARTHRITIS IN A PREVIOUS
ROUND, GO TO BOX HFJ14.
ELSE GO TO HFJ24 - OCARTHRH.
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCARTHRH
HFJ24
yes/no
BOX HFJ14
routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
rheumatoid arthritis?
IF SP HAS EVER REPORTED HAVING ARTHRITIS OTHER THAN RHEUMATOID
ARTHRITIS IN A PREVIOUS ROUND, GO TO BOX HFJ16.
ELSE GO TO HFJ25 - OCARTH.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[I've recorded that [you]] respondent is SP, second or more
time throug loop, tumor, growth or cancer previously
reported
[I've recorded that [SP]] respondent is proxy, second or more
time through loop, tumor, growth or cancer previously
reported
[Has a doctor ever told] first time through loop
[I've recorded that [you] previously reported having had a
tumor, growth, or cancer of the [READ RESPONSES BELOW].]
SP has OCCANCER = 1 in a previous round, respondent is SP
[I've recorded that [(SP)] previously reported having had a
tumor, growth, or cancer of the [READ RESPONSES BELOW].]
SP has OCCANCER =1 in a previous round, respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[you] reespondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Since (LAST HF MONTH YEAR)] second or mor time through
loop
[you] respondent is SP
[(SP)] respondent is proxy
[you] reespondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[other] SP has OCCANCER = 1 in a previous round second or
more time through loop, tumor, growth or cancer reported
previously
[you] respondent is SP
[(SP)] respondent is proxy
[you] reespondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
(01) BOX HFJ11
(02) BOX HFJ13
(-8) BOX HFJ13
(-9) BOX HFJ13
HFJ22 - OCCCODE
(01) BOX HFJ13
(02) BOX HFJ13
(03) BOX HFJ13
(04) BOX HFJ13
(05) BOX HFJ13
(06) BOX HFJ13
(07) BOX HFJ13
(08) BOX HFJ13
(09) BOX HFJ13
(10) BOX HFJ13
(11) BOX HFJ13
(12) BOX HFJ13
(13) BOX HFJ13
(14) BOX HFJ13
(15) BOX HFJ13
(91) HFJ22 - OCCOS
(-8) BOX HFJ13
(-9) BOX HFJ13
BOX HFJ13
BOX HFJ14
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
BOX HFJ16
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
BOX HFJ16
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
BOX HFJ16A
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
(01) HFJ30AA - OCDEPRSS
(02) BOX HFJ16B
(-8) BOX HFJ16B
(-9) BOX HFJ16B
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
arthritis, other than rheumatoid arthritis?
OCARTH
YRARTHRD
HFJ25
yes/no
BOX HFJ15
routing
HFJ26
yes/no
BOX HFJ16
routing
[EXPLAIN IF NECESSARY: This includes osteoarthritis.]
IF SP IS IN THE SUPPLMENTAL SAMPLE, GO TO HFJ26 - YRARTHRD.
ELSE GO TO BOX HFJ16A.
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) had (-8) Don't Know
arthritis, other than rheumatoid arthritis, in any part of (your/his/her) body?
(-9) Refused
IF SP IS IN THE SUPPLMENTAL SAMPLE, GO TO HFJ28 - OCMENTAL.
ELSE GO TO BOX HFJ16A.
[Has a doctor ever told [you/(SP)] that (you/he/she) had...]
OCMENTAL
HFJ28
yes/no
BOX HFJ16A
routing
an intellectual disability, sometimes called mental retardation?
IF SP HAS EVER REPORTED HAVING ALZHEIMER’S DISEASE IN A PREVIOUS
ROUND, GO TO HFJ30AA - OCDEPRSS.
ELSE GO TO HFJ29A - OCALZMER.
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCALZMER
HFJ29A
yes/no
BOX HFJ16B
routing
Alzheimer's disease?
IF SP HAS EVER REPORTED HAVING DEMENTIA IN A PREVIOUS ROUND, GO TO
HFJ30AA - OCDEPRSS.
ELSE GO TO HFJ29B - OCDEMENT.
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCDEMENT
HFJ29B
yes/no
any type of dementia other than Alzheimer's disease?
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCDEPRSS
HFJ30AA
yes/no
BOX HFJ17A
routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
depression?
IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO HFJ30BB - YRDEPRSS.
ELSE GO TO HFJ30A - OCPSYCHO.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
HFJ30AA - OCDEPRSS
(01) BOX HFJ17A
(02) HFJ30A - OCPSYCHO
(-8) HFJ30A - OCPSYCHO
(-9) HFJ30A - OCPSYCHO
YRDEPRSS
HFJ30BB
yes/no
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) had (-8) Don't Know
depression?
(-9) Refused
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCPSYCHO
YRPSYCHO
HFJ30A
yes/no
BOX HFJ17B
routing
HFJ31A
yes/no
BOX HFJ19
routing
a mental or psychiatric disorder other than depression?
[INCLUDE ALCOHOLISM AS A MENTAL OR PSYCHIATRIC DISORDER.]
IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO HFJ31A - YRPSYCHO.
ELSE GO TO BOX HFJ19.
(01) YES
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) had (02) NO
a mental or psychiatric disorder other than depression?
(-8) Don't Know
[INCLUDE ALCOHOLISM AS A MENTAL OR PSYCHIATRIC DISORDER.]
(-9) Refused
IF SP HAS EVER REPORTED HAVING OSTEOPOROSIS IN A PREVIOUS ROUND, GO
TO HFJ33 - OCBRKHIP.
ELSE GO TO HFJ32 - OCOSTEOP.
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCOSTEOP
HFJ32
yes/no
osteoporosis, sometimes called fragile or soft bones?
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]]
a broken hip?
OCBRKHIP
YRBRKHIP
HFJ33
yes/no
BOX HFJ20
routing
HFJ34
yes/no
BOX HFJ21
routing
HFJ35
yes/no
BOX HFJ22
routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
HFJ30A - OCPSYCHO
(01) BOX HFJ17B
(02) BOX HFJ19
(-8) BOX HFJ19
(-9) BOX HFJ19
BOX HFJ19
HFJ33 - OCBRKHIP
(01) BOX HFJ20
(02) BOX HFJ21
(-8) BOX HFJ21
(-9) BOX HFJ21
IF SP IS IN THE SUPPLMENTAL SAMPLE, GO TO HFJ34 - YRBRKHIP.
ELSE GO TO BOX HFJ21.
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) had (-8) Don't Know
a broken hip?
(-9) Refused
IF SP HAS EVER REPORTED HAVING PARKINSON’S DISEASE IN A PREVIOUS
ROUND, GO TO BOX HFJ22.
ELSE GO TO HFJ35 - OCPARKIN.
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCPARKIN
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
Parkinson's disease?
IF SP HAS EVER REPORTED HAVING EMPHYSEMA, ASTHMA OR COPD IN A
PREVIOUS ROUND, GO TO HFJ37 - OCPPARAL.
ELSE GO TO HFJ36 - OCEMPHYS.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
BOX HFJ21
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
BOX HFJ22
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCEMPHYS
HFJ36
yes/no
emphysema, asthma, or COPD?
COPD=CHRONIC OBSTRUCTIVE PULMONARY DISEASE
IF SP IS OBVIOUSLY PARTIALLY OR COMPLETELY PARALYZED, SELECT "YES" AND
DO NOT ASK. OTHERWISE, ASK:
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had...]
OCPPARAL
YRPPARAL
OCAMPUTE
HAVEPROS
YRPROST
HFJ37
yes/no
BOX HFJ23
routing
HFJ38
yes/no
BOX HFJ24
routing
HFJ39
yes/no
BOX HFJ25
routing
HFJ40
yes/no
BOX HFJ26
routing
HFJ41
yes/no
complete or partial paralysis?
IF SP IS IN THE SUPPLMENTAL SAMPLE, GO TO HFJ38 - YRPPARAL.
ELSE GO TO BOX HFJ24.
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he) had an
enlarged prostate or benign prostatic hypertrophy (BPH)?
OCDTYPE
HFJ41B
code 1
OCDTYPOS
HFJ41B
verbatim text
yes/no
[Were you/Was (SP)] told on two or more different visits that (you/he/she) had
diabetes?
OCDVISIT
HFJ41A
HFJ41C
yes/no
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that (you/he/she) had (-8) Don't Know
complete or partial paralysis?
(-9) Refused
IF SP HAS EVER REPORTED AN ABSENCE OR LOSS OF ARM OR LEG IN A PREVIOUS
ROUND, GO TO BOX HFJ25.
ELSE GO TO HFJ39 - OCAMPUTE.
(01) YES
IF SP IS OBVIOUSLY MISSING ONE OR MORE LIMBS, SELECT "YES" AND DO NOT (02) NO
ASK. OTHERWISE, ASK:
(-8) Don't Know
What about absence or loss of an arm or a leg?
(-9) Refused
IF SP IS FEMALE, GO TO HFJ41A - OCBETES.
ELSE GO TO HFJ40 - HAVEPROS.
[[Before [you/(SP)] had prostate surgery, did a doctor ever tell/Since (LAST HF
(01) YES
MONTH YEAR), has/Has]] a doctor (ever) told ] [you/(SP)] that (you/he) had...]
(02) NO
(-8) Don't Know
an enlarged prostate or benign prostatic hypertrophy (BPH)?
(-9) Refused
IF SP IS IN THE SUPPLMENTAL SAMPLE, GO TO HFJ41 - YRPROST.
ELSE GO TO HFJ41A - OCBETES.
Has a doctor ever told [you/(SP)] that (you/he/she) had any type of diabetes,
including: sugar diabetes, high blood sugar, (borderline diabetes, pre-diabetes,
or pregnancy-related diabetes/borderline diabetes, or pre-diabetes)?
SHOW CARD HF6 HF4
Looking at this card, please tell me which type of diabetes the doctor said that
[you have/(SP) has].
[IF THE RESPONDENT REPORTS MORE THAN ONE TYPE OF DIABETES, PROBE FOR
THE MOST RECENT TYPE OF DIABETES THE DOCTOR TOLD THE RESPONDENT
HE/SHE HAS.]
[EXPLAIN IF NECESSARY: “Type 1” was formerly called “insulin dependent” or
“juvenile-onset” diabetes. This type of diabetes usually develops during
childhood or adolescence; but, it also can develop in adults.
“Type 2” was formerly called “non-insulin dependent” or “adult-onset” diabetes.
Until recently, this type of diabetes was found only in adults; but, now it is also
occurring in children.]
SOME OTHER TYPE (SPECIFY)
[IF THE RESPONDENT REPORTS MORE THAN ONE TYPE OF DIABETES, PROBE FOR
THE MOST RECENT TYPE OF DIABETES THE DOCTOR TOLD THE RESPONDENT
HE/SHE HAS.]
OCBETES
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) TYPE 1
(02) TYPE 2
(03) BORDERLINE
(04) PRE-DIABETES
(05) GESTATIONAL (PREGNANCY-RELATED)
(91) SOME OTHER TYPE
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Since (LAST HF MONTH YEAR) has] second or more time
through loop HFQ has been completed in a previous round for
this respondent
[Has] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[(SP)] respondent is proxy
[ever] first time through loop HFQ has never been completed
in a previous round for this respondent
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
HFJ37 - OCPPARAL
(01) BOX HFJ23
(02) BOX HFJ24
(-8) BOX HFJ24
(-9) BOX HFJ24
BOX HFJ24
BOX HFJ25
(01) BOX HFJ26
(02) HFJ41A - OCBETES
(-8) HFJ41A - OCBETES
(-9) HFJ41A - OCBETES
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you have] respondent is SP
[(SP) has] respondent is proxy
HFJ41A - OCBETES
(01) HFJ41B - OCDTYPE
(02) BOX HFJ27
(-8) BOX HFJ27
(-9) BOX HFJ27
(01) HFJ41C - OCDVISIT
(02) HFJ41C - OCDVISIT
(03) HFJ41C - OCDVISIT
(04) HFJ41C - OCDVISIT
(05) HFJ41C - OCDVISIT
(91) HFJ41B - OCDTYPOS
(-8) HFJ41C - OCDVISIT
(-9) HFJ41C - OCDVISIT
HFJ41C - OCDVISIT
[Were you] respondent is SP
[Was (SP)] respondent is proxy
BOX HFJ27
BOX HFJ27
routing
EMCOND
HFJ42
yes/no
EMCAUSEVB
HFJ43
verbatim text
BOX HFJ28
routing
IF SP IS IN THE SUPPLEMENTAL SAMPLE AND SP'S AGE AT TIME OF CURRENT
MEDICARE ELIGIBILITY WAS UNDER 65 THEN
IF SP REPORTED “YES” TO AT LEAST ONE HFJ CONDITION, GO TO HFJ42 EMCOND.
ELSE IF SP REPORTED “NO” TO ALL HFJ CONDITIONS , GO TO HFJ43 EMCAUSEVB.
ELSE IF SP IS NOT IN THE SUPPLEMENTAL SAMPLE OR SP'S AGE AT TIME OF
CURRENT MEDICARE ELIGIBILITY WAS NOT UNDER 65 THEN GO TO BOX HFP0.
You told me that [you have/(SP) has] had [READ CONDITIONS LISTED BELOW].
(Was this/Were any of these) the original cause of [your/(SP's)] becoming
eligible for Medicare?
[NOTE THAT CONDITIONS MAY NOT BE DISPLAYED WITH THE EXACT CONDITION
NAME THAT WAS USED EARLIER IN THE INTERVIEW (E.G., HYPERTENSION CAN
ALSO BE CALLED HIGH BLOOD PRESSURE AT DIFFERENT QUESTIONS).]
What was the original cause of [your/(SP's)] becoming eligible for Medicare?
RECORD VERBATIM.
IF SP RESPONDED “YES” TO ONLY ONE HFJ CONDITION, GO TO BOX HFP0.
ELSE GO TO HFJ44 - EMCODE.
Which of these conditions was the cause of [your/(SP's)] becoming eligible for
Medicare?
EMCODE
EMOS
HLTHCAREINTRO
HFJ44
HFJ44
code all
verbatim text
BOX HFP0
routing
HFPINTRO
no entry
BOX HFP1A
routing
[PROBE: Any other condition?]
CHECK UP TO 8 CONDITIONS.
OTHER (SPECIFY)
IF THIS IS ROUND 67 73, GO TO BOX HFR1.
ELSE GO TO HFPINTRO - HLTHCAREINTRO.
Now I want to ask you about some things that [you/(SP)] may be doing to
maintain (your/his/her) health, either by getting tested for health problems or
by taking care of conditions that (you have/she has/he has).
IF (HFJ41A – OCBETES = 1/Yes) AND (HFJ41B - OCDTYPE = 1/TypeOne,
2/TypeTwo, 3/Borderline, 4/PreDiabetes, 91/Other, DK, or RF), GO TO HFP1 DIAAGE.
ELSE GO TO HFP21 - DIAEVERT.
I recorded that [you were/(SP) was] told by a doctor that (you have/she has/he
has) (Type 1 diabetes/Type 2 diabetes/borderline diabetes/prediabetes/diabetes).
DIAAGE
HFP1
numeric
How old [were you/was (SP)] when (you were/he was/she was) first told that
(you/he/she) had diabetes?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) ARTERIES HARDENING
(02) HYPERTENSION
(03) HEART ATTACK
(04) HEART DISEASE
(05) CONGESTIVE HEART FAILURE
(06) HEART VALVE PROBLEM
(07) HEART RHYTHM PROBLEM
(08) OTHER HEART PROBLEM
(09) STROKE OR HEMORRHAGE
(10) SKIN CANCER
(11) CANCER/TUMOR
(12) RHEUMATOID ARTHRITIS
(13) OTHER ARTHRITIS
(14) MENTAL RETARDATION
(15) ALZHEIMER'S
(16) DEMENTIA
(17) DEPRESSION
(18) MENTAL DISORDER
(19) OSTEOPOROSIS
(20) BROKEN HIP
(21) PARKINSON'S
(22) EMPHYSEMA/ASTHMA/COPD
(23) PARALYSIS
(24) LOSS OF LIMB
(25) DIABETES
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
[you have] respondent is SP
[(SP) has] respondent is proxy
[Was this] one condition
[Were any of these] more than one condition
[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
(01) BOX HFJ28
(02) HFJ43 - EMCAUSEVB
(-8) BOX HFP0
(-9) BOX HFP0
BOX HFP0
(01) BOX HFP0
(02) BOX HFP0
(03) BOX HFP0
(04) BOX HFP0
(05) BOX HFP0
(06) BOX HFP0
(07) BOX HFP0
(08) BOX HFP0
(09) BOX HFP0
(10) BOX HFP0
(11) BOX HFP0
(12) BOX HFP0
(13) BOX HFP0
(14) BOX HFP0
(15) BOX HFP0
(16) BOX HFP0
(17) BOX HFP0
(18) BOX HFP0
(19) BOX HFP0
(20) BOX HFP0
(21) BOX HFP0
(22) BOX HFP0
(23) BOX HFP0
(24) BOX HFP0
(25) BOX HFP0
(91) HFJ44 - EMOS
(-8) BOX HFP0
(-9) BOX HFP0
BOX HFP0
(01) CONTINUE
(-7) Empty
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you have] respondent is SP
[she has] respondent is proxy, SP female
[he has] respondent is proxy, SP male
BOX HFP1A
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
[you were] respondent is SP
[(SP) was] respondent is proxy
[you have] respondent is SP
[she has] respondent is proxy, SP female
[he has] respondent is proxy, SP male
[Type I diabetes] type I diabetes recorded
[Type II diabetes] type II diabetes recorded
[borderline diabetes] borderline diabetes recorded
[pre-diabetes] pre-diabetes recorded
[diabetes] diabetes recorded
[were you] respondent is SP
[was (SP)] respondent is proxy
[you were] respondent is SP
[he was] respondent is proxy, SP males
[she was] respondent is proxy, SP female
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
HFP1 - DIAAGE_LESSONE
BOX HFP2
DIAPRGNT
HFP2
routing
yes/no
IF THE SP IS FEMALE AND (HFP1 – DIAAGE is >= 12 and is <= 45) OR (HFP1 –
DIAAGE = DK OR RF), GO TO HFP2 - DIAPRGNT.
ELSE GO TO HFP4 - DIAINSUL.
Did [you/(SP)] have diabetes only during a pregnancy?
Please tell me whether (you use/SP uses) any of the following ways to manage
(your/his/her) diabetes. [Do you/Does (SP)]…
DIAINSUL
HFP4
list
take insulin?
Please tell me whether (you use/SP uses) any of the following ways to manage
(your/his/her) diabetes. [Do you/Does (SP)]…
DIAMEDS
HFP4
list
take prescription diabetes pills or oral diabetes medicine?
Please tell me whether (you use/SP uses) any of the following ways to manage
(your/his/her) diabetes. [Do you/Does (SP)]…
DIATEST
HFP4
list
test (your/his/her) blood for sugar or glucose?
Please tell me whether (you use/SP uses) any of the following ways to manage
(your/his/her) diabetes. [Do you/Does (SP)]…
DIASORES
HFP4
list
check for sores or irritations on (your/his/her) feet?
Please tell me whether (you use/SP uses) any of the following ways to manage
(your/his/her) diabetes. [Do you/Does (SP)]…
DIAPRESS
HFP4
list
measure (your/his/her) blood pressure at home?
Please tell me whether (you use/SP uses) any of the following ways to manage
(your/his/her) diabetes. [Do you/Does (SP)]…
DIAASPRN
HFP4
list
BOX HFP3
routing
take aspirin regularly for (your/his/her) diabetes?
IF HFP4 - DIAINSUL = 1/Yes, GO TO HFP5 - INSUTAKE.
ELSE IF HFP4 - DIAMEDS = 1/Yes, GO TO HFP6 - MEDSTAKE.
ELSE IF HFP4 - DIATEST = 1/Yes, GO TO HFP7 - TESTTAKE.
ELSE IF HFP4 - DIASORES = 1/Yes, GO TO HFP8 - SORECHEK.
ELSE GO TO HFP10 - DIATENYR.
INSUTAKE
HFP5
quantity unit
How often [do you/does (SP)] take insulin?
INSUDAY
HFP5
quantity unit
BOX HFP4
routing
How often [do you/does (SP)] take insulin?
IF HFP4 – DIAMEDS = 1/Yes, GO TO HFP6 - MEDSTAKE.
ELSE IF HFP4 - DIATEST = 1/Yes, GO TO HFP7 - TESTTAKE.
ELSE IF HFP4 - DIASORES = 1/Yes, GO TO HFP8 - SORECHEK.
ELSE GO TO HFP10 - DIATENYR.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) NUMBER OF TIMES PER DAY
(02) NUMBER OF TIMES PER WEEK
(03) USE INSULIN PUMP
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
[you] respondent is SP
[(SP)] respondent is proxy
[you use] respondent is SP
[(SP) uses] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[you use] respondent is SP
[(SP) uses] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[you use] respondent is SP
[(SP) uses] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you use] respondent is SP
[(SP) uses] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you use] respondent is SP
[(SP) uses] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you use] respondent is SP
[(SP) uses] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[do you] respondent is SP
[does (SP)] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
(01) HFP21 - DIAEVERT
(02) HFP4 - DIAINSUL
(-8) HFP21 - DIAEVERT
(-9) HFP21 - DIAEVERT
HFP4 - DIAMEDS
HFP4 - DIATEST
HFP4 - DIASORES
HFP4 - DIAPRESS
HFP4 - DIAASPRN
BOX HFP3
(01) HFP5 - INSUDAY
(02) HFP5 - INSUWEEK
(03) BOX HFP4
(-8) BOX HFP4
(-9) BOX HFP4
BOX HFP4
MEDSTAKE
HFP6
quantity unit
MEDDAY
HFP6
quantity unit
MEDWEEK
HFP6
quantity unit
MEDMONTH
HFP6
quantity unit
BOX HFP5
routing
How often [do you/does (SP)] take prescription diabetes pills or oral diabetes
medicine?
How often [do you/does (SP)] take prescription diabetes pills or oral diabetes
medicine?
How often [do you/does (SP)] take prescription diabetes pills or oral diabetes
medicine?
How often [do you/does (SP)] take prescription diabetes pills or oral diabetes
medicine?
IF HFP4 – DIATEST = 1/Yes, GO TO HFP7 - TESTTAKE.
ELSE IF HFP4 – DIASORES = 1/Yes, GO TO HFP8 - SORECHEK.
ELSE GO TO HFP10 - DIATENYR.
How often [do you/does (SP)] test (your/his/her) blood for sugar or glucose?
TESTTAKE
HFP7
quantity unit
[PROBE: Include times when it is tested by a family member or friend, but do
not include times when it is tested by a health professional.]
(01) NUMBER OF TIMES PER DAY
(02) NUMBER OF TIMES PER WEEK
(03) NUMBER OF TIMES PER MONTH
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) [Continuous answer.]
(01) [Continuous answer.]
(01) NUMBER OF TIMES PER DAY
(02) NUMBER OF TIMES PER WEEK
(03) NUMBER OF TIMES PER MONTH
(04) NUMBER OF TIMES PER YEAR
(-8) Don't Know
(-9) Refused
How often [do you/does (SP)] test (your/his/her) blood for sugar or glucose?
TESTDAY
HFP7
quantity unit
[PROBE: Include times when it is tested by a family member or friend, but do
not include times when it is tested by a health professional.]
(01) [Continuous answer.]
How often [do you/does (SP)] test (your/his/her) blood for sugar or glucose?
TESTWEEK
HFP7
quantity unit
[PROBE: Include times when it is tested by a family member or friend, but do
not include times when it is tested by a health professional.]
(01) [Continuous answer.]
How often [do you/does (SP)] test (your/his/her) blood for sugar or glucose?
TESTMNTH
HFP7
quantity unit
[PROBE: Include times when it is tested by a family member or friend, but do
not include times when it is tested by a health professional.]
(01) [Continuous answer.]
How often [do you/does (SP)] test (your/his/her) blood for sugar or glucose?
TESTYEAR
HFP7
quantity unit
BOX HFP6
routing
[PROBE: Include times when it is tested by a family member or friend, but do
not include times when it is tested by a health professional.]
IF HFP4 – DIASORES = 1/Yes, GO TO HFP8 - SORECHEK.
ELSE GO TO HFP10 - DIATENYR.
How often [do you/does (SP)] check (your/his/her) feet for sores or irritations?
SORECHEK
HFP8
quantity unit
[PROBE: Include times when they are checked by a family member or friend,
but do not include times when they are checked by a health professional.]
(01) [Continuous answer.]
(01) NUMBER OF TIMES PER DAY
(02) NUMBER OF TIMES PER WEEK
(03) NUMBER OF TIMES PER MONTH
(04) NUMBER OF TIMES PER YEAR
(-8) Don't Know
(-9) Refused
How often [do you/does (SP)] check (your/his/her) feet for sores or irritations?
SOREDAY
HFP8
quantity unit
[PROBE: Include times when they are checked by a family member or friend,
but do not include times when they are checked by a health professional.]
(01) [Continuous answer.]
How often [do you/does (SP)] check (your/his/her) feet for sores or irritations?
SOREWEEK
HFP8
quantity unit
[PROBE: Include times when they are checked by a family member or friend,
but do not include times when they are checked by a health professional.]
(01) [Continuous answer.]
How often [do you/does (SP)] check (your/his/her) feet for sores or irritations?
SOREMNTH
HFP8
quantity unit
[PROBE: Include times when they are checked by a family member or friend,
but do not include times when they are checked by a health professional.]
(01) [Continuous answer.]
How often [do you/does (SP)] check (your/his/her) feet for sores or irritations?
HEST.SOREYEAR
DIATENYR
DIADRSAW
HFP8
HFP10
HFP11
quantity unit
[PROBE: Include times when they are checked by a family member or friend,
but do not include times when they are checked by a health professional.]
yes/no
In the past year has a doctor or other medical professional examined
(your/his/her) feet for sores or irritations?
(01) [Continuous answer.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
About how many times in the past year [have you/has (SP)] seen a doctor or
other health professional for (your/his/her) diabetes?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
numeric
[do you] respondent is SP
[does (SP)] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[do you] respondent is SP
[does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[do you] respondent is SP
[does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[do you] respondent is SP
[does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[do you] respondent is SP
[does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[do you] respondent is SP
[does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[do you] respondent is SP
[does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[do you] respondent is SP
[does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[do you] respondent is SP
[does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[do you] respondent is SP
[does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[have you] respondent is SP
[has (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
(01) HFP6 - MEDDAY
(02) HFP6 - MEDWEEK
(03) ) HFP6 - MEDMONTH
(-8) BOX HFP5
(-9) BOX HFP5
BOX HFP5
BOX HFP5
BOX HFP5
(01) HFP7 - TESTDAY
(02) HFP7 - TESTWEEK
(03) HFP7 - TESTMNTH
(04) HFP7 - TESTYEAR
(-8) BOX HFP6
(-9) BOX HFP6
BOX HFP6
BOX HFP6
BOX HFP6
BOX HFP6
(01) HFP8 - SOREDAY
(02) HFP8 - SOREWEEK
(03) HFP8 - SOREMNTH
(04) HFP8 - SOREYEAR
(-8) HFP10 - DIATENYR
(-9) HFP10 - DIATENYR
HFP10 - DIATENYR
HFP10 - DIATENYR
HFP10 - DIATENYR
HFP10 - DIATENYR
HFP11 - DIADRSAW
HFP13 - DIAHEMOC
DIAHEMOC
HFP13
numeric
DIACTRLD
HFP14
code 1
DIAHYPO
HFP14A1
yes/no
A test of hemoglobin "A one C" measures the average level of blood sugar over
the past three months. It is usually done in a doctor's office. About how many
times in the past year has a doctor or other health professional checked
[you/(SP)] for hemoglobin "A one C"?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) ALL OF THE TIME
(02) MOST OF THE TIME
SHOW CARD HF4 HF5
(03) SOME OF THE TIME
Would you say that [your/(SP's)] blood sugar is well controlled all of the time,
(04) A LITTLE OF THE TIME
most of the time, some of the time, a little of the time, or none of the time? By (05) NONE OF THE TIME
"well controlled" we mean a recent hemoglobin "A one C" result of 7.5 or less or (-8) Don't Know
an average fasting blood test of 140 or less.
(-9) Refused
(01) YES
(02) NO
In the past year, [have you/has (SP)] experienced hypoglycemia, sometimes
(-8) Don't Know
called low blood sugar or an insulin reaction?
(-9) Refused
Please think about the most serious episode of hypoglycemia that [you
have/(SP)has] experienced in the past year.
[Were you/Was (SP)] able to treat (yourself/himself/herself) by taking some
form of sugar, did (you/he/she) require treatment from others, or did
(you/he/she) require treatment by a hospital?
DIAHYPTR
DIAFTEVR
DIAFEET
HFP14A2
HFP14A3
HFP14A
(01) SELF TREATMENT
(02) TREATMENT FROM OTHERS
(03) HOSPITAL TREATMENT
(-8) Don't Know
(-9) Refused
code 1
[EXPLAIN IF NECESSARY: Treatment by a hospital includes being treated in the
emergency room or outpatient department of a hospital, or being admitted as
an inpatient.]
yes/no
(01) YES
(02) NO
[Have you/Has (SP)] ever had any problems with (your/his/her) feet as a result of (-8) Don't Know
(your/his/her) diabetes?
(-9) Refused
yes/no
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Do you/Does (SP)] currently have any problems with (your/his/her) feet as a
result of (your/his/her) diabetes?
People with diabetes can develop many different foot problems. Please tell me if
[you have/(SP) has] ever been told by a doctor that (you/he/she) had any of the
following problems with (your/his/her) feet as a result of (your/his/her)
diabetes.
[Have you/Has (SP)] ever been told by a doctor that (you/he/she) had…
DIANEURO
HFP14B
list
Neuropathy or nerve damage , which may cause pain or numbness in the feet?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
People with diabetes can develop many different foot problems. Please tell me if
[you have/(SP) has] ever been told by a doctor that (you/he/she) had any of the
following problems with (your/his/her) feet as a result of (your/his/her)
diabetes.
[Have you/Has (SP)] ever been told by a doctor that (you/he/she) had…
DIACIRCF
HFP14B
list
Poor circulation or blood flow in the feet?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[have you] respondent is SP
[has (SP)] respondent is proxy
[you have] respondent is SP
[(SP) has] respondent is proxy
[Were you] respondent is SP
[Was (SP)] respondent is proxy
[yourself] respondent is SP
[himself] respondent is proxy, SP male
[herself] respondent is proxy, SP female
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[have you] respondent is SP
[has (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you have] respondent is SP
[(SP) has] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you have] respondent is SP
[(SP) has] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
HFP14 - DIACTRLD
HFP14A1 - DIAHYPO
(01) HFP14A2 - DIAHYPTR
(02) HFP14A - DIAFEET
(-8) HFP14A - DIAFEET
(-9) HFP14A - DIAFEET
HFP14A3 - DIAFTEVR
(01) HFP14A - DIAFEET
(02) HFP15 - DIAEYPRB
(-8) HFP15 - DIAEYPRB
(-9) HFP15 - DIAEYPRB
HFP14B - DIANEURO
HFP14B - DIACIRCF
HFP14B - DIAULCER
People with diabetes can develop many different foot problems. Please tell me if
[you have/(SP) has] ever been told by a doctor that (you/he/she) had any of the
following problems with (your/his/her) feet as a result of (your/his/her)
diabetes.
[Have you/Has (SP)] ever been told by a doctor that (you/he/she) had…
DIAULCER
HFP14B
list
Foot ulcers?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
People with diabetes can develop many different foot problems. Please tell me if
[you have/(SP) has] ever been told by a doctor that (you/he/she) had any of the
following problems with (your/his/her) feet as a result of (your/his/her)
diabetes.
Calluses, infections, or other skin changes affecting the feet?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Do you/Does (SP)] have any problems with (your/his/her) eyes as a result of
(your/his/her) diabetes?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Have you/Has (SP)] ever been told by a doctor that (you/he/she) had…
DIASKINC
DIAEYPRB
HFP14B
HFP15
list
yes/no
[Have you/Has (SP)] ever had any problems with (your/his/her) kidneys as a
result of (your/his/her) diabetes?
DIAKDPEV
DIAKDPRB
DIAKIDNY
DIAMNGE
DIATRAIN
HFP16A1
HFP16
HFP16A
HFP17
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
yes/no
[EXPLAIN IF NECESSARY: This is tested by looking for protein in the urine.]
yes/no
(01) YES
(02) NO
[Do you/Does (SP)] currently have any problems with (your/his/her) kidneys as a (-8) Don't Know
result of (your/his/her) diabetes?
(-9) Refused
yes/no
[Have you/Has (SP)] ever been told by a doctor that (you have/she has/he has)
chronic kidney disease?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Have you/Has (SP)] ever participated in a diabetes self-management course or
class, or received special training on how (you/he/she) can manage
(your/his/her) diabetes?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
yes/no
HFP18
code 1
BOX HFP7
routing
When was the most recent time that [you/(SP)] participated in a diabetes selfmanagement course or class or received special training on how (you/he/she)
can manage (your/his/her) diabetes?
[IF THE RESPONDENT HAS GONE TO MORE THAN ONE COURSE OR TRAINING,
PROBE FOR THE MOST RECENT TIME.]
IF THE SP IS THE RESPONDENT, GO TO HFP19 - DIAKNOW.
ELSE GO TO BOX HFR1.
(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS AGO
(03) 2 YEARS TO LESS THAN 3 YEARS AGO
(04) 3 YEARS TO LESS THAN 5 YEARS AGO
(05) 5 OR MORE YEARS AGO
(-8) Don't Know
(-9) Refused
[you have] respondent is SP
[(SP) has] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you have] respondent is SP
[(SP) has] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[you have] respondent is SP
[she has] respondent is proxy, SP female
[he has] respondent is proxy, SP male
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[your] respondent is SP
[his] resppndent is proxy, SP male
[her] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[your] respondent is SP
[his] resppndent is proxy, SP male
[her] respondent is proxy, SP female
HFP14B - DIASKINC
HFP15 - DIAEYPRB
HFP16A1 - DIAKDPEV
(01) HFP16 - DIAKDPRB
(02) HFP17 - DIAMNGE
(-8) HFP17 - DIAMNGE
(-9) HFP17 - DIAMNGE
(01) HFP16A - DIAKIDNY
(02) HFP17 - DIAMNGE
(-8) HFP17 - DIAMNGE
(-9) HFP17 - DIAMNGE
HFP17 - DIAMNGE
(01) HFP18 - DIATRAIN
(02) BOX HFP7
(-8) BOX HFP7
(-9) BOX HFP7
BOX HFP7
DIAKNOW
HFP19
code 1
DIASUPPS
HFP20
yes/no
(01) just about everything you need to know,
(02) most of what you need to know,
(03) some of what you need to know,
(04) a little of what you need to know, or
(05) almost none of what you need to know about
SHOW CARD HF3 HF6
managing your diabetes?
How much do you think you know about managing your diabetes? Do you know (-8) Don't Know
...
(-9) Refused
(01) YES
(02) NO
Before today, did you know that Medicare now helps pay the cost of diabetic
(-8) Don't Know
testing supplies and self-management education for people with diabetes?
(-9) Refused
[I have recorded that [you have/(SP) has] never been told by a doctor that (you
have/she has/he has) diabetes.]
DIAEVERT
DIARECNT
DIAAWARE
HFP21
yes/no
[Have you/Has (SP)] ever had a blood test to see if (you have/she has/he has)
diabetes?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS AGO
(03) 2 YEARS TO LESS THAN 3 YEARS AGO
(04) 3 YEARS TO LESS THAN 5 YEARS AGO
(05) 5 OR MORE YEARS AGO
(-8) Don't Know
(-9) Refused
HFP22
code 1
BOX HFP8
routing
When was the most recent time [you were/(SP) was] tested for diabetes?
IF THE SP IS THE RESPONDENT, GO TO HFP23 - DIAAWARE.
ELSE GO TO HFP24 - DIARISK.
yes/no
(01) YES
(02) NO
Before today, were you aware that there is a blood test to determine if a person (-8) Don't Know
has diabetes?
(-9) Refused
HFP23
DIARISK
HFP24
yes/no
Has a doctor or other health professional ever told [you/(SP)] that (you are/he
is/she is) at high risk for diabetes?
DIASIGNS
HFP25
yes/no
In the past year, [have you/has (SP)] received any information about the signs,
symptoms, or risk factors for diabetes?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
COLHTEST
HFR3
yes/no
COLHKIT
HFR4
yes/no
COLFDOC
HFR4A
yes/no
IF (SP HAS EVER HEARD ABOUT COLORECTAL OR COLON CANCER IS UNKNOWN)
AND (SP HAS NOT REPORTED HAVING COLON, RECTAL OR BOWEL CANCER IN
THE CURRENT ROUND OR IN A PREVIOUS ROUND), GO TO HFR1 - COLHEAR.
ELSE GO TO BOX HFS0.
Now I'd like to talk about a different illness, colorectal or colon cancer, a disease (01) YES
of the lower intestines.
(02) NO
(-8) Don't Know
Before today, had you ever heard of colorectal or colon cancer?
(-9) Refused
The fecal occult blood test is a simple test for early signs of colon cancer. It
detects invisible traces of blood found in the stool. The doctor or other health
professional can give the patient a kit to collect stool samples at the patient’s
home. The test is then sent to a laboratory for the results to be determined.
(01) YES
(02) NO
Has a doctor or other health professional ever given [you/(SP)] a home testing
(-8) Don't Know
kit to test for blood in the stool?
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
Have you ever heard of this home testing kit?
(-9) Refused
(01) YES
Has a doctor or other health professional ever performed a fecal occult blood
(02) NO
test to test for blood in the stool while [you/(SP)] [were/was] at the doctor’s
(-8) Don't Know
office?
(-9) Refused
yes/no
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
COLHEAR
COLCARD
BOX HFR1
routing
HFR1
yes/no
HFR5
Did [you/(SP)] complete the samples and return them for (your/his/her) most
recent test?
HFP20 - DIASUPPS
BOX HFR1
[I have recorded that [you have/(SP) has] never been told
by a doctor that (you have/she has/he has) diabetes.]
OCBETES = 02
[you have] respondent is SP
[(SP) has] respondent is proxy
[you have] respondent is SP
[she has] respondent is proxy, SP female
[he has] respondent is proxy, SP male
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[you have] respondent is SP
[she has] respondent is proxy, SP female
[he has] respondent is proxy, SP male
(01) HFP22 - DIARECNT
(02) BOX HFP8
(-8) BOX HFP8
(-9) BOX HFP8
[you were] respondent is SP
[(SP) was] respondent is proxy
HFP24 - DIARISK
HFP24 - DIARISK
[you] respondent is SP
[(SP)] respondent is proxy
[you are] respondent is SP
[he is] respondent is proxy, SP male
[she is] respondent is proxy, SP female
HFP25 - DIASIGNS
[have you] respondent is SP
[has (SP)] respondent is proxy
BOX HFR1
HFR3 - COLHTEST
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
(01) HFR5 - COLCARD
(02) HFR4 - COLHKIT
(-8) HFR4 - COLHKIT
(-9) HFR4 - COLHKIT
HFR4A - COLFDOC
(01) HFR7 - COLRECNT
(02) HFR8 - COLSCOPY
(-8) HFR8 - COLSCOPY
(-9) HFR8 - COLSCOPY
HFR7 - COLRECNT
COLRECNT
COLSCOPY
HFR7
HFR8
code 1
yes/no
WHENSCOP
HFR9
code 1
HEARSCOP
HFR10
yes/no
BOX HFR2
routing
COLDRREC
HFR11
yes/no
COLSCRNS
HFR13
yes/no
BOX HFS0
routing
BOX HFS1
routing
HFSINTRO
no entry
OSTINTRO
OSTEVERT
OSTHRISK
HFS1
HFS2
yes/no
yes/no
(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS AGO
(03) 2 YEARS TO LESS THAN 3 YEARS AGO
(04) 3 YEARS TO LESS THAN 5 YEARS AGO
(05) 5 OR MORE YEARS AGO
(-8) Don't Know
(-9) Refused
When did [you/(SP)] have (your/his/her) most recent blood stool test( using a
home testing kit)?
Another test for early signs of colon cancer is performed in the doctor's office.
The doctor uses a flexible lighted tube to examine the colon and rectum directly. (01) YES
This is called a sigmoidoscopy or colonoscopy.
(02) NO
(-8) Don't Know
[Have you/Has (SP)] ever had this exam?
(-9) Refused
(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS AGO
(03) 2 YEARS TO LESS THAN 3 YEARS AGO
(04) 3 YEARS TO LESS THAN 5 YEARS AGO
(05) 5 OR MORE YEARS AGO
When did [you/(SP)] have (your/his/her) most recent sigmoidoscopy or
(-8) Don't Know
colonoscopy?
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
Before today, had you ever heard of a sigmoidoscopy or colonoscopy?
(-9) Refused
IF HFR3 - COLHTEST = 1/Yes or HFR4 - COLHKIT = 1/Yes, GO TO HFR13 COLSCRNS.
ELSE GO TO BOX HFS0.
(01) YES
(02) NO
(-8) Don't Know
Has a doctor ever recommended that [you/(SP)] have this test?
(-9) Refused
(01) YES
(02) NO
Before today, did you know that Medicare now pays the cost of screening tests (-8) Don't Know
for colorectal cancer?
(-9) Refused
IF THIS IS ROUND 67 73, GO TO HFAC29 - HCTROUBL.
ELSE GO TO BOX HFS1.
IF SP HAS EVER REPORTED HAVING OSTEPOPORIS IN THE CURRENT ROUND OR
IN A PREVIOUS ROUND, GO TO HFS3 - OSTTEST.
ELSE GO TO HFSINTRO - OSTINTRO
Now I'd like to talk about a disease called osteoporosis, which can be treated if
found early. In osteoporosis, the bones lose their calcium and become fragile
(01) CONTINUE
and more easily broken.
(-7) Empty
[Have you/Has (SP)] ever talked with (your/his/her) doctor or other health
professional about osteoporosis?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Has a doctor or other health professional ever told [you/(SP)] that (you are/he
is/she is) at high risk for osteoporosis?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Have [you/(SP)] ever experienced a fracture that (your/his/her) doctor told
(you/him/her) was related to osteoporosis?
There is a test to detect osteoporosis at an early stage, called Bone Mass
Measurement or Bone Density Measurement, or DEXA scan.
OSTFRACT
HFS2A
yes/no
OSTTEST
HFS3
yes/no
[Have you/Has (SP)] ever had a Bone Mass or Bone Density Measurement test?
OSTHEAR
HFS4
yes/no
Before today, had you ever heard of this test?
OSTRECNT
HFS5
code 1
When was the most recent time that [you/(SP)] had a Bone Mass or Bone
Density Measurement test?
yes/no
Before today, did you know that Medicare would pay for Bone Mass or Bone
Density Measurement tests for Medicare beneficiaries who are at risk for
osteoporosis?
OSTMASS
HFS6
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS AGO
(03) 2 YEARS TO LESS THAN 3 YEARS AGO
(04) 3 YEARS TO LESS THAN 5 YEARS AGO
(05) 5 OR MORE YEARS AGO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
HFR8 - COLSCOPY
HFR10 - HEARSCOP
(01) YES--> WHENSCOP
(02) NO--> HEARSCOP
(8) Don't Know->HEARSCOP
(9) Refused->HEARSCOP
HFR13 - COLSCRNS
(01) HFR11 - COLDRREC
(02) BOX HFR2
(-8) BOX HFR2
(-9) BOX HFR2
HFR13 - COLSCRNS
BOX HFS0
HFS1 - OSTEVERT
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[you are] respondent is SP
[he is] respondent is proxy, SP male
[she is] respondent is proxy, SP female
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
(01) HFS2 - OSTHRISK
(02) HFS3 - OSTTEST
(-8) HFS3 - OSTTEST
(-9) HFS3 - OSTTEST
HFS2A - OSTFRACT
HFS3 - OSTTEST
(01) HFS5 - OSTRECNT
(02) HFS4 - OSTHEAR
(-8) HFS4 - OSTHEAR
(-9) HFS4 - OSTHEAR
(01) HFS6 - OSTMASS
(02) HFAC29 - HCTROUBL
(-8) HFAC29 - HCTROUBL
(-9) HFAC29 - HCTROUBL
HFS6 - OSTMASS
HFAC29 - HCTROUBL
Next, we are going to ask some questions about [your/(SP's)] health care needs
during the past year.
HCTROUBL
HFAC29
yes/no
Since (LAST HF MONTH YEAR), [have you/has (SP)] had any trouble getting
health care that (you/he/she) wanted or needed?
Why was that?
HCTCODE
HCTOTHOS
CGETAPPT
CGETCODE
HFAC30A
HFAC30A
code all
verbatim text
BOX HFF6
routing
HFAC30B
yes/no
HFAC30C
code all
BOX HFF7
routing
OFFEXPLN
HFAC30D
yes/no
OFFEXVB
HFAC30E
verbatim text
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.
OTHER (SPECIFY)
IF RESPONSE TO HFAC30A - HCTCODE INCLUDES 8/DrDoesNotAcceptMedicare
OR 10/DifficultyGettingAppt, GO TO HFAC30D - OFFEXPLN.
ELSE GO TO HFAC30B - CGETAPPT.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) SP DOES NOT HAVE MONEY
(02) COST IS TOO HIGH
(03) SERVICES/SUPPLIES NOT COVERED
(04) NEEDED TRANSPORTATION TO DOCTOR/HOSPITAL
(05) DIFFICULTY GETTING HOME HEALTH CARE
(06) NO TREATMENT AVAILABLE/DOCTOR WON’T
TREAT
(07) WAIT TOO LONG/DOCTOR TOO BUSY
(08) OWN DOCTOR DOESN’T ACCEPT
MEDICARE/COULDN’T FIND DOCTOR WHO ACCEPTS
MEDICARE
(09) NOT ELIGIBLE FOR PUBLIC COVERAGE
(10) DIFFICULTY GETTING APPOINTMENT/ DELAYS
BECAUSE SP ON MEDICARE
(11) DOCTOR REFERRED SP TO SPECIALIST OR OTHER
DOCTOR
(12) HMO REFERRAL PROCESS (DIFFICULTY GETTING)
(13) PROBLEMS WITH HMO DOCTORS NOT GOOD OR
AVAILABLE
(14) HMO WOULD NOT COVER OR PROVIDE SERVICE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), [have you/has (SP)] been told by a doctor’s office (-8) Don't Know
that they cannot schedule an appointment with [you/(SP)]?
(-9) Refused
(01) DOCTOR DOES NOT ACCEPT INSURANCE PLAN
(02) ALL OF DOCTORS APPOINTMENTS WERE FULL
(03) DOCTOR IS NOT ACCEPTING ANY NEW PATIENTS
(04) DOCTOR IS NOT ACCEPTING NEW MEDICARE
PATIENTS
(05) DOCTRS HOURS CONFLICTED WITH
REQUIREMENTS OF SP
(06) DOCTOR DOES NOT ACCEPT MEDICAID
(07) DOCTOR DOES NOT ACCEPT MEDICARE AT ALL
(08) DOCTOR DOES NOT ACCEPT MEDICARE
ASSIGNMENT
What were the reasons the doctor’s office offered as an explanation for not
(09) DOCTOR FELT ANOTHER PROVIDER WOULD BE
scheduling an appointment with [you/(SP)]?
BETTER FOR SP
(91) OTHER
[PROBE: Any other reason?]
(-8) Don't Know
CHECK ALL THAT APPLY
(-9) Refused
IF RESPONSE TO HFAC30C - CGETCODE INCLUDES
4/DocNotAcceptNewMedicare OR 7/DocNotAcceptMCAR, GO TO HFAC30D OFFEXPLN.
ELSE GO TO HFAC31 - HCDELAY.
(01) YES
(02) NO
Did the doctor’s office explain why [it is difficult for Medicare patients to get an (-8) Don't Know
appointment/Medicare is not accepted] at that practice?
(-9) Refused
What was that explanation?
RECORD VERBATIM.
(01) [Continuous answer.]
HCDELAY
HFAC31
yes/no
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), [have you/has (SP)] delayed seeking medical care (-8) Don't Know
because (you were/he was/she was) worried about the cost?
(-9) Refused
IADLINTRO
HFKINTRO
no entry
Now I'm going to ask about some everyday activities and whether [you
have/(SP) has] any difficulty doing them by (yourself/himself/herself).
PRBTELE
HFKA1
code 1
[your] respondent is SP
[(SP's)] respondent is proxy
[have you] respondent is SP
[has (SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
(01) CONTINUE
(-7) Empty
(01) YES
(02) NO
Because of a health or physical problem, [do you/does (SP)] have any difficulty... (03) DOESN'T DO
(-8) Don't Know
using the telephone?
(-9) Refused
(01) HFAC30A - HCTCODE
(02) HFAC31 - HCDELAY
(-8) HFAC31 - HCDELAY
(-9) HFAC31 - HCDELAY
(01) BOX HFF6
(02) BOX HFF6
(03) BOX HFF6
(04) BOX HFF6
(05) BOX HFF6
(06) BOX HFF6
(07) BOX HFF6
(08) BOX HFF6
(09) BOX HFF6
(10) BOX HFF6
(11) BOX HFF6
(12) BOX HFF6
(13) BOX HFF6
(14) BOX HFF6
(91) HFAC30A - HCTOTHOS
(-8) BOX HFF6
(-9) BOX HFF6
BOX HFF6
[have you] respondent is SP
[has (SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
(01) HFAC30C - CGETCODE
(02) HFAC31 - HCDELAY
(-8) HFAC31 - HCDELAY
(-9) HFAC31 - HCDELAY
[you] respondent is SP
[(SP)] respondent is proxy
(01) BOX HFF7
(02) BOX HFF7
(03) BOX HFF7
(04) BOX HFF7
(05) BOX HFF7
(06) BOX HFF7
(07) BOX HFF7
(08) BOX HFF7
(09) BOX HFF7
(91) HFAC30C - CGETOTOS
(-8) BOX HFF7
(-9) BOX HFF7
[it is difficult for Medicare patients to get an appointment]
Medicare accepted
[Medicare is not accepted] Medicare not accepted
(01) HFAC30E - OFFEXVB
(02) HFAC31 - HCDELAY
(-8) HFAC31 - HCDELAY
(-9) HFAC31 - HCDELAY
HFAC31 - HCDELAY
[have you] respondent is SP
[has (SP)] respondent is proxy
[you were] respondent is SP
[he was] respondent is proxy, SP male
[she was] respondent is proxy, SP female
[you have] respondent is SP
[(SP) has] respondent is proxy
[yourself] respondent is SP
[himself] respondent is proxy, SP male
[herself] respondent is proxy, SP female
[do you] respondent is SP
[does (SP)] respondent is proxy
HFKINTRO - IADLINTRO
HFKA1 - PRBTELE
(01) HFKB1 - PRBLHWK
(02) HFKB1 - PRBLHWK
(03) HFKA2 - DONTTELE
(-8) HFKB1 - PRBLHWK
(-9) HFKB1 - PRBLHWK
[You said that using the telephone is something that [you don't/(SP) doesn't]
do.]
DONTTELE
HFKA2
yes/no
PRBLHWK
HFKB1
code 1
DONTLHWK
HFKB2
yes/no
PRBHHWK
HFKC1
code 1
DONTHHWK
HFKC2
yes/no
PRBMEAL
HFKD1
code 1
(01) YES
(02) NO
(-8) Don't Know
Is this because of a health or physical problem?
(-9) Refused
(01) YES
(02) NO
Because of a health or physical problem, [do you/does (SP)] have any difficulty... (03) DOESN'T DO
(-8) Don't Know
doing light housework (like washing dishes, straightening up, or light cleaning)? (-9) Refused
[You said that doing light housework (like washing dishes, straightening up, or
(01) YES
light cleaning) is something that [you don't/(SP) doesn't] do.]
(02) NO
(-8) Don't Know
Is this because of a health or physical problem?
(-9) Refused
(01) YES
(02) NO
Because of a health or physical problem, [do you/does (SP)] have any difficulty... (03) DOESN'T DO
(-8) Don't Know
doing heavy housework (like scrubbing floors or washing windows)?
(-9) Refused
[You said that doing heavy housework (like scrubbing floors or washing
(01) YES
windows) is something that [you don't/(SP) doesn't] do.]
(02) NO
(-8) Don't Know
Is this because of a health or physical problem?
(-9) Refused
(01) YES
(02) NO
Because of a health or physical problem, [do you/does (SP)] have any difficulty... (03) DOESN'T DO
(-8) Don't Know
preparing (your/his/her) own meals?
(-9) Refused
[You said that preparing (your/his/her) own meals is something that [you
don't/(SP) doesn't] do.]
DONTMEAL
PRBSHOP
HFKD2
HFKE1
yes/no
code 1
DONTSHOP
HFKE2
yes/no
PRBBILS
HFKF1
code 1
DONTBILS
HFKF2
yes/no
BOX HFKA1
routing
(01) YES
(02) NO
(-8) Don't Know
Is this because of a health or physical problem?
(-9) Refused
(01) YES
(02) NO
Because of a health or physical problem, [do you/does (SP)] have any difficulty... (03) DOESN'T DO
(-8) Don't Know
shopping for personal items (such as toilet items or medicines)?
(-9) Refused
[You said that shopping for personal items (such as toilet items or medicines) is (01) YES
something that [you don't/(SP) doesn't] do.]
(02) NO
(-8) Don't Know
Is this because of a health or physical problem?
(-9) Refused
(01) YES
(02) NO
Because of a health or physical problem, [do you/does (SP)] have any difficulty... (03) DOESN'T DO
(-8) Don't Know
managing money (like keeping track of expenses or paying bills)?
(-9) Refused
[You said that managing money (like keeping track of expenses or paying bills) is (01) YES
something that [you don't/(SP) doesn't] do.]
(02) NO
(-8) Don't Know
Is this because of a health or physical problem?
(-9) Refused
IF HFKA1 - PRBTELE = 1/Yes OR HFKA2 – DONTTELE = 1/Yes, GO TO HFKA3 HELPTELE.
ELSE GO TO BOX HFKB1.
HELPTELE
HFKA3
yes/no
PERSON_HLPRTELE
HFKA4
roster
BOX HFKB1
routing
using the telephone?
You mentioned that [you receive/(SP) receives] help with using the telephone.
Who gives that help?
ENTER ALL HELPERS.
IF HFKB1 - PRBLHWK = 1/Yes or HFKB2 - DONTLHWK = 1/Yes, GO TO HFKB3 HELPLHWK.
ELSE GO TO BOX HFKC1.
[do you] respondent is SP
[does (SP)] respondent is proxy
[you don't] respondent is SP
[(SP) doesn't] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
[you don't] respondent is SP
[(SP) doesn't] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you don't] respondent is SP
[(SP) doesn't] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
[you don't] respondent is SP
[(SP) doesn't] respondent is proxy
HFKB1 - PRBLHWK
(01) HFKC1 - PRBHHWK
(02) HFKC1 - PRBHHWK
(03) HFKB2 - DONTLHWK
(-8) HFKC1 - PRBHHWK
(-9) HFKC1 - PRBHHWK
HFKC1 - PRBHHWK
(01) HFKD1 - PRBMEAL
(02) HFKD1 - PRBMEAL
(03) HFKC2 - DONTHHWK
(-8) HFKD1 - PRBMEAL
(-9) HFKD1 - PRBMEAL
HFKD1 - PRBMEAL
(01) HFKE1 - PRBSHOP
(02) HFKE1 - PRBSHOP
(03) HFKD2 - DONTMEAL
(-8) HFKE1 - PRBSHOP
(-9) HFKE1 - PRBSHOP
HFKE1 - PRBSHOP
(01) HFKF1 - PRBBILS
(02) HFKF1 - PRBBILS
(03) HFKE2 - DONTSHOP
(-8) HFKF1 - PRBBILS
(-9) HFKF1 - PRBBILS
[do you] respondent is SP
[does (SP)] respondent is proxy
HFKF1 - PRBBILS
(01) BOX HFKA1
(02) BOX HFKA1
(03) HFKF2 - DONTBILS
(-8) BOX HFKA1
(-9) BOX HFKA1
[you don't] respondent is SP
[(SP) doesn't] respondent is proxy
BOX HFKA1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[You said that [your] health makes using the telephone
difficult] respondent is SP, SP uses telephone
[You said that [(SP's)] health makes using the telephone
difficult] respondent is proxy, SP uses telephone
[You said that using the telephone is something that [you
don't do]] respondent is SP, SP doesn't use telephone
[You said that using the telephone is something that [(SP)
doesn't do]] respondent is proxy, SP doesn't use telephone
[Do you] respondent is SP
[Does (SP)] respondent is proxy
(01) HFKA4 - PERSON_HLPRTELE
(02) BOX HFKB1
(-8) BOX HFKB1
(-9) BOX HFKB1
(01) [Continuous answer.]
[you receive] respondent is SP
[(SP) receives] respondent is proxy
BOX HFKB1
[[You said that [your/(SP's)] health makes using the telephone difficult./You said
that using the telephone is something that [you don't do/(SP) doesn't do].]]
[Do you/Does (SP)] receive help from another person with...
[you don't] respondent is SP
[(SP) doesn't] respondent is proxy
[[You said that [your/(SP's)] health makes doing light housework (like washing
dishes, straightening up, or light cleaning) difficult./You said that doing light
housework (like washing dishes, straightening up, or light cleaning) is something
that [you don't do/(SP) doesn't do].]]
[Do you/Does (SP)] receive help from another person with...
HELPLHWK
HFKB3
yes/no
PERSON_HLPRLHWK
HFKB4
roster
BOX HFKC1
routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
doing light housework (like washing dishes, straightening up, or light cleaning)?
You mentioned that [you receive/(SP) receives] help with doing light housework
(like washing dishes, straightening up, or light cleaning). Who gives that help? (01) [Continuous answer.]
IF HFKC1 - PRBHHWK = 1/Yes or HFKC2 - DONTHHWK = 1/Yes, GO TO HFKC3 HELPHHWK.
ELSE GO TO BOX HFKD1
HELPHHWK
PERSON_HLPRHHWK
HFKC3
yes/no
HFKC4
roster
BOX HFKD1
routing
doing heavy housework (like scrubbing floors or washing windows)?
You mentioned that [you receive/(SP) receives] help with doing heavy
housework (like scrubbing floors or washing windows). Who gives that help?
ENTER ALL HELPERS.
IF HFKD1 – PRBMEAL = 1/Yes or HFKD2 – DONTMEAL = 1/Yes, GO TO HFKD3 HELPMEAL.
ELSE GO TO BOX HFKE1.
HELPMEAL
PERSON_HLPRMEAL
HFKD3
yes/no
HFKD4
roster
BOX HFKE1
routing
preparing (your/his/her) own meals?
You mentioned that [you receive/(SP) receives] help with preparing
(your/his/her) own meals. Who gives that help?
ENTER ALL HELPERS.
IF HFKE1 – PRBSHOP = 1/Yes or HFKE2 – DONTSHOP = 1/Yes, GO TO HFKE3 HELPSHOP.
ELSE GO TO BOX HFKF1.
(01) HFKC4 - PERSON_HLPRHHWK
(02) BOX HFKD1
(-8) BOX HFKD1
(-9) BOX HFKD1
(01) [Continuous answer.]
[you receive] respondent is SP
[(SP) receives] respondent is proxy
BOX HFKD1
(01) [Continuous answer.]
[You said that [your] health makes preparing [your] own meals
difficult] respondent is SP, SP makes meals
[You said that [(SP's)] health makes preparing [his] own meals
difficult] respondent is proxy, SP male,SP makes meals
[You said that [(SP's)] health makes preparing [her] own meals
difficult] respondent is proxy, SP female, SP makes meals
[You said that preparing [your] own meals is something that
[you don't do]] respondent is SP, SP doesn't make meals
[You said that preparing [his] own meals is something that
[(SP) doesn't do] respondent is proxy, SP male, SP doesn't
make meals
[You said that preparing [her] own meals is something that
[(SP) doesn't do] respondent is proxy, SP female, SP doesn't
make meals
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you receive] respondent is SP
[(SP) receives] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[You said that [your] health makes shopping for personal
items (such as toilet items or medicines) difficult.] respondent
is SP, SP shops
[You said that [(SP's)] health makes shopping for personal
items (such as toilet items or medicines) difficult.] respondent
is proxy, SP shops
[You said that shopping for personal items (such as toilet
items or medicines) is something that [you don't do]]
respondent is SP, SP doesn't shop
[You said that shopping for personal items (such as toilet
items or medicines) is something that [(SP) doesn't do]]
respondent is proxy, SP doesn't do shop
[Do you] respondent is SP
[Does (SP)] respondent is proxy
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[[You said that [your/(SP's)] health makes shopping for personal items (such as
toilet items or medicines) difficult./You said that shopping for personal items
(such as toilet items or medicines) is something that [you don't do/(SP) doesn't
do].]]
[Do you/Does (SP)] receive help from another person with...
HELPSHOP
HFKE3
yes/no
shopping for personal items (such as toilet items or medicines)?
BOX HFKC1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[[You said that [your/(SP's)] health makes preparing (your/his/her) own meals
difficult./You said that preparing (your/his/her) own meals is something that
[you don't do/(SP) doesn't do].]]
[Do you/Does (SP)] receive help from another person with...
(01) HFKB4 - PERSON_HLPRLHWK
(02) BOX HFKC1
(-8) BOX HFKC1
(-9) BOX HFKC1
[You said that [your] health makes doing heavy housework
(like scrubbing floors or washing windows) difficult]
respondent is SP, SP does housework
[You said that [(SP's)] health makes doing heavy housework
(like scrubbing floors or washing windows) difficult]
respondent is proxy, SP does housework
[You said that doing heavy housework (like scrubbing floors or
washing windows) is something that [you don't do]]
respondent is SP, SP doesn't do housework
[You said that doing heavy housework (like scrubbing floors or
washing windows) is something that [(SP) doesn't do]]
respondent is proxy, SP doesn't do housework
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[[You said that [your/(SP's)] health makes doing heavy housework (like scrubbing
floors or washing windows) difficult./You said that heavy housework (like
scrubbing floors or washing windows) is something that [you don't do/(SP)
doesn't do].]]
[Do you/Does (SP)] receive help from another person with...
[You said that [your] health makes doing light housework (like
washing dishes, straightening up, or light cleaning) difficult]
respondent is SP, SP does housework
[You said that [(SP's)] health makes doing light housework (like
washing dishes, straightening up, or light cleaning) difficult]
respondent is proxy, SP does housework
[You said that doing light housework (like washing dishes,
straightening up, or light cleaning) is something that [you
don't do]] respondent is SP, SP doesn't do housework
[You said that doing light housework (like washing dishes,
straightening up, or light cleaning)is something that [(SP)
doesn't do]] respondent is proxy, SP doesn't do housework
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[you receive] respondent is SP
[(SP) receives] respondent is proxy
(01) HFKD4 - PERSON_HLPRMEAL
(02) BOX HFKE1
(-8) BOX HFKE1
(-9) BOX HFKE1
BOX HFKE1
(01) HFKE4 - PERSON_HLPRSHOP
(02) BOX HFKF1
(-8) BOX HFKF1
(-9) BOX HFKF1
PERSON_HLPRSHOP
HFKE4
roster
BOX HFKF1
routing
You mentioned that [you receive/(SP) receives] help with shopping for personal
items (such as toilet items or medicines). Who gives that help?
ENTER ALL HELPERS.
(01) [Continuous answer.]
IF HFKF1- PRBBILS = 1/Yes or HFKF2 – DONTBILS = 1/Yes, GO TO HFKF3 HELPBILS.
ELSE GO TO HFLINTRO - ADLSINTRO.
[[You said that [your/(SP's)] health makes managing money (like keeping track of
expenses or paying bills) difficult./You said that managing money (like keeping
track of expenses or paying bills) is something that [you don't do/(SP) doesn't
do].]]
[Do you/Does (SP)] receive help from another person with...
HELPBILS
PERSON_HLPRBILS
ADLSINTRO
HFKF3
HFKF4
HFLINTRO
roster
managing money (like keeping track of expenses or paying bills)?
You mentioned that [you receive/(SP) receives] help with managing money (like
keeping track of expenses or paying bills). Who gives that help?
ENTER ALL HELPERS.
(01) [Continuous answer.]
no entry
Now I'll ask about some other everyday activities. I'd like to know whether [you
have/(SP) has] any difficulty doing each one by (yourself/himself/herself) and
without special equipment.
yes/no
Because of a health or physical problem, [do you/does (SP)] have any difficulty...
HPPDBATH
DONTBATH
HFLA1
HFLA2
code 1
yes/no
bathing or showering?
[You said that bathing or showering is something that [you don't/(SP) doesn't]
do.]
Is this because of a health or physical problem?
Because of a health or physical problem, [do you/does (SP)] have any difficulty...
HPPDDRES
HFLB1
code 1
dressing?
[You said that dressing is something that [you don't/(SP) doesn't] do.]
DONTDRES
HFLB2
yes/no
Is this because of a health or physical problem?
Because of a health or physical problem, [do you/does (SP)] have any difficulty...
HPPDEAT
HFLC1
code 1
eating?
[You said that eating is something that [you don't/(SP) doesn't] do.]
DONTEAT
HFLC2
yes/no
Is this because of a health or physical problem?
Because of a health or physical problem, [do you/does (SP)] have any difficulty...
HPPDCHAR
HFLD1
code 1
getting in or out of bed or chairs?
[You said that getting in or out of bed or chairs is something that [you don't/(SP)
doesn't] do.]
DONTCHAR
HFLD2
yes/no
Is this because of a health or physical problem?
Because of a health or physical problem, [do you/does (SP)] have any difficulty...
HPPDWALK
HFLE1
code 1
walking?
[You said that walking is something that [you don't/(SP) doesn't] do.]
DONTWALK
HFLE2
code 1
Is this because of a health or physical problem?
Because of a health or physical problem, [do you/does (SP)] have any difficulty...
HPPDTOIL
HFLF1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
code 1
using the toilet?
(01) CONTINUE
(-7) Empty
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
[you receive] respondent is SP
[(SP) receives] respondent is proxy
BOX HFKF1
[You said that [your] health makes managing money (like
keeping track of expenses or paying bills) difficult.] respondent
is SP, SP does manage money
[You said that [(SP's)] health makes managing money (like
keeping track of expenses or paying bills) difficult.] respondent
is proxy, SP does manage money
[You said that managing money (like keeping track of
expenses or paying bills) is something that [you don't do]]
respondent is SP, SP doesn't manage money
[You said that managing money (like keeping track of
expenses or paying bills) is something that [(SP) doesn't do]]
respondent is proxy, SP doesn't manage money
[Do you] respondent is SP
[Does (SP)] respondent is proxy
(01) HFKF4 - PERSON_HLPRBILS
(02) HFLINTRO - ADLSINTRO
(-8) HFLINTRO - ADLSINTRO
(-9) HFLINTRO - ADLSINTRO
[you receive] respondent is SP
[(SP) recieves] respondent is proxy
[you have] respondent is SP
[(SP) has] respondent is proxy
[yourself] respondent is SP
[himself] respondent is proxy, SP male
[herself] respondent is proxy, SP female
[do you] respondent is SP
[does (SP)] respondent is proxy
[you don't] respondent is SP
[(SP) doesn't] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
[you don't] respondent is SP
[(SP) doesn't] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
[you don't] respondent is SP
[(SP) doesn't] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
[you don't] respondent is SP
[(SP) doesn't] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
[you don't] respondent is SP
[(SP) doesn't] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
HFLINTRO - ADLSINTRO
HFLA1 - HPPDBATH
(01) HFLB1 - HPPDDRES
(02) HFLB1 - HPPDDRES
(03) HFLA2 - DONTBATH
(-8) HFLB1 - HPPDDRES
(-9) HFLB1 - HPPDDRES
HFLB1 - HPPDDRES
(01) HFLC1 - HPPDEAT
(02) HFLC1 - HPPDEAT
(03) HFLB2 - DONTDRES
(-8) HFLC1 - HPPDEAT
(-9) HFLC1 - HPPDEAT
HFLC1 - HPPDEAT
(01) HFLD1 - HPPDCHAR
(02) HFLD1 - HPPDCHAR
(03) HFLC2 - DONTEAT
(-8) HFLD1 - HPPDCHAR
(-9) HFLD1 - HPPDCHAR
HFLD1 - HPPDCHAR
(01) HFLE1 - HPPDWALK
(02) HFLE1 - HPPDWALK
(03) HFLD2 - DONTCHAR
(-8) HFLE1 - HPPDWALK
(-9) HFLE1 - HPPDWALK
HFLE1 - HPPDWALK
(01) HFLF1 - HPPDTOIL
(02) HFLF1 - HPPDTOIL
(03) HFLE2 - DONTWALK
(-8) HFLF1 - HPPDTOIL
(-9) HFLF1 - HPPDTOIL
HFLF1 - HPPDTOIL
(01) BOX HFLA1
(02) BOX HFLA1
(03) HFLF2 - DONTTOIL
(-8) BOX HFLA1
(-9) BOX HFLA1
[You said that using the toilet is something that [you don't/(SP) doesn't] do.]
DONTTOIL
HFLF2
yes/no
BOX HFLA1
routing
Is this because of a health or physical problem?
IF HFLA1 – HPPDBATH = 1/Yes OR HFLA2 - DONTBATH = 1/Yes, GO TO HFLA3 HELPBATH.
ELSE GO TO BOX HFLB1.
[[You said [your/(SP's)] health makes bathing or showering difficult./You said
that bathing or showering is something [you don't/(SP) doesn't] do.]]
HELPBATH
PCHKBATH
EQIPBATH
HFLA3
HFLA4
yes/no
yes/no
HFLA5
yes/no
BOX HFLA2
routing
LONGBATH
HFLA6
code 1
STILBATH
HFLA7
yes/no
BOX HFLB1
routing
[Do you/Does (SP)] receive help from another person with bathing or
showering?
Does someone usually stay nearby just in case [you need/(SP) needs] help with
bathing or showering?
[That is, does someone usually stay or come into the room to check on
(you/him/her)?]
[Do you/Does (SP)] use special equipment or aids to help (you/him/her) with
bathing or showering?
IF HFLA3 – HELPBATH = 1/Yes, GO TO HFLA6 - LONGBATH.
ELSE GO TO BOX HFLB1.
PCHKDRES
EQIPDRES
LONGDRES
STILDRES
HFLB3
HFLB4
yes/no
yes/no
HFLB5
yes/no
BOX HFLB2
routing
HFLB6
code 1
HFLB7
yes/no
BOX HFLC1
routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
How long [have you/has (SP)] needed help with bathing or showering? Has it
(-8) Don't Know
been . . .
(-9) Refused
(01) YES
(02) NO
Do you expect that [you/(SP)] will still need help with bathing or showering three (-8) Don't Know
months from now?
(-9) Refused
IF HFLB1 - HPPDDRES = 1/Yes OR HFLB2 – DONTDRES = 1/Yes, GO TO HFLB3 HELPDRES.
ELSE GO TO BOX HFLC1.
[[You said [your/(SP's)] health makes dressing difficult./You said that dressing is
something [you don't/(SP) doesn't] do.]]
HELPDRES
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Do you/Does (SP)] receive help from another person with dressing?
Does someone usually stay nearby just in case [you need/(SP) needs] help with
dressing?
[That is, does someone usually stay or come into the room to check on
(you/him/her)?]
[Do you/Does (SP)] use special equipment or aids to help (you/him/her) with
dressing?
IF HFLB3 – HELPDRES = 1/Yes, GO TO HFLB6 - LONGDRES.
ELSE GO TO BOX HFLC1.
How long [have you/has (SP)] needed help with dressing? Has it been . . .
Do you expect that [you/(SP)] will still need help with dressing three months
from now?
IF HFLC1 - HPPDEAT = 1/Yes OR HFLC2 – DONTEAT = 1/Yes, GO TO HFLC3 HELPEAT.
ELSE GO TO BOX HFLD1.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you don't] respondent is SP
[(SP) doesn't] respondent is proxy
[You said that [your] health makes bathing or showering
difficult.] respondent is SP, SP bathes or showers
[You said that [(SP's)] health makes bathing or showering
difficult.] respondent is proxy, SP bathes or showers
[You said that bathing or showering is something that [you
don't do]] respondent is SP, SP doesn't bathe or shower
[You said that bathing or showering is something that [(SP)
doesn't do]] respondent is proxy, SP doesn't bathe or shower
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[you need] respondent is SP
[(SP) needs] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
BOX HFLA1
(01) HFLA5 - EQIPBATH
(02) HFLA4 - PCHKBATH
(-8) HFLA4 - PCHKBATH
(-9) HFLA4 - PCHKBATH
HFLA5 - EQIPBATH
BOX HFLA2
[have you] respondent is SP
[has (SP)] respondent is proxy
(01) HFLA7 - STILBATH
(02) BOX HFLB1
(03) BOX HFLB1
(-8) BOX HFLB1
(-9) BOX HFLB1
[you] respondent is SP
[(SP)] respondent is proxy
BOX HFLB1
[You said that [your] health makes dressing difficult.]
respondent is SP, SP dresses
[You said that [(SP's)] health makes dressing difficult.]
respondent is proxy, SP dresses
[You said that dressing is something that [you don't do]]
respondent is SP, SP doesn't dress
[You said that dressing is something that [(SP) doesn't do]]
respondent is proxy, SP doesn't dress
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[you need] respondent is SP
[(SP) needs] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
(01) HFLB5 - EQIPDRES
(02) HFLB4 - PCHKDRES
(-8) HFLB4 - PCHKDRES
(-9) HFLB4 - PCHKDRES
HFLB5 - EQIPDRES
BOX HFLB2
[have you] respondent is SP
[has (SP)] respondent is proxy
(01) HFLB7 - STILDRES
(02) BOX HFLC1
(03) BOX HFLC1
(-8) BOX HFLC1
(-9) BOX HFLC1
[you] respondent is SP
[(SP)] respondent is proxy
BOX HFLC1
[[You said [your/(SP's)] health makes eating difficult./You said that eating is
something [you don't/(SP) doesn't] do.]]
HELPEAT
PCHKEAT
EQIPEAT
HFLC3
HFLC4
yes/no
yes/no
HFLC5
yes/no
BOX HFLC2
routing
LONGEAT
HFLC6
code 1
STILEAT
HFLC7
yes/no
BOX HFLD1
routing
[Do you/Does (SP)] receive help from another person with eating?
Does someone usually stay nearby just in case [you need/(SP) needs] help with
eating?
[That is, does someone usually stay or come into the room to check on
(you/him/her)?]
[Do you/Does (SP)] use special equipment or aids to help (you/him/her) with
eating?
IF HFLC3 - HELPEAT = 1/Yes, GO TO HFLC6 - LONGEAT.
ELSE GO TO BOX HFLD1.
HFLD3
yes/no
PCHKCHAR
HFLD4
yes/no
EQIPCHAR
HFLD5
yes/no
BOX HFLD2
routing
LONGCHAR
STILCHAR
HFLD6
code 1
HFLD7
yes/no
BOX HFLE1
routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
How long [have you/has (SP)] needed help with eating? Has it been . . .
(-9) Refused
(01) YES
(02) NO
Do you expect that [you/(SP)] will still need help with eating three months from (-8) Don't Know
now?
(-9) Refused
IF HFLD1 – HPPDCHAR = 1/Yes OR HFLD2 - DONTCHAR = 1/Yes, GO TO HFLD3 HELPCHAR.
ELSE GO TO BOX HFLE1.
[[You said [your/(SP's)] health makes getting in or out of bed or chairs
difficult./You said that getting in or out of bed or chairs is something [you
don't/(SP) doesn't] do.]]
HELPCHAR
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Do you/Does (SP)] receive help from another person with getting in or out of
bed or chairs?
Does someone usually stay nearby just in case [you need/(SP) needs] help with
getting in or out of bed or chairs?
[That is, does someone usually stay or come into the room to check on
(you/him/her)?]
[Do you/Does (SP)] use special equipment or aids to help (you/him/her) with
getting in or out of bed or chairs?
IF HFLD3 – HELPCHAR = 1/Yes, GO TO HFLD6 - LONGCHAR.
ELSE GO TO BOX HFLE1.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
How long [have you/has (SP)] needed help with getting in or out of bed or
(-8) Don't Know
chairs? Has it been . . .
(-9) Refused
(01) YES
(02) NO
Do you expect that [you/(SP)] will still need help with getting in or out of bed or (-8) Don't Know
chairs three months from now?
(-9) Refused
IF HFLE1- HPPDWALK = 1/Yes OR HFLE2 – DONTWALK = 1/Yes, GO TO HFLE3 HELPWALK.
ELSE GO TO BOX HFLF1.
[You said that [your] health makes eating difficult.]
respondent is SP, SP eats
[You said that [(SP's)] health makes eating difficult.]
respondent is proxy, SP eats
[You said that eating is something that [you don't do]]
respondent is SP, SP doesn't eat
[You said that eating is something that [(SP) doesn't do]]
respondent is proxy, SP doesn't eat
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[you need] respondent is SP
[(SP) needs] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
(01) HFLC5 - EQIPEAT
(02) HFLC4 - PCHKEAT
(-8) HFLC4 - PCHKEAT
(-9) HFLC4 - PCHKEAT
HFLC5 - EQIPEAT
BOX HFLC2
[have you] respondent is SP
[has (SP)] respondent is proxy
(01) HFLC7 - STILEAT
(02) BOX HFLD1
(03) BOX HFLD1
(-8) BOX HFLD1
(-9) BOX HFLD1
[you] respondent is SP
[(SP)] respondent is proxy
BOX HFLD1
[You said that [your] health makes getting in or out of bed or
chairs difficult.] respondent is SP, SP gets in or out of bed or
chairs
[You said that [(SP's)] health makes getting in or out of bed or
chairs difficult.] respondent is proxy, SP gets in or out of bed
or chairs
[You said that getting in or out of bed or chairs is something
that [you don't do]] respondent is SP, SP doesn't get in or our
of bed or chairs
[You said that getting in or out of bed or chairs is something
that [(SP) doesn't do]] respondent is proxy, SP doesn't get in or
out of bed or chairs
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[you need] respondent is SP
[(SP) needs] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
(01) HFLD5 - EQIPCHAR
(02) HFLD4 - PCHKCHAR
(-8) HFLD4 - PCHKCHAR
(-9) HFLD4 - PCHKCHAR
HFLD5 - EQIPCHAR
[Do you] respondent is SP
[Does (SP)] respondent is proxy
BOX HFLD2
[have you] respondent is SP
[has (SP)] respondent is proxy
(01) HFLD7 - STILCHAR
(02) BOX HFLE1
(03) BOX HFLE1
(-8) BOX HFLE1
(-9) BOX HFLE1
[you] respondent is SP
[(SP)] respondent is proxy
BOX HFLE1
[[You said [your/(SP's)] health makes walking difficult./You said that walking is
something [you don't/(SP) doesn't] do.]]
HELPWALK
PCHKWALK
EQIPWALK
LONGWALK
STILWALK
HFLE3
HFLE4
yes/no
yes/no
HFLE5
yes/no
BOX HFLE2
routing
HFLE6
code 1
HFLE7
yes/no
BOX HFLF1
routing
HELPTOIL
HFLF3
yes/no
PCHKTOIL
HFLF4
yes/no
EQIPTOIL
LONGTOIL
STILTOIL
PERSON_HLPRBATH
PERSON_HLPRDRES
PERSON_HLPREAT
HFLF5
yes/no
BOX HFLF2
routing
HFLF6
code 1
HFLF7
yes/no
BOX HFLA3
routing
HFLA9
roster
BOX HFLB3
routing
HFLB9
roster
BOX HFLC3
routing
HFLC9
roster
BOX HFLD3
routing
[Do you/Does (SP)] receive help from another person with walking?
Does someone usually stay nearby just in case [you need/(SP) needs] help with
walking?
[That is, does someone usually stay or come into the room to check on
(you/him/her)?]
[Do you/Does (SP)] use special equipment or aids to help (you/him/her) with
walking?
IF HFLE3 - HELPWALK = 1/Yes, GO TO HFLE6 - LONGWALK.
ELSE GO TO BOX HFLF1.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
How long [have you/has (SP)] needed help with walking? Has it been . . .
(-9) Refused
(01) YES
(02) NO
Do you expect that [you/(SP)] will still need help with walking three months from (-8) Don't Know
now?
(-9) Refused
IF HFLF1 – HPPDTOIL = 1/Yes OR HFLF2 – DONTTOIL = 1/Yes, GO TO HFLF3 HELPTOIL.
ELSE GO TO BOX HFLA3.
[[You said [your/(SP's)] health makes using the toilet difficult./You said that using (01) YES
the toilet is something [you don't/(SP) doesn't] do.]]
(02) NO
(-8) Don't Know
[Do you/Does (SP)] receive help from another person with using the toilet?
(-9) Refused
Does someone usually stay nearby just in case [you need/(SP) needs] help with
using the toilet?
(01) YES
(02) NO
[That is, does someone usually stay or come into the room to check on
(-8) Don't Know
(you/him/her)?]
(-9) Refused
(01) YES
(02) NO
[Do you/Does (SP)] use special equipment or aids to help (you/him/her) with
(-8) Don't Know
using the toilet?
(-9) Refused
IF HFLF3 - HELPTOIL = 1/Yes, GO TO HFLF6 - LONGTOIL.
ELSE GO TO BOX HFLA3.
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
How long [have you/has (SP)] needed help with using the toilet? Has it been . . . (-9) Refused
(01) YES
(02) NO
Do you expect that [you/(SP)] will still need help with using the toilet three
(-8) Don't Know
months from now?
(-9) Refused
IF HFLA3 - HELPBATH = 1/Yes, GO TO HFLA9 - PERSON_HLPRBATH.
ELSE GO TO BOX HFLB3.
You mentioned that [you receive/(SP) receives] help with bathing and
showering. Who gives that help?
ENTER ALL HELPERS.
(01) [Continuous answer.]
IF HFLB3 - HELPDRES = 1/Yes, GO TO HFLB9 - PERSON_HLPRDRES.
ELSE GO TO BOX HFLC3.
You mentioned that [you receive/(SP) receives] help with dressing. Who gives
that help?
ENTER ALL HELPERS.
(01) [Continuous answer.]
IF HFLC3 – HELPEAT = 1/Yes, GO TO HFLC9 - PERSON_HLPREAT.
ELSE GO TO BOX HFLD3.
You mentioned that [you receive/(SP) receives] help with eating. Who gives that
help?
ENTER ALL HELPERS.
(01) [Continuous answer.]
IF HFLD3 – HELPCHAR = 1/Yes, GO TO HFLD9 - PERSON_HLPRCHAR.
ELSE GO TO BOX HFLE3.
[You said that [your] health makes walking difficult.]
respondent is SP, SP walks
[You said that [(SP's)] health makes walking difficult.]
respondent is proxy, SP walks
[You said that walking is something that [you don't do]]
respondent is SP, SP doesn't walk
[You said that waking is something that [(SP) doesn't do]]
respondent is proxy, SP doesn't walk
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[you need] respondent is SP
[(SP) needs] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
(01) HFLE5 - EQIPWALK
(02) HFLE4 - PCHKWALK
(-8) HFLE4 - PCHKWALK
(-9) HFLE4 - PCHKWALK
HFLE5 - EQIPWALK
[Do you] respondent is SP
[Does (SP)] respondent is proxy
BOX HFLE2
[have you] respondent is SP
[has (SP)] respondent is proxy
(01) HFLE7 - STILWALK
(02) BOX HFLF1
(03) BOX HFLF1
(-8) BOX HFLF1
(-9) BOX HFLF1
[you] respondent is SP
[(SP)] respondent is proxy
BOX HFLF1
[You said that [your] health makes using the toilet difficult.]
respondent is SP, SP uses toilet
[You said that [(SP's)] health makes using the toilet difficult.]
respondent is proxy, SP uses toilet
[You said that using the toilet is something that [you don't
do]] respondent is SP, SP doesn't use toilet
[You said that using the toilet is something that [(SP) doesn't
do]] respondent is proxy, SP doesn't use toilet
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[you need] respondent is SP
[(SP) needs] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
(01) HFLF5 - EQIPTOIL
(02) HFLF4 - PCHKTOIL
(-8) HFLF4 - PCHKTOIL
(-9) HFLF4 - PCHKTOIL
HFLF5 - EQIPTOIL
[Do you] respondent is SP
[Does (SP)] respondent is proxy
BOX HFLF2
[have you] respondent is SP
[has (SP)] respondent is proxy
(01) HFLF7 - STILTOIL
(02) BOX HFLA3
(03) BOX HFLA3
(-8) BOX HFLA3
(-9) BOX HFLA3
[you] respondent is SP
[(SP)] respondent is proxy
BOX HFLA3
[you receive] respondent is SP
[(SP) recieves] respondent is proxy
BOX HFLB3
[you receive] respondent is SP
[(SP) recieves] respondent is proxy
BOX HFLC3
[you receive] respondent is SP
[(SP) recieves] respondent is proxy
BOX HFLD3
PERSON_HLPRCHAR
PERSON_HLPRWALK
PERSON_HLPRTOIL
PERSON_HLPRMOST
HFLD9
roster
BOX HFLE3
routing
HFLE9
roster
BOX HFLF3
routing
HFLF9
roster
BOX HFL4
routing
HFL10
roster
BOX HFM1
routing
FALLANY
HFM1
yes/no
FALLTIME
HFM2
numeric
FALLHELP
FALCODE
FALOTHOS
FALLIMIT
FALLBACK
FALLFEAR
HFM3A
HFM3B
HFM3B
HFM3C
HFM3D
HFM3E
yes/no
code all
verbatim text
yes/no
You mentioned that [you receive/(SP) receives] help with getting in or out of bed
or chairs. Who gives that help?
ENTER ALL HELPERS.
IF HFLE3 – HELPWALK = 1/Yes, GO TO HFLE9 - PERSON_HLPRWALK.
ELSE GO TO BOX HFLF3.
You mentioned that [you receive/(SP) receives] help with walking. Who gives
that help?
ENTER ALL HELPERS.
IF HFLF3 – HELPTOIL = 1/Yes, GO TO HFLF9 - PERSON_HLPRTOIL.
ELSE GO TO BOX HFL4.
You mentioned that [you receive/(SP) receives] help with using the toilet. Who
gives that help?
ENTER ALL HELPERS.
IF MORE THAN ONE PERSON SELECTED AT HFLA9, HFLB9, HFLC9, HFLD9, HFLE9,
AND/OR HFLF9, GO TO HFL10 - PERSON_HLPRMOST.
ELSE GO TO BOX HFM1.
Which of these persons gives [you/(SP)] the most help with these things?
SELECT ONLY ONE.
IF THIS IS ROUND 67 73, GO TO HFM1 - FALLANY.
ELSE GO TO HFN1 - MEMLOSS.
(01) [Continuous answer.]
[you receive] respondent is SP
[(SP) recieves] respondent is proxy
BOX HFLE3
(01) [Continuous answer.]
[you receive] respondent is SP
[(SP) recieves] respondent is proxy
BOX HFLF3
(01) [Continuous answer.]
[you receive] respondent is SP
[(SP) recieves] respondent is proxy
BOX HFL4
(01) [Continuous answer.]
[you] respondent is SP
[(SP)] respondent is proxy
BOX HFM1
[have you] respondent is SP
[has (SP)] respondent is proxy
(01) HFM2 - FALLTIME
(02) HFN1 - MEMLOSS
(-8) HFN1 - MEMLOSS
(-9) HFN1 - MEMLOSS
(01) YES
(02) NO
(-8) Don't Know
Since (LAST HF MONTH YEAR), [have you/has (SP)] fallen down?
(-9) Refused
[Continuous answer.]
Since (LAST HF MONTH YEAR), how many times [have you/has (SP)] fallen down? Don't Know
ENTER "95" IF 95 OR MORE FALLS REPORTED.
Refused
(01) YES
(02) NO
Thinking about the [most recent) time that [you/(SP)] fell, did (you/he/she) hurt (-8) Don't Know
(yourself/himself/herself) badly enough to get medical help?
(-9) Refused
(01) BROKEN BONE/FRACTURE
(02) SPRAIN/STRAIN
(03) BRUISE
(04) CUT/WOUND/LACERATION
(05) CONCUSSION
(06) DISLOCATION
What kind of injury did [you/(SP)] have in that (most recent) fall?
(91) OTHER
(96) NO INJURY
[PROBE: Anything else?]
(-8) Don't Know
CHECK ALL THAT APPLY.
(-9) Refused
OTHER (SPECIFY)
(01) [Continuous answer.]
Did [your/(SP's)] (most recent) fall cause (you/him/her) to limit (your/his/her)
regular acivities?
code 1
How long did it take [you/(SP)] to get back to regular activities after
(your/his/her) (most recent) fall?
numeric
How would you rate [your/(SP's)] fear of falling on a scale of 1 to 6, where 1 is
"Not at all afraid of falling" and 6 is "Extremely afraid of falling"?
MEMLOSS
HFN1
yes/no
[Do you/Does (SP)] experience memory loss such that it interferes with daily
activities?
PROBDECS
HFN2
yes/no
[Do you/Does (SP)] have problems making decisions to the point that it
interferes with daily activities?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) LESS THAN ONE WEEK
(02) ONE WEEK OR MORE
(03) NEVER RESUMED REGULAR ACTIVITIES
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[have you] respondent is SP
[has (SP)] respondent is proxy
[most recent] SP fell more than once
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[yourself] respondent is SP
[himself] respondent is proxy, SP male
[herself] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[most recent] SP fell more than once
[your] respondent is SP
[(SP's)] respondent is proxy
[most recent] SP fell more than once
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[most recent] SP fell more than once
HFM3A - FALLHELP
HFM3B - FALCODE
(01) HFM3C - FALLIMIT
(02) HFM3C - FALLIMIT
(03) HFM3C - FALLIMIT
(04) HFM3C - FALLIMIT
(05) HFM3C - FALLIMIT
(06) HFM3C - FALLIMIT
(91) HFM3B - FALOTHOS
(96) HFM3C - FALLIMIT
(-8) HFM3C - FALLIMIT
(-9) HFM3C - FALLIMIT
HFM3C - FALLIMIT
(01) HFM3D - FALLBACK
(02) HFM3E - FALLFEAR
(-8) HFM3E - FALLFEAR
(-9) HFM3E - FALLFEAR
HFM3E - FALLFEAR
[your] respondent is SP
[(SP's)] respondent is proxy
HFN1 - MEMLOSS
[Do you] respondent is SP
[Does (SP)] respondent is proxy
HFN2 - PROBDECS
[Do you] respondent is SP
[Does (SP)] respondent is proxy
HFN3 - TROBCONC
TROBCONC
TIMESAD
LOSTINTR
HFN3
HFN4
HFN5
yes/no
[Do you/Does (SP)] have trouble concentrating or keeping (your/his/her) mind
on what (you are/he is/she is) doing?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
code 1
SHOW CARD HF4 HF5
In the past 12 months, how much of the time did [you/(SP)] feel sad, blue, or
depressed? Would you say [you were/(SP) was] sad or depressed all of the time,
most of the time, some of the time, a little of the time, or none of the time?
[WE ARE ASKING FOR A SUBJECTIVE EVALUATION OF THE RESPONDENT'S
EMOTIONAL STATE; WE ARE NOT LOOKING FOR A MEDICAL DIAGNOSIS AT THIS
QUESTION.]
(01) ALL OF THE TIME
(02) MOST OF THE TIME
(03) SOME OF THE TIME
(04) A LITTLE OF THE TIME
(05) NONE OF THE TIME
(-8) Don't Know
(-9) Refused
yes/no
In the past 12 months, [have you/has (SP)] had 2 weeks or more when
(you/he/she) lost interest or pleasure in things that (you/he/she) usually cared
about or enjoyed?
LOSTURIN
HFQ1
code 1
TALKURIN
HFQ2
yes/no
FEELURIN
REASURIN
SURGURIN
HFQ3
HFQ4
yes/no
yes/no
HFQ5
yes/no
BOX HFT0
routing
BOX HFT1
routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) MORE THAN ONCE A WEEK
(02) ABOUT ONCE A WEEK
(03) 2-3 TIMES A MONTH
(04) ABOUT ONCE A MONTH
(05) EVERY 2-3 MONTHS
(06) ONCE OR TWICE A YEAR
SHOW CARD HF2 HF7
(07) NOT AT ALL
I'd like to ask about a health problem that is more common than people think. (08) SP IS ON DIALYSIS OR CATHETERIZATION OR
Please look at this card and tell me how often, if at all, since (LAST HF MONTH
UROSTOMY OR BLADDER BAG
YEAR) [you have/(SP) has] lost urine because (you/he/she) could not control
(-8) Don't Know
(your/his/her) bladder.
(-9) Refused
(01) YES
(02) NO
[Have you/Has (SP)] talked about this problem with [your/(SP’s)] doctor or other (-8) Don't Know
medical professional?
(-9) Refused
Has [your/(SP’s)] doctor or other medical professional asked (you/him/her)
about how (you/he/she) (feel/feels) about this problem?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Has [your/(SP’s)] doctor or other medical professional examined (you/him/her)
to figure out why (you/he/she) (lose/loses) urine?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
Has [your/(SP’s)] doctor or other medical professional talked with (you/him/her) (-8) Don't Know
about taking medicine or having surgery for this problem?
(-9) Refused
IF THIS IS ROUND 67 73, GO TO BOX HFT1.
ELSE GO TO BOX HFEND.
IF HFJ2 - OCHBP = 1/Yes, GO TO HFT1 - HYPETOLD.
ELSE GO TO BOX HFEND.
We have recorded that [you were/(SP) was] told by a doctor that (you had/he
had/she had) hypertension, also called high blood pressure.
[Were you/Was (SP)] told on two or more different medical visits that
(you/he/she) had high blood pressure or hypertension?
HYPETOLD
HFT1
code 1
[EXPLAIN IF NECESSARY: We are interested in knowing whether [your/(SP’s)]
blood pressure was high for more than one reading.]
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[[you are] respondent is SP
[he is] respondent is proxy, SP male
[she is] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[you were] respondent is SP
[(SP) was] respondent is proxy
[have you] respondent is SP
[has (SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you have] respondent is SP
[(SP) has] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[feel] respondent is SP
[feels] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[lose] respondent is SP
[loses] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you were] respondent is SP
[(SP) was] respondent is proxy
[you had] respondent is SP
[he had] respondent is proxy, SP male
[she had] respondent is proxy, SP female
[Were you] respondent is SP
(01) YES
[Was (SP)] respondent is proxy
(02) NO
[you] respondent is SP
(03) SP NEVER HAD HIGH BLOOD PRESSURE/PREVIOUS [he] respondent is proxy, SP male
RESPONSE ENTERED IN ERROR
[she] respondent is proxy, SP female
(-8) Don't Know
[your] respondent is SP
(-9) Refused
[(SP's)] respondent is proxy
HFN4 - TIMESAD
HFN5 - LOSTINTR
HFQ1 - LOSTURIN
(01) HFQ2 - TALKURIN
(02) HFQ2 - TALKURIN
(03) HFQ2 - TALKURIN
(04) HFQ2 - TALKURIN
(05) HFQ2 - TALKURIN
(06) HFQ2 - TALKURIN
(07) BOX HFT0
(08) BOX HFT0
(-8) BOX HFT0
(-9) BOX HFT0
(01) HFQ3 - FEELURIN
(02) BOX HFT0
(-8) BOX HFT0
(-9) BOX HFT0
HFQ4 - REASURIN
HFQ5 - SURGURIN
BOX HFT0
(01) HFT2 - HYPEAGE
(02) HFT2 - HYPEAGE
(03) BOX HFEND
(-8) HFT2 - HYPEAGE
(-9) HFT2 - HYPEAGE
HYPEAGE
HYPEAGE_LESSONE
HYPEHOME
HYPEMEDS
HYPEDRNK
HYPELONG
HYPEMANY
HYPECOND
HYPECTRL
HFT2
HFT2
HFT6D
HFT6G
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
numeric
How old [were you/was (SP)] when (you were/he was/she was) first told that
(you/he/she) had high blood pressure?
(01) LESS THAN ONE YEAR OLD
(-7) Empty
Because of (your/his/her) high blood pressure, [are you/is (SP)] now measuring
(your/his/her) blood pressure at home?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Because of (your/his/her) high blood pressure, [are you/is (SP)] now taking
prescribed medicine for (your/his/her) high blood pressure?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
yes/no
yes/no
yes/no
BOX HFT2
routing
HFT7
numeric
BOX HFT3
routing
HFT11A
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
[have you] respondent is SP
[has (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
numeric
How old [were you/was (SP)] when (you were/he was/she was) first told that
(you/he/she) had high blood pressure?
HFT6J
HFT8
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[were you] respondent is SP
[was (SP)] respondent is proxy
[you were] respondent is SP
[he was] respondent is proxy, SP male
[she was] respondent is proxy, SP female
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[were you] respondent is SP
[was (SP)] respondent is proxy
[you were] respondent is SP
[he was] respondent is proxy, SP male
[she was] respondent is proxy, SP female
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[are you] respondent is SP
[is (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[are you] respondent is SP
[is (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
numeric
code 1
HFT12A
code 1
BOX HFT4
routing
(You mentioned that in a typical month in the past year [you/(SP)] did not drink
alcohol. Is that because of (your/his/her) high blood pressure?/[Have you/Has
(SP)] cut down on drinking alcoholic beverages because of (your/his/her) high
blood pressure?)
IF HFT6G - HYPEMEDS = 1/Yes, GO TO HFT7 - HYPELONG.
ELSE GO TO HFT12A - HYPECTRL.
How long [have you/has (SP)] been treated with prescribed medicines for
(your/his/her) high blood pressure?
IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO HFT8 - HYPEMANY.
ELSE GO TO HFT11A - HYPECOND.
How many different prescribed medicines [do you/does (SP)] take for
(your/his/her) high blood pressure?
[WE ARE ASKING ABOUT HOW MANY DIFFERENT PRESCRIBED MEDICINES FOR
(01) [Continuous answer.]
HIGH BLOOD PRESSURE ARE TAKEN BY THE RESPONDENT, NOT THE NUMBER OF (-8) Don't Know
PILLS THEY MIGHT TAKE IN ONE DAY.]
(-9) Refused
How often [do you/does (SP)] have trouble with side effects from (your/his/her)
blood pressure (medicine/medicines)? Please tell me if (you/he/she) always,
(01) ALWAYS
sometimes, or never (have/has) trouble with side effects.
(02) SOMETIMES
(03) NEVER
[EXPLAIN IF NECESSARY: By "side effects", I mean that the medicine causes any (-8) Don't Know
condition such as fatigue, headache, or coughing.]
(-9) Refused
Doctors often recommend changing your habits or lifestyle, such as changing
(01) VERY CONFIDENT
your diet, or getting regular exercise in order to control blood pressure. How
(02) CONFIDENT
confident are you that [you/(SP)] can follow these recommendation?
(03) SOMEWHAT CONFIDENT
(04) NOT AT ALL CONFIDENT
Would you say that you are very confident, confident, somewhat confident, or (-8) Don't Know
not at all confident?
(-9) Refused
IF HFT6G - HYPEMEDS = 1/Yes, GO TO HFT13 - HYPEPAY.
ELSE GO TO BOX HFEND.
[do you] respondent is SP
[does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[do you] respondent is SP
[does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[medicine] SP takes one medicine
[medicines] SP takes more than one medicine
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[have] respondent is SP
[has] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
HFT2 - HYPEAGE_LESSONE
HFT6D - HYPEHOME
HFT6G - HYPEMEDS
HFT6J - HYPEDRNK
BOX HFT2
HFT7 - HYPELONG_LESSONE
HFT11A - HYPECOND
HFT12A - HYPECTRL
BOX HFT4
HYPEPAY
HYPESKIP
HFT13
HFT14
yes/no
yes/no
[Do you/Does (SP)] have difficulty paying for the (medicine/medicines)
(your/his/her) doctor prescribes for (your/his/her) high blood pressure?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Do you/Does (SP)] ever skip taking (your/his/her) medicine, take less medicine
than prescribed, or share medicine because of the cost of the medicine?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[medicine] SP only takes one medicine
[medicines] SP takes more than one medicine
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
HFT14 - HYPESKIP
BOX HFEND
Satisfaction with Care (SCQ)
Variable Name
MR Screen Name
Question type
Question text/description
Code list
SHOW CARD SC1
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 and
hospitals. Please tell me how satisfied you have been with the
following:
MCQUALTY
SC1
code 1
MCAVAIL
SC2
code 1
MCEASE
SC3
code 1
MCCOSTS
SC4
code 1
MCINFO
SC5
code 1
MCFOLUP
SC6
code 1
MCCONCRN
SC7
code 1
MCSAMLOC
SC8
code 1
(01) VERY SATISFIED
(02) SATISFIED
(03) DISSATISFIED
(04) VERY DISSATISFIED
(05) NOT APPLICABLE
The overall quality of the health care [you have /(SP) has] received
(-8) Don't Know
[over the past year/since (SURVEY REFERENCE DATE)].
(-9) Refused
(01) VERY SATISFIED
(02) SATISFIED
(03) DISSATISFIED
SHOW CARD SC1
(04) VERY DISSATISFIED
[Please tell me how satisfied you have been with . . .]
(05) NOT APPLICABLE
(-8) Don't Know
The availability of health care at night and on weekends.
(-9) Refused
(01) VERY SATISFIED
(02) SATISFIED
SHOW CARD SC1
(03) DISSATISFIED
[Please tell me how satisfied you have been with . . .]
(04) VERY DISSATISFIED
(05) NOT APPLICABLE
The ease and convenience of getting to a doctor from where [you/(SP)] (-8) Don't Know
[live/lives].
(-9) Refused
(01) VERY SATISFIED
(02) SATISFIED
(03) DISSATISFIED
SHOW CARD SC1
(04) VERY DISSATISFIED
[Please tell me how satisfied you have been with . . .]
(05) NOT APPLICABLE
(-8) Don't Know
The out-of-pocket costs [you/(SP)] paid for health care.
(-9) Refused
(01) VERY SATISFIED
(02) SATISFIED
SHOW CARD SC1
(03) DISSATISFIED
[Please tell me how satisfied you have been with . . .]
(04) VERY DISSATISFIED
(05) NOT APPLICABLE
The information given to [you/you or (SP)] about what was wrong with (-8) Don't Know
[you/(SP)].
(-9) Refused
(01) VERY SATISFIED
(02) SATISFIED
SHOW CARD SC1
(03) DISSATISFIED
[Please tell me how satisfied you have been with . . .]
(04) VERY DISSATISFIED
(05) NOT APPLICABLE
The follow-up care [you/(SP)] received after an initial treatment or
(-8) Don't Know
operation.
(-9) Refused
(01) VERY SATISFIED
(02) SATISFIED
SHOW CARD SC1
(03) DISSATISFIED
[Please tell me how satisfied you have been with . . .]
(04) VERY DISSATISFIED
(05) NOT APPLICABLE
The concern of doctors for [your/(SP’s)] overall health rather than just (-8) Don't Know
for an isolated symptom or disease.
(-9) Refused
(01) VERY SATISFIED
(02) SATISFIED
SHOW CARD SC1
(03) DISSATISFIED
[Please tell me how satisfied you have been with . . .]
(04) VERY DISSATISFIED
(05) NOT APPLICABLE
Getting all [your/(SP’s)] health care needs taken care of at the same
(-8) Don't Know
location.
(-9) Refused
SHOW CARD SC1
[Please tell me how satisfied you have been with . . .]
MCSPECAR
SC8A
code 1
The availability of care by specialists when [you/(SP)] (feel/feels)
(you/he/she) (need/needs) it.
SHOW CARD SC1
[Please tell me how satisfied you have been with . . .]
MCTELANS
SC8B
code 1
The ease of obtaining answers to questions over the telephone about
[your/(SP’s)] treatment or prescriptions.
(01) VERY SATISFIED
(02) SATISFIED
(03) DISSATISFIED
(04) VERY DISSATISFIED
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
(01) VERY SATISFIED
(02) SATISFIED
(03) DISSATISFIED
(04) VERY DISSATISFIED
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
Text Fill Logic
[you have] respondent is SP
[(SP) has] respondent is proxy
[over the past year] SP is in supplemental sample or did not
receive the Fall supplement sections in the past year
[(SURVEY REFERENCE MONTH AND YEAR)] SP not in
supplemental sample or received Fall supplement sectons in
past year
[you have] respondent is SP
[(SP) has] respondent is proxy
[over the past year] SP is in supplemental sample or did not
receive the Fall supplement sections in the past year
[(SURVEY REFERENCE MONTH AND YEAR)] SP not in
supplemental sample or received Fall supplement sectons in
past year
Input mask Routing
SC2 - MCAVAIL
SC3 - MCEASE
[you] respondent is SP
[(SP)] respondent is proxy
[live] respondent is SP
[lives] respondent is proxy
SC4 - MCCOSTS
[you] respondent is SP
[(SP)] respondent is proxy
SC5 - MCINFO
[you] respondent is SP
[you or (SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
SC6 - MCFOLUP
[you] respondent is SP
[(SP)] respondent is proxy
SC7 - MCCONCRN
[your] respondent is SP
[(SP's)] respondent is proxy
SC8 - MCSAMLOC
[your] respondent is SP
[(SP's)]
respondent
is proxy
[you] respondent
is SP
SC8A - MCSPECAR
[(SP)] respondent is proxy
[feel] respondent is SP
[feels] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[need] respondent is SP
[needs] respondent is proxy
SC8B - MCTELANS
[your] respondent is SP
[(SP's)] respondent is proxy
SC8C - MCAMTPAY
SHOW CARD SC1
[Please tell me how satisfied you have been with . . .]
MCAMTPAY
SC8C
BOX SC1A
code 1
The amount [you have/(SP) has] to pay for [your/(SP's)] prescribed
medicines.
routing
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.
ELSE GO TO SC9 - MDISSFY.
SHOW CARD SC1
[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.
MCDRGLST
SC8D
code 1
[EXPLAIN IF NECESSARY: By prescription drug plan, we mean any
health insurance plan that provides drug coverage.]
SHOW CARD SC1
[Please tell me how satisfied you have been with . . .]
The ease of finding a pharmacy which accepts your prescription drug
plan.
MCFNDPCY
SC8E
code 1
[EXPLAIN IF NECESSARY: By prescription drug plan, we mean any
health insurance plan that provides drug coverage.]
Would [you/(SP)] recommend [your/his/her] prescription drug plan to
other people like [you/him/her]?
MCRECPLN
SC8F
code 1
[EXPLAIN IF NECESSARY: By prescription drug plan, we mean any
health insurance plan that provides your drug coverage.]
(01) VERY SATISFIED
(02) SATISFIED
(03) DISSATISFIED
(04) VERY DISSATISFIED
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
[you have] respondent is SP
[(SP) has] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
BOX SC1A
(01) VERY SATISFIED
(02) SATISFIED
(03) DISSATISFIED
(04) VERY DISSATISFIED
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
SC8E - MCFNDPCY
(01) VERY SATISFIED
(02) SATISFIED
(03) DISSATISFIED
(04) VERY DISSATISFIED
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
[[You receive/(SP) receives] [your/his/her] prescription drug coverage
through a[Medicare Prescription Drug Plan/Medicare Advantage
plan./Some Medicare beneficiaries receive their prescription drug
coverage through Medicare Prescription Drug plans, also called
"Medicare Part D" plans.]
DHEVHEAR
SC8G
BOX SC1AA
yes/no
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.
(01) YES
(02) NO
Before today, have you heard about the coverage gap or "doughnut
(-8) Don't Know
hole" that is part of most Medicare drug plans?
(-9) Refused
routing
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.
ELSE GO TO SC9 - MDISSFY.
Does [your/(SP's)] [(CURRENT MEDICARE PRESCRIPTION DRUG
PLAN)/(CURRENT MEDICARE ADVANTAGE PLAN)] plan have a
coverage gap, or “doughnut hole”?
DHPLAN
SC8I
yes/no
[EXPLAIN IF NECESSARY: The coverage gap, or "doughnut hole", is
a phase in coverage during which there is a reduction in coverage and
people have to pay a higher share of their drug costs.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
SC8F - MCRECPLN
SC8G - DHEVHEAR
[[You receive] [your] prescription drug coverage through a
[Medicare Prescription Drug Plan] respondent is SP, SP has
current Medicare Prescription Drug Plan
[[You receive] [your] prescription drug coverage through a
[Medicare Advantage Plan] respondent is SP, SP has current
Medicare Advantage Plan
[[(SP) recieves] [his] prescription drug coverage through a
[Medicare Prescription Drug Plan] respondent is proxy, SP male,
SP has current Medicare Prescription Drug Plan
[[(SP) recieves] [his] prescription drug coverage through a
[Medicare Advantage Plan] respondent is proxy, SP male, SP
has current Medicare Advantage Plan
[[(SP) recieves] [her] prescription drug coverage through a
[Medicare Prescription Drug Plan] respondent is proxy, SP
female, SP has current Medicare Prescription Drug Plan
[[(SP) recieves] [her] prescription drug coverage through a
[Medicare Advantage Plan] respondent is proxy, SP female, SP
has current Medicare Advantage Plan
[Some Medicare beneficiaries receive their prescription drug
coverage through Medicare Prescription Drug plans, also called
"Medicare Part D" plans] SP doesn't have current Medicare
Prescription Drug Plan or Medicare Advantage Plan
BOX SC1AA
[your] respondent is SP
[(SP's)] respondent is proxy
[(CURRENT MEDICARE PRESCRIPTION DRUG PLAN)] SP
has current medicare prescription drug plan
[(CURRENT MEDICARE ADVANTAGE PLAN)] SP has current
medicare advantage plan
(01) SC8L - DHTHISYR
(02) SC9 - MDISSFY
(-8) SC9 - MDISSFY
(-9) SC9 - MDISSFY
[Have you/Has (SP)] reached the start of the coverage gap during
(CURRENT YEAR)?
DHTHISYR
DHSTART
DHSTAROS
SC8L
SC8M
SC8M
yes/no
code 1
verbatim text
[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.]
REFER TO THE MOST RECENT MEDICARE PRESCRIPTION DRUG
PLAN STATEMENT TO HELP THE RESPONDENT VERIFY THIS
INFORMATION.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
How did [you/(SP)] first find out that (you/he/she) reached the start of
the coverage gap?
OTHER (SPECIFY)
(01) SP OR SOMEONE FOR THE SP KEPT
TRACK OF TOTAL MEDICINE SPENDING
(02) INFORMATION PROVIDED BY THE PART
D PLAN
(03) INFORMATION PROVIDED BY THE
PHARMACY
(91)OTHER
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
[Have you/Has (SP)] reached the end of the coverage gap during
[CURRENT YEAR]?
DHEND
DHWORRY
MDISSFY
SC8N
SC8O
SC9
SC9
SC10A
(01) SC8N - DHEND
(02) SC8N - DHEND
(03) SC8N - DHEND
(91) SC8M - DHSTAROS
(-8) SC8N - DHEND
(-9) SC8N - DHEND
SC8N - DHEND
(01) SC8O - DHWORRY
(02) SC8O - DHWORRY
(-8) SC9 - MDISSFY
(-9) SC9 - MDISSFY
code 1
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
(01) VERY WORRIED
coverage gap?
(02) SOMEWHAT WORRIED
(03) NOT AT ALL WORRIED
Would you say that [you/(SP)] [are/is/were/was] very worried,
(-8) Don't Know
somewhat worried, or not at all worried?
(-9) Refused
[are] respondent is SP, currently experiecing coverage gap
[is] respondent is proxy, SP currently experiencing coverage gap
[were] respondent is SP, SP no longer experiencing coverage
gap
[was] respondent is proxy, SP no longer experiencing coverage
gap
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[are] respondent is SP, currently experiecing coverage gap
[is] respondent is proxy, SP currently experiencing coverage gap
[were] respondent is SP, SP no longer experiencing coverage
gap
[was] respondent is proxy, SP no longer experiencing coverage
gap
[you] respondent is SP
SC9 - MDISSFY
verbatim text
Please think about all of the health care services [you/(SP)]
(01) RESPONDENT IS NOT DISSATISFIED
[receive/receives], including services provided by doctors, hospitals and WITH ANYTHING
pharmacies.
(91) RESPONDENT IS DISSATISFIED (RECORD
VERBATIM IN THE NEXT SCREEN)
What things, if anything, about the health care services [you/(SP)]
(-8) Don't Know
[receive/receives] are you dissatisfied with?
(-9) Refused
[(SP)] respondent is proxy
[receive] respondent is SP
[receives] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[receive] respondent is SP
[receives]
respondent
[you] respondent
is SPis proxy
(01) SC10A - MCWORRY
(91) SC9 - MCDISVB
(-8) SC10A - MCWORRY
(-9) SC10A - MCWORRY
yes/no
[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.]
REFER TO THE MOST RECENT MEDICARE PRESCRIPTION DRUG
PLAN STATEMENT TO HELP THE RESPONDENT VERIFY THIS
INFORMATION.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
verbatim text
What things, if anything, about the health care services [you/(SP)]
(receive/receives) are you dissatisfied with?
(01) [Continuous answer.]
Please tell me whether each of the following statements is true or
false.
MCWORRY
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
(01) SC8M - DHSTART
(02) SC9 - MDISSFY
(-8) SC9 - MDISSFY
(-9) SC9 - MDISSFY
[you have] respondent is SP
[(SP) has] respondent is proxy
[you have] respondent is SP
[he has] respondent is proxy, SP male
[she has] respondent is proxy, SP female
[you pay] respondent is SP
[he pays] respondent is proxy, SP male
[she pays] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
Please think about all of the health care services [you/(SP)]
(receive/receives), including services provided by doctors, hospitals and
pharmacies.
MCDISVB
[Have you] respondent is SP
[Has (SP)] respondent is proxy
[you have] respondent is SP
[(SP) has] respondent is proxy
[you have] respondent is SP
[he has] respondent is proxy, SP male
[she has] respondent is proxy, SP female
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
list
[You/(SP)] (worry/worries) about (your/his/her) health more than other
people (your/his/her) age.
[Is this statement true or false?]
(01) TRUE
(02) FALSE
(-8) Don't Know
(-9) Refused
[(SP)] respondent is proxy
[receive] respondent is SP
[receives] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[receive] respondent is SP
[receives] respondent is proxy
[You] respondent is SP
[(SP)] respondent is proxy
[worry] respondent is SP
[worries] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
SC10A - MCWORRY
SC10A - MCAVOID
Please tell me whether each of the following statements is true or
false.
MCAVOID
SC10A
list
[You/(SP)] will do just about anything to avoid going to the doctor.
Please tell me whether each of the following statements is true or
false.
MCSICK
SC10A
list
When [you/(SP)] [are/is] sick, [you/he/she] [try/tries] to keep it to
[yourself/himself/herself].
Please tell me whether each of the following statements is true or
false.
MCDRSOON
SC10A
list
MCDRNSEE
SC11
yes/no
TEMPCOND1
SC12AA
text
TEMPCOND2
SC12AA
text
TEMPCOND3
SC12AA
text
Usually, [you/(SP)] (go/goes) to the doctor as soon as (you/he/she)
(start/starts) to feel bad.
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?
[INCLUDE ALL TYPES OF HEALTH PROBLEMS RANGING FROM
MINOR TO SERIOUS ISSUES.]
What was the health problem or condition?
ENTER ALL CONDITIONS.
What was the health problem or condition?
ENTER ALL CONDITIONS.
What was the health problem or condition?
ENTER ALL CONDITIONS.
Did [you/(SP)] attempt to see a doctor about this [READ
CONDITION(S) BELOW]?
(01) TRUE
(02) FALSE
(-8) Don't Know
(-9) Refused
(01) TRUE
(02) FALSE
(-8) Don't Know
(-9) Refused
[You] respondent is SP
[(SP)]respondent
respondentisisSP
proxy
[you]
[(SP)] respondent is proxy
[are] respondent is SP
[is] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[try] respondent is SP
[tries] respondent is proxy
[yourself] respondent is SP
[himself] respondent is proxy, SP male
[herself]
respondent
is proxy, SP female
[you] respondent
is SP
(01) TRUE
(02) FALSE
(-8) Don't Know
(-9) Refused
[(SP)] respondent is proxy
[go] respondent is SP
[goes] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[start] respondent is SP
[starts] respondent is proxy
SC11 - MCDRNSEE
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
(01) SC12AA - TEMPCOND1
(02) SC15 - PMNOTGET
(-8) SC15 - PMNOTGET
(-9) SC15 - PMNOTGET
(01) [Continuous answer.]
(01) [Continuous answer.]
(-7) Empty
(01) [Continuous answer.]
(-7) Empty
SC10A - MCSICK
SC10A - MCDRSOON
SC12AA - TEMPCOND2
(01) SC12AA - TEMPCOND3
(-7) SC12A - MCDRATMP
SC12A - MCDRATMP
(CONDITION 1 FROM SC12AA)
(CONDITION 2 FROM SC12AA)
(CONDITION 3 FROM SC12AA)
MCDRATMP
SCRCODES
SCROTOS
SC12A
yes/no
SC13A
SC13A
code all
verbatim text
BOX SC1B
routing
[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)?]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
(01) DIDN'T THINK THE PROBLEM WAS
SERIOUS
(02) THOUGHT IT WOULD COST TOO MUCH
SHOW CARD SC2
(03) TROUBLE FINDING/GETTING TO DOCTOR
This card lists some reasons people have given for not seeing a doctor (04) TIME/SCHEDULE OR PERSONAL
or other medical person about a health problem or condition.
CONFLICTS
(05) THOUGHT DOCTOR COULDN'T DO MUCH
Which of these reasons explains why [you/(SP)] did not see a doctor
ABOUT PROBLEM
about the [READ CONDITION(S) BELOW]?
(06) WAS AFRAID OF FINDING OUT WHAT
WAS WRONG
(CONDITION 1 FROM SC12AA)
(07) DOCTOR WOULD NOT ACCEPT MY
(CONDITION 2 FROM SC12AA)
INSURANCE
(CONDITION 3 FROM SC12AA)
(91) (OTHER/SC13A - SCROTOS OTHER
SPECIFY TEXT)
[PROBE: Any other reason?]
(-8) Don't Know
[you] respondent is SP
CHECK ALL THAT APPLY.
(-9) Refused
[(SP)] respondent is proxy
OTHER (SPECIFY)
(01) [Continuous answer.]
IF SC13A - SCRCODES INCLUDES MORE THAN ONE RESPONSE,
GO TO SC14A - SCRMAIN.
ELSE GO TO SC15 - PMNOTGET.
SC13A - SCRCODES
(01) BOX SC1B
(02) BOX SC1B
(03) BOX SC1B
(04) BOX SC1B
(05) BOX SC1B
(06) BOX SC1B
(07) BOX SC1B
(91) SC13A - SCROTOS
(-8) SC15 - PMNOTGET
(-9) SC15 - PMNOTGET
BOX SC1B
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.]
SCRMAIN
SC14A
code 1
PMNOTGET
SC15
yes/no
TEMPMED1
SC16
text
TEMPMED2
SC16
text
TEMPMED3
SC16
text
TEMPMED4
SC16
text
TEMPMED5
SC16
text
SCINT2
SC17INTR
no entry
(CONDITION 1 FROM SC12AA)
(CONDITION 2 FROM SC12AA)
(CONDITION 3 FROM SC12AA)
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.
What were the names of those medicines?
ENTER ALL MEDICINES.
What were the names of those medicines?
ENTER ALL MEDICINES.
What were the names of those medicines?
ENTER ALL MEDICINES.
What were the names of those medicines?
ENTER ALL MEDICINES.
What were the names of those medicines?
ENTER ALL MEDICINES.
SHOW CARD SC3
This card lists some reasons people have given for not having
prescriptions filled or refilled.
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]
SCPMCODS
SCPMOTOS
SC17A
SC17A
code all
verbatim text
BOX SC2
routing
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.
OTHER (SPECIFY)
IF SC17A - SCPMCODS INCLUDES MORE THAN ONE RESPONSE,
GO TO SC18A - SCPMMAIN.
ELSE GO TO SC20 - GENERRX.
Which of these was the main reason [you/(SP)] did not obtain [this
medicine/these medicines] during (CURRENT YEAR)?
[READ REASONS BELOW IF NECESSARY.]
SCPMMAIN
SC18A
code 1
[MEDICINE 1 FROM SC16]
[MEDICINE 2 FROM SC16]
[MEDICINE 3 FROM SC16]
[MEDICINE 4 FROM SC16]
[MEDICINE 5 FROM SC16]
SHOW CARD SC4
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…
GENERRX
SC20
list
asked for generics instead of brand name drugs?
(01) DIDN'T THINK THE PROBLEM WAS
SERIOUS
(02) THOUGHT IT WOULD COST TOO MUCH
(03) TROUBLE FINDING/GETTING TO DOCTOR
(04) TIME/SCHEDULE OR PERSONAL
CONFLICTS
(05) THOUGHT DOCTOR COULDN'T DO MUCH
ABOUT PROBLEM
(06) WAS AFRAID OF FINDING OUT WHAT
WAS WRONG
(07) DOCTOR WOULD NOT ACCEPT MY
INSURANCE
(91) (OTHER/SC13A - SCROTOS OTHER
SPECIFY TEXT)
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[this condition] only one condition listed in previous questions (If
SC12AA - TEMPCOND2 = empty and SC12AA -TEMPCOND3 =
empty)
[these conditions] more than one condition listed in previous
questions
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
(01) [Continuous answer.]
(01) [Continuous answer.]
(-7) Empty
(01) [Continuous answer.]
(-7) Empty
(01) [Continuous answer.]
(-7) Empty
(01) [Continuous answer.]
(-7) Empty
SC15 - PMNOTGET
(01) SC16 - TEMPMED1
(02) SC20 - GENERRX
(-8) SC20 - GENERRX
(-9) SC20 - GENERRX
SC16 - TEMPMED2
(01) SC16 - TEMPMED3
(-7) SC17INTR - SCINT2
(01) SC16 - TEMPMED4
(-7) SC17INTR - SCINT2
(01) SC16 - TEMPMED5
(-7) SC17INTR - SCINT2
SC17INTR - SCINT2
(01) CONTINUE
(-7) Empty
SC17A - SCPMCODS
(01) THOUGHT IT WOULD COST TOO MUCH
(02) DIDN'T THINK MEDICINE WOULD HELP
CONDITION
(03) WAS AFRAID OF MEDICINE
REACTIONS/CONTRAINDICATIONS
(04) DON'T LIKE TO TAKE MEDICINE
(05) DIDN'T THINK MEDICINE WAS
NECESSARY
(06) NOT COVERED BY INSURANCE/NOT ON
PLAN FORMULARY
(07) TROUBLE OBTAINING MEDICINE
(08) OBTAINED/USED SAMPLES
(09) USED ANOTHER MEDICINE AS A
SUBSTITUTION
(91) (OTHER/SC17A - SCPMOTOS OTHER
SPECIFY TEXT)
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) BOX SC2
(02) BOX SC2
(03) BOX SC2
(04) BOX SC2
(05) BOX SC2
(06) BOX SC2
(07) BOX SC2
(08) BOX SC2
(09) BOX SC2
(91) SC17A - SCPMOTOS
(-8) SC20 - GENERRX
(-9) SC20 - GENERRX
BOX SC2
[you] respondent is SP
[(SP)] respondent is proxy
(01) THOUGHT IT WOULD COST TOO MUCH
(02) DIDN'T THINK MEDICINE WOULD HELP
CONDITION
(03) WAS AFRAID OF MEDICINE
REACTIONS/CONTRAINDICATIONS
(04) DON'T LIKE TO TAKE MEDICINE
(05) DIDN'T THINK MEDICINE WAS
NECESSARY
(06) NOT COVERED BY INSURANCE/NOT ON
PLAN FORMULARY
(07) TROUBLE OBTAINING MEDICINE
(08) OBTAINED/USED SAMPLES
(09) USED ANOTHER MEDICINE AS A
SUBSTITUTION
(91) (OTHER/SC17A - SCPMOTOS OTHER
SPECIFY TEXT)
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[this medicine] one medicine listed
[these medicines] more than one medicine listed
SC20 - GENERRX
(01) OFTEN
(02) SOMETIMES
(03) NEVER
(-8) Don't Know
(-9) Refused
[you have ] respondent is SP
[(SP) has] respondent is proxy
[Have you] respondent is SP
[has (SP)] respondent is proxy
SC20 - MAILRX
SHOW CARD SC4
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…
MAILRX
SC20
list
purchased prescription drugs through the mail or on the Internet?
SHOW CARD SC4
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…
DOSESRX
SC20
list
taken smaller doses than prescribed of a medicine to make the
medicine last longer?
SHOW CARD SC4
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…
SKIPRX
SC20
list
skipped doses to make the medicine last longer?
SHOW CARD SC4
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…
DELAYRX
SC20
list
delayed getting a prescription filled because the medicine cost too
much?
(01) OFTEN
(02) SOMETIMES
(03) NEVER
(-8) Don't Know
(-9) Refused
[you have ] respondent is SP
[(SP) has] respondent is proxy
[Have you] respondent is SP
[has (SP)] respondent is proxy
SC20 - DOSESRX
(01) OFTEN
(02) SOMETIMES
(03) NEVER
(-8) Don't Know
(-9) Refused
[you have ] respondent is SP
[(SP) has] respondent is proxy
[Have you] respondent is SP
[has (SP)] respondent is proxy
SC20 - SKIPRX
(01) OFTEN
(02) SOMETIMES
(03) NEVER
(-8) Don't Know
(-9) Refused
[you have ] respondent is SP
[(SP) has] respondent is proxy
[Have you] respondent is SP
[has (SP)] respondent is proxy
SC20 - DELAYRX
(01) OFTEN
(02) SOMETIMES
(03) NEVER
(-8) Don't Know
(-9) Refused
[you have ] respondent is SP
[(SP) has] respondent is proxy
[Have you] respondent is SP
[has (SP)] respondent is proxy
SC21 - SAMPLERX
[you have ] respondent is SP
[(SP) has] respondent is proxy
[Have you] respondent is SP
[has (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
SC21 - COMPARRX
(01) OFTEN
(02) SOMETIMES
(03) NEVER
(-8) Don't Know
(-9) Refused
[you have ] respondent is SP
[(SP) has] respondent is proxy
[Have you] respondent is SP
[has (SP)] respondent is proxy
SC21 - NOFILLRX
(01) OFTEN
(02) SOMETIMES
(03) NEVER
(-8) Don't Know
(-9) Refused
[you have ] respondent is SP
[(SP) has] respondent is proxy
[Have you] respondent is SP
[has (SP)] respondent is proxy
SC21 - SPENTLRX
(01) OFTEN
(02) SOMETIMES
(03) NEVER
(-8) Don't Know
(-9) Refused
[you have ] respondent is SP
[(SP) has] respondent is proxy
[Have you] respondent is SP
[has (SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
SC22 - CHAINRX
[you have ] respondent is SP
[(SP) has] respondent is proxy
[Have you] respondent is SP
[has (SP)] respondent is proxy
SC22 - STOPRX
[you have ] respondent is SP
[(SP) has] respondent is proxy
[Have you] respondent is SP
[has (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
SC22 - CREDRX
SHOW CARD SC4
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…
SAMPLERX
SC21
list
(01) OFTEN
(02) SOMETIMES
(03) NEVER
asked for or received free samples from (your/his/her) doctor or health (-8) Don't Know
provider?
(-9) Refused
SHOW CARD SC4
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…
COMPARRX
SC21
list
compared prices or shopped around for the best price?
SHOW CARD SC4
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…
NOFILLRX
SC21
list
decided not to fill a prescription because it cost too much?
SHOW CARD SC4
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…
SPENTLRX
SC21
list
spent less money on food, heat, or other basic needs so that
(you/he/she) would have money for medicine?
SHOW CARD SC4
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…
CHAINRX
SC22
list
(01) OFTEN
(02) SOMETIMES
(03) NEVER
purchased prescription drugs from a large retail chain, like Wal-Mart or (-8) Don't Know
Target, because of its discount plan?
(-9) Refused
SHOW CARD SC4
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…
STOPRX
SC22
list
talked with (your/his/her) doctor about stopping a medicine to save
money or substituting a medicine with one that is less expensive?
(01) OFTEN
(02) SOMETIMES
(03) NEVER
(-8) Don't Know
(-9) Refused
SHOW CARD SC4
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…
CREDRX
SC22
list
(01) OFTEN
(02) SOMETIMES
(03) NEVER
used a credit card so that (you/he/she) could pay for prescription drugs (-8) Don't Know
over time?
(-9) Refused
SHOW CARD SC4
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.
NOINSRX
SC23
BOX SCEND
code 1
routing
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?
GO TO NEXT SECTION
(01) OFTEN
(02) SOMETIMES
(03) NEVER
(-8) Don't Know
(-9) Refused
[you have ] respondent is SP
[(SP) has] respondent is proxy
[Have you] respondent is SP
[has (SP)] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
SC23 - NOINSRX
[you have] respondent is SP
[(SP) has] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
BOX SCEND
Usual Source of Care (USQ)/Patient Perceptions of Integrated Care (PPIC): Sections have been merged and de-duplicated
Variable Name
MR Screen Name
Question type Question text/description
Code list
Text fills
Routing
[you] respondent is SP
[(SP)] respondent is proxy
PLACEPAR
US1
yes/no
Is there a particular medical person or a clinic [you/(SP)] usually [go/goes] to when [you are/he is/she is] sick or for advice about [your/his/her] health?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[go] respondent is SP
[goes] respondent is proxy
[you are] respondent is SP
[he is] respondent is proxy, SP is male
[she is] respondent is proxy, SP is female
(01) US2 - PLACEKND
(02) US39 - NUSNOTSK
(-8) PP57-RATECARE
(-9) PP57-RATECARE
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
What kind of place [do you/does (SP)] usually go to when [you are/he is/she is] sick or for advice about [your/his/her] health -- is that a managed care plan or HMO center, a clinic, a
medical provider's office, a hospital, or some other place?
PLACEKND
US2
code one
IF CLINIC, ASK: Is it a hospital outpatient clinic, or some other kind of clinic?
IF SOME OTHER PLACE, ASK: Where is this?
PLACEOS
PLACEMCP
CLNAME
US2
text
OTHER (SPECIFY)
BOX USB
routing
IF SP WAS COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND, GO TO US2A - PLACEMCP.
ELSE IF US2 - PLACEKND = 1/DoctorsOffice, GO TO US5A - MDNAME.
ELSE GO TO US3A - CLNAME.
US2A
yes/no
Is this (medical provider/medical clinic) associated with (your/his/her) [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
BOX USC
routing
IF US2 - PLACEKND = 1/DoctorsOffice, GO TO US5A - MDNAME.
ELSE GO TO US3A - CLNAME.
US3A
verbatim text
What is the complete name of the [place/managed care plan or HMO center/(US2 RESPONSE)] that [you go to/(SP) goes to)?
[ENCOURAGE THE RESPONDENT TO REFER TO A BILL, TELEPHONE DIRECTORY, APPOINTMENT CARD, ETC., FOR COMPLETE INFORMATION.]
(01) DOCTOR'S OFFICE OR GROUP PRACTICE
(02) MEDICAL CLINIC
(03) MANAGED CARE PLAN CENTER/HMO
(04) NEIGHBORHOOD/FAMILY HEALTH CENTER
(05) FREESTANDING SURGICAL CENTER
(06) RURAL HEALTH CLINIC
(07) COMPANY CLINIC
(08) OTHER CLINIC
(09) WALK-IN URGENT CENTER
(10) DOCTOR COMES TO SP'S HOME
(11) HOSPITAL EMERGENCY ROOM
(12) HOSPITAL OUTPATIENT DEPARTMENT/CLINIC
(13) VA FACILITY
(14) MENTAL HEALTH CENTER
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
[do you] respondent is SP
[does (SP)] respondent is proxy
[you are] respondent is SP
[he is] respondent is proxy, SP is male
[she is] respondent is proxy, SP is female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
(01) CONTINUOUS ANSWER
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(01) BOX USB
(02) BOX USB
(03) US3A - CLNAME
(04) US3A - CLNAME
(05) US3A - CLNAME
(06) US3A - CLNAME
(07) US3A - CLNAME
(08) US3A - CLNAME
(09) US3A - CLNAME
(10) US5A - MDNAME
(11) US3A - CLNAME
(12) US3A - CLNAME
(13) US3A - CLNAME
(14) US3A - CLNAME
(91) US2 - PLACEOS
(-8) US3A - CLNAME
(-9) US3A - CLNAME
US3A - CLNAME
[medical provider] If US2 - PLACEKND=1/DoctorsOffice
[medical clinic] If US2 - PLACEKND is not equal to 1/DoctorsOffice
[your] - respondent is SP
[his] -respondent is proxy, SP is male
[her] - respondent is proxy, SP is female
[place] US2 - PLACEKND=DK or RF
[managed care plan or HMO center] US2 - PLACEKND=3/HMO
Else if US2 - PLACEKND=91/Other, display US2 Other specify response, US2 - PLACEOS.
Else display US2 - PLACEKND response.
BOX USC
US4 - USUALDOC
[you go to] respondent is SP
[(SP) goes to] respondent is proxy
[you usually see] respondent is SP
[(SP) usually sees] respondent is proxy
USUALDOC
US4
yes/no
Is there a particular medical provider [you usually see/(SP) usually sees] at this [place/managed care plan or HMO center/(US2 RESPONSE)] ?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
MDNAME
US5A
verbatim text
What is the complete name of that medical provider?
[ENCOURAGE THE RESPONDENT TO REFER TO A BILL, TELEPHONE DIRECTORY, APPOINTMENT CARD, ETC., FOR COMPLETE INFORMATION.]
(01) CONTINUOUS ANSWER
US5B-MDSEX
Is (US5A PROVIDER NAME) a male or female?
(01) MALE
(02) FEMALE
(-8) DON’T KNOW
(-9) REFUSED
US6A - MDSPEC
MDSEX
US5B
code one
[place] US2 - PLACEKND=DK or RF
[managed care plan or HMO center] US2 - PLACEKND=3/HMO
Else if US2 - PLACEKND=91/Other, display US2 Other specify response, US2 - PLACEOS.
Else display US2 - PLACEKND response.
(01) US5A - MDNAME
(02) BOX US1
(-8) US8 - GETUSHOW
(-9) US8 - GETUSHOW
MDSPEC
MDSPECOS
US6A
US6A
code one
SHOW CARD AC1
What is (US5A PROVIDER NAME)'s specialty?
[PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE CARD IF THEY MENTION A 'GENERIC' SPECIALITY LIKE ‘HEART DOCTOR.’ IF RESPONDENT ONLY GIVES A 'GENERIC' SPECIALTY
AND THE GENERIC WORD IS SHOWN IN PARENTHESES FOLLOWING ONE OF THE RESPONSES, SELECT THE RESPONSE CATEGORY FOR THAT SPECIALTY (E.G., 'CARDIOLOGY'). OTHERWISE
SELECT 'OTHER DR SPECIALTY'.]
(01) ALLERGY/IMMUNOLOGY
(02) ANESTHESIOLOGY
(03) CARDIOLOGY (HEART)
(05) DERMATOLOGY (SKIN)
(07) ENDOCRINOLOGY/ METABOLISM (DIABETES, THYROID)
(08) FAMILY PRACTICE
(09) GASTROENTEROLOGY
(10) GENERAL PRACTICE
(11) GENERAL SURGERY
(12) GERIATRICS (ELDERLY)
(13) GYNECOLOGY - OBSTETRICS
(14) HEMATOLOGY (BLOOD)
(15) HOSPITAL RESIDENCE
(16) INTERNAL MEDICINE (INTERNIST)
(17) NEPHROLOGY (KIDNEYS)
(18) NEUROLOGY
(19) NUCLEAR MEDICINE
(20) ONCOLOGY (TUMORS, CANCER)
(21) OPHTHALMOLOGY (EYES)
(22) ORTHOPEDICS
(24) OSTEOPATHY (DO)
(25) OTORHINOLARYNGOLOGY (EAR, NOSE, THROAT)
(26) PATHOLOGY
(27) PHYS MED/REHAB
(28) PLASTIC SURGERY
(29) PROCTOLOGY
(30) PSYCHIATRY/PSYCHIATRIST
(31) PULMONARY (LUNGS)
(32) RADIOLOGY
(33) RHEUMATOLOGY (ARTHRITIS)
(34) THORACIC SURGERY (CHEST)
text
OTHER DR SPECIALTY (SPECIFY)
[PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE CARD IF THEY MENTION A 'GENERIC' SPECIALITY LIKE ‘HEART DOCTOR.’ IF RESPONDENT ONLY GIVES A 'GENERIC' SPECIALTY
AND THE GENERIC WORD IS SHOWN IN PARENTHESES FOLLOWING ONE OF THE RESPONSES, SELECT THE RESPONSE CATEGORY FOR THAT SPECIALTY (E.G., 'CARDIOLOGY'). OTHERWISE
SELECT 'OTHER DR SPECIALTY'.]
(01) CONTINUOUS ANSWER
(01)-(05) BOX US1
(07)-(35) BOX US1
(91) US6A - MDSPECOS
(-8) BOX US1
(-9) BOX US1
BOX US1
BOX US1
routing
IF US2 - PLACEKND = 10/AtHome, GO TO US15 - USHOWLNG.
ELSE GO TO US8 - GETUSHOW.
How [do you/does (SP)] usually get to [(US5A PROVIDER NAME)'S office/(US3A PROVIDER NAME)]?
(01) WALKING
(02) DRIVING
(03) BEING DRIVEN
(04) AMBULANCE OR OTHER SPECIAL VEHICLE
(05) TAXI
(06) OTHER PUBLIC TRANSPORTATION
(07) DR. USUALLY COMES TO HOME
(91) SOME OTHER WAY
(-8) DON'T KNOW
(-9) REFUSED
GETUSHOW
US8
code one
GETUSOS
US8
verbatim text
SOME OTHER WAY (SPECIFY)
GETUSUNT
US9
code one
About how long does it usually take for [you/(SP)] to get there?
GETUSHRS
US9
numeric
(01) CONTINUOUS ANSWER
GETUSMIN
US9
numeric
(01) CONTINUOUS ANSWER
[EXPLAIN IF NEEDED: [Do you/Does (SP)] get there by walking, driving, being driven by someone else, by ambulance or other special vehicle for disabled people, by taxi, other public
transportation, or some other way?]
(01) continuous answer
(01) HOURS ONLY
(02) MINUTES ONLY
(03) HOURS AND MINUTES
(-8) DON'T KNOW
(-9) REFUSED
ACCOMPUS
US10
yes/no
[Do you/Does (SP)] usually have someone accompany [you/him/her] there?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PERSON_USUALGO
US11
roster
Who usually goes with [you/(SP)]?
SELECT OR ADD ONLY ONE PERSON
(01) CONTINUOUS ANSWER
PERSWITH
US11A1
code one
How often (are you/is that person) with [you/(SP)] while [you/(SP)] (see/sees) the medical provider or other medical person? Would you say always, sometimes, or never?
What are the reasons [you accompany (SP)/this person accompanies you/this person accompanies (SP)] there? What (do you/does this person) do?
ACCREAS
ACCOTHOS
US11AA
US11AA
code all
verbatim text
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.
OTHER (SPECIFY)
(01) ALWAYS
(02) SOMETIMES
(03) NEVER
(-8) DON'T KNOW
(-9) REFUSED
(01) WRITES DOWN WHAT DOCTOR SAYS/RECORDS
INSTRUCTIONS/TAKES NOTES/REMEMBERS
(02) GIVES INFORMATION/EXPLAINS SP'S MEDICAL
CONDITION OR NEEDS TO THE DOCTOR
(03) EXPLAINS DOCTOR’S INSTRUCTIONS TO SP
(04) ASKS QUESTIONS
(05) TRANSLATES LANGUAGE
(06) SCHEDULES APPOINTMENTS
(07) NOTHING/KEEPS SP COMPANY/SITS WITH SP/MORAL
SUPPORT
(08) TRANSPORTATION
(09) SP NEEDS PHYSICAL ASSISTANCE
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(01) US9 - GETUSUNT
(02) US9 - GETUSUNT
(03) US9 - GETUSUNT
(04) US9 - GETUSUNT
If (US2 - PLACEKND=1/DoctorsOffice) or (US4 - USUALDOC=1/Yes), Display "(US5A PROVIDER NAME)'S
(05) US9 - GETUSUNT
office". Display US5A - MDNAME provider name.
(06) US9 - GETUSUNT
Else Display "(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
(07) US15 - USHOWLNG
(91) US8 - GETUSOS
[Do you] respondent is SP
(-8) US15 - USHOWLNG
[Does (SP)] respondent is proxy
(-9) US15 - USHOWLNG
[do you] respondent is SP
[does (SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
US9 - GETUSUNT
(01) US9 - GETUSHRS
(02) US9 - GETUSMIN
(03) US9 - GETUSHRS
(-8) US10 - ACCOMPUS
(-9) US10 - ACCOMPUS
If US9 GETUSUNT=3/HoursAndMinutes go to US9 GETUSMIN.
Else go to US10 - ACCOMPUS.
US10 - ACCOMPUS
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
[you] respondent is SP
[(SP)] respondent is proxy
(01) US11 - PERSON_USUALGO
(02) US15 - USHOWLNG
(-8) US15 - USHOWLNG
(-9) US15 - USHOWLNG
US11A1 - PERSWITH
[are you] respondent is proxy
[is that person] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
US11AA - ACCREAS
[see] respondent is SP
[sees] respondent is proxy
If proxy interview and person selected at US11 is proxy, display "you accompany (SP)".
Else if proxy interview and person selected at US11 is not the proxy, display "this person accompanies
(SP)".
Else display "this person accompanies you".
If proxy interview and person selected at US11 is proxy, display "do you".
Else display "does this person".
(01) US15 - USHOWLNG
(02) US15 - USHOWLNG
(03) US15 - USHOWLNG
(04) US15 - USHOWLNG
(05) US15 - USHOWLNG
(06) US15 - USHOWLNG
(07) US15 - USHOWLNG
(08) US15 - USHOWLNG
(09) US15 - USHOWLNG
(91) US11AA - ACCOTHOS
(-8) US15 - USHOWLNG
(-9) US15 - USHOWLNG
US15 - USHOWLNG
SHOW CARD US1
USHOWLNG
US15
code one
How long [have you/has (SP)] been [seeing (US5A PROVIDER NAME)/going to (US3A PROVIDER NAME)]?
(01) LESS THAN 1 YEAR
(02) 1 YEAR TO LESS THAN 3 YEARS
(03) 3 YEARS TO LESS THAN 5 YEARS
(04) 5 YEARS TO LESS THAN 10 YEARS
(05) 10 YEARS OR MORE
(-8) DON'T KNOW
(-9) REFUSED
[have you] respondent is SP
[has SP)] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "seeing
(US5A PROVIDER NAME)".
Display US5A - MDNAME provider name.
Else Display "going to (US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
(01) US17 - PREVMEDC
(02) PP1- REMINDAPPT
(03) PP1- REMINDAPPT
(04) PP1- REMINDAPPT
(05) PP1- REMINDAPPT
(-8) PP1- REMINDAPPT
(-9) PP1- REMINDAPPT
[you] respondent is SP
[(SP)] respondent is proxy
PREVMEDC
US17
yes/no
Before [you/(SP)] started [seeing (US5A PROVIDER NAME)/going to (US3A PROVIDER NAME)], had [you/(SP)] usually been going to some other place or seeing some other medical
provider for medical care?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "seeing
(US5A PROVIDER NAME)".
Display US5A - MDNAME provider name.
PP1- REMINDAPPT
Else Display "going to (US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
[you] respondent is SP
[(SP)] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)’s office". Display US5A - MDNAME provider name.
Else Display "(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
REMINDAPPT
PP1
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
yes/no
[your] respondent is SP
[(SP)'s] respondent is proxy
PP2- PREPARE
[you] respondent is SP
[he] respondent is proxy, SP is male
[she] respondent is proxy, SP is female
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)’s office". Display US5A - MDNAME provider name.
Else Display "(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
The next questions ask about the care [you/(SP)] received from [(US5A PROVIDER NAME)'S office/(US3A PROVIDER NAME)].
Some offices remind patients about appointments. Before [your/(SP)'s] most recent visit with [(US5A PROVIDER NAME)/(US3A PROVIDER NAME) ], did [you/he/she] get a reminder from
[(US5A PROVIDER NAME)'S office /(US3A PROVIDER NAME)] about the appointment?
[your] respondent is SP
[(SP)'s] respondent is proxy
PREPARE
PP2
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
yes/no
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER NAME)".
Display US3A - CLNAME provider name.
[you] respondent is SP
[he] respondent is proxy, SP is male
[she] respondent is proxy, SP is female
PP3- APPTCANCEL
[you] respondent is SP
[him] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
Before [your/(SP)'s] most recent visit with [(US5A PROVIDER NAME)/(US3A PROVIDER NAME)], did [you/he/she] get instructions telling [you/him/her] what to expect or how to prepare?
APPTCANCEL
PP3
code one
Now I’m going to read you questions about the medical providers you have seen in the last six months, that is since {CurrentMonth – 6}.
In the last six months, how often has [(US5A PROVIDER NAME)/(US3A PROVIDER NAME)] canceled or changed the date of an appointment?
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
APPTMISS
PP4
code one
People have busy lives and miss appointments for many reasons. In the last six months, how often did [you/(SP)] miss an appointment with [(US5A PROVIDER NAME)/(US3A PROVIDER
NAME)]?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER NAME)". PP4- APPTMISS
Display US3A - CLNAME provider name.
[you] respondent is SP
[(SP)] respondent is proxy
(01) PP6- PPREPEAT
(02) PP5- APPTNEW
(03) PP5- APPTNEW
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
(04) PP5- APPTNEW
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER NAME)".
(-8) PP6- PPREPEAT
Display US3A - CLNAME provider name.
(-9) PP6- PPREPEAT
[you] respondent is SP
[(SP)] respondent is proxy
SHOW CARD US2
APPTNEW
PP5
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, when [ you/(SP)] missed an appointment with US5A PROVIDER NAME/US3A PROVIDER NAME), how often did someone from [(US5A PROVIDER NAME)'S
office/(US3A PROVIDER NAME)] contact [you/him/her] to make a new appointment?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER NAME)".
Display US3A - CLNAME provider name.
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)’s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
[you] respondent is SP
[him] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
PP6- PPREPEAT
SHOW CARD US2
PPREPEAT
PP6
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, how often did [you/(SP) have to repeat information that [you/(SP)] had already provided during the same visit?
SHOW CARD US2
PPINFO
PP7
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] seem to know the important information about [your/(SP)'s] medical
history?
SHOW CARD US2
DOCLIFE
PP8
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] ask about things in [your/(SP)'s] work or life at home that affect
[your/(SP)'s] life?
SHOW CARD US2
EXPLAINEASY
PP9
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] explain things in a way that was easy [for (SP)] to understand?
PPLISTEN
PP10
code one
SHOW CARD US2
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
PP7- PPINFO
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
PP8- DOCLIFE
[your] respondent is SP
[(SP)'s] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
PP9- EXPLAINEASY
[your] respondent is SP
[(SP)'s] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
PP10- PPLISTEN
[for (SP)] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
PP11- PPRESPECT
[you] respondent is SP
[(SP)] respondent is proxy
In the last six months, how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] listen carefully to [you/(SP)]?
SHOW CARD US2
PPRESPECT
PP11
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] show respect for what [you/(SP)] had to say?
SHOW CARD US2
ENOUGHTIME
PP12
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] spend enough time with [you/(SP)]?
SHOW CARD US2
PPIDEAS
PP13
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] ask whether [you/(SP)] had ideas about how to improve [your/his/her]
health?
PPVALUE
PP14
code one
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
PP12- ENOUGHTIME
[you] respondent is SP
[(SP)] respondent is proxy
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
(01) POOR
(02) FAIR
How would you rate [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] knowledge of [your/(SP)'s] values and beliefs that are important to [your/his/her] health (03) GOOD
care?
(04) EXCELLENT
(-8) Don't Know
(-9) Refused
PP13- PPIDEAS
[you] respondent is SP
[(SP)] respondent is proxy
PP14- PPVALUE
[you] respondent is SP
[(SP)] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
PP15- SETGOAL
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
SETGOAL
PP15
code one
In the last six months, did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] talk with [you/(SP)] about setting goals for [your/his/her] health?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
(01) PP16- MEETGOAL
(02) PP16- MEETGOAL
(03) PP17-OSTAFF
(-8) PP17-OSTAFF
(-9) PP17-OSTAFF
[you] respondent is SP
[(SP)] respondent is proxy
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
MEETGOAL
PP16
code one
In the last six months, did the care [you/(SP)] received from [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] help [you/(SP)] meet [your/his/her] goals?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
SHOW CARD U+D46S3
USCKEVRY
USCOMPET
USUNWRNG
USHURRY
US27
US27
list
Now I am going to read some statements people have made about their health care. Think about the care [you receive/(SP) receives] from (US5A PROVIDER NAME/US3A PROVIDER
NAME). For each statement, please tell me whether you strongly agree, agree, disagree, or strongly disagree.
[(US5A PROVIDER NAME) is/The medical providers at (US3A PROVIDER NAME) are] very careful to check everything when examining (you/him/her).
SHOW CARD US3
[(US5A PROVIDER NAME) is/The medical providers at (US3A PROVIDER NAME) are] competent and well-trained.
list
US27
list
US27
list
SHOW CARD US3
[(US5A PROVIDER NAME) has/The medical providers at (US3A PROVIDER NAME) have] a complete understanding of the things that are wrong with [you/him/her].
SHOW CARD US3
[(US5A PROVIDER NAME) often seems/The medical providers at (US3A PROVIDER NAME)]) often (seem/seems)] to be in a hurry.
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
US27-USCKEVRY
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
[you receive] respondent is SP
[(SP) receives] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name.
Else Display "(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME) is".
Display US5A - MDNAME provider name.
US27 - USCOMPET
US27-USUNWRNG
Else Display "The medical providers at (US3A PROVIDER NAME) are". Display US3A - CLNAME provider
name.
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME) has".
Display US5A - MDNAME provider name.
Else Display "The medical providers at (US3A PROVIDER NAME) have". Display US3A - CLNAME provider
US27 - USHURRY
name.
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME) often seems".
Display US5A - MDNAME provider name.
US32 - USEXPPRB
Else Display "The medical providers at (US3A PROVIDER NAME) often seem". Display US3A - CLNAME
provider name.
[you] respondent is SP
[(SP)] respondent is proxy
[receive] respondent is SP
[receives] respondent is proxy
SHOW CARD US2 US3
USEXPPRB
US32
list
[Think about the care [you/(SP)] [receive/receives] from [(US5A PROVIDER NAME)/(US3A PROVIDER NAME)].]
/[(US5A PROVIDER NAME) often does/The medical providers at (US3A PROVIDER NAME)]) often (does/do)] not explain (your/his/her) medical problems to (you/him/her).
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display “(US5A
PROVIDER NAME)”. Else Display “(US3A PROVIDER NAME)”. Display US3A - CLNAME provider name.
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display “(US5A
PROVIDER NAME) often does”. Else Display “The medical providers at (US3A PROVIDER NAME) often
do”. Display US3A - CLNAME provider name.
US32 - USDISCUS
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
USDISCUS
US32
list
SHOW CARD US3
[You/(SP)] often (have/has) health problems that should be discussed but are not.
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
[You] respondent is SP
[(SP)] respondent is proxy
[have] respondent is SP
[has] respondent is proxy
US32 - USFAVOR
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display “(US5A
PROVIDER NAME) often acts”. Else Display “The medical providers at (US3A PROVIDER NAME) often
act”. Display US3A - CLNAME provider name.
USFAVOR
US32
list
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
SHOW CARD US3
(04) STRONGLY DISAGREE
[(US5A PROVIDER NAME) often acts/The medical providers at (US3A PROVIDER NAME) often act] as though [(he/she) was/they were] doing [you/(SP)] a favor by talking to (you/him/her).
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(he/she)
was".
Always display "(he/she)" in parenthesis.
Else display "they were".
US32 - USTELALL
[you] respondent is SP
[(SP)] respondent is proxy
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME) tells".
Else Display "The medical providers at (US3A PROVIDER NAME) tell". Display US3A - CLNAME provider
name.
USTELALL
US32
list
SHOW CARD US3
[(US5A PROVIDER NAME) tells/The medical providers at (US3A PROVIDER NAME) tell] (you/him/her) all (you want/he wants/she wants) to know about (your/his/her) condition and
treatment.
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
US32 - USANSQUX
[you want] respondent is SP
[he wants] respondent is proxy, SP male
[she wants] respondent is proxy, SP female
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
USANSQUX
US32
list
SHOW CARD US3
[(US5A PROVIDER NAME) answers/The medical providers at (US3A PROVIDER NAME) answer] all (your/his/her) questions.
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME) answers".
Else Display "The medical providers at (US3A PROVIDER NAME) answer". Display US3A - CLNAME
provider name.
US37 - USCONFID
[your] respondent is SP
[his] respondent is proxy
[her] respondent is SP
[you] respondent is SP
[(SP)] respondent is proxy
[receive] respondent is SP
[receives] respondent is proxy
SHOW CARD US3
USCONFID
US37
list
[Think about the care [you/(SP)] (receive/receives) from (US5A PROVIDER NAME/US3A PROVIDER NAME).]
[You have/(SP) has] great confidence in (US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)].
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name.
Else Display "(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
US37 - USDEPEND
[You have] respondent is SP
[(SP) has] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name.
Else Display "The medical providers at (US3A PROVIDER NAME)". Display US3A - CLNAME provider
name.
Always display brackets around question text.
USDEPEND
US37
list
SHOW CARD US3
[You depend/(SP) depends)] on [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] in order to feel better both physically and emotionally.
People often get instructions about their health from more than one person in the same office, such as other medical providers, nurses, nutritionists, and social workers.
OSTAFF
PP17
yes/no
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, did [you/(SP)] get any instructions about your health from any other staff [in (US5A PROVIDER NAME)'s office/ at (US3A PROVIDER NAME)]?
SHOW CARD US2
OSAWARE
PP18
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, how often did these other staff seem up-to-date about the care [you were/(SP) was] receiving from [(US5A PROVIDER NAME)/the medical providers at (US3A
PROVIDER NAME)]?
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
[You depend] respondent is SP
[(SP) depends] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name.
Else Display "The medical providers at (US3A PROVIDER NAME)". Display US3A - CLNAME provider
name.
PP17-OSTAFF
[you] respondent is SP
[(SP)] respondent is proxy
(01) PP18- OSAWARE
(02) PP21- OSTEST
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "in (US5A
(-8) PP21- OSTEST
PROVIDER NAME)'s office". Display US5A - MDNAME provider name. Else Display "at (US3A PROVIDER (-9) PP21- OSTEST
NAME)". Display US3A - CLNAME provider name.
[you were] respondent is SP
[(SP) was] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
PP19- OSCARE
[you] respondent is SP
[(SP) ] respondent is proxy
SHOW CARD US2
OSCARE
PP19
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, how often did these other staff talk with [you/(SP)] about care [you/he/she] [were/was] receiving from [(US5A PROVIDER NAME)/the medical providers at (US3A
PROVIDER NAME)]?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
PP20- OSINFO
[you] respondent is SP
[he] respondent is proxy, SP is male
[she] respondent is proxy, SP is female
[were] respondent is SP
[was] respondent is proxy
SHOW CARD US2
OSINFO
PP20
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, how often did these other staff seem to know the important information about [your/(SP)'s] medical history?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP)'s ] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
PP21- OSTEST
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
The next set of questions ask about the care you received from [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office.
OSTEST
PP21
yes/no
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office order a blood test, x-ray, or other test for
[you/(SP)]?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[his] US5B-MDSEX = 01/MALE
[her] US5B-MDSEX = 02/FEMALE
[their] US5B-MDEX not in(01,02)
if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 01/MALE, FILL [his]
else if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 02/FEMALE, FILL [her]
else fill [their]
[you] respondent is SP
[(SP)] respondent is proxy
(01) PP22- OSFOLLOWUP
(02) PP25- PPHARD
(-8) PP25- PPHARD
(-9) PP25 - PPHARD
[his] US5B-MDSEX = 01/MALE
[her] US5B-MDSEX = 02/FEMALE
[their] US5B-MDEX not in(01,02)
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)'s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
SHOW CARD US2
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
OSFOLLOWUP
PP22
code one
In the last six months, when [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or someone from [his/her/their] office ordered a blood test, x-ray, or other test
for [you/(SP)], how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or someone from [his/her/their] office follow up to give [you/(SP)] those
results?
[his] US5B-MDSEX = 01/MALE
[her] US5B-MDSEX = 02/FEMALE
[their] US5B-MDEX not in(01,02)
if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 01/MALE, FILL [his]
else if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 02/FEMALE, FILL [her]
else fill [their]
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
PP23- REQUEST
[(US5A PROVIDER NAME)'s office/(US3A PROVIDER NAME)]
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)’s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
[his] US5B-MDSEX = 01/MALE
[her] US5B-MDSEX = 02/FEMALE
[their] US5B-MDEX not in(01,02)
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
REQUEST
PP23
code one
In the last six months, how often did [you/(SP)] have to request [your/his/her] test results before [you/he/she] got them?
SHOW CARD US2
TESTCLEAR
PP24
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, how often were [your/(SP)'s] test results presented in a way that was easy to understand?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
PP24- TESTCLEAR
[you] respondent is SP
[he] respondent is proxy, SP is male
[she] respondent is proxy, SP is female
[your] respondent is SP
[(SP)'s] respondent is proxy
PP25- PPHARD
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
PPHARD
PP25
code one
In the last six months, were there things that made it hard for [you/(SP)] to take care of your health?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[(SP)] respondent is proxy
(01) PP26- ASKHARD
(02) PP26 - ASKHARD
(03) PP28- PPIDENTIFY
(-8) PP28- PPIDENTIFY
(-9) PP28- PPIDENTIFY
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)'s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
ASKHARD
PP26
yes/no
In the last six months, did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office ask you about these things that made it hard
for [you/(SP)] to take care of [your/his/her] health?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[his] US5B-MDSEX = 01/MALE
[her] US5B-MDSEX = 02/FEMALE
[their] US5B-MDEX not in(01,02)
if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 01/MALE, FILL [his]
else if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 02/FEMALE, FILL [her]
else fill [their]
PP27- PLANHARD
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)'s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
PLANHARD
PP27
code one
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
In the last six months, did you and [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office come up with a plan to help [you/(SP)]
(03) NO
deal with the things that make it hard for [you/(SP)] to take care of [your/his/her] health?
(-8) DON'T KNOW
(-9) REFUSED
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
[his] US5B-MDSEX = 01/MALE
[her] US5B-MDSEX = 02/FEMALE
[their] US5B-MDEX not in(01,02)
if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 01/MALE, FILL [his]
else if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 02/FEMALE, FILL [her]
else fill [their]
PP28- PPIDENTIFY
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)'s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
SHOW CARD US2
PPIDENTIFY
PP28
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office help you identify the most
important things for [you/(SP)] to do for [your/his/her] health?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
[his] US5B-MDSEX = 01/MALE
[her] US5B-MDSEX = 02/FEMALE
[their] US5B-MDEX not in(01,02)
if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 01/MALE, FILL [his]
else if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 02/FEMALE, FILL [her]
else fill [their]
PP29- PPSERVICES
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
[you] respondent is SP
[(SP)] respondent is proxy
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
PPSERVICES
PP29
yes/no
In the last six months, did [you/(SP)] need services at home to help [you/him/her] take care of [your/his/her] health?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[him] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
(01) PP30- HELPGET
(02) PP31- PPINSTRUCTIONS
(-8) PP31- PPINSTRUCTIONS
(-9) PP31- PPINSTRUCTIONS
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)'s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
SHOW CARD US2
HELPGET
PP30
code one
(01) NEVER
(02) SOMETIMES
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
(03) USUALLY
(04) ALWAYS
In the last six months, how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office help [you/(SP)] get these services at (-8) Don't Know
home to take care of [your/his/her] health?
(-9) Refused
[his] US5B-MDSEX = 01/MALE
[her] US5B-MDSEX = 02/FEMALE
[their] US5B-MDEX not in(01,02)
if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 01/MALE, FILL [his]
else if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 02/FEMALE, FILL [her]
else fill [their]
PP31- PPINSTRUCTIONS
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)'s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
PPINSTRUCTIONS
PP31
yes/no
In the last six months, did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office give [you/(SP)] instructions about how to take
care of [your/his/her] health?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[his] US5B-MDSEX = 01/MALE
[her] US5B-MDSEX = 02/FEMALE
[their] US5B-MDEX not in(01,02)
if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 01/MALE, FILL [his]
else if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 02/FEMALE, FILL [her]
else fill [their]
(01) PP32- PPFOLLOWUP
(02) PP34- KNOWASK
(-8) PP34- KNOWASK
(-9) PP34- KNOWASK
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
SHOW CARD US2
PPFOLLOWUP
PP32
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, how often [were you/was (SP)] able to follow these instructions about taking care of [your/his/her] health?
SHOW CARD US2
INSTUHELP
PP33
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
code one
In the last six months, how often did the instructions [you/(SP)] received help [you/him/her] take care of [your/his/her] health?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
[were you] respondent is SP
[was (SP)] respondent is proxy
PP33- INSTUHELP
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
PP34- KNOWASK
[you] respondent is SP
[(SP)] respondent is proxy
KNOWASK
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
PP34
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, if [you /(SP)] had any trouble taking care of [your/his/her] health at home, would [you/he/she] know who to ask for help?
code one
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
PPMED
PP35
yes/no
In the last six months, did [you/(SP)] take any prescription medicine?
[THIS IS DIFFERENT FROM THE PRESCRIPTION DRUG WHERE WE ASK IF THE R HAD ANY PRESCRIPTIONS FILLED]
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[he] respondent is proxy, SP is male
[she] respondent is proxy, SP is female
PP35- PPMED
[you] respondent is SP
[(SP)] respondent is proxy
(01) PP36- HOWMED
(02) PP39-CONTACTBW
(-8) PP39-CONTACTBW
(-9) PP39-CONTACTBW
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)'s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
SHOW CARD US2
HOWMED
PP36
code one
(01) NEVER
(02) SOMETIMES
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
(03) USUALLY
(04) ALWAYS
In the last six months, how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office talk with [you/(SP)] about how [you (-8) Don't Know
were/he was/she was] supposed to take [your/his/her] medicine?
(-9) Refused
[his] US5B-MDSEX = 01/MALE
[her] US5B-MDSEX = 02/FEMALE
[their] US5B-MDEX not in(01,02)
if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 01/MALE, FILL [his]
else if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 02/FEMALE, FILL [her]
else fill [their]
[you] respondent is SP
[(SP)] respondent is proxy
PP37- ASPRESCRIBED
[you were] respondent is SP
[he was] respondent is proxy, SP is male
[she was] respondent is proxy, SP is female
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
SHOW CARD US2
ASPRESCRIBED
PP37
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
There are many reasons why people may not always be able to take their medicines as prescribed. In the last six months, how often [were you/was (SP)] able to take [your/his/her]
medicine as prescribed?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
[were you] respondent is SP
[was (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
PP38- REACTION
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)'s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
SHOW CARD US2
REACTION
PP38
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office talk with [you/(SP)] about what to
do if [you have/he has/she has] a bad reaction to [your/his/her] medicine?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
[his] US5B-MDSEX = 01/MALE
[her] US5B-MDSEX = 02/FEMALE
[their] US5B-MDEX not in(01,02)
if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 01/MALE, FILL [his]
else if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 02/FEMALE, FILL [her]
else fill [their]
[you] respondent is SP
[(SP)] respondent is proxy
PP39- CONTACTBW
[you have] respondent is SP
[he has] respondent is proxy, SP is male
[she has] respondent is proxy, SP is female
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)'s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
SHOW CARD US2
CONTACTBW
PP39
code one
(01) NEVER
(02) SOMETIMES
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
(03) USUALLY
(04) ALWAYS
In the last six months, how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office contact [you/(SP)] between visits to (-8) Don't Know
see how [you were/he was/she was] doing?
(-9) Refused
[his] US5B-MDSEX = 01/MALE
[her] US5B-MDSEX = 02/FEMALE
[their] US5B-MDEX not in(01,02)
if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 01/MALE, FILL [his]
else if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 02/FEMALE, FILL [her]
else fill [their]
PP40- MEDQAFTER
[you] respondent is SP
[(SP)] respondent is proxy
[you were] respondent is SP
[he was] respondent is proxy, SP is male
[she was] respondent is proxy, SP is female
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
MEDQAFTER
PP40
yes/no
In the last six months, did [you/(SP)] try to contact [(US5A PROVIDER NAME)'s office/(US3A PROVIDER NAME)] with a medical question after regular office hours?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[(SP)] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)'s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
(01) PP41- QTIMELY
(02) PP42- SPCLCARE
(-8) PP42- SPCLCARE
(-9) PP42- SPCLCARE
[you] respondent is SP
[(SP)] respondent is proxy
SHOW CARD US2
QTIMELY
PP41
code one
(01) NEVER
(02) SOMETIMES
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
(03) USUALLY
(04) ALWAYS
In the last six months, when [you/(SP)] tried to contact [(US5A PROVIDER NAME)'s office/(US3A PROVIDER NAME)] after regular office hours, how often did [you/he/she] get an answer to (-8) Don't Know
[your/his/her] medical question in a timely manner?
(-9) Refused
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)'s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
[you] respondent is SP
[he] respondent is proxy, SP is male
[she] respondent is proxy, SP is female
PP42-SPCLCARE
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
SHOW CARD US5 AC1
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
Specialists are medical providers who specialize in one area of health care. This card lists some examples of specialists.
SPCLCARE
PP42
yes/no
In the last six months, did [you/(SP)] receive care from any specialists outside the office of [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)]?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[(SP)] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
(01) PP43- DRINFORMED
(02) PP50- ADMITHOS
(-8) PP50 - ADMITHOS
(-9) PP50 - ADMITHOS
SHOW CARD US2
In general, how often (does/do) [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] seem informed and up-to-date about the care [you/(SP)] (get/gets) from
specialists?
DRINFORMED
PP43
[does] if (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes)
[do] if US3A-CLNAME is displayed below
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
code one
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
PP44- REMINDDR
[you] respondent is SP
[(SP)] respondent is proxy
[get] respondent is SP
[gets] respondent is proxy
SHOW CARD US2
In general, how often (do/does) [you/(SP)] have to remind [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] about care [you/(SP)] (receive/receives) from
specialists?
[does] respondent is proxy
[do] respondent is SP
[you] respondent is SP
[(SP)] respondent is proxy
REMINDDR
PP44
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
code one
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
PP45- SPCLSTPM
[you] respondent is SP
[(SP)] respondent is proxy
[receive] respondent is SP
[receives] respondent is proxy
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, did any specialists outside the [office of (US5A PROVIDER NAME)/(US3A PROVIDER NAME)] prescribe medicine for [you/(SP)]?
SPCLSTPM
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PP45
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "the office
of(US5A PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
[you] respondent is SP
[(SP)] respondent is proxy
(01) PP46- TALKPMS
(02) PP47- SPLKNOW
(-8) PP47 -SPLKNOW
(-9) PP47- SPLKNOW
yes/no
SHOW CARD US2
In general, how often (does/do) [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] talk with [you/(SP)] about the medicines prescribed by these specialists?
TALKPMS
PP46
code one
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
[does] if (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes)
[do] if US3A-CLNAME is displayed below
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NAME)". Display US3A - CLNAME provider name.
[you] respondent is SP
[(SP)] respondent is proxy
US37E1-SPCLNAME
The next questions ask about care [you/(SP)] received from the specialist [you/he/she] saw most often in the last six months outside the [office of (US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)].
[you] respondent is SP
[(SP)] respondent is proxy
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
First, what is the name of the specialist [you/(SP)] saw most often in the last six months?
SPCLNAME
US37E1
verbatim text
(01) continuous answer
(-8) DON’T KNOW
(-9) REFUSED
[you] respondent is SP
[he] respondent is proxy, SP is male
[she] respondent is proxy, SP is female
US37E2-SPCLSEX
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "office of
(US5A PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
SPCLSEX
US37E2
code one
Is [(US37E1 PROVIDER NAME)/the specialist you saw most often in the last six months] a male or female?
(01) MALE
(02) FEMALE
(-8) DON’T KNOW
(-9) REFUSED
[US37E1 PROVIDER NAME)] US37E1 NE -8 or -9
[the specialist you saw most often in the last six months] US37E1 in(-8,-9)
PP47- SPLKNOW
[you see] respondent is SP
[(SP) sees] respondent is proxy
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
SPLKNOW
PP47
code one
[(US37E1-SPCLNAME)] US37E1 NE -8 or -9
[this specialist] US37E1 in(-8,-9)
The next questions ask about care [you/(SP)] received from the specialist [you/he/she] saw most often in the last six months outside the [office of (US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)].
When [you see/(SP) sees] [(US37E1-SPCLNAME)/this specialist], does [he/she/he or she] seem to know enough information about [your/his/her] medical history?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
[he] US37E2 = 01
[she] US37E2 = 02
[this specialist] US37E2 NE 1 or 2
PP48- SPLREPEAT
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
[you see] ] respondent is SP
[(SP) sees] respondent is proxy
[(US37E1-SPCLNAME)] US37E1 NE -8 or -9
[this specialist] US37E1 in(-8,-9)
SPLREPEAT
PP48
code one
(01) NEVER
SHOW CARD US2
(02) SOMETIMES
(03) USUALLY
When [you see/(SP) sees] [(US37E1-SPCLNAME)/this specialist], how often [do you/does he/does she] have to repeat information that [you have/he has/she has] already given to [(US5A (04) ALWAYS
PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)]?
(-8) Don't Know
(-9) Refused
[do you] respondent is SP
[does he] respondent is proxy, SP is male
[does she] respondent is proxy, SP if female
PP49- SPLKNTEST
[you have] respondent is SP
[he has] respondent is proxy, SP is male
[she has] respondent is proxy, SP is female
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name. Else Display "the medical providers at
(US3A PROVIDER NA
[you see] ] respondent is SP
[(SP) sees] respondent is proxy
SPLKNTEST
PP49
SHOW CARD US2
code one
When [you see/(SP) sees] [(US37E1-SPCLNAME)/this specialist], how often does [he/she/he or she] seem to know [your/(SP)'s] important test results from other providers?
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
ADMITHOS
PP50
yes/no
In the last six months, [were you/was (SP)] admitted to a hospital overnight or longer?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[(US37E1-SPCLNAME)] US37E1 NE -8 or -9
[this specialist] US37E1 in(-8,-9)
[your] respondent is SP
[(SP)'s] respondent is proxy
[were you] respondent is SP
[was (SP)] respondent is proxy
PP50-ADMITHOS
(01) PP51- HOSFLWUP
(02) PP57- RATECARE
(-8) PP57- RATECARE
(-9) PP57- RATECARE
[your] respondent is SP
[(SP)'s] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)'s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
HOSFLWUP
PP51
yes/no
After [your/(SP)'s] most recent hospital stay, did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office contact [you/him/her]
to see how [you were/he was/she was] doing?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[his] US5B-MDSEX = 01/MALE
[her] US5B-MDSEX = 02/FEMALE
[their] US5B-MDEX not in(01,02)
if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 01/MALE, FILL [his]
else if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 02/FEMALE, FILL [her]
else fill [their]
PP52- HOSMED
[you] respondent is SP
[him] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
[you were] respondent is SP
[he was] respondent is proxy, SP is male
[she was] respondent is proxy, SP is female
HOSMED
PP52
yes/no
After [your/(SP)'S] most recent hospital stay, [were you/was (SP)] prescribed any medicines?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[your] respondent is SP
[(SP)'s] respondent is proxy
[were you] respondent is SP
[was (SP)] respondent is proxy
(01) PP53- HOSFOLLOWUP
(02) PP54- HOSINSTU
(-8) PP54- HOSINSTU
(-9) PP54- HOSINSTU
[your] respondent is SP
[(SP)'s] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)'s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
HOSFOLLOWUP
PP53
yes/no
After (your/(SP)'s)] most recent hospital stay, did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office contact [you/SP] to
check if [you were/he was/she was ] able to follow instructions about any medicines [you were/he was/she was] prescribed?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[his] US5B-MDSEX = 01/MALE
[her] US5B-MDSEX = 02/FEMALE
[their] US5B-MDEX not in(01,02)
if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 01/MALE, FILL [his]
else if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 02/FEMALE, FILL [her]
else fill [their]
PP54- HOSINSTU
[you] respondent is SP
[SP] respondent is proxy
[you were] respondent is SP
[he was] respondent is proxy, SP is male
[she was] respondent is proxy, SP is female
[you were] respondent is SP
[he was] respondent is proxy, SP is male
[she was] respondent is proxy, SP is female
[your] respondent is SP
[(SP)'s] respondent is proxy
HOSINSTU
PP54
yes/no
After (your/(SP)'s] most recent hospital stay, (were you/was he/was she] given instructions about caring for [yourself/himself/herself] at home?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[were you] respondent is SP
[was he] respondent is proxy, SP is male
[was she] respondent is proxy, SP is female
(01) PP55- INSTUEASY
(02) PP56- HOSINFO
(-8) PP56- HOSINFO
(-9) PP56- HOSINFO
[yourself] respondent is SP
[himself] respondent is proxy, SP is male
[herself] respondent is proxy, SP is female
After [your/(SP)'s] most recent hospital stay, were the instructions [you were/(SP) was] given easy to understand?
INSTUEASY
PP55
code one
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
HOSINFO
PP56
code one
After (your/(SP)'s) most recent hospital stay, did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] seem to know the important information about this
hospital stay?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
SHOW CARD PP1
RATECARE
PP57
code one
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all [your/(SP)'s) health care in the
last six months?
SHOW CARD PP2
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
RATEMANAGE
PP58
code one
People sometimes need to manage their medical care by making appointments with multiple providers, following their instructions, and taking medicines as prescribed.
Using any number from 0 to 10, where 0 is hard and 10 is easy, what number would you use to rate how easy it was for [you/(SP)] to manage [your/his/her] medical care in the last six
months?
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
DOCKNOWALL
PP59
code one
In the last six months, was there one provider who knew about all [your/(SP)'s] medical care needs?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
KNOWMEDS
PP60
code one
In the last six months, was there one provider who knew about all the medicines [you were/(SP) was] taking?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
KNOWPERSON
PP61
code one
In the last six months, was there one provider who knew [you/(SP)] well as a person?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
(00) 0 WORST HEALTH CARE POSSIBLE
(01) 1
(02) 2
(03) 3
(04) 4
(05) 5
(06) 6
(07) 7
(08) 8
(09) 9
(10) 10 BEST HEALTH CARE POSSIBLE
(00) 0 HARD TO MANAGE
(01) 1
(02) 2
(03) 3
(04) 4
(05) 5
(06) 6
(07) 7
(08) 8
(09) 9
(10) 10 EASY TO MANAGE
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
[your] respondent is SP
[(SP)'s] respondent is proxy
PP56- HOSINFO
[you were] respondent is SP
[(SP) was] respondent is proxy
[your] respondent is SP
[(SP)'s] respondent is proxy
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)'s office". Display US5A - MDNAME provider name. Else Display "(US3A PROVIDER
NAME)". Display US3A - CLNAME provider name.
[your] respondent is SP
[(SP)'s] respondent is proxy
PP57- RATECARE
PP58- RATEMANAGE
[your] respondent is SP
[(SP)'s] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
PP59- DOCKNOWALL
[your] respondent is SP
[(SP)'s] respondent is proxy
PP60- KNOWMEDS
[you were] respondent is SP
[(SP) was] respondent is proxy
PP61- KNOWPERSON
[you] respondent is SP
[(SP)] respondent is proxy
PP62- PROB_INFO
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
The next questios are about problems you might have had with your health care.
PROB_INFO
PP62
code one
SHOWCARD PP3
In the last six months, how much of a problem was each of these to [you/(SP)]?
(01) NOT A PROBLEM AT ALL
(02) A SMALL PROBLEM
(03) A MODERATE PROBLEM
(04) A BIG PROBLEM
(05) A VERY BIG PROBLEM
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP)'s] respondent is proxy
PP63- PROB_TRMT
Lack of information about [your/(SP)'s] medical conditions?
SHOWCARD PP3
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
PROB_TRMT
PP63
code one
[IF NEEDED: In the last six months, how much of a problem was each of these to [you/(SP)]?]
Lack of information about treatment options?
SHOWCARD PP3
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
PROB_CNCRNS
PP64
code one
[IF NEEDED: In the last six months, how much of a problem was each of these to [you/(SP)]?]
Bringing up concerns about [your/(SP]'S] health or health care with [your/his/her] providers?
(01) NOT A PROBLEM AT ALL
(02) A SMALL PROBLEM
(03) A MODERATE PROBLEM
(04) A BIG PROBLEM
(05) A VERY BIG PROBLEM
(-8) DON'T KNOW
(-9) REFUSED
(01) NOT A PROBLEM AT ALL
(02) A SMALL PROBLEM
(03) A MODERATE PROBLEM
(04) A BIG PROBLEM
(05) A VERY BIG PROBLEM
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[(SP)] respondent is proxy
PP64- PROB_CNCRNS
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP)'s] respondent is proxy
PP65- ASST_MED
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
In the last six months, did [you/(SP)] ever need assistance with the following?
ASST_MED
PP65
code one
Taking medicines
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[(SP)] respondent is proxy
(01) PP65A
(02) PP65A
(03) PP66-ASST_MNGE
(-8) PP66-ASST_MNGE
(-9) PP66-ASST_MNGE
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
PP65A
code one
In the last six months, did one or more friends or relatives help [you/(SP)] with taking medicines?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[(SP)] respondent is proxy
PP66-ASST_MNGE
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
[IF NEEDED: In the last six months, did [you/(SP)] ever need assistance with the following?]
ASST_MNGE
PP66
code one
Making medical-related appointments
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[(SP)] respondent is proxy
Always display (In the last six months…) in parentheses
(01) PP66A
(02) PP66A
(03) PP67- ASST_TRANSPORT
(-8) PP67- ASST_TRANSPORT
(-9) PP67- ASST_TRANSPORT
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
PP66A
code one
In the last six months, did one or more friends or relatives help [you/(SP)] with making medical-related appointments?
[IF NEEDED: In the last six months, did [you/(SP)] ever need assistance with the following?]
ASST_TRANSPORT
PP67
code one
Getting to or from a medical appointment
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
PP67A
code one
In the last six months, did one or more friends or relatives help [you/(SP)] with getting to or from a medical appointment?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
Always display (In the last six months…) in parentheses
[you] respondent is SP
[(SP)] respondent is proxy
PP67- ASST_TRANSPORT
(01) PP67A
(02) PP67A
(03) PP68- ASST_UNDSTND
(-8) PP68- ASST_UNDSTND
(-9) PP68- ASST_UNDSTND
PP68- ASST_UNDSTND
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
[IF NEEDED: In the last six months, did [you/(SP)] ever need assistance with the following?]
ASST_UNDSTND
PP68
code one
Understanding information from a health care provider
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[(SP)] respondent is proxy
Always display (In the last six months…) in parentheses
(01) PP68A
(02) PP68A
(03) PP70- AGREE_INTRO
(-8) PP70- AGREE_INTRO
(-9) PP70- AGREE_INTRO
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
PP68A
code one
In the last six months, did one or more friends or relatives help [you/(SP)] with understanding information from a health care provider?
Now I’m going to ask you two questions about all the doctors you have seen in the last two years.
RECORDNA
UNMEDTST
US37I
US37J
code one
code one
In the last two years, when getting care for a medical problem, was there ever a time when test results, medical records, or reasons for referrals were not available at the time of
[your/(SP)’s] scheduled doctor’s appointment?
In the last 2 years, when getting care for a medical problem, was there ever a time when medical providers ordered a medical test that [you/(SP)] felt was unnecessary because the test
had already been done?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[(SP)] respondent is proxy
US37I-RECORDNA
(01) YES
(02) NO
(03) NOT APPLICABLE
(04) NOT SURE
(-9) Refused
[your] respondent is SP
[(SP)'s] respondent is proxy
US37J-UNMEDTST
(01) YES
(02) NO
(03) NOT APPLICABLE
(04) NOT SURE
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
US37K - EMEDREC
EMEDREC
US37K
yes/no
Many health care providers are beginning to use electronic or computer-based medical records instead of using paper-based records. When you visit [(US5A PROVIDER NAME)/the
medical providers at (US3A PROVIDER NAME)] [does he or she/do they] generally enter your health information into a computer while you are present?
[EXPLAIN IF NEEDED: An “electronic health record” is an electronic version of a patient’s medical history maintained by a provider over time. It automates the way in which doctors can
access patient health information. "Health Information" includes information such as symptoms, vital signs, test results, or prescribed medicines.]
BOX PP2
routing
IF US1-PLACEPAR = 2 (NO) GO TO US39-NUSNOTSK
OTHERWISE GO TO BOX PP70
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "(US5A
PROVIDER NAME)". Display US5A - MDNAME provider name.
Else Display "the medical providers at (US3A PROVIDER NAME)". Display US3A - CLNAME provider
name.
If (US2 - PLACEKND=1/DoctorsOffice or 10/AtHome) or (US4 - USUALDOC=1/Yes), Display "does he or
she".
Else Display "do they".
if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 01/MALE, FILL [does he]
else if (US2-PLACEKND IN (1,10) or US4-USUSALDOC=1) AND US5B-MDSEX = 02/FEMALE, FILL [does
she]
else fill [do they]
BOX PP2
[you do] respondent is SP
[(SP) does] respondent is proxy
NUSNOTSK
US39A
list
I am going to read some reasons that people have given for not having a usual source of health care. For each one, please tell me whether or not it is a reason [you do/(SP) does] not
have a usual place for health care.
There is no reason to have a usual source of health care because [you/(SP)] seldom or never (get/gets) sick. [Is that a reason [you do/(SP) does] not have a usual source of health care?]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[(SP)] respondent is proxy
US39 - NUSMOVIN
[get] respondent is SP
[gets] respondent is proxy
Always display "[Is that a reason…]" in brackets.
NUSMOVIN
US39B
list
[You/(SP)] recently moved into the area. [Is that a reason [you do/(SP) does] not have a usual source of health care?]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[You] respondent is SP
[(SP)] respondent is proxy
[you do] respondent is SP
[(SP) does] respondent is proxy
US39 - NUSAVAIL
Always display "[Is that a reason…]" in brackets.
NUSAVAIL
US39C
list
[Your/(SP’s)] usual source of health care in this area is no longer available. [Is that a reason [you do/(SP) does] not have a usual source of health care?]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[Your] respondent is SP
[(SP)] respondent is proxy
[you do] respondent is SP
[(SP) does] respondent is proxy
(01) US42 - USWHYNAV
(02) US43 - NUSDIFFP
(-8) US43 - NUSDIFFP
(-9) US43 - NUSDIFFP
Always display "[Is that a reason…]" in brackets.
USWHYNAV
US42
code one
Why is [your/(SP’s)] usual source of health care no longer available?
(01) PREVIOUS DOCTOR RETIRED
(02) PREVIOUS DOCTOR DIED
(03) PREVIOUS DOCTOR MOVED
(04) SP MOVED
(05) PREVIOUS DR/PLACE TOO FAR AWAY
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
USWHYNO1
US42
verbatim text
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
[your] respondent is SP
[(SP)'s] respondent is proxy
(01) US43 - NUSDIFFP
(02) US43 - NUSDIFFP
(03) US43 - NUSDIFFP
(04) US43 - NUSDIFFP
(05) US43 - NUSDIFFP
(91) US42 - USWHYNO1
(-8) US43 - NUSDIFFP
(-9) US43 - NUSDIFFP
US43 - NUSDIFFP
[you] respondent is SP
[(SP)] respondent is proxy
Thinking about other possible reasons that people have for not having a usual source of health, please tell me if this statement applies to [you/(SP)]:
NUSDIFFP
US43
list
[You like/(SP) likes] to go to different places for different health care needs. [Is that a reason [you do/(SP) does] not have a usual source of health care?]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[you like] respondent is SP
[(SP) likes)] respondent is proxy
US43 - NUSTOOFR
[you do] respondent is respondent is SP
[(SP) does] respondent is proxy
Always display "[Is that a reason…]" in brackets.
NUSTOOFR
US43
list
The places where [you/(SP)] can receive health care are too far away. [Is that a reason [you do/(SP) does] not have a usual source of health care?]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[you] respondent is SP
[(SP)] respondent is proxy
[you do] respondent is respondent is SP
[(SP) does] respondent is proxy
US43 - NUSTOOEX
Always display "[Is that a reason…]" in brackets.
NUSTOOEX
US43
BOX PP70
AGREE_INTRO
PP70
list
routing
The cost of health care is too expensive. [Is that a reason [you do/(SP) does] not have a usual source of health care?]
PP71
[you do] respondent is respondent is SP
[(SP) does] respondent is proxy
BOX PP70
Always display "[Is that a reason…]" in brackets.
If respondent = proxy, go to BOX USEND
else go to PP70-AGREE_INTRO
Please indicate how much you agree or disagree with each of the following statements. Please be as honest and as accurate as you can. Try not to let your response to one statement
influence your response to other statements. There are no "correct" or "Incorrect" answers. Answer according to your own feelings, rather than how you think "most people" would
answer.
SHOW CARD PPX4
AGREE_BEST
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[IF NEEDED: Please indicate how much you agree or disagree with the following statement.]
In uncertain times, I usually expect the best.
(01) CONTINUE
PP71- AGREE_BEST
(01) AGREE A LOT
(02) AGREE A LITTLE
(03) NEITHER AGREE NOR DISAGREE
(04) DISAGREE A LITTLE
(05) DISAGREE A LOT
(-8) DON'T KNOW
(-9) REFUSED
PP72- AGREE_RELAX
SHOW CARD PP4
AGREE_RELAX
PP72
[IF NEEDED: Please indicate how much you agree or disagree with the following statement.]
It is easy for me to relax.
SHOW CARD PP4
AGREE_WRONG
PP73
[IF NEEDED: Please indicate how much you agree or disagree with the following statement.]
If something can go wrong for me, it will.
SHOW CARD PP4
AGREE_OPTMSTC
PP74
[IF NEEDED: Please indicate how much you agree or disagree with the following statement.]
I am always optimistic about my future.
SHOW CARD PP4
AGREE_WAY
PP75
[IF NEEDED: Please indicate how much you agree or disagree with the following statement.]
I hardly ever expect things to go my way.
SHOW CARD PP4
AGREE_GOOD
PP76
[IF NEEDED: Please indicate how much you agree or disagree with each of the following statements.]
I rarely count on good things happening to me.
SHOW CARD PP4
AGREE_BAD
PP77
[IF NEEDED: Please indicate how much you agree or disagree with the following statement.]
Overall, I expect more good things to happen to me than bad.
(01) AGREE A LOT
(02) AGREE A LITTLE
(03) NEITHER AGREE NOR DISAGREE
(04) DISAGREE A LITTLE
(05) DISAGREE A LOT
(-8) DON'T KNOW
(-9) REFUSED
PP73- AGREE_WRONG
(01) AGREE A LOT
(02) AGREE A LITTLE
(03) NEITHER AGREE NOR DISAGREE
(04) DISAGREE A LITTLE
(05) DISAGREE A LOT
(-8) DON'T KNOW
(-9) REFUSED
PP74- AGREE_OPTMSTC
(01) AGREE A LOT
(02) AGREE A LITTLE
(03) NEITHER AGREE NOR DISAGREE
(04) DISAGREE A LITTLE
(05) DISAGREE A LOT
(-8) DON'T KNOW
(-9) REFUSED
PP75- AGREE_WAY
(01) AGREE A LOT
(02) AGREE A LITTLE
(03) NEITHER AGREE NOR DISAGREE
(04) DISAGREE A LITTLE
(05) DISAGREE A LOT
(-8) DON'T KNOW
(-9) REFUSED
PP76- AGREE_GOOD
(01) AGREE A LOT
(02) AGREE A LITTLE
(03) NEITHER AGREE NOR DISAGREE
(04) DISAGREE A LITTLE
(05) DISAGREE A LOT
(-8) DON'T KNOW
(-9) REFUSED
PP77- AGREE_BAD
(01) AGREE A LOT
(02) AGREE A LITTLE
(03) NEITHER AGREE NOR DISAGREE
(04) DISAGREE A LITTLE
(05) DISAGREE A LOT
(-8) DON'T KNOW
(-9) REFUSED
BOX USEND
Patient Activation (PAQ): THIS SECTION HAS BEEN DELETED
MR Screen
Variable Name
Name
Question type Question text/description
Code list
BOX PA1 routing
GO TO PAINTRO - PAINTRO.
Now I have some questions about how you make health care decisions. Answers
to questions like these will help Medicare better understand how people use
medical services.
PAINTRO
PAINTRO
no entry
PANECESS
PA1
code 1
PASIDEFX
PA2
code 1
PAINSTRC
PA3
code 1
PAMEDREC
PA4
code 1
PACHGDRS
PA5
code 1
Please keep in mind that there are no right or wrong answers to these questions. (01) CONTINUE
Your opinions and experiences are important to us.
(-7) Empty
(01) VERY CONFIDENT
(02) CONFIDENT
(03) SOMEWHAT
CONFIDENT
(04) NOT AT ALL
SHOW CARD PA1
CONFIDENT
Please tell me how confident you are that you can identify when it is necessary (-8) Don't Know
for you to get medical care.
(-9) Refused
(01) VERY CONFIDENT
(02) CONFIDENT
(03) SOMEWHAT
CONFIDENT
SHOW CARD PA1
(04) NOT AT ALL
[How confident are you that you can...]
CONFIDENT
(-8) Don't Know
Identify when you are having side effects from your medications?
(-9) Refused
(01) VERY CONFIDENT
(02) CONFIDENT
(03) SOMEWHAT
SHOW CARD PA1
CONFIDENT
Doctors often give instructions about how you should care for yourself at home, (04) NOT AT ALL
like changing a bandage, taking medicines on schedule, or applying ice packs.
CONFIDENT
How confident are you that you can follow instructions to care for yourself at
(-8) Don't Know
home?
(-9) Refused
(01) VERY CONFIDENT
(02) CONFIDENT
(03) SOMEWHAT
SHOW CARD PA1
CONFIDENT
Doctors also often give instructions about changing your habits or lifestyle, such (04) NOT AT ALL
as changing your diet, stopping smoking, or getting regular exercise. How
CONFIDENT
confident are you that you can follow this kind of instruction, to change your
(-8) Don't Know
habits or lifestyle?
(-9) Refused
(01) VERY LIKELY
SHOW CARD PA2
(02) LIKELY
Please use this card to respond to the following statements.
(03) UNLIKELY
(04) VERY UNLIKELY
How likely are you to change doctors if you are dissatisfied with the way you and (-8) Don't Know
your doctor communicate?
(-9) Refused
Text Fill Input
Logic
mask Routing
PA1 - PANECESS
PA2 - PASIDEFX
PA3 - PAINSTRC
PA4 - PAMEDREC
PA5 - PACHGDRS
PA6 - PADISAGR
PADISAGR
PAHCONDS
PA6
PA9
code 1
code 1
SHOW CARD PA2
How likely are you to tell your doctor when you disagree with him or her?
SHOW CARD PA3
These next questions are about practices sometimes associated with receiving
medical care. Please tell me if you always, usually, sometimes, or never do the
following:
Do you always, usually, sometimes, or never read about health conditions in
newspapers, magazines, or on the Internet?
SHOW CARD PA3
[Do you always, usually, sometimes, or never...]
PARXINFO
PA10
code 1
Read information about a new prescription, such as side effects and
precautions?
SHOW CARD PA3
[Do you always, usually, sometimes, or never...]
PADRQUEX
PA11
code 1
Bring with you to your doctor visits a list of questions or concerns you want to
cover?
SHOW CARD PA3
[Do you always, usually, sometimes, or never...]
PAANSWR
PA12
code 1
Leave your doctor's office feeling that all of your concerns or questions have
been fully answered?
SHOW CARD PA3
[Do you always, usually, sometimes, or never...]
PALISTRX
PA13
code 1
Take a list of all of your prescribed medicines to your doctor visits?
SHOW CARD PA3
[Do you always, usually, sometimes, or never...]
PATRSLT
PA14
code 1
Make sure you understand the results of any medical test or procedure such as
an x-ray, blood test, or EKG for heart conditions?
SHOW CARD PA3
[Do you always, usually, sometimes, or never...]
PAOPTION
PA15
code 1
Talk with your doctor or other medical person about your options if you need
tests, follow-up care, or a referral for care by a medical specialist?
(01) VERY LIKELY
(02) LIKELY
(03) UNLIKELY
(04) VERY UNLIKELY
(-8) Don't Know
(-9) Refused
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
(04) NEVER
(-8) Don't Know
(-9) Refused
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
(04) NEVER
(-8) Don't Know
(-9) Refused
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
(04) NEVER
(-8) Don't Know
(-9) Refused
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
(04) NEVER
(-8) Don't Know
(-9) Refused
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
(04) NEVER
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
(04) NEVER
(-8) Don't Know
(-9) Refused
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
(04) NEVER
(-8) Don't Know
(-9) Refused
PA9 - PAHCONDS
PA10 - PARXINFO
PA11 - PADRQUEX
PA12 - PAANSWR
PA13 - PALISTRX
PA14 - PATRSLT
PA15 - PAOPTION
PA16 - PADRLISN
SHOW CARD PA3
Now I am going to read some statements that may describe your relationship
with your doctor. Please tell me if the following statements always, usually,
sometimes, or never happen.
PADRLISN
PA16
code 1
PADREXPL
PA20
code 1
PADVICE
PA21
code 1
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
(04) NEVER
My doctor listens to what I have to say about my symptoms and concerns. [Does (-8) Don't Know
that always, usually, sometimes, or never happen?]
(-9) Refused
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
SHOW CARD PA3
(04) NEVER
My doctor explains things to me in terms that I can easily understand. Does that (-8) Don't Know
always, usually, sometimes, or never happen?
(-9) Refused
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
SHOW CARD PA3
(04) NEVER
I can call my doctor's office to get medical advice when I need it. Does that
(-8) Don't Know
always, usually, sometimes, or never happen?
(-9) Refused
PA20 - PADREXPL
PA21 - PADVICE
BOX PA2
Income and Assets (IAQ): Existing section below has been replaced with new items
Variable Name
SPSEINHH
ADLTINHH
MR
Screen
Name
Questio
n type Question text/description
Code list
IF (SP IS IN THE EXIT SAMPLE AND
PREVIOUS ROUND INTERVIEW
WAS NOT SKIPPED), GO TO IAINT8 SPSEINHH.
BOX IA1A routing ELSE GO TO IAINTRO - IAINT.
(01) YES
WAS SP'S SPOUSE LIVING IN THE (02) NO
HOUSEHOLD DURING THIS
(-8) Don't
IAINT8
code 1 ROUND?
Know
BESIDES SP (AND SP'S SPOUSE),
WAS ANY OTHER ADULT, AGE 15 (01) YES
OR OLDER, LIVING IN THE
(02) NO
HOUSEHOLD DURING THIS
(-8) Don't
IAINT9
code 1 ROUND?
Know
Text Fill Logic
Input
mask Routing
IAINT9 ADLTINHH
IAINTRO IAINT
Now I have some questions about
(PREVIOUS YEAR) income and
other financial resources for
[you/(SP)/you and your
(wife/husband)/(SP) and (his/her)
(wife/husband)].
IAINT
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
As with all information collected by
[you and your] respondent is SP, SP
the MCBS, the data are
married
confidential and covered by the
[wife] SP's spouse female
Privacy Act of 1974. Your answers
[husband] SP's spouse male
will be combined with those of
[(SP)] respondent is proxy
other respondents, and
[his] SP male
[your/his/her] Medicare benefits
[her] SP female
will not be affected in any way by
[wife] SP's spouse female
your answers to these questions.
[husband] SP's spouse male
GIVE BROCHURE TO RESPONDENT.
[your] respondent is SP
ALLOW A FEW MINUTES FOR
[his] respondent is proxy, SP male
RESPONDENT TO REVIEW
(01) CONTINUE [her] respondent is proxy, SP
IAINTRO no entry BROCHURE IF NECESSARY.
(-7) Empty
female
IAINTRO1 IAINT1
As the brochure explains, your
responses to these questions can
help us determine the impact of
income on [your/his/her] use and
access to health care. I will be
asking a series of questions about
[your/(SP’s)/you and your
(wife’s/husband’s)/(SP) and
(his/her) (wife’s/husband’s)]
income and other financial
resources. First, I will ask whether
[you/(SP)/you and your
(wife/husband)/(SP) and (his/her)
(wife/husband)] had particular
types of income or other
resources. All these questions can
be answered with a "yes" or a
"no." Then, I will ask you to
estimate [your/(SP's)/their] total
income. [Please answer all
questions for [you and your
(wife/husband)/(SP) and (his/her)
(wife/husband)].
IAINT1
Please feel free to refer to any
records or other persons who may
IAINTRO1 no entry be of assistance to you.
In (PREVIOUS YEAR), did
[you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)]. . .
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP
female
[your] respondent is SP, not
married
[(SP's)] respondent is proxy, SP not
married
[you and your] respondent is SP, SP
married
[wife's] SP's spouse female
[husband's] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife's] SP's spouse female
[husband's] SP's spouse male
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you and your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
(01) CONTINUE [wife] SP's spouse female
(-7) Empty
[husband] SP's spouse male
receive Social Security and/or
Railroad Retirement payments?
SSRRPROB
IA1A
list
[READ IF NECESSARY: Social
Security checks are either
automatically deposited in the
bank or mailed, and payment
generally arrives on the 3rd of the
month.]
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
IA1A SSRRPROB
IA1A SSIPROBE
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
In (PREVIOUS YEAR), did
[you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)]. . .
SSIPROBE
IA1A
list
(01) YES
receive Supplemental Security
(02) NO
Income, which is also called SSI, or (-8) Don't
Social Security Disability Insurance, Know
also called SSDI?
(-9) Refused
In (PREVIOUS YEAR), did
[you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)]. . .
DISAPROB
IA1A
list
receive any disability payments
(other than Social Security, SSDI,
and/or Railroad Retirement)?
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
In (PREVIOUS YEAR), did
[you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)]. . .
PENPROBE
JOBPROBE
IA1A
IA1B
list
list
receive any retirement or survivor
pension or annuity (other than
Social Security or Railroad
Retirement)?
In (PREVIOUS YEAR), did
[you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)] . . .
work at a job or business for pay?
That is, did [you/he/she/he or his
wife/she or her husband/you or
your (wife/husband)] receive
income by working for an
employer or by being selfemployed, such as owning a
business, professional practice, or
farm?
IA1A DISAPROB
IA1A PENPROBE
IA1B JOBPROBE
IA1B WELPROBE
In (PREVIOUS YEAR), did
[you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)] . . .
WELPROBE
IA1B
list
receive any income from public
assistance or welfare from the
state or local welfare office?
Please include programs such as
Temporary Assistance for Needy
Families, or TANF, and food
stamps.
In (PREVIOUS YEAR), did
[you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)] . . .
RELPROBE
IA1B
list
receive financial assistance from
relatives or friends?
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
In (PREVIOUS YEAR), did
[you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)] . . .
IRAWD
IA1B
list
convert or withdraw any funds
from an IRA, Keogh, 401K, or other
retirement savings account in
(PREVIOUS YEAR)?
In (PREVIOUS YEAR), did
[you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)]. . .
STOKPROB
IA1C
list
receive any dividends from any
investments in stocks or mutual
funds or other investments?
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
IA1B RELPROBE
IA1B IRAWD
IA1C STOKPROB
IA1C LUMPPROB
In (PREVIOUS YEAR), did
[you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)]. . .
LUMPPROB
IA1C
list
receive a lump sum or any onetime payments such as a life
insurance or pension settlement,
inheritance, or a capital gain from
the sale of securities, property, or
a business?
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
In (PREVIOUS YEAR), did
[you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)]. . .
ESTPROBE
IA1C
list
(01) YES
receive any regular payments from (02) NO
estates, trusts, annuities (other
(-8) Don't
than pensions), life insurance, or Know
royalties?
(-9) Refused
In (PREVIOUS YEAR), did
[you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)]. . .
PROPRENT
OTHPROBE
IA1C
IA13
list
(01) YES
(02) NO
(-8) Don't
receive any income from the rental Know
of properties?
(-9) Refused
code 1
Not including anything you've
already told me about, did
[you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)] receive income
from any other sources, such as
Department of Veterans Affairs
payments, worker's or
unemployment compensation,
child support, or alimony?
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
IA1C ESTPROBE
IA1C PROPRENT
IA13 OTHPROBE
BOX IA1
BOX IA1
routing
IF AT LEAST ONE INCOME PROBE
AT IA1A, IA1B, IA1C, OR IA13 WAS
ANSWERED "YES", GO TO IA14 INCYRAMT.
ELSE GO TO BOX IA2AA.
SHOW CARD IA1
Taking all of these income sources
into account, please estimate
[your/(SP’s)/you and your
(wife’s/husband’s)/(SP) and
(his/her) (wife’s/husband’s)]
income for (PREVIOUS YEAR).
[PROBE: In estimating
(your/his/her/their) total income
you can respond for all of
(PREVIOUS YEAR), or, if you prefer,
provide a one month estimate.]
INCYRAMT
IA14
[PROBE: REVIEW THESE SOURCES
WITH RESPONDENT: [Social
Security or Railroad Retirement/
(SSI/SSDI)/disability/pensions/job,
business, professional practice,
farm/public assistance
programs/assistance from
relatives or friends/withdrawal
from retirement or
savings/dividends/lump sum
payments/other regular
quantity payments/rental properties/other
unit
sources]]
(01)
[Continuous
answer.]
(-8) Don't
Know
(-9) Refused
[your] respondent is SP, not
married
[(SP's)] respondent is proxy, SP not
married
[you and your] respondent is SP, SP
married
[wife's] SP's spouse female
[husband's] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife's] SP's spouse female
[husband's] SP's spouse male
[your] respondent is SP
[his] respondent is proxy, SP male,
SP not married
[her] respondent is proxy, SP
female, SP not married
[their] respondent is proxy, SP
married
IA14 INCYRUNT
SHOW CARD IA1
Taking all of these income sources
into account, please estimate
[your/(SP’s)/you and your
(wife’s/husband’s)/(SP) and
(his/her) (wife’s/husband’s)]
income for (PREVIOUS YEAR).
INCYRUNT
INCYRMT1
IA14
IA15
[your] respondent is SP, not
[PROBE: In estimating
married
(your/his/her/their) total income
[(SP's)] respondent is proxy, SP not
you can respond for all of
married
(PREVIOUS YEAR), or, if you prefer,
[you and your] respondent is SP, SP
provide a one month estimate.]
married
[wife's] SP's spouse female
[PROBE: REVIEW THESE SOURCES
[husband's] SP's spouse male
WITH RESPONDENT: [Social
[(SP)] respondent is proxy
Security or Railroad Retirement/
[his] SP male
(SSI/SSDI)/disability/pensions/job,
[her] SP female
business, professional practice,
[wife's] SP's spouse female
farm/public assistance
(01) TOTAL
[husband's] SP's spouse male
programs/assistance from
FOR (PREVIOUS [your] respondent is SP
relatives or friends/withdrawal
YEAR)
[his] respondent is proxy, SP male,
from retirement or
(02) ONE
SP not married
savings/dividends/lump sum
MONTH
[her] respondent is proxy, SP
payments/other regular
(-8) Don't
female, SP not married
quantity payments/rental properties/other Know
[their] respondent is proxy, SP
unit
sources]]
(-9) Refused
married
code 1
INCYRMT2
IA16
code 1
INCYRMT3
IA17
code 1
(01) YES
(02) NO
Was it more than
(-8) Don't
($20,000/$1,700/$40,000/$3,300) Know
?
(-9) Refused
(01) YES
(02) NO
Was it more than
(-8) Don't
($12,000/$1,000/$25,000/$2,000) Know
?
(-9) Refused
(01) YES
(02) NO
(-8) Don't
Was it more than
Know
($7,700/$640/$17,000/$1,400)?
(-9) Refused
(01) BOX
IA2AA
(02) BOX
IA2AA
(-8) IA15 INCYRMT1
(-9) IA15 INCYRMT1
(01) BOX
IA2AA
(02) IA16 INCYRMT2
(-8) BOX
IA2AA
(-9) BOX
IA2AA
(01) BOX
IA2AA
(02) IA17 INCYRMT3
(-8) BOX
IA2AA
(-9) BOX
IA2AA
BOX IA2AA
BOX
IA2AA
HHINCOME
IA17A
routing
code 1
IF (IAINT9 - ADLTINHH = 1/Yes) OR
(THERE IS AN ADULT AGE 15 OR
OLDER LIVING WITH THE SP IN THE
CURRENT ROUND OTHER THAN
THE SPOUSE), GO TO IA17A HHINCOME.
ELSE GO TO IA18A - HOMEPRBB.
SHOW CARD IA2
According to our records, other
than [you/(SP)/you and your
(wife/husband)/(SP) and (his/her)
(wife/husband)], at least one
person 15 years of age or older
lives in (your household/the
household). Including their
income as well as [your/(SP’s)/you
and your (wife’s/husband’s)/(SP)
and (his/her) (wife’s/husband’s)]
income, please look at this card
and tell me which letter represents
the total combined income of all
the members of [your
household/(SP’s) household]. This
includes income from jobs, Social
Security, Railroad Retirement,
other retirement, and any other
money income received by all
members of (your household/the
household).
(01) A. Less
than $5,000
(02) B. $5,000
– 9,999
(03) C. $10,000
– 14,999
(04) D. $15,000
– 19,999
(05) E. $20,000
– 24,999
(06) F.$25,000
– 29,999
(07) G. $30,000
– 34,999
(08) H. $35,000
– 39,999
(09) I. $40,000
– 44,999
(10) J. $45,000
– 49,999
(11) K. $50,000
and more
(-8) Don't
Know
(-9) Refused
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you and your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[your household] respondent is SP
[the household] respondent is
proxy
[you] respondent is SP
[he] respondent is proxy, SP male,
not married
[she] respondent is proxy, SP
female, not married
[they] respondent is proxy, SP
married
[your household] respondent is SP
[(SP's) household] respondent is
proxy
[your household] respondent is SP
[the household] respondent is
proxy
IA18A HOMEPRBB
HOMEPRBB
HOMEEVAL
IA18A
IA19
code 1
dollar
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you and your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
(01) OWN
[wife] SP's spouse female
IF THE SP IS HOMELESS, IS
(02) RENT
[husband] SP's spouse male
TRANSIENT WITH NO PERMANENT (03) DOESN'T [live] respondent is SP
HOME, OR IS IN JAIL OR PRISON, OWN OR RENT [lives] respondent is proxy
CODE WITHOUT ASKING. SELECT " (04) BOTH
[lived] SP has no permanent home
SP IS HOMELESS/TRANSIENT/IN
OWN AND
[Do] respondent is SP
JAIL OR PRISON".
RENT
[Did] SP has no permanent home or
The next questions are about the (05) SP
SP deceased
place where [you/(SP)/you and
REPORTED
[Does] respondent is proxy
your (wife/husband)/(SP) and
SUBSIDIZED
[you] respondent is SP, not married
(his/her) (wife/husband)]
RENTAL
[(SP)] respondent is proxy, SP not
(live/lives/lived).
HOUSING
married
(06) SP IS
[you and your] respondent is SP, SP
(Do/Did/Does) [you/(SP)/you and HOMELESS/TR married
your (wife/husband)/(SP) and
ANSIENT/IN
[wife] SP's spouse female
(his/her) (wife/husband)]] own the JAIL OR PRISON [husband] SP's spouse male
place where (you/he/she/they)
(-8) Don't
[(SP)] respondent is proxy
(live/lives/lived), or (do/did/does) Know
[his] SP male
(you/he/she/they) rent it?
(-9) Refused
[her] SP female
[your] respondent is SP, not
married
Please tell me the present value of
[(SP's)] respondent is proxy, SP not
[your/(SP’s)/you and your
married
(wife’s/husband’s)/(SP) and
[you and your] respondent is SP, SP
(his/her) (wife’s/husband’s)]
(01)
married
home. About how much do you
[Continuous
[wife's] SP's spouse female
think this (house and
answer.]
[husband's] SP's spouse male
lot/condominium unit) would sell (-8) Don't
[house and lot] SP lives in house
for if it were for sale? Please give Know
[conodominium unit] SP lives in
your best estimate.
(-9) Refused
condominium
(01) IA19 HOMEEVAL
(02) IA22 HOMERENT
(03)
IAINTRO4 IAINT4
(04) DO
NOT
DISPLAY.
DATA
EDITING
ONLY.
(05) DO
NOT
DISPLAY.
DATA
EDITING
ONLY.
(06)
IAINTRO4 IAINT4
(-8)
IAINTRO4 IAINT4
(-9)
IAINTRO4 IAINT4
IA20 HOMEMOR
T
HOMEMORT
HOMEOWE
IA20
IA21
code 1
(Do/Did/Does) [you/(SP)/you or
your (wife/husband)/(SP) or
(his/her) (wife/husband)] have a
mortgage, deed of trust, home
equity loan, or a land contract on
the property?
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
dollar
How much (do/did/does)
[you/(SP)/you and your
(wife/husband)/(SP) and (his/her)
(wife/husband)] owe, in total, on
any mortgages, deeds, loans, or
land contracts for this property?
(01)
[Continuous
answer.]
(-8) Don't
Know
(-9) Refused
[Do] respondent is SP
[Did] SP no longer has permanent
home or SP deceased
[Does] respondent is proxy
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[Do] respondent is SP
[Did] SP no longer has permanent
home or SP deceased
[Does] respondent is proxy
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
(01) IA21 HOMEOWE
(02)
IAINTRO4 IAINT4
(-8)
IAINTRO4 IAINT4
(-9)
IAINTRO4 IAINT4
IAINTRO4 IAINT4
dollar
How much monthly rent
(do/did/does) [you/(SP)/you and
your (wife/husband)/(SP) and
(his/her) (wife/husband)] pay for
the place where (you/he/she/they)
(live/lives/lived)?
HOMERENT
IA22
IAINT4
Now, let's turn to savings or other
assets which can be used to
provide income. I will ask whether
[you/(SP)/you and your
(wife/husband)/(SP) and (his/her)
(wife/husband)] had particular
types of assets in (PREVIOUS
YEAR). All these questions can be
answered with a "yes" or a "no".
[Please answer for [you and your
(wife/husband)/(SP) and (his/her)
IAINTRO4 no entry (wife/husband)].
(01)
[Continuous
answer.]
(-8) Don't
Know
(-9) Refused
[Do] respondent is SP
[Did] SP no longer has permanent
home or SP deceased
[Does] respondent is proxy
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[you] respondent is SP
[he] respondent is proxy, SP male,
SP not married
[she] respondent is proxy, SP
female, SP not married
[they] respondent is proxy, SP
married
[live] respondent is SP
[lives] respondent is proxy
[lived] SP no longer has permanent
home or SP deceased
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you and your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[you and your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
IAINTRO4 IAINT4
RAPROBE
IA23A
list
For all or part of (PREVIOUS YEAR),
did [you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)]. . .
(01) YES
(02) NO
have any IRA, Keogh, 401K
(-8) Don't
accounts, thrift plans, or other
Know
retirement savings accounts?
(-9) Refused
For all or part of (PREVIOUS YEAR),
did [you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)]. . .
SAVPROBE
IA23A
list
have money in any kind of savings,
interest earning checking, or other
bank account? Include checking,
savings, money market funds,
certificates of deposit, or any other
interest earning bank accounts.
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
For all or part of (PREVIOUS YEAR),
did [you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)]. . .
BONDPROB
IA23A
list
have any stocks, mutual funds,
municipal or corporate bonds, or
U.S. Government securities such as
savings bonds, treasury bills or
bonds?
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
For all or part of (PREVIOUS YEAR),
did [you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)]. . .
INSPROBE
IA23A
list
own any life insurance policies
which build up cash equity
(sometimes called whole life or
universal life)?
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
IA23A SAVPROBE
IA23A BONDPROB
IA23A INSPROBE
IA23B PROPPROB
For all or part of (PREVIOUS YEAR),
did [you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)] . . .
PROPPROB
CARPROBE
ASTPROBE
IA23B
IA23B
IA23B
list
list
list
own any property, [other than
(your/his/her/their) primary
residence,] such as a vacation
home, apartment house,
commercial property, or rental
property?
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
For all or part of (PREVIOUS YEAR),
did [you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(01) YES
(wife/husband)] . . .
(02) NO
(-8) Don't
own any cars, trucks, recreational Know
vehicles, or boats?
(-9) Refused
For all or part of (PREVIOUS YEAR),
did [you/(SP)/you or your
(wife/husband)/(SP) or (his/her)
(wife/husband)] . . .
have any other savings, assets, a
business or professional practice,
property such as a farm,
mortgages from which payments
are received, or any other financial
investments not already
mentioned?
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[your] respondent is SP
[his] respondent is proxy, SP male,
SP not married
[her] respondent is proxy, SP
female, SP not married
[their] respondent is proxy, SP
married
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
IA23B CARPROBE
IA23B ASTPROBE
(01) IA30 ASTCODE
(02) BOX
IA2
(-8) BOX IA2
(-9) BOX IA2
ASTCODE
IA30
BOX IA2
What type of asset is it?
code all CHECK ALL THAT APPLY.
IF AT LEAST ONE ASSET PROBE AT
IA23A OR IA23B WAS ANSWERED
"YES", GO TO IA31 - ASSTTOTL.
routing ELSE GO TO IA34 - OTHDEBTS.
(01) SAVINGS
(02) ASSETS
(03) FARM
(04) BUSINESS
(05)
PROFESSIONAL
PRACTICE
(91) OTHER
(-8) Don't
Know
(-9) Refused
SHOW CARD IA3
You've mentioned [READ ASSETS
LISTED BELOW]. Please estimate
[your/(SP’s)/you and your
(wife’s/husband’s)/(SP) and
(his/her) (wife’s/husband’s)] assets
for (PREVIOUS YEAR). Do not
include interest or dividend
payments already reported as
income. [Please exclude the value
of (your/his/her/their) home.]
ASSTTOTL
IA31
dollar
(01) BOX
IA2
(02) DATA
EDITING
ONLY. DO
NOT
DISPLAY.
(03) BOX
IA2
(04) BOX
IA2
(05) BOX
IA2
(91) IA30 ASTSPECI
(-8) BOX IA2
(-9) BOX IA2
(01)
[(retirement savings
[Continuous
accounts/other bank
answer.]
accounts/stocks, mutual funds,
(-8) Don't
bonds/life insurance policies/other Know
property/vehicles/other assets)] (-9) Refused
[your] respondent is SP, not
married
[(SP's)] respondent is proxy, SP not
married
[you and your] respondent is SP, SP
married
[wife's] SP's spouse female
[husband's] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife's] SP's spouse female
[husband's] SP's spouse male
[your] respondent is SP
[his] respondent is proxy, SP male,
SP not married
[her] respondent is proxy, SP
female, SP not married
[their] respondent is proxy, SP
married
(01) IA32 ASSTDEBT
(-8) IA31A VALSSET
(-9) IA31A VALSSET
It is often difficult to place an exact
dollar amount on the value of
assets. Thinking about all of the
assets that you mentioned, [READ
ASSETS LISTED BELOW], would you
say that the total value of
[your/(SP’s)/you and your
(wife’s/husband’s)/(SP) and
(his/her) (wife’s/husband’s)] assets
for (PREVIOUS YEAR) was less than
$40,000.00 or was it $40,000.00 or
more?
VALSSET
VALPICK
IA31A
IA31B
code 1
[your] respondent is SP, not
married
[(SP's)] respondent is proxy, SP not
married
[you and your] respondent is SP, SP
married
[wife's] SP's spouse female
[husband's] SP's spouse male
[(retirement savings
[(SP)] respondent is proxy
accounts/other bank
[his] SP male
accounts/stocks, mutual funds,
[her] SP female
bonds/life insurance policies/other
[wife's] SP's spouse female
property/vehicles/other assets)] (01) LESS THAN [husband's] SP's spouse male
$40,000.00
[your] respondent is SP
[READ IF NECESSARY: Again do not (02)
[his] respondent is proxy, SP male,
include interest or dividend
$40,000.00 OR SP not married
payments already reported as
MORE
[her] respondent is proxy, SP
income [, and please exclude the (-8) Don't
female, SP not married
value of (your/his/her/their)
Know
[their] respondent is proxy, SP
home]].
(-9) Refused
married
(01) IA31B VALPICK
(02) IA31B VALPICK
(-8) IA32 ASSTDEBT
(-9) IA32 ASSTDEBT
code 1
(01) A. Less
than $5,000
(02) B. $5,000 9,999
SHOW CARD IA4
(03) C. $10,000
Which of these categories do you - 19,999
[Do] respondent is SP
think is a good estimate of the
(04) D. $20,000 [Did] respondent is proxy, SP
total value of [your/(SP’s)/you and – 39,999
deceased
your (wife’s/husband’s)/(SP) and (05) E. $40,000 -[Does] respondent is proxy, SP alive
(his/her) (wife’s/husband’s)] assets 74,999
[you] respondent is SP, not married
for (PREVIOUS YEAR)?
(06) F. $75,000 - [(SP)] respondent is proxy, SP not
149,999
married
[READ IF NECESSARY: You
(07) G.
[you or your] respondent is SP, SP
mentioned the following assets:
$150,000 –
married
[READ ASSETS LISTED BELOW].]
299,999
[wife] SP's spouse female
(08) H.
[husband] SP's spouse male
[(retirement savings
$300,000 and [(SP)] respondent is proxy
accounts/other bank
more
[his] SP male
accounts/stocks, mutual funds,
(-8) Don't
[her] SP female
bonds/life insurance policies/other Know
[wife's] SP's spouse female
property/vehicles/other assets)] (-9) Refused
[husband's] SP's spouse male
IA32 ASSTDEBT
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
[Do] respondent is SP
[Did] respondent is proxy, SP
deceased
[Does] respondent is proxy, SP alive
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife's] SP's spouse female
[husband's] SP's spouse male
(01) IA33 ADEBTTOT
(02) IA34 OTHDEBTS
(-8) IA34 OTHDEBTS
(-9) IA34 OTHDEBTS
(01)
How much (do/did/does)
[Continuous
[you/(SP)/you and your
answer.]
(wife/husband)/(SP) and (his/her) (-8) Don't
(wife/husband)] owe, in total, on Know
these debts?
(-9) Refused
[do] respondent is SP
[did] respondent is proxy, SP
deceased
[does] respondent is proxy, SP alive
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you and your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
IA34 OTHDEBTS
(Do/Did/Does) [you/(SP)/you or
your (wife/husband)/(SP) or
(his/her) (wife/husband)] have any
outstanding debts associated with
the [READ ASSETS LISTED BELOW]?
ASSTDEBT
ADEBTTOT
IA32
IA33
code 1
dollar
[(retirement savings
accounts/other bank
accounts/stocks, mutual funds,
bonds/life insurance policies/other
property/vehicles/other assets)]
OTHDEBTS
IA34
code 1
DEBTTOT
IA35
dollar
DEBTMED
IA36
dollar
(Do/Did/Does) [you/(SP)/you or
your (wife/husband)/(SP) or
(his/her) (wife/husband)] have any
(other) outstanding debts (that we
haven't talked about), such as
credit card charges, loans, medical
bills, or legal bills?
(01) YES
(02) NO
(-8) Don't
Know
(-9) Refused
(01)
[Continuous
answer.]
(-8) Don't
Know
(-9) Refused
(01)
[Continuous
answer.]
(-8) Don't
How much of the (AMOUNT FROM Know
IA35) is for medical care costs?
(-9) Refused
If you added up all of these other
debts for [you/(SP)/you and your
(wife/husband)/(SP) and (his/her)
(wife/husband)], about how much
would they amount to right now?
[Do] respondent is SP
[Did] respondent is proxy, SP
deceased
[Does] respondent is proxy, SP alive
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you or your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
(01) IA35 DEBTTOT
(02) BOX
IA6
(-8) BOX IA6
(-9) BOX IA6
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not
married
[you and your] respondent is SP, SP
married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
(01) IA36 DEBTMED
(-8) BOX IA6
(-9) BOX IA6
BOX IA6
Income and Assets (IAQ): Existing section has been replaced with new items below
Variable Name
MR Screen Name Question type Question text/description
Now I have some questions about (PREVIOUS YEAR)
income and other financial resources for [you/(SP)/you
and your (wife/husband)/(SP) and (his/her)
(wife/husband)].
LFINTRO1
LFINTRO1
no entry
As with all information collected by the MCBS, the data
are confidential and covered by the Privacy Act of 1974.
Your answers will be combined with those of other
respondents, and [your/his/her] Medicare benefits will
not be affected in any way by your answers to these
questions.
GIVE BROCHURE TO RESPONDENT. ALLOW A FEW
MINUTES FOR RESPONDENT TO REVIEW BROCHURE IF
NECESSARY.
Code list
(01)
CONTINUE
(-7) Empty
As the brochure explains, your responses to these
questions can help us determine the impact of income on
[your/his/her] use and access to health care. I will be
asking a series of questions about [your/(SP’s)/you and
your (wife’s/husband’s)/(SP) and (his/her)
(wife’s/husband’s)] income and other financial resources.
First, I will ask whether [you/(SP)/you and your
(wife/husband)/(SP) and (his/her) (wife/husband)] had
particular types of income or other resources. All these
questions can be answered with a "yes" or a "no." Then, I
will ask you to estimate [your/(SP's)/their] total income.
[Please answer all questions for [you and your
(wife/husband)/(SP) and (his/her) (wife/husband)].
LFINTRO2
WORKWEEK
RETNEVWK
IAABSENT
LFINTRO2
LF1
LF1B
LF2
no entry
code one
code one
code one
WORKMONTH
LF3
code one
MULTIJOB
LF4
yes/no
(01)
CONTINUE
(-7) Empty
(1) YES
(2) NO
(3)
Did [you/SP] do any work for pay in the last week? By the RETIRED/DON’
last week, I mean the week beginning on Sunday
T WORK
{MONTH, DAY OF SUNDAY PRIOR TO TODAY/MONTH, DAY ANYMORE
OF SUNDAY PRIOR TO THE SATURDAY BEFORE TODAY’S
(-8) DON’T
DATE} and ending {today/on Saturday {MONTH, DAY OF KNOW
SATURDAY PRIOR TO TODAY’S DATE}?
(-9) REFUSED
Please feel free to refer to any records or other persons
who may be of assistance to you.
(01) RETIRED
(02) NEVER
WORKED
(03) NO,
NEITHER OF
THESE IS TRUE
(-8) DON'T
Is this because (you were/SP was) retired or (you/SP)
KNOW
never worked?
(-8) REFUSED
(1) YES
(2) NO
(3)
RETIRED/DON’
T WORK
ANYMORE
{Do you/Does SP} have a job from which {you
(-8) DON’T
were/{he/she} was} absent last week because of illness, KNOW
vacation, or some other reason?
(-9) REFUSED
(1) YES
(2) NO
Now think about last month, that is {MONTH BEFORE
(-8) DON’T
INTERVIEW MONTH}. Did {you/SP} do any work for pay at KNOW
any time in the last month?
(-9) REFUSED
(1) YES
(2) NO
(-8) DON’T
Last week, did {you/SP} have more than one job, including KNOW
part-time, evening, or weekend work?
(-9) REFUSED
Text Fill Logic
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not married
[you and your] respondent is SP, SP married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[your] respondent is SP, not married
[(SP's)] respondent is proxy, SP not married
[you and your] respondent is SP, SP married
[wife's] SP's spouse female
[husband's] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife's] SP's spouse female
[husband's] SP's spouse male
[you] respondent is SP, not married
[(SP)] respondent is proxy, SP not married
[you and your] respondent is SP, SP married
[wife] SP's spouse female
[husband] SP's spouse male
[(SP)] respondent is proxy
[his] SP male
[her] SP female
[wife] SP's spouse female
[husband] SP's spouse male
[your] respondent is SP
[(SP's)] respondent is proxy, SP not married
[their] respondent is proxy, SP married
[you and your] respondent is SP, SP married
[wife] SP's spouse female
[husband] SP's spouse male
[you] respondent is SP
[(SP)] respondent is proxy
[beginning on Sunday (MONTH, DAY OF SUNDAY PRIOR
TO INTERVIEW)] TODAY’S date is a Saturday
[on Sunday (MONTH, DAY OF SUNDAY PRIOR TO THE SATURDAY BEFORE TODAY’S DATE})] if TODAY’S date is not a Saturday
Input mask Routing
LFINTRO2
LF1
[today] TODAY’S date is a Saturday
[on Saturday (MONTH, DAY OF SATURDAY PRIOR TO TODAY’S DATE)] if TODAY’S date is not a Saturday
(1) LF4
(2) LF2 LF1B
(3) BOX LF13
(-8) BOX LF13
(-9) BOX LF13
(you were) respondent is SP
(SP was) respondent is proxy
(1) BOX LF13
(2) BOX LF13
(3) LF3
(-8) BOX LF13
(-9) BOX LF13
[Do you] respondent is SP
[Does SP] respondent is proxy
[you were] respondent is SP
[he was] respondent is proxy, SP is male
[she was[ respondent is proxy, SP is female
(1) LF4
(2) LF3
(3) BOX LF13
(-8) BOX LF13
(-9) BOX LF13
[you] respondent is SP
[SP] respondent is proxy
(1) LF8
(2) BOX LF13
(-8) BOX LF13
(-9) BOX LF13
[you] respondent is SP
[SP] respondent is proxy
LF5
[do you] respondent is SP
[does SP] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP is male
[her] respondent is proxy, SP is female
[main job] LF4=1 (YES)
[job] LF4≠ 1(YES)
[By main job, I mean the job at which you work}
the most hours.] LF4=1 (YES), respondent is SP
[By main job, I mean the job at which he works}
the most hours.] LF4=1 (YES), respondent is proxy, SP is male
[By main job, I mean the job at which she works}
the most hours.] LF4=1 (YES), respondent is proxy, SP is female
[job] LF4≠ 1(YES)
HOURSPERWEEK
HOURSLASTWEEK1
HOURSLASTWEEK2
LF5
quantity unit
BOX LF1
routing
LF6
LF7
quantity unit
quantity unit
PAYSCHEDULE
LF8
code one
OSPAYSCHEDULE
LF8A
verbatim
How many hours per week {do you/does SP} usually work
at {your/his/her} {job/main job}? {By main job, I mean the (1)
job at which {you work/{he/she} works} the most hours.} [continuous
response]
ENTER NUMBER OF HOURS USUALLY WORK
(-8) DON’T
KNOW
IF NUMBER OF HOURS VARY EACH WEEK, ENTER 997
(-9) REFUSED
If LF2=1 (YES, ABSENT LAST WEEK), go to LF7.
Otherwise go to LF6.
(1)
[continuous
response]
How many hours did {you/SP} work last week?
(-8) DON’T
KNOW
[you] respondent is SP
ENTER NUMBER OF HOURS
(-9) REFUSED [SP] respondent is proxy
[you were] respondent is SP
[SP was] respondent is proxy
(1)
You said {you were/SP was} absent from work last week. [continuous
How many hours did {you/he/she} work the last week
response]
{you were/{he/she} was} at work?
(-8) DON’T
KNOW
ENTER NUMBER OF HOURS
(-9) REFUSED
(1) EVERY
WEEK
(2) EVERY
TWO WEEKS
(3) TWO
TIMES A
MONTH
(4) ONCE A
MONTH
(5) DAILY
(9) OTHER
SCHEDULE
(SPECIFY)
{{Are you/Is SP} /In {your/SP’s} main job, {are you/is
(-8) DON’T
{he/she} }}paid every week, every two weeks, two times a KNOW
month, or on some other schedule?
(-9) REFUSED
(1)
[continuous
SPECIFY OTHER PAYMENT SCHEDULE
response]
How much was {your/SP’s} last paycheck before taxes and
any other deductions {for {your/his/her} main job}?
(1) LF7 LF8
(-8) LF8
(-9) LF8
[you] respondent is SP
[he] respondent is proxy, SP is male
[she] respondent is proxy, SP is female
[you were] respondent is SP
[he was] respondent is proxy, SP is male
[she was] respondent is proxy, SP is female
[Are you] LF4≠ 1(YES), respondent is SP
[Is SP] LF4≠ 1(YES), respondent is proxy
[In your main job, are you] LF4= 1(YES), respondent is SP
[In SP's main job, is he] LF4= 1(YES), respondent is proxy, SP male
[In SP's main job, is she] LF4= 1(YES), respondent is proxy, SP female
LF8
(1) LF9
(2) LF9
(3) LF9
(4) LF9
(5) LF9
(9) LF8A
(-8) LF9
(-9) LF9
LF9
IF NEEDED: We don’t need an exact dollar amount. An
approximate amount is fine.
LASTPAYCHECK
LF9
code one
(1) ENTER
PAYCHECK
AMOUNT
IF NEEDED: If it is easier, you can just tell me how much
(2) ENTER PAY
{you earn/SP earns} per hour or per day.
PER HOUR
(3) ENTER PAY
IF NEEDED: We know questions like these may be difficult PER DAY
to answer, but we need to know this to understand how (-8) DON’T
people manage financially as they age and what effect this KNOW
might have on their health.
(-9) REFUSED
(1) BOX LF1
(-8) LF8
(-9) LF8
ENTER PAYCHECK AMOUNT
PAYCHECKAMT
LF9A
quantity unit
$
(1)
[continuous
response]
[your] respondent is SP
[SP's] respondent is proxy
[for your main job] LF4=1(YES), respondent is SP
[for his main job] LF4=1(YES), respondent is proxy, SP is male
[for her main job] LF4=1(YES), respondent is proxy, SP is female
(1) LF9A
(2) LF9B
(3) LF9C
(-8) BOX LF13
(-9) BOX LF13
Use input
mask in
response
field
($999,999)
so that
dollar sign is
displayed
and
commas are
inserted
appropriatel
y.
LF10
ENTER PAY PER HOUR
PAYCHECKHOURLY
LF9B
quantity unit
$
ENTER PAY PER DAY
PAYCHECKDAILY
LF9C
quantity unit
$
Now thinking about the month of {CURRENT MONTH -1
MONTH}, how much did {you/SP} earn altogether from
any work {you/he/she} did in {CURRENT MONTH -1
MONTH}, before taxes and before any other deductions?
Use input
mask in
response
field
($999.99) so
that dollar
sign is
displayed
and decimal
point is
inserted
appropriatel
y.
LF10
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and comma
is inserted
appropriatel
y.
LF10
(1)
[continuous
response]
(1)
[continuous
response]
IF NEEDED: We don’t need an exact dollar amount. An
approximate amount is fine.
MONTHPAY
LF10
quantity unit
BOX LF13
routing
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how (1)
people manage financially as they age and what effect this [continuous
might have on their health.
response]
(-8) DON’T
ENTER DOLLAR AMOUNT
KNOW
$
(-9) REFUSED
If ENS11-JOBSTAT = 1 of [ROSTREL = 2 (SPOUSE) or
ROSTREL = 51 (PARTNER) for anyone living in HH from ENS
go to LF13.
Otherwise, go to HO1
[you] respondent is SP
[SP] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP is male
[she] respondent is proxy, SP is female
Use input
mask in
response
field
($999,999)
so that
dollar sign is
displayed
and
commas are
inserted
appropriatel
y.
BOX LF13
[your partner] respondent is SP, LIVING WITH A PARTNER
[your husband] respondent is SP, spouse is male
[your wife] respondent is SP, spouse is female
SPOUSEWORK
LF13
code one
SPOUSEEARN
LF14
quantity unit
IAOWNHOME
HO1
code one
Did {you/your/SP’s} {husband/wife/partner} do any work
for pay in the month of {CURRENT MONTH-1 MONTH}?
In {CURRENT MONTH -1 MONTH}, how much altogether
did {you/your/SP’s} {husband/wife/partner} earn before
taxes and before any other deductions?
(1) YES
(2) NO
(-8) DON’T
KNOW
(-9) REFUSED
[you] respondent is proxy, PROXY RELATIONSHIP=SPOUSE or PARTNER
[SP's partner] respondent is proxy, PROXY RELATIONSHIP≠SPOUSE or PARTNER, LIVING WITH A PARTNER
[SP's husband] respondent is proxy, PROXY RELATIONSHIP≠SPOUSE or PARTNER, spouse is male
[SP's wife] respondent is proxy, PROXY RELATIONSHIP≠SPOUSE or PARTNER, spouse is female
(1) LF14
(2) HO1
(-8) HO1
(-9) HO1
Use input
mask in
response
IF NEEDED: We don’t need an exact dollar amount. An
field
approximate amount is fine.
($999,999)
[you] respondent is proxy, IN6-ROSTREL =SPOUSE (2) or PARTNER (56) and HHFLAG = 1
so that
IF NEEDED: We know questions like these may be difficult
[your husband] respondent is SP, MARISTAT = 1, spouse is male
dollar sign is
to answer, but we need to know this to understand how (1)
[your wife] respondent is SP, MARISTAT = 1, spouse is female
displayed
people manage financially as they age and what effect this [continuous [your partner] respondent is SP, person in ENS enumerated as partner (ROSTREL = 56) and HHFLAG = 1
and
might have on their health.
response]
[SP's husband] respondent is proxy, IN6-ROSTREL NE SPOUSE (2) or PARTNER (56), MARISTAT = 1, spouse is male
commas are
(-8) DON’T
[SP's wife] respondent is proxy, IN6-ROSTREL NE SPOUSE (2) or PARTNER (56), spouse is female
inserted
ENTER DOLLAR AMOUNT
KNOW
[SP's partner] respondent is proxy, IN6-ROSTREL NE SPOUSE (2) or PARTNER (56), someone in ENS ROSTREL = 56 (Partner) and HHFLAG = 1 appropriatel
$
(-9) REFUSED
y.
HO1
[home] HAQ-Dwelling in(1,2,4,5,91,96,-8,-9)
[apartment or condo] HAQ-Dwelling in(3,6)
(1) OWN
(2) RENT (OR [Do you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with partner
Next, I'd like to ask you some questions about the
PAY MONTHLY [Do you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER
{home/apartment or condo} at {SP’s {ADDRESS 1,
AMOUNT)
[Do you] respondent is SP, SP is not married or living with a partner
ADDRESS 2} from PERSON ROSTER}.
(3) SOME
[Does SP or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy
OTHER
relationship≠SPOUSE or PARTNER
{Do you/Does SP} {or {SP FIRSTNAME
ARRANGEMEN [Does SP] respondent is proxy, SP is not married or living with a partner
(1) HO2
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}}
T
(2) HO6
own the {home/apartment or condo} at {SP’s {ADDRESS 1, (-8) DON’T
(3) HO5
ADDRESS 2} from PERSON ROSTER}, rent it, or is there
KNOW
(-8) HO5
some other arrangement?
(-9) REFUSED
(-9) HO5
MORTGAGE
HO2
code one
MORTGAGE_AMT1
HO3
quantity unit
MORTGATE_AMT2
HO3A
code one
MORTGAGELGNTH
HO3B
code one
(1) PAID OFF
(2) STILL
Is {your/SP’s} {or {SP FIRSTNAME
MAKE
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}’s} PAYMENTS
mortgage paid off or are monthly mortgage payments still (3) REVERSE
being made?
MORTGAGE
(-8) DON’T
IF NEEDED: Include any payments on a home equity loan KNOW
or second mortgage.
(-9) REFUSED
(1)
[continuous
response]
How much altogether is that each month?
(-8) DON’T
KNOW
ENTER DOLLAR AMOUNT
(-9) REFUSED
(1) LESS THAN
$250
(2) $250 TO
LESS THAN
$500
(3) $500 TO
LESS THAN
$1,000
(4) $1,000 TO
LESS THAN
$3,000
(5) $3,000 TO
LESS THAN
SHOW CARD HO1 IA1
$5,000
(6) $5,000 OR
Please look at this card and tell me which is closest.
MORE
(-8) DON’T
IF NEEDED: Include any payments on a home equity loan KNOW
or second mortgage.
(-9) REFUSED
(1) WITHIN 5
YEARS
(2) WITHIN 10
{Do you/Does SP} {or {SP FIRSTNAME
YEARS
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}
(3) LONGER
expect to pay off the mortgage within 5 years, 10 years, or THAN 10
longer?
YEARS
(-8) DON’T
IF NEEDED: Include any payments on a home equity loan KNOW
or second mortgage.
(-9) REFUSED
About how much {do you/does SP} {or {SP FIRSTNAME
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}}
still owe on the mortgage?
[your or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with partner
[your or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER
[your] respondent is SP, SP is not married or living with a partner
[SP's or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship≠SPOUSE
or PARTNER
[SP's] respondent is proxy, SP is not married or living with a partner
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) HO3B
appropriatel (-8) HO3A
y.
(-9) HO3B
HO3B
[Do you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with partner
[Do you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER
[Do you] respondent is SP, SP is not married or living with a partner
[Does SP or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy
relationship≠SPOUSE or PARTNER
[Does SP] respondent is proxy, SP is not married or living with a partner
IF NEEDED: The nearest $10,000 is fine.
MORTGAGEOWE1
HO3C
quantity unit
MORTGAGEOWE2
HO3D
code one
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how
people manage financially as they age and what effect this
might have on their health.
(1)
[continuous
IF NEEDED: Include any payments on a home equity loan response]
or second mortgage.
(-8) DON’T
KNOW
ENTER DOLLAR AMOUNT
(-9) REFUSED
(1) less than
$50,000,
(2) $50,000 to
less than
$100,000, or
(3) $100,000
or more?
(-8) DON’T
KNOW
Is the amount owed…
(-9) REFUSED
(1) HO4
(2) HO3
(3) HO4
(-8) HO4
(-9) HO4
[do you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with partner
[do you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER
[do you] respondent is SP, SP is not married or living with a partner
[does SP or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy
relationship≠SPOUSE or PARTNER
[does SP] respondent is proxy, SP is not married or living with a partner
HO3C
Use input
mask in
response
field
($9,999,999)
so that
dollar sign is
displayed
and
commas are
inserted
(1) HO4
appropriatel (-8) HO3D
y.
(-9) HO4
HO4
What is the present value of this [home/apartment or
condo]? I mean, about what would it bring if it was sold
today, not counting any loans or outstanding mortgages?
IF NEEDED: Your best guess or the nearest $10,000 is fine.
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how
people manage financially as they age and what effect this
might have on their health.
PRESENTVALUE1
HO4
quantity unit
PRESENTVALUE2
HO4A
code one
PAYRENT
HO5
yes/no
(1)
[continuous
response]
(-8) DON’T
KNOW
[home] HAQ-Dwelling in(1,2,4,5,91,96,-8,-9)
ENTER DOLLAR AMOUNT
(-9) REFUSED [apartment or condo] HAQ-Dwelling in(3,6)
(1) LESS THAN
$50,000
(2) $50,000
TO LESS THAN
$75,000
(3) $75,000
TO LESS THAN
$100,000
(4) $100,000
TO LESS THAN
$200,000
(5) $200,000
TO LESS THAN
$300,000
(6) $300,000
TO LESS THAN
$500,000
(7) $500,000
TO LESS THAN
$750,000
(8) $750,000
OF MORE
SHOW CARD HO2 IA2
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
[Do you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with partner
(1) YES
[Do you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER
(2) NO
[Do you] respondent is SP, SP is not married or living with a partner
{Do you/Does SP} {or {SP FIRSTNAME
(-8) DON’T
[Does SP or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME} pay KNOW
relationship≠SPOUSE or PARTNER
rent to live here?
(-9) REFUSED [Does SP] respondent is proxy, SP is not married or living with a partner
How much is that each month?
RENTAMT1
HO6
quantity unit
ENTER DOLLAR AMOUNT
SHOW CARD HO3 IA3
RENTAMT2
SECTION8
HO6A
code one
BOX HO1
routing
HO7
yes/no
Please look at this card and tell me which is closest.
If HO6>=$750 or HO6A=4 ($1,000 TO LESS THAN $3,000),
5 ($3,000 TO LESS THAN $5,000), OR 6 ($5,000 OR MORE)
go to IAQINTRO1.
Otherwise, go to HO7.
Is this home in Section 8 or public housing or housing for
low-income seniors?
(1)
[continuous
response]
(-8) DON’T
KNOW
(-9) REFUSED
(1) LESS THAN
$250
(2) $250 TO
LESS THAN
$500
(3) $500 TO
LESS THAN
$1,000
(4) $1,000 TO
LESS THAN
$3,000
(5) $3,000 TO
LESS THAN
$5,000
(6) $5,000 OR
MORE
(-8) DON’T
KNOW
(-9) REFUSED
(1) YES
(2) NO
(-8) DON’T
KNOW
(-9) REFUSED
Use input
mask in
response
field
($9,999,999)
so that
dollar sign is
displayed
and
commas are
inserted
(1) IAQINTRO1
appropriatel (-8) HO4A
y.
(-9) IAQINTRO1
IAQINTRO1
(1) HO6
(2) IAQINTRO1
(-8) IAQINTRO1
(-9) IAQINTRO1
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) IAQINTRO1
appropriatel (-8) HO6A
y.
(-9) HO6A
BOX HO1
IAQINTRO1
We are interested in how people are getting along
financially these days. The next few questions are about
income and other resources. Your responses can help us
understand how people manage financially as they age.
Please feel free to refer to any records or other persons
that may be of assistance in answering these questions.
IAQINTRO1
IAQINTRO1
no entry
Many of these questions ask about “last month.” By last
month, I mean in {CURRENT MONTH – 1}.
Did {you/SP} {or {SP FIRSTNAME
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}}
receive Social Security retirement and/or Railroad
Retirement payments in the last month, that is in
{CURRENT MONTH –
1}?
IF NEEDED: These checks are either automatically
deposited in the bank or mailed to arrive on the 3rd of
every month. If mailed, they are often sent in gold or
manila-colored envelopes.
SSRR_LASTMONTH
SSDEPOSIT
MMSTARTSS
YYSTARTSS
SSI_LASTMONTH
IAQ1
code all
BOX IAQ1
routing
IAQ2
IAQ3
IAQ3
IAQ4
[SELECT ALL THAT APPLY]
IF IAQ1 NE (1) SP PAYMENT THEN GO TO IAQ4, ELSE GO
TO IAQ2
(1) YES, SP
RECEIVED
PAYMENT
FROM
SOURCE
(2) YES,
SPOUSE/PART
NER RECEIVED
PAYMENT
FROM
SOURCE
(3) NO
PAYMENT
RECEIVED
FROM THIS
SOURCE
(-8) DON’T
KNOW
(-9) REFUSED
(1) MAIL
(2) DIRECT
DEPOSIT
(3) PREPAID
CARD
(-8) DON’T
KNOW
(-9) REFUSED
(1)
[continuous
response]
(-8) DON’T
KNOW
(-9) REFUSED
(1)
[continuous
response]
(-8) DON’T
KNOW
(-9) REFUSED
code one
{Do you/Does SP} get payments by direct deposit, on a
prepaid card, or by mail?
quantity unit
What month and year did {you/SP} start receiving Social
Security? ENTER MONTH
quantity unit
What month and year did {you/SP} start receiving Social
Security? ENTER YEAR
code all
(1) YES, SP
RECEIVED
PAYMENT
FROM
SOURCE
(2) YES,
SPOUSE/PART
NER RECEIVED
PAYMENT
FROM
Did {you/SP} {or {SP FIRSTNAME
SOURCE
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}}
(3) NO
receive Supplemental Security Income, which is also called PAYMENT
SSI, last month?
RECEIVED
FROM THIS
IF NEEDED: These are monthly government payments to SOURCE
lower-income people in need.
(-8) DON’T
KNOW
{SELECT ALL THAT APPLY}
(-9) REFUSED
[you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with partner
[you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER
[you] respondent is SP, SP is not married or living with a partner
[SP's or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship≠SPOUSE
or PARTNER
[SP's] respondent is proxy, SP is not married or living with a partner
Display "SELECT ALL THAT APPLY" and response option
2, “YES, SPOUSE/PARTNER RECEIVED PAYMENT FROM SOURCE if SP is married or living with a partner
Do no display "SELECT ALL THAT APPLY" and response option
2, “YES, SPOUSE/PARTNER RECEIVED PAYMENT FROM SOURCE if SP is not married or living with a partner
Display “in the last month” in underlined text.
(1) BOX IAQ1
(2) BOX IAQ1
(3) IAQ4
(-8) IAQ4
(-9) IAQ4
[Do you] respondent is SP
[Does SP] respondent is proxy
IAQ3-MMSTARTSS
[you] respondent is SP
[SP] respondent is proxy
IAQ3-YYSTARTSS
[you] respondent is SP
[SP] respondent is proxy
IAQ4
[you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with partner
[you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER
[you] respondent is SP, SP is not married or living with a partner
[SP's or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship≠SPOUSE
or PARTNER
[SP's] respondent is proxy, SP is not married or living with a partner
Display "SELECT ALL THAT APPLY" and response option
2, “YES, SPOUSE/PARTNER RECEIVED PAYMENT FROM SOURCE if SP is married or living with a partner
Do no display "SELECT ALL THAT APPLY" and response option
2, “YES, SPOUSE/PARTNER RECEIVED PAYMENT FROM SOURCE if SP is not married or living with a partner
Display “in the last month” in bold underlined text.
IAQ5
VA_LASTMONTH
PENSION_LASTMONTH
401K_LASTMONTH
MUTUALFUNDS
IAQ5
IAQ6
IAQ7
IAQ8
code all
(1) YES, SP
RECEIVED
PAYMENT
FROM
SOURCE
(2) YES,
SPOUSE/PART
NER RECEIVED
PAYMENT
Did {you/SP} {or {SP FIRSTNAME
FROM
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}}
SOURCE
receive any payments from the Veteran’s Administration, (3) NO
last month related to military service or veteran survivor’s PAYMENT
benefits?
RECEIVED
FROM THIS
[IF NEEDED: The Veteran's Administration is also known as SOURCE
the U.S. Department of Veterans Affairs.]
(-8) DON’T
KNOW
{SELECT ALL THAT APPLY}
(-9) REFUSED
People sometimes have other retirement income. This
may be from pensions or retirement plans related to their
jobs.
(1) YES, SP
{Do you/Does SP} {or {SP FIRSTNAME
HAS PENTION
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}}
(2) YES,
have any pension plans that were a job-related or union SPOUSE/PART
benefit?
NER HAS
PENSION
IF NEEDED: These plans often require that a person work (3) NO
for a certain number of years before they qualify or “are PENSIONS
vested” in the pension plan.
(-8) DON’T
KNOW
{SELECT ALL THAT APPLY}
(-9) REFUSED
(1) YYES, SP
HAS 401K,
403B, IRA, OR
SHOW CARD IA4
OTHER
RETIREMENT
Please look at the types of retirement plans on this card. PLANS
{Do you/Does SP} {or {SP FIRSTNAME
(2) YES,
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}}
SPOUSE/PART
have any of these?
NER HAS
401K, 403B,
IF NEEDED: 401Ks and 403Bs are plans where you
IRA, OR
contribute an amount each month from your paycheck,
OTHER
and your employer may match some of your contribution. RETIREMENT
PLANS
IF NEEDED: IRAs, also known as Individual Retirement
(3) NO PLANS
Accounts, are a type of plan you set up on your own.
(-8) DON’T
KNOW
{SELECT ALL THAT APPLY}
(-9) REFUSED
code all
(1) YES, SP
HAS ASSET
(2) YES,
SPOUSE/PART
NER HAS
ASSET
(3) YES, SP
AND
SPOUSE/PART
NER HAVE
{Not including the retirement accounts we have already ASSET JOINTLY
talked about, {do you/does SP}/{Do you/Does SP}} {or {SP (4) NO ASSET
FIRSTNAME LASTNAME/SPOUSE/PARTNER FIRSTNAME
OF THIS TYPE
LASTNAME}} own any mutual funds or stocks?
(-8) DON’T
KNOW
{SELECT ALL THAT APPLY}
(-9) REFUSED
code all
code all
[you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with partner
[you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER
[you] respondent is SP, SP is not married or living with a partner
[SP's or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship≠SPOUSE
or PARTNER
[SP's] respondent is proxy, SP is not married or living with a partner
Display "SELECT ALL THAT APPLY" and response option 2, “YES, SPOUSE/PARTNER RECEIVED PAYMENT FROM SOURCE if SP is married or
living with a partner
Do no display "SELECT ALL THAT APPLY" and response option 2, “YES, SPOUSE/PARTNER RECEIVED PAYMENT FROM SOURCE if SP is not
married or living with a partner
IAQ6
[Do you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with partner
[Do you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER
[Do you] respondent is SP, SP is not married or living with a partner
[Does SP or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy
relationship≠SPOUSE or PARTNER
[Does SP] respondent is proxy, SP is not married or living with a partner
Display "SELECT ALL THAT APPLY" and response option 2, “YES, SPOUSE/PARTNER RECEIVED PAYMENT FROM SOURCE if SP is married or
living with a partner
Do no display "SELECT ALL THAT APPLY" and response option 2, “YES, SPOUSE/PARTNER RECEIVED PAYMENT FROM SOURCE if SP is not
married or living with a partner
IAQ7
[Do you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with partner
[Do you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER
[Do you] respondent is SP, SP is not married or living with a partner
[Does SP or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy
relationship≠SPOUSE or PARTNER
[Does SP] respondent is proxy, SP is not married or living with a partner
Display "SELECT ALL THAT APPLY" and response option
2, “YES, SPOUSE/PARTNER HAS 401K, 403B, IRA, OR KEOGH”. if SP is married or living with a partner
Do no display "SELECT ALL THAT APPLY" and response option
2, “YES, SPOUSE/PARTNER HAS 401K, 403B, IRA, OR KEOGH” if SP is not married or living with a partner
[Not including the retirement accounts we have already talked about, do you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is
SP, SP is married or living with a partner, IA7 = 1 (SP RETIREMENT ACCT) or 2 (SPOUSE RETIREMENT ACCT)
[Not including the retirement accounts we have already talked about, do you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is
married or living with partner, proxy relationship= SPOUSE or PARTNER, IA7 = 1 (SP RETIREMENT ACCT) or 2 (SPOUSE RETIREMENT ACCT)
[Not including the retirement accounts we have already talked about, do you] respondent is SP, SP is not married or living with a partner,
IA7 = 1 (SP RETIREMENT ACCT) or 2 (SPOUSE RETIREMENT ACCT)
[Not including the retirement accounts we have already talked about, does SP or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent
is proxy, SP is married or living with partner, proxy relationship≠SPOUSE or PARTNER, IA7 = 1 (SP RETIREMENT ACCT) or 2 (SPOUSE
RETIREMENT ACCT)
[Not including the retirement accounts we have already talked about, does SP] respondent is proxy, SP is married or living with partner,
proxy relationship≠SPOUSE or PARTNER, IA7 = 1 (SP RETIREMENT ACCT) or 2 (SPOUSE RETIREMENT ACCT)
IAQ8
[Do you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with a partner, IA7 ≠ 1 (SP RETIREMENT
ACCT) or 2 (SPOUSE RETIREMENT ACCT)
[Do you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER,
IA7 ≠ 1 (SP RETIREMENT ACCT) or 2 (SPOUSE RETIREMENT ACCT)
[Do you] respondent is SP, SP is not married or living with a partner, IA7 ≠ 1 (SP RETIREMENT ACCT) or 2 (SPOUSE RETIREMENT ACCT)
[Does SP or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy
relationship≠SPOUSE or PARTNER, IA7 ≠ 1 (SP RETIREMENT ACCT) or 2 (SPOUSE RETIREMENT ACCT)
[Does SP] respondent is proxy, SP is married or living with partner, proxy relationship≠SPOUSE or PARTNER, IA7 ≠ 1 (SP RETIREMENT ACCT)
or 2 (SPOUSE RETIREMENT ACCT)
Display “SELECT ALL THAT APPLY” and response option
2, “YES, SPOUSE/PARTNER HAS ASSET” and 3, “YES, SP AND SPOUSE/PARTNER HAVE ASSET JOINTLY” if SP married or living with a partner
Do not display “SELECT ALL THAT APPLY” and response option
2, “YES, SPOUSE/PARTNER HAS ASSET” and 3, “YES, SP AND SPOUSE/PARTNER HAVE ASSET JOINTLY” if SP not married or living with a
partner
IAQ9
Not including what we’ve already talked about, {do
you/does SP} {or {SP FIRSTNAME
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}}
own any bonds, such as Government Savings Bonds,
corporate, municipal, or other types of bonds?
BONDS
CHECKING
IAQ9
IAQ10
code all
{SELECT ALL THAT APPLY}
code all
(1) YES, SP
HAS ASSET
(2) YES,
SPOUSE/PART
NER HAS
ASSET
The next questions ask about different kinds of bank or
(3) YES, SP
savings accounts people sometimes have or property they AND
own.
SPOUSE/PART
NER HAVE
Not counting what we’ve already talked about, {do
ASSET JOINTLY
you/does SP} {or {SP FIRSTNAME
(4) NO ASSET
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}}
OF THIS TYPE
have...
(-8) DON’T
KNOW
A checking account?
(-9) REFUSED
code all
(1) YES, SP
HAS ASSET
(2) YES,
SPOUSE/PART
NER HAS
ASSET
(3) YES, SP
AND
SPOUSE/PART
NER HAVE
ASSET JOINTLY
(4) NO ASSET
OF THIS TYPE
(-8) DON’T
KNOW
(-9) REFUSED
[IF NEEDED: Not counting what we’ve already talked
about, {do you/does SP} {or {SP FIRSTNAME
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}}
have...]
SAVINGS
IAQ11
A savings account or money market account?
[IF NEEDED: Not counting what we’ve already talked
about, {do you/does SP} {or {SP FIRSTNAME
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}}
have…]
CERTDEPOSIT
IAQ12
code all
Certificates of deposit?
{Do you/Does SP} {or {SP FIRSTNAME
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}}
own a business, a farm, or any other real estate {besides
{your/SP’s} home}, including land or rental properties?
OTHER_LAND
IAQ13
(1) YES, SP
HAS ASSET
(2) YES,
SPOUSE/PART
NER HAS
ASSET
(3) YES, SP
AND
SPOUSE/PART
NER HAVE
ASSET JOINTLY
(4) NO ASSET
OF THIS TYPE
(-8) DON’T
KNOW
(-9) REFUSED
code all
{SELECT ALL THAT APPLY}
(1) YES, SP
HAS ASSET
(2) YES,
SPOUSE/PART
NER HAS
ASSET
(3) YES, SP
AND
SPOUSE/PART
NER HAVE
ASSET JOINTLY
(4) NO ASSET
OF THIS TYPE
(-8) DON’T
KNOW
(-9) REFUSED
(1) YES, SP
HAS ASSET
(2) YES,
SPOUSE/PART
NER HAS
ASSET
(3) YES, SP
AND
SPOUSE/PART
NER HAVE
ASSET JOINTLY
(4) NO ASSET
OF THIS TYPE
(-8) DON’T
KNOW
(-9) REFUSED
[do you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with partner
[do you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER
[do you] respondent is SP, SP is not married or living with a partner
[does SP or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy
relationship≠SPOUSE or PARTNER
[does SP] respondent is proxy, SP is not married or living with a partner
Display “SELECT ALL THAT APPLY” and response option
2, “YES, SPOUSE/PARTNER HAS ASSET” and 3, “YES, SP AND SPOUSE/PARTNER HAVE ASSET JOINTLY” if SP is married or living with a partner
Do not display “SELECT ALL THAT APPLY” and response option
2, “YES, SPOUSE/PARTNER HAS ASSET” and 3, “YES, SP AND SPOUSE/PARTNER HAVE ASSET JOINTLY” if SP is not married or living with a
partner
IAQ10
[do you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with partner
[do you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER
[do you] respondent is SP, SP is not married or living with a partner
[does SP or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy
relationship≠SPOUSE or PARTNER
[does SP] respondent is proxy, SP is not married or living with a partner
Display “SELECT ALL THAT APPLY” and response option
2, “YES, SPOUSE/PARTNER HAS ASSET” and 3, “YES, SP AND SPOUSE/PARTNER HAVE ASSET JOINTLY” if SP is married or living with a partner
Do not display “SELECT ALL THAT APPLY” and response option
2, “YES, SPOUSE/PARTNER HAS ASSET” and 3, “YES, SP AND SPOUSE/PARTNER HAVE ASSET JOINTLY” if SP is not married or living with a
partner
IAQ11
[do you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with partner
[do you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER
[do you] respondent is SP, SP is not married or living with a partner
[does SP or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy
relationship≠SPOUSE or PARTNER
[does SP] respondent is proxy, SP is not married or living with a partner
Display “SELECT ALL THAT APPLY” and response option
2, “YES, SPOUSE/PARTNER HAS ASSET” and 3, “YES, SP AND SPOUSE/PARTNER HAVE ASSET JOINTLY” if SP is married or living with a partner
Do not display “SELECT ALL THAT APPLY” and response option
2, “YES, SPOUSE/PARTNER HAS ASSET” and 3, “YES, SP AND SPOUSE/PARTNER HAVE ASSET JOINTLY” if SP is not married or living with a
partner
IAQ12
[do you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with partner
[do you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER
[do you] respondent is SP, SP is not married or living with a partner
[does SP or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy
relationship≠SPOUSE or PARTNER
[does SP] respondent is proxy, SP is not married or living with a partner
Display “SELECT ALL THAT APPLY” and response option
2, “YES, SPOUSE/PARTNER HAS ASSET” and 3, “YES, SP AND SPOUSE/PARTNER HAVE ASSET JOINTLY” if SP is married or living with a partner
Do not display “SELECT ALL THAT APPLY” and response option
2, “YES, SPOUSE/PARTNER HAS ASSET” and 3, “YES, SP AND SPOUSE/PARTNER HAVE ASSET JOINTLY” if SP is not married or living with a
partner
IAQ13
[do you or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is SP, SP is married or living with partner
[do you or {SP FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy relationship= SPOUSE or PARTNER
[do you] respondent is SP, SP is not married or living with a partner
[does SP or {SPOUSE/PARTNER FIRSTNAME LASTNAME}] respondent is proxy, SP is married or living with partner, proxy
relationship≠SPOUSE or PARTNER
[does SP] respondent is proxy, SP is not married or living with a partner
Display “SELECT ALL THAT APPLY” and response option
2, “YES, SPOUSE/PARTNER HAS ASSET” and 3, “YES, SP AND SPOUSE/PARTNER HAVE ASSET JOINTLY” if SP is married or living with a partner
Do not display “SELECT ALL THAT APPLY” and response option
2, “YES, SPOUSE/PARTNER HAS ASSET” and 3, “YES, SP AND SPOUSE/PARTNER HAVE ASSET JOINTLY” if SP is not married or living with a
partner
[besides SP's home] respondent is proxy, SP owns home
[besides your home] respondent is SP, SP owns home
IAQINTRO2
IAQINTRO2
SSRR_COMBINED1
SSRR_COMBINED2
IAQINTRO2
no entry
BOX IAQ2
routing
IAQ14
IAQ14A
code one
quantity unit
We now have a few questions about income which are
important for understanding how
people manage financially as they age.
If IAQ1 = 1 (SP RECEIVED SS/RR) and 2 (SPOUSE RECEIVED
SS/RR), go to IAQ14.
Else if IA1 = 1 (SP RECEIVED SS/RR), go to IAQ15A.
Else if IA1 = 2 (SPOUSE RECEIVED SS/RR), go to IAQ16A.
Otherwise, go to BOX IAQ3.
First, what was the amount of {your/SP’s} and {SP
FIRSTNAME LASTNAME/SPOUSE/PARTNER FIRSTNAME
LASTNAME}’s most recent monthly Social Security or
Railroad Retirement payment (for the month of {CURRENT
MONTH – 1})?
(1) ENTER
COMBINED
AMOUNT
(2) ENTER SP
AND
SPOUSE/PART
IF NEEDED: We don’t need an exact dollar amount.
NER
AMOUNTS
IF NEEDED: We know questions like these may be difficult SEPARATELY
to answer, but we need to know this to understand how (-8) DON’T
people manage financially as they age and what effect this KNOW
might have on their health.
(-9) REFUSED
ENTER COMBINED SP AND SPOUSE/PARTNER SOCIAL
SECURITY/RAILROAD RETIREMENT AMOUNT
SHOW CARD IA5
SSRR_COMBINED3
IAQ14B
code one
BOX IAQ2
Please look at this card and tell me which is closest.
What was the amount of {your/SP’s} most recent monthly
Social Security or Railroad Retirement payment
(for the month of {CURRENT MONTH – 1})?
[your] respondent is SP or proxy who is spouse or partner
[SP's] respondent is proxy who is not spouse or partner
[SPOUSE/PARTNER FIRSTNAME LASTNAME] respondent is SP or proxy who is not spouse or partner and SP is married or living with a
partner
[SP FIRSTNAME LASTNAME] respondent is proxy, proxy relationship= SPOUSE or PARTNER
(1)
[continuous
response]
(-8) DON’T
KNOW
(-9) REFUSED
(1) LESS THAN
$1,300
(2) $1,300 TO
LESS THAN
$1,700
(3) $1,700 TO
LESS THAN
$2,200
(3) $2,200 TO
LESS THAN
$2,600
(5) $2,600 OR
MORE
(-8) DON’T
KNOW
(-9) REFUSED
IF NEEDED: We don’t need an exact dollar amount.
SSRR_SP_AMT1
IAQ15A
quantity unit
SSRR_SP_AMT2
IAQ15B
code one
BOX IAQ2A
routing
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how (1)
people manage financially as they age and what effect this [continuous
might have on their health.
response]
(-8) DON’T
ENTER SP SOCIAL SECURITY/RAILROAD RETIREMENT
KNOW
[your] respondent is SP
AMOUNT
(-9) REFUSED [SP's] respondent is proxy
(1) LESS THAN
$700
(2) $700 TO
LESS THAN
$1,000
(3) $1,000 TO
LESS THAN
$1,300
(4) $1,300 TO
LESS THAN
$1,600
(5) $1,600 OR
MORE
SHOW CARD IA6
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
If IAQ14 = 2 (ENTER SP AND SPOUSE/PARTNER AMOUNTS
SEPARATELY), go to IAQ16A.
Otherwise, go to BOX IAQ3.
(1) IAQ14A
(2) IAQ15A
(-8) IAQ14B
(-9) IAQ14B
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ3
appropriatel (-8) IAQ14B
y.
(-9) IAQ14B
BOX IAQ3
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ2A
appropriatel (-8) IAQ15B
y.
(-9) IAQ15B
BOX IAQ2A
What was the amount of {your/{SPOUSE/PARTNER
FIRSTNAME LASTNAME}’s} most recent monthly Social
Security or Railroad Retirement payment (for the month
of {CURRENT MONTH – 1})?
IF NEEDED: We don’t need an exact dollar amount.
SSRR_SPOUSE_AMT1
IAQ16A
quantity unit
SSRR_SPOUSE_AMT2
IAQ16B
code one
BOX IAQ3
routing
SSRR_COMBINED1
IAQ17
code one
SSRR_COMBINED2
IAQ17A
quantity unit
SSRR_COMBINED3
IAQ17B
code one
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how (1)
people manage financially as they age and what effect this [continuous
might have on their health.
response]
(-8) DON’T
ENTER SPOUSE/PARTNER SOCIAL SECURITY/RAILROAD
KNOW
RETIREMENT AMOUNT
(-9) REFUSED
(1) LESS THAN
$700
(2) $700 TO
LESS THAN
$1,000
(3) $1,000 TO
LESS THAN
$1,300
(4) $1,300 TO
LESS THAN
$1,600
(5) $1,600 OR
MORE
SHOW CARD IA6
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
If IAQ4 = 1 (SP RECEIVED SSI) and 2 (SPOUSE RECEIVED
SSI), go to IAQ17.
Else if IAQ4 = 1 (SP RECEIVED SSI), go to IAQ18A.
Else if IAQ4 = 2 (SPOUSE RECEIVED SSI), go to IAQ19A.
Otherwise, go to BOX IAQ4.
(1) ENTER
What was the amount of {your/SP’s} and {SP FIRSTNAME COMBINED
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}’s AMOUNT
most recent monthly SSI payment (for the month of
(2) ENTER SP
{CURRENT MONTH – 1})?
AND
SPOUSE/PART
IF NEEDED: We don’t need an exact dollar amount.
NER
AMOUNTS
IF NEEDED: We know questions like these may be difficult SEPARATELY
to answer, but we need to know this to understand how (-8) DON’T
people manage financially as they age and what effect this KNOW
might have on their health.
(-9) REFUSED
(1)
[continuous
response]
(-8) DON’T
KNOW
ENTER COMBINED SP AND SPOUSE/PARTNER SSI AMOUNT (-9) REFUSED
(1) LESS THAN
$300
(2) $300 TO
LESS THAN
$700
(3) $700 TO
LESS THAN
$1,000
(4) $1,000 OR
MORE
SHOW CARD IA7
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display “your”.
Otherwise, display “{SPOUSE/PARTNER FIRSTNAME LASTNAME}’s”.
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ3
appropriatel (-8) IAQ16B
y.
(-9) IAQ16B
BOX IAQ3
If SPPROXY = 1 (SAMPLE PERSON) or (SPPROXY = 2(PROXY) and IN6-ROSTREL in(2,56)), display “your”.
Otherwise, display “SP’s”.
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display "SP FIRSTNAME LASTNAME".
Otherwise, display "SPOUSE/PARTNER FIRSTNAME LASTNAME".
(1) IAQ17A
(2) IAQ18A
(-8) IAQ17B
(-9) IAQ17B
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ4
appropriatel (-8) IAQ17B
y.
(-9) IAQ17B
BOX IAQ4
What was the amount of {your/SP’s} most recent monthly
SSI payment (for the month of {CURRENT MONTH – 1})?
IF NEEDED: We don’t need an exact dollar amount.
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how
people manage financially as they age and what effect this
might have on their health.
SSI_SP_AMT1
IAQ18A
quantity unit
ENTER SP SSI AMOUNT
SHOW CARD IA8
SSI_SP_AMT2
IAQ18B
code one
BOX IAQ3A
routing
Please look at this card and tell me which is closest.
If IAQ17 = 2 (ENTER SP AND SPOUSE/PARTNER AMOUNTS
SEPARATELY), go to IAQ19A.
Otherwise, go to BOX IAQ4.
(1)
[continuous
response]
(-8) DON’T
KNOW
[your] respondent is SP
(-9) REFUSED [SP's] respondent is proxy
(1) LESS THAN
$100
(2) $100 TO
LESS THAN
$200
(3) $200 TO
LESS THAN
$400
(4) $400 TO
LESS THAN
$700
(5) $700 OR
MORE
(-8) DON’T
KNOW
(-9) REFUSED
What was the amount of {your/{SPOUSE/PARTNER
FIRSTNAME LASTNAME}’s} most recent monthly SSI
payment (for the month of {CURRENT MONTH – 1})?
IF NEEDED: We don’t need an exact dollar amount.
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how
people manage financially as they age and what effect this
might have on their health.
SSI_SPOUSE_AMT3
IAQ19A
quantity unit
ENTER SPOUSE/PARTNER SSI AMOUNT
SHOW CARD IA8
SSI_SPOUSE_AMT4
IAQ19B
code one
BOX IAQ4
routing
Please look at this card and tell me which is closest.
If IAQ5 = 1 (SP RECEIVED VA) and 2 (SPOUSE RECEIVED
VA), go to IAQ20.
Else if IAQ5 = 1 (SP RECEIVED VA), go to IA21A.
Else if IAQ5 = 2 (SPOUSE RECEIVED VA), go to IAQ22A.
Otherwise, go to BOX IAQ5.
(1)
[continuous
response]
(-8) DON’T
KNOW
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display “your”.
(-9) REFUSED Otherwise, display “{SPOUSE/PARTNER FIRSTNAME LASTNAME}’s”.
(1) LESS THAN
$100
(2) $100 TO
LESS THAN
$200
(3) $200 TO
LESS THAN
$400
(4) $400 TO
LESS THAN
$700
(5) $700 OR
MORE
(-8) DON’T
KNOW
(-9) REFUSED
(1) ENTER
COMBINED
AMOUNT
(2) ENTER SP
AND
SPOUSE/PART
IF NEEDED: We don’t need an exact dollar amount.
NER
AMOUNTS
IF NEEDED: We know questions like these may be difficult SEPARATELY
to answer, but we need to know this to understand how (-8) DON’T
people manage financially as they age and what effect this KNOW
might have on their health.
(-9) REFUSED
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ3A
appropriatel (-8) IAQ18B
y.
(-9) IAQ18B
BOX IAQ3A
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ4
appropriatel (-8) IAQ19B
y.
(-9) IAQ19B
BOX IAQ4
What was the amount of {your/SP’s} and {SP FIRSTNAME
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}’s
most recent monthly Veteran’s Administration payment
(for the month of {CURRENT MONTH – 1})?
VA_AMT_COMBINED1
IAQ20
code one
If SPPROXY = 1 (SAMPLE PERSON) or (SPPROXY = 2(PROXY) and IN6-ROSTREL in(2,56)), display “your”.
Otherwise, display “SP’s”.
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display "SP FIRSTNAME LASTNAME".
Otherwise, display "SPOUSE/PARTNER FIRSTNAME LASTNAME".
(1) IAQ20A
(2) IAQ21A
(-8) IAQ20B
(-9) IAQ20B
VA_AMT_COMBINED2
IAQ20A
quantity unit
VA_AMT_COMBINED3
IAQ20B
code one
(1)
[continuous
response]
(-8) DON’T
KNOW
ENTER COMBINED SP AND SPOUSE/PARTNER VA AMOUNT (-9) REFUSED
(1) LESS THAN
$1,000
(2) $1,000 TO
LESS THAN
$1,400
(3) $1,400 TO
LESS THAN
$1,800
(4) $1,800 TO
LESS THAN
$2,200
(5) $2,200 OR
MORE
SHOW CARD IA9
(-8) DON’T
KNOW
If SPPROXY = 1(SAMPLE PERSON), display “your”.
Please look at this card and tell me which is closest.
(-9) REFUSED Otherwise, display “SP’s”.
What was the amount of {your/SP’s} most recent monthly
Veteran’s Administration payment (for the month of
{CURRENT MONTH – 1})?
IF NEEDED: We don’t need an exact dollar amount.
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how
people manage financially as they age and what effect this
might have on their health.
VA_SP_AMT1
IAQ21A
quantity unit
ENTER SP VA AMOUNT
SHOW CARD IA10
VA_SP_AMT2
IAQ21B
code one
BOX IAQ4A
routing
Please look at this card and tell me which is closest.
If IAQ20 = 2 (ENTER SP AND SPOUSE/PARTNER AMOUNTS
SEPARATELY), go to IAQ22A.
Otherwise, go to BOX IAQ5.
What was the amount of {your/{SPOUSE/PARTNER
FIRSTNAME LASTNAME}’s} most recent monthly Veteran’s
Administration payment (for the month of {CURRENT
MONTH – 1})?
(1)
[continuous
response]
(-8) DON’T
KNOW
If SPPROXY = 1(SAMPLE PERSON), display “your”.
(-9) REFUSED Otherwise, display “SP’s”.
(1) LESS THAN
$500
(2) $500 TO
LESS THAN
$700
(3) $700 TO
LESS THAN
$900
(4) $900 TO
LESS THAN
$1,100
(5) $1,100 OR
MORE
(-8) DON’T
KNOW
(-9) REFUSED
IF NEEDED: We don’t need an exact dollar amount.
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how
people manage financially as they age and what effect this
might have on their health.
VA_SPOUSE_AMT1
IAQ22A
quantity unit
ENTER SPOUSE/PARTNER VA AMOUNT
(1)
[continuous
response]
(-8) DON’T
KNOW
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display “your”.
(-9) REFUSED Otherwise, display “{SPOUSE/PARTNER FIRSTNAME LASTNAME}’s”.
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ5
appropriatel (-8) IAQ20B
y.
(-9) IAQ20B
BOX IAQ5
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ4A
appropriatel (-8) IAQ21B
y.
(-9) IAQ21B
BOX IAQ4A
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ5
appropriatel (-8) IAQ22B
y.
(-9) IAQ22B
SHOW CARD IA10
VA_SPOUSE_AMT2
IAQ22B
BOX IAQ5
PENSION_COMBINED1
PENSION_COMBINED2
IAQ23
IAQ23A
code one
routing
code one
quantity unit
Please look at this card and tell me which is closest.
If IAQ6 = 1 (SP RECEIVED PENSION PLAN) and 2 (SPOUSE
RECEIVED PENSION PLAN), go to IAQ23.
Else if IAQ6 = 1 (SP RECEIVED PENSION PLAN), go to
IAQ24A.
Else if IAQ6 = 2 (SPOUSE RECEIVED PENSION PLAN), go to
IAQ25A.
Otherwise, go to BOX IAQ6.
You told me earlier that {you/SP} and {SP FIRSTNAME
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}
have job-related pension plans. In all, how much was
received from these pension plans in the last month,
before any federal or state taxes were taken out (for the
month of {CURRENT MONTH – 1})?
IAQ23B
code one
BOX IAQ5
If SPPROXY = 1 (SAMPLE PERSON) or (SPPROXY = 2(PROXY) and IN6-ROSTREL in(2,56)), display “you”.
Otherwise, display “SP”.
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display "SP FIRSTNAME LASTNAME".
Otherwise, display "SPOUSE/PARTNER FIRSTNAME LASTNAME".
(1) ENTER
COMBINED
AMOUNT
(2) ENTER SP
AND
SPOUSE/PART
IF NEEDED: We don’t need an exact dollar amount.
NER
AMOUNTS
IF NEEDED: We know questions like these may be difficult SEPARATELY
to answer, but we need to know this to understand how (-8) DON’T
people manage financially as they age and what effect this KNOW
might have on their health.
(-9) REFUSED
ENTER COMBINED SP AND SPOUSE/PARTNER PENSION
PLAN AMOUNT
SHOW CARD IA11
PENSION_COMBINED3
(1) LESS THAN
$500
(2) $500 TO
LESS THAN
$700
(3) $700 TO
LESS THAN
$900
(4) $900 TO
LESS THAN
$1,100
(5) $1,100 OR
MORE
(-8) DON’T
KNOW
(-9) REFUSED
Please look at this card and tell me which is closest.
{You told me earlier that {you have/SP has} a job-related
pension plan.} In all, how much was received from
{{your/SP's} job-related /this} pension plan in the last
month, before any federal or state taxes were taken out
(for the month of {CURRENT MONTH – 1})?
(1) IAQ23A
(2) IAQ24A
(-8) IAQ23B
(-9) IAQ23B
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ6
appropriatel (-8) IAQ23B
y.
(-9) IAQ23B
(1)
[continuous
response]
(-8) DON’T
KNOW
(-9) REFUSED
(1) LESS THAN
$600
(2) $600 TO
LESS THAN
$1,300
(3) $1,300 TO
LESS THAN
$2,100
(4) $2,100 TO
LESS THAN
$5,900
(5) $5,900 OR
MORE
(-8) DON’T
KNOW
(-9) REFUSED
BOX IAQ6
IF NEEDED: We don’t need an exact dollar amount.
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how
people manage financially as they age and what effect this
might have on their health.
PENSION_SP_AMT1
IAQ24A
quantity unit
ENTER SP PENSION PLAN AMOUNT
(1)
[continuous
response]
(-8) DON’T
KNOW
(-9) REFUSED
If SPPROXY = 1(SAMPLE PERSON), display “you have” and "your".
Otherwise, display “SP has" and "SP's".
If IA23=2, (ENTER SP AND SPOUSE/PARTNER AMOUNTS SEPARATELY), display "{your/SP's} job-related".
Otherwise, display "You told me earlier that {you have/SP has} a job-related pension plan." and "this".
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ5A
appropriatel (-8) IAQ24B
y.
(-9) IAQ24B
SHOW CARD IA12
PENSION_SP_AMT2
IAQ24B
code one
BOX IAQ5A
routing
Please look at this card and tell me which is closest.
If IAQ23 = 2 (ENTER SP AND SPOUSE/PARTNER AMOUNTS
SEPARATELY), go to IAQ25A.
Otherwise, go to BOX IAQ6.
{You told me earlier that {you have/{SPOUSE/PARTNER
FIRSTNAME LASTNAME} has} a job-related pension plan.}
In all, how much was received from
{{your/{SPOUSE/PARTNER FIRSTNAME LASTNAME}'s} jobrelated/this} pension plan in the last month, before any
federal or state taxes were taken out (for the month of
{CURRENT MONTH – 1})?
(1) LESS THAN
$400
(2) $400 TO
LESS THAN
$900
(3) $900 TO
LESS THAN
$1,600
(4) $1,600 TO
LESS THAN
$3,800
(5) $3,800 OR
MORE
(-8) DON’T
KNOW
(-9) REFUSED
BOX IAQ5A
IF NEEDED: We don’t need an exact dollar amount.
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how
people manage financially as they age and what effect this
might have on their health.
PENSION_SPOUSE_AMT1
IAQ25A
quantity unit
ENTER SPOUSE/PARTNER PENSION PLAN AMOUNT
SHOW CARD IA12
PENSION_SPOUSE_AMT2
IAQ25B
BOX IAQ6
401K_COMBINED1
IAQ26
code one
routing
code one
Please look at this card and tell me which is closest.
(1)
[continuous
response]
(-8) DON’T
KNOW
(-9) REFUSED
(1) LESS THAN
$400
(2) $400 TO
LESS THAN
$900
(3) $900 TO
LESS THAN
$1,600
(4) $1,600 TO
LESS THAN
$3,800
(5) $3,800 OR
MORE
(-8) DON’T
KNOW
(-9) REFUSED
If IAQ7 = 1 (SP HAS RETIREMENT ACCT) and 2 (SPOUSE
HAS RETIREMENT ACCT), go to IAQ26.
Else if IAQ7 = 1 (SP HAS RETIREMENT ACCT), go to IAQ27A.
Else if IAQ7 = 2 (SPOUSE HAS RETIREMENT ACCT), go to
IAQ28A.
Otherwise, go to BOX IAQ9.
This next question is a bit different. You mentioned that
{you/SP} and {SP FIRSTNAME
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}
have retirement accounts. In total, about how much is
(1) ENTER
currently in all of these retirement accounts?
COMBINED
AMOUNT
IF NEEDED: Retirement accounts include 401K, 403B, IRA, (2) ENTER SP
and other retirement accounts.
AND
SPOUSE/PART
IF NEEDED: We don’t need an exact dollar amount.
NER
AMOUNTS
IF NEEDED: We know questions like these may be difficult SEPARATELY
to answer, but we need to know this to understand how (-8) DON’T
people manage financially as they age and what effect this KNOW
might have on their health.
(-9) REFUSED
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display “you have” and "your".
Otherwise, display “{SPOUSE/PARTNER FIRSTNAME LASTNAME} has” and "{SPOUSE/PARTNER FIRSTNAME LASTNAME}'s".
If IA23 = 2 (ENTER SP and SPOUSE/PARTNER AMOUNTS SEPARATELY), display "{your/SP's} job-related".
Otherwise, display "You told me earlier that {you have/{SPOUSE/PARTNER FIRSTNAME LASTNAME} has} a jobrelated pension plan" and
"this".
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ6
appropriatel (-8) IAQ25B
y.
(-9) IAQ25B
BOX IAQ6
If SPPROXY = 1 (SAMPLE PERSON) or (SPPROXY = 2(PROXY) and IN6-ROSTREL in(2,56)), display “you”. Otherwise, display “SP”.
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display "SP FIRSTNAME LASTNAME".
Otherwise, display "SPOUSE/PARTNER FIRSTNAME LASTNAME".
Display “currently” in underlined text.
(1) IAQ26A
(2) IAQ27A
(-8) IAQ26B
(-9) IAQ26B
401K_COMBINED2
IAQ26A
quantity unit
401K_COMBINED3
IAQ26B
code one
(1)
[continuous
response]
(-8) DON’T
ENTER COMBINED SP AND SPOUSE/PARTNER RETIREMENT KNOW
ACCOUNT AMOUNT
(-9) REFUSED
(1) LESS THAN
$34,000
(2) $34,000
TO LESS THAN
$82,000
(3) $82,000
TO LESS THAN
$175,000
(4) $175,000
TO LESS THAN
$413,000
(5) $413,000
OR MORE
SHOW CARD IA13
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
This next question is a bit different. You mentioned that
{you have/SP has} retirement accounts. In total, about
how much is currently in all of these retirement accounts?
IF NEEDED: Retirement accounts include 401K, 403B, IRA
and other retirement accounts.
IF NEEDED: We don’t need an exact dollar amount.
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how
people manage financially as they age and what effect this
might have on their health.
401K_SP_AMT1
IAQ27A
quantity unit
ENTER SP RETIREMENT ACCOUNT AMOUNT
SHOW CARD IA14
401K_SP_AMT2
IAQ27B
code one
BOX IAQ6A
routing
Please look at this card and tell me which is closest.
If IAQ26 = 2 (ENTER SP AND SPOUSE/PARTNER AMOUNTS
SEPARATELY), go to IAQ28A.
Otherwise, go to BOX IAQ7.
This next question is a bit different. You mentioned that
{you have/{SPOUSE/PARTNER FIRSTNAME LASTNAME}
has} retirement accounts. In total, about how much is
currently in all of these retirement accounts?
(1)
[continuous
response]
(-8) DON’T
If SPPROXY = 1(SAMPLE PERSON), display “you have”.
KNOW
Otherwise, display “SP has”.
(-9) REFUSED Display “currently” in underlined text.
(1) LESS THAN
$20,000
(2) $20,000
TO LESS THAN
$47,000
(3) $47,000
TO LESS THAN
$92,000
(4) $92,000
TO LESS THAN
$218,000
(5) $218,000
OR MORE
(-8) DON’T
KNOW
(-9) REFUSED
IF NEEDED: Retirement accounts include 401K, 403B, IRA
and other retirement accounts.
IF NEEDED: We don’t need an exact dollar amount.
401K_SPOUSE_AMT1
IAQ28A
quantity unit
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how (1)
people manage financially as they age and what effect this [continuous
might have on their health.
response]
(-8) DON’T
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display “you have”.
ENTER SPOUSE/PARTNER RETIREMENT ACCOUNT
KNOW
Otherwise, display “{SPOUSE/PARTNER FIRSTNAME LASTNAME} has”.
AMOUNT
(-9) REFUSED Display “currently” in underlined text.
Use input
mask in
response
field
($9,999,999)
so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ7
appropriatel (-8) IAQ26B
y.
(-9) IAQ26B
BOX IAQ7
Use input
mask in
response
field
($9,999,999)
so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ6A
appropriatel (-8) IAQ27B
y.
(-9) IAQ27B
BOX IAQ6A
Use input
mask in
response
field
($9,999,999)
so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ7
appropriatel (-8) IAQ28B
y.
(-9) IAQ28B
SHOW CARD IA14
401K_SPOUSE_AMT2
IAQ28B
BOX IAQ7
RECIEVE_COMBINED1
IAQ29
code one
Please look at this card and tell me which is closest.
routing
If IAQ7 = 1 (SP HAS RETIREMENT ACCT) and 2 (SPOUSE
HAS RETIREMENT ACCT), go to IAQ29.
Else if IAQ7 = 1 (SP HAS RETIREMENT ACCT), go to IAQ30A.
Else if IAQ7 = 2 (SPOUSE HAS RETIREMENT ACCT), go to
IAQ31A.
Otherwise, go to BOX IAQ8.
Last month, how much altogether did {you/SP} and {SP
FIRSTNAME LASTNAME/SPOUSE/PARTNER FIRSTNAME
LASTNAME} receive or withdraw from all of these
retirement accounts (for the month of {CURRENT MONTH
– 1})?
code one
RECIEVE_COMBINED2
IAQ29A
quantity unit
RECIEVE_COMBINED3
IAQ29B
code one
(1) LESS THAN
$20,000
(2) $20,000
TO LESS THAN
$47,000
(3) $47,000
TO LESS THAN
$92,000
(4) $92,000
TO LESS THAN
$218,000
(5) $218,000
OR MORE
(-8) DON’T
KNOW
(-9) REFUSED
(1) ENTER
COMBINED
AMOUNT
(2) ENTER SP
AND
SPOUSE/PART
IF NEEDED: We don’t need an exact dollar amount.
NER
AMOUNTS
IF NEEDED: We know questions like these may be difficult SEPARATELY
to answer, but we need to know this to understand how (-8) DON’T
people manage financially as they age and what effect this KNOW
might have on their health.
(-9) REFUSED
BOX IAQ7
If SPPROXY = 1 (SAMPLE PERSON) or (SPPROXY = 2(PROXY) and IN6-ROSTREL in(2,56)), display “you”.
Otherwise, display “SP”.
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display "SP FIRSTNAME LASTNAME".
Otherwise, display "SPOUSE/PARTNER FIRSTNAME LASTNAME".
Display “Last month” in bold underlined text.
(1)
[continuous
response]
(-8) DON’T
ENTER COMBINED SP AND SPOUSE/PARTNER RETIREMENT KNOW
ACCOUNT RECEIVED/WITHDRAWN AMOUNT
(-9) REFUSED
(1) LESS THAN
$200
(2) $200 TO
LESS THAN
$500
(3) $500 TO
LESS THAN
$1,000
(4) $1,000 TO
LESS THAN
$2,500
(5) $2,500 OR
MORE
SHOW CARD IA15
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED Display “last month” in underlined text.
Last month, how much altogether did {you/SP} receive or
withdraw from {your/his/her} retirement accounts (for the
month of {CURRENT MONTH – 1})?
IF NEEDED: We don’t need an exact dollar amount.
RECEIVE_SP1
IAQ30A
quantity unit
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how (1)
people manage financially as they age and what effect this [continuous
might have on their health.
response]
(-8) DON’T
If SPPROXY = 1(SAMPLE PERSON), display “you” and “your”.
ENTER SP RETIREMENT ACCOUNT RECEIVED/WITHDRAWN KNOW
Otherwise, display “SP” and “{his/her}”.
AMOUNT
(-9) REFUSED Display “last month” in underlined text.
(1) IAQ29A
(2) IAQ30A
(-8) IAQ29B
(-9) IAQ29B
Use input
mask in
response
field
($99,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ8
appropriatel (-8) IAQ29B
y.
(-9) IAQ29B
BOX IAQ8
Use input
mask in
response
field
($99,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ7A
appropriatel (-8) IAQ30B
y.
(-9) IAQ30B
RECEIVE_SP2
IAQ30B
code one
BOX IAQ7A
routing
SHOW CARD IA16
Please look at this card and tell me which is closest.
If IAQ29 = 2 (ENTER SP AND SPOUSE/PARTNER AMOUNTS
SEPARATELY), go to IAQ31A.
Otherwise, go to BOX IAQ8.
Last month, how much altogether did
{you/{SPOUSE/PARTNER FIRSTNAME LASTNAME}} receive
or withdraw from {your/his/her} retirement accounts (for
the month of {CURRENT MONTH – 1})?
(1) LESS THAN
$100
(2) $100 TO
LESS THAN
$300
(3) $300 TO
LESS THAN
$700
(4) $700 TO
LESS THAN
$1,700
(5) $1,700 OR
MORE
(-8) DON’T
KNOW
(-9) REFUSED Display “last month” in underlined text.
IF NEEDED: We don’t need an exact dollar amount.
RECEIVE_SPOUSE1
IAQ31A
quantity unit
RECEIVE_SPOUSE2
IAQ31B
code one
BOX IAQ8
YRRECIEVE_COMBINED1
YRRECIEVE_COMBINED2
IAQ32
IAQ32A
routing
code one
quantity unit
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how (1)
people manage financially as they age and what effect this [continuous
might have on their health.
response]
(-8) DON’T
ENTER SPOUSE/PARTNER RETIREMENT ACCOUNT
KNOW
RECEIVED/WITHDRAWN AMOUNT
(-9) REFUSED
(1) LESS THAN
$100
(2) $100 TO
LESS THAN
$300
(3) $300 TO
LESS THAN
$700
(4) $700 TO
LESS THAN
$1,700
(5) $1,700 OR
MORE
SHOW CARD IA16
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display “you” and “your”.
Otherwise, display “{SPOUSE/PARTNER FIRSTNAME LASTNAME}” and “{his/her}.
Display “Last month” in underlined text.
BOX IAQ7A
Use input
mask in
response
field
($99,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ8
appropriatel (-8) IAQ31B
y.
(-9) IAQ31B
Display “last month” in underlined text.
BOX IAQ8
If SPPROXY = 1 (SAMPLE PERSON) or (SPPROXY = 2(PROXY) and IN6-ROSTREL in(2,56)), display “you”.
Otherwise, display “SP”.
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display "SP FIRSTNAME LASTNAME".
Otherwise, display "SPOUSE/PARTNER FIRSTNAME LASTNAME".
Display “last year” in underlined text.
(1) IAQ32A
(2) IAQ33A
(-8) IAQ32B
(-9) IAQ32B
If IAQ7 = 1 (SP HAS RETIREMENT ACCT) and 2 (SPOUSE
HAS RETIREMENT ACCT), go to IAQ32.
Else if IAQ7 = 1 (SP HAS RETIREMENT ACCT), go to IAQ33A.
Else if IAQ7 = 2 (SPOUSE HAS RETIREMENT ACCT), go to
IAQ34A.
Otherwise, go to BOX IAQ9.
Now thinking about all of last year, that is calendar year
{CURRENT YEAR – 1}, how much altogether did {you/SP}
and {SP FIRSTNAME LASTNAME/SPOUSE/PARTNER
FIRSTNAME LASTNAME} receive or withdraw from all of
these retirement accounts?
(1) ENTER
COMBINED
AMOUNT
(2) ENTER SP
AND
IF NEEDED: We don’t need an exact dollar amount.
SPOUSE/PART
NER
IF NEEDED: We know questions like these may be difficult AMOUNTS
to answer, but we need to know this to understand how SEPARATELY
people manage financially as they age and what effect this (-8) DON’T
might have on
KNOW
their health.
(-9) REFUSED
(1)
[continuous
response]
(-8) DON’T
ENTER COMBINED SP AND SPOUSE/PARTNER RETIREMENT KNOW
ACCOUNT RECEIVED/WITHDRAWN AMOUNT
(-9) REFUSED
Use input
mask in
response
field
($9,999,999)
so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ9
appropriatel (-8) IAQ32B
y.
(-9) IAQ32B
SHOW CARD IA17
YRRECIEVE_COMBINED3
IAQ32B
code one
Please look at this card and tell me which is closest.
Now thinking about all of last year, that is calendar year
{CURRENT YEAR – 1}, how much altogether did {you/SP}
receive or withdraw from all of {your/his/her} retirement
plans?
(1) LESS THAN
$2,400
(2) $2,400 TO
LESS THAN
$6,000
(3) $6,000 TO
LESS THAN
$12,000
(4) $12,000
TO LESS THAN
$30,000
(5) $30,000
OR MORE
(-8) DON’T
KNOW
(-9) REFUSED Display “last year” in underlined text.
IF NEEDED: We don’t need an exact dollar amount.
YRRECEIVE_SP1
IAQ33A
quantity unit
YRRECEIVE_SP2
IAQ33B
code one
BOX IAQ8A
routing
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how (1)
people manage financially as they age and what effect this [continuous
might have on their health.
response]
(-8) DON’T
ENTER SP RETIREMENT ACCOUNT RECEIVED/WITHDRAWN KNOW
AMOUNT
(-9) REFUSED
(1) LESS THAN
$1,200
(2) $1,200 TO
LESS THAN
$3,600
(3) $3,600 TO
LESS THAN
$8,400
(4) $8,400 TO
LESS THAN
$20,400
(5) $20,400
SHOW CARD IA18
OR MORE
(-8) DON’T
For last year, that is calendar year {CURRENT YEAR – 1},
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
If IAQ32 = 2 (ENTER SP AND SPOUSE/PARTNER AMOUNTS
SEPARATELY), go to IAQ34A.
Otherwise, go to BOX IAQ9.
If SPPROXY = 1(SAMPLE PERSON), display “you” and “your”.
Otherwise, display “SP” and “{his/her}”.
Display “last year” in underlined text.
Display “last year” in underlined text.
Now thinking about all of last year, that is calendar year
{CURRENT YEAR – 1}, how much altogether did
{you/{SPOUSE/PARTNER FIRSTNAME LASTNAME}} receive
or withdraw from all of {your/his/her} retirement plans?
IF NEEDED: We don’t need an exact dollar amount.
YRRECEIVE_SPOUSE1
IAQ34A
quantity unit
YRRECEIVE_SPOUSE2
IAQ34B
code one
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how (1)
people manage financially as they age and what effect this [continuous
might have on their health.
response]
(-8) DON’T
ENTER SPOUSE/PARTNER RETIREMENT ACCOUNT
KNOW
RECEIVED/WITHDRAWN AMOUNT
(-9) REFUSED
(1) LESS THAN
$1,200
(2) $1,200 TO
LESS THAN
$3,600
(3) $3,600 TO
LESS THAN
$8,400
(4) $8,400 TO
LESS THAN
$20,400
(5) $20,400
OR MORE
SHOW CARD IA15 IA18
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display “you” and “your”.
Otherwise, display “{SPOUSE/PARTNER FIRSTNAME LASTNAME}” and “{his/her}”.
Display “last year” in underlined text.
Display “last year” in underlined text.
BOX IAQ9
Use input
mask in
response
field
($9,999,999)
so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ8A
appropriatel (-8) IAQ33B
y.
(-9) IAQ33B
BOX IAQ8A
Use input
mask in
response
field
($9,999,999)
so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ9
appropriatel (-8) IAQ34B
y.
(-9) IAQ34B
BOX IAQ9
BOX IAQ9
OTHER_COMBINED1
IAQ35
routing
code one
OTHER_COMBINED2
IAQ35A
quantity unit
OTHER_COMBINED3
IAQ35B
code one
BOX IAQ9A
routing
IAQ35C
code one
OTHER_COMBINED4
If [IAQ8 = 1 (SP MUTUAL FUNDS) and IAQ8 = 2 (SPOUSE
MUTUAL FUNDS)] or IAQ8 = 3 (JOINT MUTUAL
FUNDS) or [IAQ9 = 1 (SP BONDS) and IAQ9 = 2 (SPOUSE
BONDS)] or IAQ9 = 3 (JOINT BONDS), go to IAQ35.
Else if IAQ8 = 1 (SP MUTUAL FUNDS) or IAQ9 = 1 (SP
BONDS), go to IAQ36A.
Else if IAQ8 = 2 (SPOUSE MUTUAL FUNDS) or IAQ9 = 2
(SPOUSE BONDS), go to IAQ37A.
Otherwise, go to BOX IAQ10.
You told me earlier that {you/SP} and {SP FIRSTNAME
LASTNAME/SPOUSE/PARTNER FIRSTNAME
LASTNAME} own {mutual funds or stocks} {government,
corporate, or other bonds} that are not part of retirement
accounts. About how much are these worth?
(1) ENTER
COMBINED
AMOUNT
(2) ENTER SP
AND
SPOUSE/PART
IF NEEDED: We don’t need an exact dollar amount.
NER
AMOUNTS
IF NEEDED: We know questions like these may be difficult SEPARATELY
to answer, but we need to know this to understand how (-8) DON’T
people manage financially as they age and what effect this KNOW
might have on their health.
(-9) REFUSED
If SPPROXY = 1 (SAMPLE PERSON) or (SPPROXY = 2(PROXY) and IN6-ROSTREL in(2,56)), display “you”.
Otherwise, display “SP”.
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display "SP FIRSTNAME LASTNAME".
Otherwise, display "SPOUSE/PARTNER FIRSTNAME LASTNAME".
If IA8 = 1 (SP MUTUAL FUNDS) or 2 (SPOUSE MUTUAL FUNDS) or 3 (JOINT MUTUAL FUNDS), display
“mutual funds or stocks”.
If IA9 = 1 (SP BONDS) or 2 (SPOUSE BONDS) or 3 (JOINT BONDS), display “government, corporate, or
other bonds”.
If more than one type of asset displayed, display “and” between them.
Use input
mask in
response
field
($9,999,999)
so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ10
appropriatel (-8) BOX IAQ9A
y.
(-9) BOX IAQ9A
(1)
[continuous
response]
(-8) DON’T
ENTER COMBINED SP AND SPOUSE’S/PARTNER'S MUTUAL KNOW
FUNDS/STOCKS/BONDS AMOUNT
(-9) REFUSED
(1) LESS THAN
$9,000
(2) $9,000 TO
LESS THAN
$18,000
(3) $18,000
TO LESS THAN
$93,000
(4) $93,000
TO LESS THAN
$350,000
(5) $350,000
OR MORE
SHOW CARD IA16 IA19
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
If [IAQ8 = 1 (SP MUTUAL FUNDS) and IAQ8 = 2 (SPOUSE
MUTUAL FUNDS)] or IAQ8= 3 (JOINT MUTUAL FUNDS), go
to IAQ35B.
Otherwise, go to IAQ35C.
(1) LESS THAN
$600
(2) $600 TO
LESS THAN
$5,000
(3) $5,000 TO
LESS THAN
$16,000
(4) $16,000
TO LESS THAN
$62,000
(5) $62,000
SHOW CARD IA17 IA20
OR MORE
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
You told me earlier that {you own/SP owns} {mutual funds
or stocks} {government, corporate, or other bonds} that
are not part of retirement accounts. About how much are
these worth?
BOX IAQ10
IF NEEDED: We don’t need an exact dollar amount.
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how
people manage financially as they age and what effect this
might have on their health.
OTHER_SP1
IAQ36A
quantity unit
BOX IAQ9B
routing
ENTER SP MUTUAL FUNDS/STOCKS/BONDS AMOUNT
If IAQ8 = 1 (SP MUTUAL FUNDS), go to IAQ36B.
Otherwise, go to IAQ36C.
(1)
[continuous
response]
(-8) DON’T
KNOW
(-9) REFUSED
(1) IAQ35A
(2) IAQ36A
(-8) IAQ35B
(-9) IAQ35B
If SPPROXY = 1(SAMPLE PERSON), display “you own”.
Otherwise, display “SP owns”.
If IA8 = 1 (SP MUTUAL FUNDS), display “mutual funds or stocks”.
If IA9 = 1 (SP BONDS), display “government, corporate, or other bonds”.
If more than one type of asset displayed, display “and” between them.
BOX IAQ10
Use input
mask in
response
field
($9,999,999)
so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ9C
appropriatel (-8) BOX IAQ9B
y.
(-9) BOX IAQ9B
SHOW CARD IA18 IA21
OTHER_SP2
IAQ36B
code one
Please look at this card and tell me which is closest.
SHOW CARD IA19 IA22
OTHER_SP3
IAQ36C
code one
BOX IAQ9C
routing
Please look at this card and tell me which is closest.
If IAQ8 = 2 (SPOUSE MUTUAL FUNDS) or IAQ9 = 2 (SPOUSE
BONDS), go to IAQ37A.
Otherwise, go to BOX IAQ10.
You told me earlier that {you own/{SPOUSE/PARTNER
FIRSTNAME LASTNAME} owns} {mutual funds or stocks}
{government, corporate, or other bonds} that are not part
of retirement accounts. About how much are these
worth?
(1) LESS THAN
$8,000
(2) $8,000 TO
LESS THAN
$62,000
(3) $62,000
TO LESS THAN
$192,000
(4) $192,000
TO LESS THAN
$213,000
(5) $213,000
OR MORE
(-8) DON’T
KNOW
(-9) REFUSED
(1) LESS THAN
$300
(2) $300 TO
LESS THAN
$2,500
(3) $2,500 TO
LESS THAN
$8,000
(4) $8,000 TO
LESS THAN
$37,000
(5) $37,000
OR MORE
(-8) DON’T
KNOW
(-9) REFUSED
BOX IAQ9C
BOX IAQ9C
IF NEEDED: We don’t need an exact dollar amount.
OTHER_SPOUSE1
IAQ37A
quantity unit
BOX IAQ9D
routing
OTHER_SPOUSE2
IAQ37B
code one
OTHER_SPOUSE3
IAQ37C
code one
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how (1)
people manage financially as they age and what effect this [continuous
might have on their health.
response]
(-8) DON’T
ENTER SPOUSE’S/PARTNER’S MUTUAL
KNOW
FUNDS/STOCKS/BONDS AMOUNT
(-9) REFUSED
If IAQ8 = 2 (SPOUSE MUTUAL FUNDS), go to IAQ37B.
Otherwise, go to IA37B.
(1) LESS THAN
$8,000
(2) $8,000 TO
LESS THAN
$62,000
(3) $62,000
TO LESS THAN
$192,000
(4) $192,000
TO LESS THAN
$213,000
(5) $213,000
SHOW CARD IA18 IA21
OR MORE
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
(1) LESS THAN
$300
(2) $300 TO
LESS THAN
$2,500
(3) $2,500 TO
LESS THAN
$8,000
(4) $8,000 TO
LESS THAN
$37,000
(5) $37,000
SHOW CARD IA19 IA22
OR MORE
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display “you own”.
Otherwise, display “{SPOUSE/PARTNER FIRSTNAME LASTNAME} owns”.
If IA8 = 2 (SPOUSE MUTUAL FUNDS), display “mutual funds or stocks”.
If IA9 = 2 (SPOUSE BONDS), display “government, corporate, or other bonds”.
If more than one type of asset displayed, display “and” between each one.
Use input
mask in
response
field
($9,999,999)
so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ10
appropriatel (-8) BOX IAQ9D
y.
(-9) BOX IAQ9D
BOX IAQ10
BOX IAQ10
BOX IAQ10
ACCTS_COMBINED1
ACCTS_COMBINED2
IAQ38
routing
code one
IAQ38A
quantity unit
BOX IAQ10A
routing
If [IAQ10 = 1 (SP CHECKING) and IAQ10 = 2 (SPOUSE
CHECKING)] or IAQ10 = 3 (JOINT CHECKING) or [IAQ11 = 1
(SP SAVINGS) and IAQ11 = 2 (SPOUSE SAVINGS)] or IAQ11
= 3 (JOINT SAVINGS), or
[IAQ12 = 1 (SP CDS) and IAQ12= 2 (SPOUSE CDS)] or IAQ12
= 3 (JOINT CDS), go to IAQ38.
Else if IAQ10 = 1 (SP CHECKING) or IAQ11 = 1 (SP SAVINGS)
or IAQ13 = 1 (SP CDS), go to IAQ39A.
Else if IAQ10 = 2 (SPOUSE CHECKING) or IAQ11 = 2
(SPOUSE SAVINGS) or IAQ13 = 2 (SPOUSE CDS), go to
IAQ40A.
Otherwise, go to BOX IAQ11.
You told me earlier that {you/SP} and {SP FIRSTNAME
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}
have {checking accounts} {savings or money market
accounts} {certificates of deposit or CDs}.
(1) ENTER
COMBINED
If you added up all of these accounts, about how much
AMOUNT
were they worth early last month (meaning in the
(2) ENTER SP
beginning of {CURRENT MONTH – 1})?
AND
SPOUSE/PART
IF NEEDED: We don’t need an exact dollar amount.
NER
AMOUNTS
IF NEEDED: We know questions like these may be difficult SEPARATELY
to answer, but we need to know this to understand how (-8) DON’T
people manage financially as they age and what effect this KNOW
might have on their health.
(-9) REFUSED
ENTER COMBINED SP AND SPOUSE'S/PARTNER'S
ACCOUNTS TOTAL AMOUNT
If IAQ12 = [1 (SP CDs) and 2 (SPOUSE CDs)] or 3 (JOINT
CDs), go to IAQ38B.
Otherwise, go to IAQ38C.
SHOW CARD IA20 IA23
ACCTS_SEPARATE1
IAQ38B
code one
Please look at this card and tell me which is closest.
SHOW CARD IA21 IA24
ACCTS_SEPARATE2
IAQ38C
code one
Please look at this card and tell me which is closest.
(1)
[continuous
response]
(-8) DON’T
KNOW
(-9) REFUSED
(1) LESS THAN
$11,000
(2) $11,000
TO LESS THAN
$25,000
(3) $25,000
TO LESS THAN
$50,000
(4) $50,000
TO LESS THAN
$108,000
(5) $108,000
OR MORE
(-8) DON’T
KNOW
(-9) REFUSED
(1) LESS THAN
$2,000
(2) $2,000 TO
LESS THAN
$7,000
(3) $7,000 TO
LESS THAN
$17,000
(4) $17,000
TO LESS THAN
$57,000
(5) $57,000
OR MORE
(-8) DON’T
KNOW
(-9) REFUSED
If SPPROXY = 1 (SAMPLE PERSON) or (SPPROXY = 2(PROXY) and IN6-ROSTREL in(2,56)), display “you”.
Otherwise, display “SP”.
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display "SP FIRSTNAME LASTNAME".
Otherwise, display "SPOUSE/PARTNER FIRSTNAME LASTNAME".
If IA10a = 1 (SP CHECKING) or IA10a = 2 (SPOUSE CHECKING) or IA10a = 3 (JOINT CHECKING), display “checking
accounts”.
If IA10b = 1 (SP SAVINGS) or IA10b = 2 (SPOUSE SAVINGS) or IA10b = 3 (JOINT SAVINGS), display “savings or money
market accounts”.
If IA10c = 1 (SP CDS) or IA10c = 2 (SPOUSE CDS) or IA10c = 3 (JOINT CDS), display “certificates of deposit or
CDs”.
If more than one type of account displayed, display “and” between each one.
Display “last month” in underlined text.
(1) IAQ38A
(2) IAQ39A
(-8) IAQ38B
(-9) IAQ38B
Use input
mask in
response
field
($9,999,999)
so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ11
appropriatel (-8) BOX IAQ10A
y.
(-9) BOX IAQ10A
BOX IAQ11
BOX IAQ11
You told me earlier that {you have/SP has} {a checking
account} {a savings or money market account} {certificates
of deposit or CDs}.
If you added up all of these accounts, about how much
were they worth early last month (meaning in the
beginning of {CURRENT MONTH – 1})?
IF NEEDED: We don’t need an exact dollar amount.
ACCTS_SP1
IAQ39A
quantity unit
BOX IAQ10B
routing
ACCTS_SP2
IAQ39B
code one
ACCTS_SP3
IAQ39C
code one
BOX IAQ10C
routing
If SPPROXY = 1(SAMPLE PERSON), display “you have”.
IF NEEDED: We know questions like these may be difficult (1)
Otherwise, display “SP has”.
to answer, but we need to know this to understand how [continuous If IA10a = 1 (SP CHECKING), display “a checking account”.
people manage financially as they age and what effect this response]
If IA10b = 1 (SP SAVINGS), display “a savings or money market account”.
might have on their health.
(-8) DON’T
If IA10c = 1 (SP CDS), display “certificates of deposit or CDs”.
KNOW
If more than one type of account displayed, display “and” between each one.
ENTER SP ACCOUNTS TOTAL AMOUNT
(-9) REFUSED Display “last month” in underlined text.
If IAQ12 = 1 (SP CDs), go to IAQ39b.
Otherwise, go to IAQ39c.
(1) LESS THAN
$8,000
(2) $8,000 TO
LESS THAN
$13,000
(3) $13,000
TO LESS THAN
$28,000
(4) $28,000
TO LESS THAN
$54,000
(5) $54,000
SHOW CARD IA22 IA25
OR MORE
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
(1) LESS THAN
$500
(2) $500 TO
LESS THAN
$1,900
(3) $1,900 TO
LESS THAN
$5,000
(4) $5,000 TO
LESS THAN
$20,000
(5) $20,000
SHOW CARD IA23 IA26
OR MORE
(-8) DON'T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
If IAQ10 = 2 (SPOUSE CHECKING) or IAQ11 = 2 (SPOUSE
SAVINGS) or IAQ12 = 2 (SPOUSE CDS), go to IAQ40A.
Otherwise, go to BOX IAQ11.
You told me earlier that {you have/{SPOUSE/PARTNER
FIRSTNAME LASTNAME} has} {a checking account} {a
savings or money market account} {certificates of deposit
or CDs}.
If you added up all of these accounts, about how much
were they worth early last month (meaning in the
beginning of {CURRENT MONTH – 1})?
IF NEEDED: We don’t need an exact dollar amount.
ACCTS_SPOUSE1
IAQ40A
quantity unit
BOX IAQ10D
routing
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display “you have”.
IF NEEDED: We know questions like these may be difficult (1)
Otherwise, display “{SPOUSE/PARTNER FIRSTNAME LASTNAME} has”.
to answer, but we need to know this to understand how [continuous If IA10a = 2 (SPOUSE CHECKING), display “a checking account”.
people manage financially as they age and what effect
response]
If IA10b = 2 (SPOUSE SAVINGS), display “a savings or money market account”.
this might have on their health.
(-8) DON’T
If IA10c = 2 (SPOUSE CDS), display “certificates of deposit or CDs”.
KNOW
If more than one type of account displayed, display “and” between each one.
ENTER SPOUSE/PARTNER ACCOUNTS TOTAL AMOUNT
(-9) REFUSED Display “last month” in underlined text.
If IAQ12 = 2 (SPOUSE CDS), go to IAQ40b.
Otherwise, go to IAQ40c.
Use input
mask in
response
field
($9,999,999)
so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ10C
appropriatel (-8) BOX IAQ10B
y.
(-9) BOX IAQ10B
BOX IAQ10C
BOX IAQ10C
Use input
mask in
response
field
($9,999,999)
so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ11
appropriatel (-8) BOX IAQ10D
y.
(-9) BOX IAQ10D
SHOW CARD IA22 IA25
ACCTS_SPOUSE2
IAQ40B
code one
Please look at this card and tell me which is closest.
SHOW CARD IA23 IA26
ACCTS_SPOUSE3
INTEREST_COMBINED1
INTEREST_COMBINED2
IAQ40C
code one
BOX IAQ11
routing
IAQ41
IAQ41A
code one
quantity unit
Please look at this card and tell me which is closest.
If [IAQ8 = 1 (SP MUTUAL FUNDS) and IAQ8 = 2 (SPOUSE
MUTUAL FUNDS)] or IAQ8 = 3 (JOINT MUTUAL FUNDS) or
[IAQ9 = 1 (SP BONDS) and IAQ9 = 2 (SPOUSE BONDS)] or
IAQ9 = 3 (JOINT BONDS), or
[IAQ10 = 1 (SP CHECKING) and IAQ10 = 2 (SPOUSE
CHECKING)] or IAQ10 = 3 (JOINT CHECKING) or
[IAQ11 = 1 (SP SAVINGS) and IAQ11 = 2 (SPOUSE
SAVINGS)] or IAQ11 = 3 (JOINT SAVINGS), or
[IAQ12 = 1 (SP CDS) and IAQ12= 2 (SPOUSE CDS)] or IAQ12
= 3 (JOINT CDS), go to IAQ41.
Else if IAQ8 = 1 (SP MUTUAL FUNDS) or IAQ9 = 1 (SP
BONDS) or IAQ10 = 1 (SP CHECKING) or IAQ11 = 1 (SP
SAVINGS) or IAQ12 = 1 (SP CDS), go to IAQ42A.
Else if IAQ8 = 2 (SPOUSE MUTUAL FUNDS) or IAQ9 = 2
(SPOUSE BONDS) or IAQ10 = 2 (SPOUSE CHECKING) or
IAQ11 = 2 (SPOUSE SAVINGS) or IAQ12 = 2 (SPOUSE CDS),
go to IAQ43A.
Otherwise, go to BOX IAQ12.
Now thinking about all of last year, that is calendar year
{CURRENT YEAR – 1}, how much interest and dividend
income did {you/SP} and {SP FIRSTNAME
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}
have altogether from {mutual funds or stocks}
{government, corporate, or other bonds} {bank accounts
or CDs}?
(1) LESS THAN
$8,000
(2) $8,000 TO
LESS THAN
$13,000
(3) $13,000
TO LESS THAN
$28,000
(4) $28,000
TO LESS THAN
$54,000
(5) $54,000
OR MORE
(-8) DON’T
KNOW
(-9) REFUSED
(1) LESS THAN
$500
(2) $500 TO
LESS THAN
$1,900
(3) $1,900 TO
LESS THAN
$5,000
(4) $5,000 TO
LESS THAN
$20,000
(5) $20,000
OR MORE
(-8) DON'T
KNOW
(-9) REFUSED
If SPPROXY = 1 (SAMPLE PERSON) or (SPPROXY = 2(PROXY) and IN6-ROSTREL in(2,56)), display “you”.
(1) ENTER
Otherwise, display “SP”.
COMBINED
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display "SP FIRSTNAME LASTNAME".
AMOUNT
Otherwise, display "SPOUSE/PARTNER FIRSTNAME LASTNAME".
(2) ENTER SP If IA8 = 1 (SP MUTUAL FUNDS) or 2 (SPOUSE MUTUAL FUNDS) or 3 (JOINT MUTUAL FUNDS), display “mutual
AND
funds or stocks”.
SPOUSE/PART If IA9 = 1 (SP BONDS) or 2 (SPOUSE BONDS) or 3 (JOINT BONDS), display “government, corporate, or other
IF NEEDED: We don’t need an exact dollar amount.
NER
bonds”.
AMOUNTS
If [IA10a = 1 (SP CHECKING) or 2 (SPOUSE CHECKING) or 3 (JOINT CHECKING)] or [IA10b = 1 (SP SAVINGS) or 2
IF NEEDED: We know questions like these may be difficult SEPARATELY (SPOUSE SAVINGS) or 3 (JOINT SAVINGS)] or [IA10c = 1 (SP CDS) or 2 (SPOUSE CDS) or 3 (JOINT CDS)], display
to answer, but we need to know this to understand how (-8) DON’T
“bank accounts or CDs”.
people manage financially as they age and what effect this KNOW
If more than one type of asset displayed, display “and” between each one.
might have on their health.
(-9) REFUSED Display “In the last year” in underlined text.
ENTER SP AND SPOUSE’S/PARTNER’S INTEREST AND
DIVIDEND INCOME AMOUNT
(1)
[continuous
response]
(-8) DON’T
KNOW
(-9) REFUSED
BOX IAQ11
BOX IAQ11
(1) IAQ41A
(2) IAQ42A
(-8) IAQ41B
(-9) IAQ41B
Use input
mask in
response
field
($99,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ12
appropriatel (-8) BOX IAQ11A
y.
(-9) BOX IAQ11A
SHOW CARD IA24 IA27
INTEREST_COMBINED3
IAQ41B
code one
Please look at this card and tell me which is closest.
Now thinking about all of last year, that is calendar year
{CURRENT YEAR – 1}, how much interest and dividend
income did {you/SP} have altogether from {mutual funds
or stocks} {bonds} {bank accounts or CDs}?
(1) LESS THAN
$200
(2) $200 TO
LESS THAN
$1,000
(3) $1,000 TO
LESS THAN
$4,000
(4) $4,000 TO
LESS THAN
$16,000
(5) $16,000
OR MORE
(-8) DON’T
KNOW
(-9) REFUSED
IF NEEDED: We don’t need an exact dollar amount.
INTEREST_SP1
IAQ42A
quantity unit
INTEREST_SP2
IAQ42B
code one
BOX IAQ11A
routing
If SPPROXY = 1(SAMPLE PERSON), display “you”.
IF NEEDED: We know questions like these may be difficult (1)
Otherwise, display “SP”.
to answer, but we need to know this to understand how [continuous If IA8 = 1 (SP MUTUAL FUNDS), display “mutual funds or stocks”.
people manage financially as they age and what effect this response]
If IA9 = 1 (SP BONDS), display “bonds”.
might have on their health.
(-8) DON’T
If IA10a = 1 (SP CHECKING) or IA10b = 1 (SP SAVINGS) or IA10c = 1 (SP CDS), display “bank accounts or CDs”.
KNOW
If more than one type of asset displayed, display “and” between each one.
ENTER SP INTEREST AND DIVIDEND INCOME AMOUNT
(-9) REFUSED Display “In the last year” in underlined text.
(1) LESS THAN
$400
(2) $400 TO
LESS THAN
$1,000
(3) $1,000 TO
LESS THAN
$2,000
(4) $2,000 TO
LESS THAN
$11,000
(5) $11,000
OR MORE
SHOW CARD IA25 IA28
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
If IAQ8 = 2 (SPOUSE MUTUAL FUNDS) or IAQ9 = 2 (SPOUSE
BONDS) or IAQ10 = 2 (SPOUSE CHECKING) or IAQ11 =
2 (SPOUSE SAVINGS) or IAQ12 = 2 (SPOUSE CDS), go to
IAQ43A.
Otherwise, go to BOX IAQ12.
Now thinking about all of last year, that is calendar year
{CURRENT YEAR – 1}, how much interest and dividend
income did {you/{SPOUSE/PARTNER FIRSTNAME
LASTNAME}} have altogether from {mutual funds or
stocks} {bonds} {bank accounts or CDs}?
IF NEEDED: We don’t need an exact dollar amount.
INTEREST_SPOUSE1
IAQ43A
quantity unit
INTEREST_SPOUSE2
IAQ43B
code one
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display “you”.
IF NEEDED: We know questions like these may be difficult
Otherwise, display “{SPOUSE/PARTNER FIRSTNAME LASTNAME}”.
to answer, but we need to know this to understand how (1)
If IA8 = 2 (SPOUSE MUTUAL FUNDS,) display “mutual funds or stocks”.
people manage financially as they age and what effect this [continuous If IA9 = 2 (SPOUSE BONDS), display “bonds”.
might have on their health.
response]
If IA10a = 2 (SPOUSE CHECKING) or IA10b = 2 (SPOUSE SAVINGS) or IA10c = 2 (SPOUSE CDS), display “bank
(-8) DON’T
accounts or CDs”.
ENTER SPOUSE/PARTNER INTEREST AND DIVIDEND
KNOW
If more than one type of asset displayed, display “and” between each one.
INCOME AMOUNT
(-9) REFUSED Display “In the last year” in bold underlined text.
(1) LESS THAN
$400
(2) $400 TO
LESS THAN
$1,000
(3) $1,000 TO
LESS THAN
$2,000
(4) $2,000 TO
LESS THAN
$11,000
(5) $11,000
OR MORE
SHOW CARD IA25 IA28
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
BOX IAQ12
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ11A
appropriatel (-8) IAQ42B
y.
(-9) IAQ42B
BOX IAQ11A
Use input
mask in
response
field
($9,999) so
that dollar
sign is
displayed
and
commas are
inserted
(1) BOX IAQ12
appropriatel (-8) IAQ43B
y.
(-9) IAQ43B
BOX IAQ12
BOX IAQ12
LAND_COMBINED1
LAND_COMBINED2
IAQ44
IAQ44A
routing
code one
quantity unit
If [IAQ13 = 1 (SP BUSINESS/FARM/REAL ESTATE) and IAQ13
= 2 (SPOUSE BUSINESS/FARM/REAL ESTATE)] or IAQ13 =3
(JOINT BUSINESS/FARM/REAL ESTATE), go to IAQ44.
Else if IAQ13 = 1 (SP BUSINESS/FARM/REAL ESTATE), go to
IAQ45A.
Else if IAQ13 = 2 (SPOUSE BUSINESS/FARM/REAL ESTATE),
go to IAQ46A.
Otherwise, go to BOX IAQ13.
You told me earlier that {you/SP} and {SP FIRSTNAME
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}
have a business, a farm, or real estate {other than {SP}’s
home}. If that were sold today and any debts on it were
paid off, about how much would it bring?
(1) ENTER
COMBINED
AMOUNT
(2) ENTER SP
AND
SPOUSE/PART
IF NEEDED: We don’t need an exact dollar amount.
NER
AMOUNTS
IF NEEDED: We know questions like these may be difficult SEPARATELY
to answer, but we need to know this to understand how (-8) DON’T
people manage financially as they age and what effect this KNOW
might have on their health.
(-9) REFUSED
ENTER SP AND SPOUSE/PARTNER BUSINESS/FARM/REAL
ESTATE COMBINED AMOUNT
SHOW CARD IA26 IA29
LAND_COMBINED3
IAQ44B
code one
Please look at this card and tell me which is closest.
You told me earlier that {you have/SP has} a business, a
farm, or real estate {other than {SP}’s home}. If that were
sold today and any debts on it were paid off, about how
much would it bring?
If SPPROXY = 1 (SAMPLE PERSON) or (SPPROXY = 2(PROXY) and IN6-ROSTREL in(2,56)), display “you”.
Otherwise, display “SP”.
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display "SP FIRSTNAME LASTNAME".
Otherwise, display "SPOUSE/PARTNER FIRSTNAME LASTNAME".
If HP1 = 1 (OWNS HOME), display “other than {SP}’s home”.
(1)
[continuous
response]
(-8) DON’T
KNOW
(-9) REFUSED
(1) LESS THAN
$30,000
(2) $30,000
TO LESS THAN
$101,000
(3) $101,000
TO LESS THAN
$247,000
(4) $247,000
TO LESS THAN
$703,000
(5) $703,000
OR MORE
(-8) DON’T
KNOW
(-9) REFUSED
IF NEEDED: We don’t need an exact dollar amount.
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how
people manage financially as they age and what effect this
might have on their health.
LAND_SP1
IAQ45A
quantity unit
ENTER SP BUSINESS/FARM/REAL ESTATE AMOUNT
SHOW CARD IA27 IA30
LAND_SP2
IAQ45B
code one
BOX IAQ12A
routing
Please look at this card and tell me which is closest.
If IAQ13 = 2 (SPOUSE BUSINESS/FARM/REAL ESTATE), go
to IAQ46A.
Otherwise, go to BOX IAQ13.
(1)
[continuous
response]
(-8) DON’T
If SPPROXY = 1(SAMPLE PERSON), display “you have”.
KNOW
Otherwise, display “SP has”.
(-9) REFUSED If HP1 = 1 (OWNS HOME), display “other than {SP}’s home”
(1) LESS THAN
$18,000
(2) $18,000
TO LESS THAN
$68,000
(3) $68,000
TO LESS THAN
$122,000
(4) $122,000
TO LESS THAN
$293,000
(5) $293,000
OR MORE
(-8) DON’T
KNOW
(-9) REFUSED
(1) IAQ44A
(2) IAQ45A
(-8) IAQ44B
(-9) IAQ44B
Use input
mask in
response
field
($99,999,99
9) so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ13
appropriatel (-8) IAQ44B
y.
(-9) IAQ44B
BOX IAQ13
Use input
mask in
response
field
($99,999,99
9) so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ12A
appropriatel (-8) IAQ45B
y.
(-9) IAQ45B
BOX IAQ12A
You told me earlier that {you have/{SPOUSE/PARTNER
FIRSTNAME LASTNAME} has} a business, a farm, or real
estate {other than {SP}’s home}. If that were sold today
and any debts on it were paid off, about how much would
it bring?
IF NEEDED: We don’t need an exact dollar amount.
LAND_SPOUSE1
IAQ46A
quantity unit
LAND_SPOUSE2
IAQ46B
code one
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how (1)
people manage financially as they age and what effect this [continuous
might have on their health.
response]
(-8) DON’T
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display “you have”.
ENTER SPOUSE/PARTNER BUSINESS/FARM/REAL ESTATE KNOW
Otherwise, display “{SPOUSE/PARTNER FIRSTNAME LASTNAME} has”.
AMOUNT
(-9) REFUSED If HP1 = 1 (OWNS HOME), display “other than {SP}’s home”
(1) LESS THAN
$18,000
(2) $18,000
TO LESS THAN
$68,000
(3) $68,000
TO LESS THAN
$122,000
(4) $122,000
TO LESS THAN
$293,000
(5) $293,000
OR MORE
SHOW CARD IA27 IA30
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
routing
If [IAQ13 = 1 (SP BUSINESS/FARM/REAL ESTATE) and IAQ13
= 2 (SPOUSE BUSINESS/FARM/REAL ESTATE)] or IAQ13
= 3 (JOINT BUSINESS/FARM/REAL ESTATE), go to IAQ47.
Else if IAQ13 = 1 (SP BUSINESS/FARM/REAL ESTATE), go to
IAQ48A.
Else if IAQ13 = 2 (SPOUSE BUSINESS/FARM/REAL ESTATE),
go to IAQ49A.
Otherwise, go to IAQ50.
BOX IAQ13
BOX IAQ13
Now thinking about all of last year, that is calendar year
{CURRENT YEAR – 1}, how much income did {you/SP} and
{SP FIRSTNAME LASTNAME/SPOUSE/PARTNER FIRSTNAME
LASTNAME} receive from these businesses or property
before any federal or state taxes were taken out?
INCOME_COMBINED1
INCOME_COMBINED2
IAQ47
IAQ47A
code one
quantity unit
(1) ENTER
COMBINED
AMOUNT
(2) ENTER SP
AND
SPOUSE/PART
IF NEEDED: We don’t need an exact dollar amount.
NER
AMOUNTS
IF NEEDED: We know questions like these may be difficult SEPARATELY
to answer, but we need to know this to understand how (-8) DON’T
people manage financially as they age and what effect this KNOW
might have on their health.
(-9) REFUSED
Use input
mask in
response
field
($99,999,99
9) so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ13
appropriatel (-8) IAQ46B
y.
(-9) IAQ46B
ENTER SP AND SPOUSE/PARTNER FROM
BUSINESS/FARM/REAL ESTATE COMBINED AMOUNT
SHOW CARD IA28 IA31
INCOME_COMBINED3
IAQ47B
code one
Please look at this card and tell me which is closest.
(1)
[continuous
response]
(-8) DON’T
KNOW
(-9) REFUSED
(1) LESS THAN
$3,600
(2) $3,600 TO
LESS THAN
$12,000
(3) $12,000
TO LESS THAN
$25,000
(4) $25,000
TO LESS THAN
$64,000
(5) $64,000
OR MORE
(-8) DON’T
KNOW
(-9) REFUSED
If SPPROXY = 1 (SAMPLE PERSON) or (SPPROXY = 2(PROXY) and IN6-ROSTREL in(2,56)), display “you”.
Otherwise, display “SP”.
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display "SP FIRSTNAME LASTNAME".
Otherwise, display "SPOUSE/PARTNER FIRSTNAME LASTNAME".
Display “In the last year” in underlined text.
(1) IAQ47A
(2) IAQ48A
(-8) IAQ47B
(-9) IAQ47B
Use input
mask in
response
field
($99,999,99
9) so that
dollar sign is
displayed
and
commas are
inserted
(1) IAQ50
appropriatel (-8) IAQ47B
y.
(-9) IAQ47B
IAQ50
Now thinking about all of last year, that is calendar year
{CURRENT YEAR – 1}, how much income did {you/SP}
receive from these businesses or property before any
federal or state taxes were taken out?
IF NEEDED: We don’t need an exact dollar amount.
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how
people manage financially as they age and what effect this
might have on their health.
INCOME_SP1
IAQ48A
quantity unit
ENTER SP BUSINESS/FARM/REAL ESTATE AMOUNT
SHOW CARD IA29 IA32
INCOME_SP2
IAQ48B
code one
BOX IAQ13A
routing
Please look at this card and tell me which is closest.
If IAQ3 = 2 (SPOUSE BUSINESS/FARM/REAL ESTATE), go to
IAQ49A.
Otherwise, go to IAQ50.
(1)
[continuous
response]
(-8) DON’T
If SPPROXY = 1(SAMPLE PERSON), display “you”.
KNOW
Otherwise, display “SP”.
(-9) REFUSED Display “In the last year” in underlined text.
(1) LESS THAN
$3,600
(2) $3,600 TO
LESS THAN
$7,200
(3)$7,200 TO
LESS THAN
$14,000
(4) $14,000
TO LESS THAN
$38,000
(5) $38,000
OR MORE
(-8) DON’T
KNOW
(-9) REFUSED
Now thinking about all of last year, that is calendar year
{CURRENT YEAR – 1}, how much income did
{you/{SPOUSE/PARTNER FIRSTNAME LASTNAME}} receive
from these businesses or property before any federal or
state taxes were taken out?
IF NEEDED: We don’t need an exact dollar amount.
INCOME_SPOUSE1
IAQ49A
quantity unit
INCOME_SPOUSE2
IAQ49B
code one
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how (1)
people manage financially as they age and what effect this [continuous
might have on their health.
response]
(-8) DON’T
If IN6-ROSTREL = 2(Spouse) or 56(Partner), display “you”.
ENTER SPOUSE/PARTNER BUSINESS/FARM/REAL ESTATE KNOW
Otherwise, display “{SPOUSE/PARTNER FIRSTNAME LASTNAME}”.
AMOUNT
(-9) REFUSED Display “in the last year” in underlined text.
(1) LESS THAN
$3,600
(2) $3,600 TO
LESS THAN
$7,200
(3)$7,200 TO
LESS THAN
$14,000
(4) $14,000
TO LESS THAN
$38,000
(5) $38,000
OR MORE
SHOW CARD IA29 IA32
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
Use input
mask in
response
field
($99,999,99
9) so that
dollar sign is
displayed
and
commas are
inserted
(1) BOX IAQ13A
appropriatel (-8) IAQ48B
y.
(-9) IAQ48B
BOX IAQ13A
Use input
mask in
response
field
($99,999,99
9) so that
dollar sign is
displayed
and
commas are
inserted
(1) IAQ50
appropriatel (-8) IAQ49B
y.
(-9) IAQ49B
IAQ50
[your] respondent is SP or respondent is proxy and proxy relationship= SPOUSE or PARTNER
[SP's] respondent is proxy and proxy relatonship≠SPOUSE or PARTNER
Now I want to ask about {your/SP’s} {and SP FIRSTNAME
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}’s}
total income for last year, that is, for the calendar year
ending in December {CURRENT YEAR - 1} before any
federal or state taxes were taken out.
[and {SP FIRSTNAME LASTNAME/SPOUSE/PARTNER FIRTNAME LASTNAME}'s] SP is married or living with a partner
otherwise do not display
[SP FIRSTNAME LASTNAME] respondent is proxy and proxy relationship=SPOUSE or PARTNER
[SPOUSE/PARTNER FIRSTNAME LASTNAME] respondent is SP or respondent is proxy and proxy relationship≠SPOUSE or PARTNER
Now think about that total income from:
{Social Security or Railroad Retirement} {Supplemental
Security Income} {the Veteran’s Administration} {a pension
plan} {any retirement accounts} {mutual funds or stocks}
{bonds}
{bank accounts} {CDs} {business, farm or real estate} {jobs}
and from any other sources.
[Social Security or Railroad Retirement] IAQ1=1 or 2
otherwise do not display
[Supplemental Security Income] IAQ4=1 or 2
otherwise do not display
How much was {your/SP’s} {and SP FIRSTNAME
LASTNAME/SPOUSE/PARTNER FIRSTNAME LASTNAME}’s}
total income before taxes for last year (this is, for the 12
months ending in December {CURRENT YEAR - 1})?
[the Veteran’s Administration] IAQ5=1 or 2
otherwise do not display
[a pension plan] IAQ6=1 or 2
otherwise do not display
IF NEEDED: We don’t need an exact dollar amount – the
nearest $1,000 is fine.
IF NEEDED: We know questions like these may be difficult
to answer, but we need to know this to understand how
people manage financially as they age and what effect this
might have on their health.
TOTAL_COMBINED1
IAQ50
quantity unit
BOX IAQ14
routing
ENTER TOTAL INCOME FOR LAST YEAR
If SPMARSTA = 1 (MARRIED) go to IAQ51A.
Otherwise, go to IAQ51B.
SHOW CARD IA30 IA33
TOTAL_COMBINED2
IAQ51A
code one
Please look at this card and tell me which is closest.
SHOW CARD IA31 IA34
TOTAL_SP1
IAQ51B
code one
Please look at this card and tell me which is closest.
[any retirement accounts] IAQ7=1 or 2
otherwise do not display
(1)
[continuous
response]
(-8) DON’T
KNOW
(-9) REFUSED
[mutual funds or stocks] IAQ8=1, 2 or 3
otherwise do not display
[bonds] IAQ9=1, 2, or 3
otherwise do not display
(1) LESS THAN
$30,000
(2) $30,000
TO LESS THAN
$43,000
(3) $43,000
TO LESS THAN
$66,000
(4) $66,000
TO LESS THAN
$109,000
(5) $109,000
OR MORE
(-8) DON’T
KNOW
(-9) REFUSED
(1) LESS THAN
$18,000
(2) $18,000
TO LESS THAN
$22,000
(3) $22,000
TO LESS THAN
$36,000
(4) $36,000
TO LESS THAN
$56,000
(5) $56,000
OR MORE
(-8) DON’T
KNOW
(-9) REFUSED
Use input
mask in
response
field
($99,999,99
9) so that
dollar sign is
displayed
and
commas are
inserted
(1) CO1
appropriatel (-8) BOX IAQ14
y.
(-9) BOX IAQ14
CO1
CO1
[you own] if SPPROXY = 1 or (SPPROXY = 2 and IN6-ROSTREL in(2,56))
[SP owns] if SPPROXY = 2 and IN6-ROSTREL not in (2,56)
Now, I would like to change topics and talk about
automobiles {you own/SP owns} {or {your/his/her}
{husband/wife/partner owns}}.
{Do you/Does SP} {or {your/his/her}
{husband/wife/partner}} own any cars, trucks, or vans?
OWNCAR
CO1
yes/no
IF NEEDED: Do not include recreational vehicles, such as
motorcycles, trailers, motor homes, boats, or airplanes.
[or your husband] (if SPPROXY = 1 and IN13-SPMARSTA=1 (married) and spouse gender is male) or (if SPPROXY = 2 and IN6-ROSTREL = 2
and IN13-SPMARSTA=1 (married) and spouse gender is male)
[or his husband] if SPPROXY = 2 and IN6-ROSTREL not in (2,56) and IN13-SPMARSTA=1 (married) and spouse gender is male and IN11ROSTSEX = 1 (male))
[or her husband] if SPPROXY = 2 and IN6-ROSTREL not in (2,56) and IN13-SPMARSTA=1 (married) and spouse gender is male and IN11ROSTSEX = 2 (female)
[or your wife] (if SPPROXY = 1 and IN13-SPMARSTA=1 (married) and spouse gender is female) or (if SPPROXY = 2 and IN6-ROSTREL = 2 and
and IN13-SPMARSTA=1 (married) and spouse gender is female)
[or his wife] if SPPROXY = 2 and IN6-ROSTREL not in (2,56) and IN13-SPMARSTA=1 (married) and spouse gender is female and IN11ROSTSEX = 1 (male))
[or her wife] if SPPROXY = 2 and IN6-ROSTREL not in (2,56) and IN13-SPMARSTA=1 (married) and spouse gender is female and IN11ROSTSEX = 2 (female)
[or your partner] (if SPPROXY = 1 and someone on person roster rostrel = 56 and hhflag = 1 ) or (if SPPROXY = 2 and IN6-ROSTREL = 56)
[or his partner] if SPPROXY = 2 and IN6-ROSTREL not in (2,56) and someone on person roster rostrel = 56 and hhflag = 1 and IN11-ROSTSEX
= 1 (male))
[or her partner] if SPPROXY = 2 and IN6-ROSTREL not in (2,56) and someone on person roster rostrel = 56 and hhflag = 1 and IN11ROSTSEX = 2 (female))
(1) YES
(2) NO
(-8) DON’T
KNOW
[Do you] if SPPROXY = 1 or (SPPROXY = 2 and IN6-ROSTREL in(2,56))
(-9) REFUSED [Does SP] if SPPROXY = 2 and IN6-ROSTREL not in (2,56)
(1) CO2
(2) FSINTRO1
(-8) FSINTRO1
(-9) FSINTRO1
[do you] if SPPROXY = 1 or (SPPROXY = 2 and IN6-ROSTREL in(2,56))
[does SP] if SPPROXY = 2 and IN6-ROSTREL not in (2,56)
How many vehicles {do you/does SP} {or {your/his/her}
{husband/wife/partner}} own?
NUMCAR
CO2
BOX CO2
quantity unit
routing
PVCAR1
CO3
quantity unit
PVCAR2
CO3A
code one
ENTER NUMBER OF VEHICLES
if CO2 GE 2 go to CO3 else go to FSINTRO1
(1)
[continuous
response]
(-8) DON’T
KNOW
(-9) REFUSED
[or your husband] (if SPPROXY = 1 and IN13-SPMARSTA=1 (married) and spouse gender is male) or (if SPPROXY = 2 and IN6-ROSTREL = 2
and IN13-SPMARSTA=1 (married) and spouse gender is male)
[or his husband] if SPPROXY = 2 and IN6-ROSTREL not in (2,56) and IN13-SPMARSTA=1 (married) and spouse gender is male and IN11ROSTSEX = 1 (male))
[or her husband] if SPPROXY = 2 and IN6-ROSTREL not in (2,56) and IN13-SPMARSTA=1 (married) and spouse gender is male and IN11ROSTSEX = 2 (female)
[or your wife] (if SPPROXY = 1 and IN13-SPMARSTA=1 (married) and spouse gender is female) or (if SPPROXY = 2 and IN6-ROSTREL = 2 and
and IN13-SPMARSTA=1 (married) and spouse gender is female)
[or his wife] if SPPROXY = 2 and IN6-ROSTREL not in (2,56) and IN13-SPMARSTA=1 (married) and spouse gender is female and IN11ROSTSEX = 1 (male))
[or her wife] if SPPROXY = 2 and IN6-ROSTREL not in (2,56) and IN13-SPMARSTA=1 (married) and spouse gender is female and IN11ROSTSEX = 2 (female)
[or your partner] (if SPPROXY = 1 and someone on person roster rostrel = 56 and hhflag = 1 ) or (if SPPROXY = 2 and IN6-ROSTREL = 56)
[or his partner] if SPPROXY = 2 and IN6-ROSTREL not in (2,56) and someone on person roster rostrel = 56 and hhflag = 1 and IN11-ROSTSEX
= 1 (male))
[or her partner] if SPPROXY = 2 and IN6-ROSTREL not in (2,56) and someone on person roster rostrel = 56 and hhflag = 1 and IN11ROSTSEX = 2 (female))
(1)
Altogether, what is their present value, that is, about how [continuous
much would they bring if {you/SP} sold them on today’s
response]
market?
(-8) DON’T
KNOW
[you] if SPPROXY = 1 or (SPPROXY = 2 and IN6-ROSTREL in(2,56))
ENTER DOLLAR AMOUNT
(-9) REFUSED [SP] if SPPROXY = 2 and IN6-ROSTREL not in (2,56)
(1) LESS THAN
$2,500
(2) $2,500 TO
LESS THAN
$5,000
(3) $5,000 TO
LESS THAN
$7,500
(4) $7,500 TO
LESS THAN
$10,000
(5) $10,000
TO LESS THAN
$20,000
(6) $20,000
OR MORE
SHOW CARD IA32 IA35
(-8) DON’T
KNOW
Please look at this card and tell me which is closest.
(-9) REFUSED
[your] If SPPROXY = 1 (SAMPLE PERSON) or (SPPROXY = 2(PROXY) and IN6-ROSTREL in(2,56))
[(SP)'s] If SPPROXY = 2(PROXY) and IN6-ROSTREL not in(2,56))
(1) BOX CO2
(-8) FSINTRO1
(-9) FSINTRO1
Use input
mask in
response
field
($99,999,99
9) so that
dollar sign is
displayed
and
commas are
inserted
(1) FSINTRO1
appropriatel (-8) CO3A
y.
(-9) CO3A
FSINTRO1
[you were] (If SPPROXY = 1 (SAMPLE PERSON) or ((SPPROXY = 2(PROXY) and the proxy's HHFLAG = 1)
[he was] IF SPPROXY = 2(proxy) and SP lives alone and SP is male
[she was] IF SPPROXY = 2(proxy) and SP lives alone and SP is female
[they were] If SPPROXY = 2(proxy) and count of persons with HHFLAG = 1 is more than one and proxy's HHFLAG ne 1
FSINTRO1
FSINTRO1
no entry
These next questions are about the food eaten in
[your/(SP)'s] household in the last 12 months, since
{current month} of last year and whether [you were/he
was/she was/they were] able to afford the food [you
need/he needs/she needs/they need].
[you need] (If SPPROXY = 1 (SAMPLE PERSON) or ((SPPROXY = 2(PROXY) and the proxy's HHFLAG = 1)
[he needs] IF SPPROXY = 2(proxy) and SP lives alone and SP is male
[she needs] IF SPPROXY = 2(proxy) and SP lives alone and SP is female
[they need] If SPPROXY = 2(proxy) and count of persons with HHFLAG = 1 is more than one and proxy's HHFLAG ne 1
FS1
[you] SPPROXY = 1(sample person) and SP lives alone
[your household] (If SPPROXY = 1 (SAMPLE PERSON) or ((SPPROXY = 2(PROXY) and the proxy's HHFLAG = 1)) and count of persons with
HHFLAG = 1 is more than one
[(SP)] IF SPPROXY = 2(proxy) and SP lives alone
[(SP)'s household] If SPPROXY = 2(proxy) and count of persons with HHFLAG = 1 is more than one and proxy's HHFLAG ne 1
[I] SPPROXY = 1(sample person) and SP lives alone
[We] (If SPPROXY = 1 (SAMPLE PERSON) or ((SPPROXY = 2(PROXY) and the proxy's HHFLAG = 1)) and count of persons with HHFLAG = 1 is
more than one
[(SP)] IF SPPROXY = 2(proxy) and SP lives alone and SP is male
[(SP) or other adults in (SP)'s household] If SPPROXY = 2(proxy) and count of persons with HHFLAG = 1 is more than one and proxy's
HHFLAG ne 1
I’m going to read you some statements that people have
made about their food situation. For these statements,
please tell me whether the statement was often true,
sometimes true, or never true for [you/your
household/(SP)/(SP)'s household] in the last 12
months—that is, since last {name of current month}.
The first statement is, The food that [I/we/(SP)/(SP) or
other adults in (SP)'s household] bought just didn’t last,
and [I/we/he/she/they] didn’t have money to get more.
FOODLAST
FS1
code one
Was that often, sometimes, or never true for [you/your
household/(SP)/(SP)'s household] in the last 12 months?
(1) OFTEN
TRUE
(2)
SOMETIMES
TRUE
(3) NEVER
TRUE
(-8) DON’T
KNOW
(-9) REFUSED
The next statement is: [I/we/(SP)/(SP or other adults in
(SP)'s household] couldn’t afford to eat balanced meals.
FOODLAST_OFTEN
SKIPMEAL
SKIPMEAL_OFTEN
EATLESS
HUNGRY
FS2
FS3
FS3A
FS4
FS5
code one
code one
code one
(1) OFTEN
TRUE
Was that often, sometimes, or never true for [you/your
(2)
household/(SP)/(SP)'s household] in the last 12 months? SOMETIMES
TRUE
[IF NEEDED: For these statements, please tell me whether (3) NEVER
the statement was often true, sometimes true, or never TRUE
true for [you/your household/(SP)/(SP)'s household] in the (-8) DON’T
last 12 months—that is, since last {name of current
KNOW
month}.]
(-9) REFUSED
[I] SPPROXY = 1(sample person) and SP lives alone
[We] (If SPPROXY = 1 (SAMPLE PERSON) or ((SPPROXY = 2(PROXY) and the proxy's HHFLAG = 1)) and count of persons with HHFLAG = 1 is
more than one
[he] IF SPPROXY = 2(proxy) and SP lives alone and SP is male
[she] IF SPPROXY = 2(proxy) and SP lives alone and SP is female
[they] If SPPROXY = 2(proxy) and count of persons with HHFLAG = 1 is more than one and proxy's HHFLAG ne 1
[you] SPPROXY = 1(sample person) and SP lives alone
[your household] (If SPPROXY = 1 (SAMPLE PERSON) or ((SPPROXY = 2(PROXY) and the proxy's HHFLAG = 1)) and count of persons with
HHFLAG = 1 is more than one
[(SP)] IF SPPROXY = 2(proxy) and SP lives alone
[(SP)'s household] If SPPROXY = 2(proxy) and count of persons with HHFLAG = 1 is more than one and proxy's HHFLAG ne 1
[I] SPPROXY = 1(sample person) and SP lives alone
[We] (If SPPROXY = 1 (SAMPLE PERSON) or ((SPPROXY = 2(PROXY) and the proxy's HHFLAG = 1)) and count of persons with HHFLAG = 1 is
more than one
[(SP)] IF SPPROXY = 2(proxy) and SP lives alone
[(SP) or other adults in (SP)'s household] If SPPROXY = 2(proxy) and count of persons with HHFLAG = 1 is more than one and proxy's
HHFLAG ne 1
[you] SPPROXY = 1(sample person) and SP lives alone
[your household] (If SPPROXY = 1 (SAMPLE PERSON) or ((SPPROXY = 2(PROXY) and the proxy's HHFLAG = 1)) and count of persons with
HHFLAG = 1 is more than one
[(SP)] IF SPPROXY = 2(proxy) and SP lives alone
[(SP)'s household] If SPPROXY = 2(proxy) and count of persons with HHFLAG = 1 is more than one and proxy's HHFLAG ne 1
[you] SPPROXY = 1(sample person) and SP lives alone
In the last 12 months, since last (name of current month), (1) YES
[your household] (If SPPROXY = 1 (SAMPLE PERSON) or ((SPPROXY = 2(PROXY) and the proxy's HHFLAG = 1)) and count of persons with
did [you/you or other adults in your household/(SP)/((SP) (2) NO
HHFLAG = 1 is more than one
or other adults in (SP)'s household] ever cut the size of
(-8) DON’T
[(SP)] IF SPPROXY = 2(proxy) and SP lives alone
your meals or skip meals because there wasn't enough
KNOW
[(SP) or other adults in (SP)'s household] If SPPROXY = 2(proxy) and count of persons with HHFLAG = 1 is more than one and proxy's
money for food?
(-9) REFUSED HHFLAG ne 1
How often did this happen—almost every month, some
months but not every month, or in only 1 or 2 months?
code one
In the last 12 months, did [you/(SP)] ever eat less than
[you/he/she] felt [you/he/she] should because there
wasn't enough money for food?
code one
In the last 12 months, [were you/was (SP)] ever hungry
but didn't eat because there wasn't enough money for
food?
(1) ALMOST
EVERY
MONTH
(2) SOME
MONTHS BUT
NOT EVERY
MONTH
(3) IN ONLY 1
OR 2 MONTHS
(-8) DON’T
KNOW
(-9) REFUSED
(1) YES
(2) NO
(-8) DON’T
KNOW
(-9) REFUSED
(1) YES
(2) NO
(-8) DON’T
KNOW
(-9) REFUSED
FS2
FS3
(1) FS3A
(2) FS4
(-8) FS4
(-9) FS4
FS4
[you] SPPROXY = 1(sample person)
[(SP)] SPPROXY = 2(proxy)
[you] SPPROXY = 1(sample person)
[he] SPPROXY = 2(proxy) and SP is male
[she] SPPROXY = 2(proxy) and SP is female
FS5
[were you] SPPROXY = 1(sample person)
[was (SP)] SPPROXY = 2(proxy)
BOX ENDIAQ
Demographics (DIQ)
Variable Name
DIINT
MR Screen Name
DIINTROA
Question type
no entry
Question text/description
The next few questions are about Hispanic origin and race.
HISPORIG
DI1A
yes/no
[Are you/Is (SP)] of Hispanic, (Latino/Latina), or Spanish origin?
code all
verbatim text
(01) 1 MEXICAN/MEXICAN AMERICAN/CHICANO(A)
(02) PUERTO RICAN
SHOW CARD DI1
(03) CUBAN
Looking at this card, [are you/is SP] Mexican, Mexican American, or (91) OTHER HISPANIC, LATINO(A), OR SPANISH
(Chicano/Chicana), Puerto Rican, Cuban, or of another Hispanic,
ORIGIN
(Latino/Latina) or Spanish origin?
(-8) Don't Know
CHECK ALL THAT APPLY.
(-9) Refused
OTHER ORIGIN (SPECIFY)
(01)
(01) continuous
AMERICANanswer
INDIAN OR ALASKA NATIVE
HISPORDT
HISPDTOS
RACECODE
RACEOS
RACEASDT
RACEASOS
DI1B
DI1B
DI2A
DI2A
code all
verbatim text
BOX DI2B
routing
DI2B
DI2B
code all
verbatim text
BOX DI2C
routing
RACEPIDT
DI2C
code all
RACEPIOS
DI2C
verbatim text
OTHER PACIFIC ISLANDER GROUP (SPECIFY)
ENGWELL
DI2F
code one
How well [Do you/Does (SP)] speak English? Would you say…
yes/no
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Are you] respondent is SP
[Is (SP)] respondent is proxy
[Latino] SP is male
[Latina] SP is female
(02) CHINESE
(03) FILIPINO
SHOW CARD DI3
(04) JAPANESE
Looking at this card, [are you/is (SP)] Asian Indian, Chinese,
(05) KOREAN
Filipino, Japanese, Korean, Vietnamese or some other Asian group? (06) VIETNAMESE
(91) OTHER ASIAN GROUP
You can choose more than one group.
(-8) Don't Know
CHECK ALL THAT APPLY.
(-9) Refused
OTHER ASIAN GROUP (SPECIFY)
(01) continuous answer
IF DI2A-RACECODE INCLUDES 4/NatHawOrOthPaclsl, GO TO
DI2C - RACEPIDT.
ELSE GO TO DI3INTRO - DIINT3 DI2D - OTHRLANG. ENGWELL D12F
You can choose more than one group.
CHECK ALL THAT APPLY.
DI2D
Text Fill Logic
(02) ASIAN
(03) BLACK OR AFRICAN AMERICAN
(04) NATIVE HAWAIIAN OR OTHER PACIFIC
ISLANDER
SHOW CARD DI2
(05) WHITE
Looking at this card, what [is/was] [your/(SP's)] race?
(91) SOME OTHER RACE
[ASK IF NECESSARY: Are there any options from this card that you (-8) Don't Know
would like me to record?]
(-9) Refused
SOME OTHER RACE (SPECIFY)
(01) continuous answer
IF DI2A-RACECODE INCLUDES 2/Asian, GO TO DI2B RACEASDT.
ELSE GO TO BOX DI2C.
(01) ASIAN INDIAN
SHOW CARD DI4
Looking at this card, [are you/is (SP)] Native Hawaiian, Guamanian
or Chamorro, Samoan, or some other Pacific Islander group?
OTHRLANG
Code list
(01) NATIVE HAWAIIAN
(02) GUAMANIAN OR CHAMORRO
(03) SAMOAN
(91) OTHER PACIFIC ISLANDER GROUP
(-8) Don't Know
(-9) Refused
[Do you/Does (SP)] speak a language other than English at home?
(01) continuous answer
(01) Very well
(02) Well
(03) Not Well, or
(04) Not at all?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
WHATLANG
DI2E
code one
What [is/was] this language?
(01) SPANISH
(91) OTHER
(-8) Don't Know
(-9) Refused
WHTLNGOS
DI2E
verbatim text
SOME OTHER LANGUAGE (SPECIFY)
(01) continuous answer
DIINT3
DI3INTRO
no entry
The next two questions are about education and income.
[are you] respondent is SP
[is (SP)] respondent is proxy
[Chicano] SP is male
[Chicana] SP is female
[Latino] SP is male
[Latina] SP is female
[is] SP is alive
[was] SP is deceased
[your] respondent is SP
[(SP's)] respondent is proxy
[are you] respondent is SP
[is (SP)] respondent is proxy
[are you] respondent is SP
[is (SP)] respondent is proxy
Input mask Routing
DI1A - HISPORIG
(01) DI1B - HISPORDT
(02) DI2A - RACECODE
(-8) DI2A - RACECODE
(-9) DI2A - RACECODE
(01) DI2A - RACECODE
(02) DI2A - RACECODE
(03) DI2A - RACECODE
(91) DI1B - HISPDTOS
(-8) DI2A - RACECODE
(-9) DI2A - RACECODE
DI2A - RACECODE
(01) BOX DI2B
(02) BOX DI2B
(03) BOX DI2B
(04) BOX DI2B
(05) BOX DI2B
(91) DI2A - RACEOS
(-8) BOX DI2B
(-9) BOX DI2B
BOX DI2B
(01) BOX DI2C
(02) BOX DI2C
(03) BOX DI2C
(04) BOX DI2C
(05) BOX DI2C
(06) BOX DI2C
(91) DI2B - RACEASOS
(-8) BOX DI2C
(-9) BOX DI2C
BOX DI2C
(01) DI3INTRO - DIINT3 DI2D OTHRLANG ENGWELL - D12F
(02) DI3INTRO - DIINT3 DI2D OTHRLANG ENGWELL - D12F
(03) DI3INTRO - DIINT3 DI2D OTHRLANG ENGWELL - D12F
(91) DI2C - RACEPIOS
(-8) DI3INTRO - DIINT3 DI2D OTHRLANG ENGWELL - D12F
(-9) DI3INTRO - DIINT3 DI2D OTHRLANG ENGWELL - D12F
DI3INTRO - DIINT3 DI2D - OTHRLANG
ENGWELL - D12F
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[is] SP is alive
[was] SP is deceased
DI3INTRO - DIINT3 OTHRLANG - D12D
(01) DI2E - WHATLANG
(02) DI3INTRO - DIINT3
(-8) DI3INTRO - DIINT3
(-9) DI3INTRO
(01) DI2F - ENGWELL D13INTRO - D13
(91) DI2E - WHTLNGOS
(-8) DI2F - ENGWELL D13INTRO - D13
(-9) DI2F - ENGWELL D13INTRO - D13
DI2F - ENGWELL D13INTRO - DINT3
DI3A - SPDEGRCV
SPDEGRCV
DI3A
code one
DIINT4
DI4INTRO
no entry
(01) NO SCHOOLING COMPLETED
(02) NURSERY SCHOOL TO 8TH GRADE
(03) 9TH-12TH GRADE, NO DIPLOMA
(04) HIGH SCHOOL GRADUATE (HIGH SCHOOL
DIPLOMA OR THE EQUIVALENT)
(05) VOCATIONAL/TECHNICAL/BUSINESS/TRADE
SCHOOL CERTIFICATE OR DIPLOMA (BEYOND THE
SHOW CARD DI5
HIGH SCHOOL LEVEL)
What is the highest degree or level of school [you have/(SP) has]
(06) SOME COLLEGE, BUT NO DEGREE
completed?
(07) ASSOCIATE DEGREE
[IF THE SAMPLE PERSON ATTENDED SCHOOL IN A FOREIGN (08) BACHELOR'S DEGREE
COUNTRY, IN AN UNGRADED SCHOOL, HOME SCHOOLING, OR (09) MASTER'S, PROFESSIONAL OR DOCTORATE
UNDER OTHER UNIQUE CIRCUMSTANCES, REFER THE
DEGREE
RESPONDENT TO THE SHOWCARD AND ASK FOR THE
(-8) Don't Know
[you have] respondent is SP
NEAREST EQUIVALENT.]
(-9) Refused
[(SP) has] respondent is proxy
In studies like this, people are sometimes grouped together
according to income.
DI4INTRO - DIINT4
DI4 - SPINC25K
Was [your and your spouse's/(SP's) and (his/her)
spouse's/[your/(SP's)]] total income during the past 12 months less
than $25,000 or $25,000 or more, before taxes? Include income
from jobs, Social Security, Railroad Retirement, other retirement
income, Supplemental Security Income (SSI), pensions, interest,
and any other sources.
[PROBE IF NECESSARY: In estimating [your/(SP's)] total income,
you can respond for all of the past 12 months, or provide a one
month estimate.]
SPINC25K
SPINCLET
DI4
DI5A
BOX DI3
code one
(01) LESS THAN $25,000/YEAR
[EXPLAIN IF NECESSARY: Income is important in analyzing the
(02) $25,000 OR MORE/YEAR
information we collect. For example, this information helps us learn (03) LESS THAN $2080/MONTH
whether persons in one income group use certain types of medical (04) $2080/MONTH OR MORE
care services or have certain medical conditions more or less often (-8) Don't Know
than those in another group.]
(-9) Refused
code one
routing
(01) A. Less than $5,000
(02) B. $5,000 - 9,999 less than $10,000
SHOW CARD DI6/DI7
(03) C. $10,000 - 14,999 less than $15,000
Looking at this card, which letter best represents [your and your
(04) D. $15,000 - 19,999 less than $20,000
spouse's/(SP's) and (his/her) spouse's/[your/(SP's)]] total income
before taxes during the past 12 months? Include income from jobs, (05) E. $20,000 - 24,999 less than $25,000
Social Security, Railroad Retirement, other retirement income, and (06) F. $25,000 - 29,999 less than $30,000
(07) G. $30,000 - 39,999 less than $40,000
the other sources of income we just talked about.
(08) H. $40,000 - 49,999 less than $50,000
(09) I. $50,000 or more - less than $66,000
[EXPLAIN IF NECESSARY: Income is important in analyzing the
information we collect. For example, this information helps us learn (10) J. $66,000 - less than $109,000
whether persons in one income group use certain types of medical (11) K. $109,000 or more
care services or have certain medical conditions more or less often (-8) Don't Know
than those in another group.]
(-9) Refused
GO TO NEXT SECTION.
[you and your spouse's] respondent is SP,
SP married
[(SP's) and his spouse's] respondent is
proxy, SP male and married
[(SP's) and her spouse's] respondent is
proxy, SP female and married
[your] respondent is SP, SP unmarried
[(SP's)] respondent is proxy, SP unmarried
(01) DI5A - SPINCLET
(02) DI5A - SPINCLET
(03) DI5A - SPINCLET
(04) DI5A - SPINCLET
(-8) BOX DI3
(-9) BOX DI3
[you and your spouse's] respondent is SP,
SP married
[(SP's) and his spouse's] respondent is
proxy, SP male and married
[(SP's) and her spouse's] respondent is
proxy, SP female and married
[your] respondent is SP, SP unmarried
[(SP's)] respondent is proxy, SP unmarried
BOX DI3
Closing (CLQ)
Variable Name
MR Screen Name
BOX CLBEG
Question type
Question text/description
routing
IF (SP IS RESPONDENT) OR ((PROXY IS RESPONDENT AND PROXY
LIVES WITH THE SP IN THE CURRENT ROUND) AND (SP IS ALIVE AND
NOT INSTITUTIONALIZED)), GO TO BOX CL8.
ELSE IF (PROXY IS RESPONDENT) AND (AN ADDRESS HAS BEEN
COLLECTED FOR THE PROXY), GO TO CL4 - VERIFY.
ELSE GO TO CL1 - STADDR1.
STADDR1
CL1
address
What is your address?
STADDR2
CL1
address
What is your address?
CITY
CL1
address
What is your address?
STATE
CL1
address
What is your address?
ZIPCODE
CL1
address
What is your address?
PHONAREA
CL2
phone
What is your phone number?
PHONEXCH
CL2
phone
What is your phone number?
PHONLOCL
CL2
phone
What is your phone number?
NOPHONE
CL2
phone
BOX CL2
routing
PHONAREA
CL3
phone
PHONEXCH
CL3
phone
PHONLOCL
CL3
phone
NOPHONE
CL3
phone
Code list
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) PERSON DOES NOT HAVE PHONE
What is your phone number?
(-7) Empty
IF CL2 - NOPHONE = 1/NoPhone OR CL2 - PHONAREA = RF, GO TO BOX
CL8.
ELSE GO TO CL3 - PHONAREA.
(01) [Continuous answer.]
Do you have a second phone number?
(-7) Empty
(-8) Don't Know
[PROBE: What is that number?]
(-9) Refused
(01) [Continuous answer.]
Do you have a second phone number?
(-7) Empty
(-8) Don't Know
[PROBE: What is that number?]
(-9) Refused
(01) [Continuous answer.]
Do you have a second phone number?
(-7) Empty
(-8) Don't Know
[PROBE: What is that number?]
(-9) Refused
Do you have a second phone number?
(01) PERSON DOES NOT HAVE PHONE
[PROBE: What is that number?]
(-7) Empty
Text Fill Logic
Input mask
Routing
CL1 - STADDR2
CL1 - CITY
CL1 - STATE
CL1 - ZIPCODE
CL2 - PHONAREA
CL2 - PHONEXCH
CL2 - PHONLOCL
CL2 - NOPHONE
BOX CL2
(01) CL3 - PHONEXCH
(-7) CL3 - PHONEXCH
(-8) CL3 - PHONEXCH
(-9) BOX CL8
CL3 - PHONLOCL
CL3 - NOPHONE
BOX CL8
I'd like to verify your address. I have it listed as .. [READ ADDRESS LISTED
BELOW].
Is this correct?
STREET ADDRESS 1: (STREET ADDRESS LINE 1)
STREET ADDRESS 2: (STREET ADDRESS LINE 2)
VERIFY
CL4
yes/no
CITY: (CITY) STATE: (STATE) ZIPCODE: (ZIPCODE)
[IF ANY INFORMATION IS MISSING (E.G., AN APARTMENT NUMBER),
SELECT “NO” TO ENTER THE MISSING DATA.]
(01) YES
(02) NO
(01) BOX CL5
(02) CL5 - STADDR1
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CL5 - STADDR2
I'd like to verify your address. I have it listed as .. [READ ADDRESS LISTED
BELOW].
Is this correct?
STREET ADDRESS 1: (STREET ADDRESS LINE 1)
STREET ADDRESS 2: (STREET ADDRESS LINE 2)
STADDR1
CL5
address
CITY: (CITY)
STATE: (STATE)
ZIPCODE: (ZIPCODE)
I'd like to verify your address. I have it listed as .. [READ ADDRESS LISTED
BELOW].
Is this correct?
STREET ADDRESS 1: (STREET ADDRESS LINE 1)
STREET ADDRESS 2: (STREET ADDRESS LINE 2)
STADDR2
CL5
address
CITY: (CITY)
STATE: (STATE)
ZIPCODE: (ZIPCODE)
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL5 - CITY
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CL5 - STATE
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CL5 - ZIPCODE
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
BOX CL5
I'd like to verify your address. I have it listed as .. [READ ADDRESS LISTED
BELOW].
Is this correct?
STREET ADDRESS 1: (STREET ADDRESS LINE 1)
STREET ADDRESS 2: (STREET ADDRESS LINE 2)
CITY
CL5
address
CITY: (CITY)
STATE: (STATE)
ZIPCODE: (ZIPCODE)
I'd like to verify your address. I have it listed as .. [READ ADDRESS LISTED
BELOW].
Is this correct?
STREET ADDRESS 1: (STREET ADDRESS LINE 1)
STREET ADDRESS 2: (STREET ADDRESS LINE 2)
STATE
CL5
address
CITY: (CITY)
STATE: (STATE)
ZIPCODE: (ZIPCODE)
I'd like to verify your address. I have it listed as .. [READ ADDRESS LISTED
BELOW].
Is this correct?
STREET ADDRESS 1: (STREET ADDRESS LINE 1)
STREET ADDRESS 2: (STREET ADDRESS LINE 2)
ZIPCODE
CL5
BOX CL5
address
CITY: (CITY)
STATE: (STATE)
ZIPCODE: (ZIPCODE)
routing
IF A PRIMARY PHONE NUMBER HAS BEEN COLLECTED FOR THE
PROXY, GO TO CL6 - VERIFY.
ELSE GO TO CL7 - PHONAREA.
Next, I would like to verify your phone number(s). I have them listed as ...
[READ PHONE NUMBER(S) LISTED BELOW].
Are these correct?
PHONE 1: (PRIMARY PHONE NUMBER)
PHONE 2: [(SECONDARY PHONE NUMBER)/NONE]
VERIFY
CL6
yes/no
[IF ANY PART OF THE PHONE NUMBER(S) IS NOT CORRECT, SELECT
“NO”. PROBE FOR A SECOND PHONE NUMBER IF ONE IS NOT
PRESENT. IF THERE IS A SECOND NUMBER TO ADD, SELECT “NO” TO
ENTER THE MISSING NUMBER.]
PHONAREA
CL7
phone
What is your phone number?
PHONEXCH
CL7
phone
What is your phone number?
PHONLOCL
CL7
phone
What is your phone number?
NOPHONE
CL7
phone
BOX CL7
routing
What is your phone number?
IF CL7 - NOPHONE = 1/NoPhone OR CL7 - PHONAREA = RF, GO TO BOX
CL8.
ELSE GO TO CL8 - PHONAREA.
(01) YES
(02) NO
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) PERSON DOES NOT HAVE PHONE
(-7) Empty
(01) BOX CL8
(02) CL7 - PHONAREA
(01) CL7 - PHONEXCH
(-7) CL7 - PHONEXCH
(-8) CL7 - PHONEXCH
(-9) BOX CL7
CL7 - PHONLOCL
CL7 - NOPHONE
BOX CL7
Do you have a second phone number?
PHONAREA
CL8
phone
[PROBE: What is that number?]
Do you have a second phone number?
PHONEXCH
CL8
phone
[PROBE: What is that number?]
Do you have a second phone number?
PHONLOCL
NOPHONE
CL8
CL8
BOX CL8
PHONBEST
CL9
phone
[PROBE: What is that number?]
Do you have a second phone number?
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) PERSON DOES NOT HAVE PHONE
(-7) Empty
(01) CL8 - PHONEXCH
(-7) CL8 - PHONEXCH
(-8) CL8 - PHONEXCH
(-9) BOX CL8
CL8 - PHONLOCL
CL8 - NOPHONE
phone
[PROBE: What is that number?]
BOX CL8
routing
IF SP DECEASED OR INSTITUTIONALIZED, GO TO CL62 THANK_PROXY.
ELSE IF A PHONE NUMBER FOR ARRANGING THE NEXT INTERVIEW
HAS BEEN COLLECTED, GO TO CL9 - PHONBEST.
ELSE GO TO CL10 - PHONNINT.
yes/no
As you may know, the Medicare Current Beneficiary Survey involves another
interview. The next interview will be similar to the one we had today. We will
be calling in about 4 months to set up a convenient time for the next
(01) YES
interview.
(02) NO, ANOTHER NUMBER IS BEST
(03) NO, PHONE NUMBER NOT AVAILABLE
Is (PREVIOUS BEST PHONE NUMBER FOR NEXT INTERVIEW) the best
(-8) Don't Know
phone number to call to arrange for the next interview?
(-9) Refused
(01) BOX CL14
(02) CL11 - PHONAREA
(03) BOX CL14
(-8) BOX CL14
(-9) BOX CL14
(01) BOX CL14
(02) CL11 - PHONAREA
(-8) BOX CL14
(-9) BOX CL14
PHONNINT
CL10
yes/no
As you may know, the Medicre Current Beneficiary Survey involves another
interview. The next interview will be similar to the one we had today. We will
be calling in about 4 months to set up a convenient time for the next
(01) YES
interview.
(02) NO
(-8) Don't Know
Is there a phone number to call to arrange for the next interview?
(-9) Refused
PHONAREA
CL11
phone
What is the best number to call to arrange for the next interview?
(01) [Continuous answer.]
CL11 - PHONEXCH
PHONEXCH
CL11
phone
What is the best number to call to arrange for the next interview?
(01) [Continuous answer.]
CL11 - PHONLOCL
PHONLOCL
CL11
phone
What is the best number to call to arrange for the next interview?
(01) [Continuous answer.]
CL12 - PHONWHER
(01) PROXY'S OR SP'S HOME
(02) PROXY'S OR SP'S WORK/OFFICE
(03) NEIGHBOR'S
(04) FRIEND'S
(05) RELATIVE'S
(91) SOMEWHERE ELSE
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) BOX CL14
(02) BOX CL14
(03) CL13 - PERSON_INTNNAME
(04) CL13 - PERSON_INTNNAME
(05) CL13 - PERSON_INTNNAME
(91) CL12 - PHONWHOS
(-8) BOX CL14
(-9) BOX CL14
BOX CL14
(01) [Continuous answer.]
CL14 - SAMENAME
(01) SAME AS CONTACT NAME LISTED ABOVE
(91) OTHER NAME
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) BOX CL14
(91) CL14 - NAMEOS
(-8) BOX CL14
(-9) BOX CL14
BOX CL14
PHONWHER
PHONWHOS
CL12
CL12
code 1
verbatim text
PERSON_INTNNAME
CL13
roster
SAMENAME
NAMEOS
CL14
CL14
BOX CL14
And where is that phone located?
SOMEWHERE ELSE (SPECIFY)
What is this (CL12 RESPONSE) name?
ENTER ONLY ONE.
code 1
verbatim text
Under what name is that telephone number likely to be listed?
OTHER NAME (SPECIFY)
routing
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP'S PREVIOUS ROUND
INTERVIEW WAS IN A FACILITY) OR (THERE WERE NO CONTACT
PERSONS REPORTED IN THE PREVIOUS ROUND), GO TO CL23 REPORT_CONTACT1.
ELSE (IF THE FIRST CONTACT PERSON REPORTED IN THE PREVIOUS
ROUND LIVES WITH THE SP IN THE CURRENT ROUND) OR (IF IT'S A
PROXY INTERVIEW AND THE PROXY WAS THE FIRST CONTACT
PERSON REPORTED IN THE PREVIOUS ROUND), GO TO CL23 REPORT_CONTACT1.
ELSE GO TO CL15 - CON1INFO.
During our last interview we recorded name and address information for
[READ NAME BELOW], who would know where [you/(SP)] could be
contacted in case we have trouble arranging for the next interview.
[READ INFORMATION BELOW] Is this correct?
CONTACT 1: (FIRST CONTACT NAME FROM PREVIOUS ROUND)
STREET ADDRESS 1: (STREET ADDRESS LINE 1)
STREET ADDRESS 2: (STREET ADDRESS LINE 2)
CITY: (CITY) STATE: (STATE)
ZIPCODE: (ZIPCODE)
PHONE 1: (PRIMARY PHONE NUMBER)
PHONE 2: [(SECONDARY PHONE NUMBER)/NONE]
CONTACT 2: [(SECOND CONTACT NAME FROM PREVIOUS
ROUND)/NONE]
IS CONTACT ONE INFORMATION CORRECT?
CON1INFO
CL15
code 1
REFER TO INFORMATION SHEET AND VERIFY INFORMATION WITH
RESPONDENT.
[PROBE FOR A REPLACEMENT CONTACT THAT DOES NOT LIVE WITH
RESPONDENT IF THIS CONTACT IS NO LONGER VALID.]
(01) YES, CONTACT ONE INFORMATION CORRECT
(02) NO, NEED TO REPLACE CONTACT ONE
(03) NO, NEED TO CORRECT INFORMATION FOR
CONTACT ONE
(04) NO, NEED TO DELETE CONTACT ONE - NO
REPLACEMENT
[you] respondent is SP
[(SP)] respondent is proxy
[(SECOND CONTACT NAME FROM PREVIOUS ROUND)]
second or more time through loop, second contact name
provided in previous round
[NONE] first time through loop or no name provided in
previous round
(01) BOX CL29
(02) CL24- PERSON_CONTACT1
(03) CL16-VERIFY
(04) BOX CL29
I'd like to verify (FIRST CONTACT NAME)' s address. I have it listed
as...[READ ADDRESS LISTED BELOW]. Is this correct?
STREET ADDRESS 1: (STREET ADDRESS LINE 1)
STREET ADDRESS 2: (STREET ADDRESS LINE 2)
VERIFY
CL16
yes/no
CITY: (CITY) STATE: (STATE) ZIPCODE: (ZIPCODE)
[IF ANY INFORMATION IS MISSING (E.G., AN APARTMENT NUMBER),
SELECT “NO” TO ENTER THE MISSING DATA.]
STADDR1
CL17
address
ENTER CORRECT ADDRESS.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
STADDR2
CL17
address
ENTER CORRECT ADDRESS.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
(01) YES
(02) NO
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX CL17
(02) CL17 - STADDR1
yes/no
[IF ANY PART OF THE PHONE NUMBER(S) IS NOT CORRECT, SELECT
“NO”. PROBE FOR A SECOND PHONE NUMBER IF ONE IS NOT
PRESENT. IF THERE IS A SECOND NUMBER TO ADD, SELECT “NO” TO
ENTER THE MISSING NUMBER.]
(01) YES
(02) NO
(01) BOX CL29
(02) CL19 - PHONAREA
phone
Please give me a phone number for contacting (FIRST CONTACT NAME)
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) CL19 - PHONEXCH
(-7) CL19 - PHONEXCH
(-8) CL19 - PHONEXCH
(-9) BOX CL19
phone
Please give me a phone number for contacting (FIRST CONTACT NAME)
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL19 - PHONLOCL
CITY
CL17
address
ENTER CORRECT ADDRESS.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
STATE
CL17
address
ENTER CORRECT ADDRESS.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
address
ENTER CORRECT ADDRESS.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
routing
IF A PRIMARY PHONE HAS BEEN COLLECTED FOR THE FIRST
CONTACT PERSON, GO TO CL18 - VERIFY.
ELSE GO TO CL19 - PHONAREA.
ZIPCODE
CL17
BOX CL17
CL17 - STADDR2
CL17 - CITY
CL17 - STATE
CL17 - ZIPCODE
BOX CL17
Next, I would like to verify (FIRST CONTACT NAME)'s phone number(s). I
have them listed as ... [READ PHONE NUMBER(S) LISTED BELOW].
Are these correct?
PHONE 1: (PRIMARY PHONE NUMBER)
PHONE 2: [(SECONDARY PHONE NUMBER)/NONE]
VERIFY
PHONAREA
PHONEXCH
CL18
CL19
CL19
PHONLOCL
NOPHONE
SAMENAME
NAMEOS
CL19
phone
CL19
phone
BOX CL19
routing
CL20
CL20
code 1
verbatim text
Please give me a phone number for contacting (FIRST CONTACT NAME)
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
Please give me a phone number for contacting (FIRST CONTACT NAME)
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
IF CL19 - NOPHONE = 1/NoPhone OR CL19 - PHONAREA = RF, GO TO
BOX CL29.
ELSE GO TO CL20 - SAMENAME.
Under what name is that telephone number likely to be listed?
OTHER NAME (SPECIFY)
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL19 - NOPHONE
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
BOX CL19
(01) SAME AS CONTACT NAME LISTED ABOVE
(91) OTHER NAME
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) CL21 - PHONAREA
(91) CL20 - NAMEOS
(-8) CL21 - PHONAREA
(-9) CL21 - PHONAREA
CL21 - PHONAREA
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) CL21 - PHONEXCH
(-7) CL21 - PHONEXCH
(-8) CL21 - PHONEXCH
(-9) BOX CL21
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL21 - PHONLOCL
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL21 - NOPHONE
(01) PERSON DOES NOT HAVE PHONE
(-7) Empty
BOX CL21
(01) SAME AS CONTACT NAME LISTED ABOVE
(91) OTHER NAME
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) BOX CL29
(91) CL22 - NAMEOS
(-8) BOX CL29
(-9) BOX CL29
BOX CL29
Is there a second phone number for contacting (FIRST CONTACT NAME)?
PHONAREA
CL21
phone
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
Is there a second phone number for contacting (FIRST CONTACT NAME)?
PHONEXCH
CL21
phone
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
Is there a second phone number for contacting (FIRST CONTACT NAME)?
PHONLOCL
CL21
phone
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
Is there a second phone number for contacting (FIRST CONTACT NAME)?
NOPHONE
SAMENAME
NAMEOS
REPORT_CONTACT1
PERSON_CONTACT1
STADDR1
STADDR2
CITY
CL21
phone
BOX CL21
routing
CL22
CL22
CL23
CL24
CL25
CL25
CL25
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
IF CL21 - NOPHONE = 1/NoPhone OR CL21 - PHONAREA = RF, GO TO
BOX CL29.
ELSE GO TO CL22 - SAMENAME.
code 1
verbatim text
Under what name is the second telephone number likely to be listed?
OTHER NAME (SPECIFY)
code 1
[Besides yourself, please/Please] give me the name, address, and telephone
number of a relative or close friend who would know where [(you/(SP)] would
be in case we have trouble arranging for the next interview. Please give me
the name of someone who is not living with [you/(SP)].
[PROXIES AND HOUSEHOLD MEMBERS SHOULD NOT BE USED AS
CONTACTS. IF YOU USED A PROXY RESPONDENT, IF POSSIBLE TRY
TO GET SOMEONE WHO IS RELATED TO BOTH THE RESPONDENT AND
THE PROXY. IF THE RESPONDENT AND PROXY ARE NOT RELATED,
TRY TO GET A RELATIVE OF THE RESPONDENT.]
roster
[Please give me the name of a relative or close friend who would know where
[you/(SP)] would be. Please give me the name of someone who is not living
with [you/(SP)].]
ENTER ONLY ONE CONTACT.
(01) [Continuous answer.]
address
[Please give me an address for contacting (FIRST CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CL25 - STADDR2
address
[Please give me an address for contacting (FIRST CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL25 - CITY
address
[Please give me an address for contacting (FIRST CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CL25 - STATE
(01) RESPONDENT REPORTS A CONTACT NAME
(02) RESPONDENT DID NOT REPORT A CONTACT NAME
(-8) Don't Know
(-9) Refused
[Besides yourself, please] respondent is SP
[Please] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
(01) CL24 - PERSON_CONTACT1
(02) BOX CL44
(-8) BOX CL44
(-9) BOX CL44
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
CL25 - STADDR1
STATE
ZIPCODE
PHONAREA
PHONEXCH
PHONLOCL
NOPHONE
SAMENAME
NAMEOS
CL25
CL25
CL26
CL26
CL26
address
[Please give me an address for contacting (FIRST CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CL25 - ZIPCODE
address
[Please give me an address for contacting (FIRST CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CL26 - PHONAREA
Please give me a phone number for contacting (FIRST CONTACT NAME)
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) CL26 - PHONEXCH
(-7) CL26 - PHONEXCH
(-8) CL26 - PHONEXCH
(-9) BOX CL26
phone
Please give me a phone number for contacting (FIRST CONTACT NAME)
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL26 - PHONLOCL
phone
Please give me a phone number for contacting (FIRST CONTACT NAME)
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL26 - NOPHONE
(01) PERSON DOES NOT HAVE PHONE
(-7) Empty
BOX CL26
(01) SAME AS CONTACT NAME LISTED ABOVE
(91) OTHER NAME
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) CL28 - PHONAREA
(91) CL27 - NAMEOS
(-8) CL28 - PHONAREA
(-9) CL28 - PHONAREA
CL28 - PHONAREA
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) CL28 - PHONEXCH
(-7) CL28 - PHONEXCH
(-8) CL28 - PHONEXCH
(-9) BOX CL28
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL28 - PHONLOCL
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL28 - NOPHONE
(01) PERSON DOES NOT HAVE PHONE
(-7) Empty
BOX CL28
(01) SAME AS CONTACT NAME LISTED ABOVE
(91) OTHER NAME
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) BOX CL29
(91) CL29 - NAMEOS
(-8) BOX CL29
(-9) BOX CL29
BOX CL29
phone
CL26
phone
BOX CL26
routing
CL27
CL27
code 1
verbatim text
Please give me a phone number for contacting (FIRST CONTACT NAME)
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
IF CL26 - NOPHONE = 1/NoPhone OR CL26 -PHONAREA = RF, GO TO
BOX CL29.
ELSE GO TO CL27 - SAMENAME.
Under what name is that telephone number likely to be listed?
OTHER NAME (SPECIFY)
Is there a second phone number for contacting (FIRST CONTACT NAME)?
PHONAREA
CL28
phone
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
Is there a second phone number for contacting (FIRST CONTACT NAME)?
PHONEXCH
CL28
phone
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
Is there a second phone number for contacting (FIRST CONTACT NAME)?
PHONLOCL
CL28
phone
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
Is there a second phone number for contacting (FIRST CONTACT NAME)?
NOPHONE
SAMENAME
NAMEOS
CL28
phone
BOX CL28
routing
CL29
CL29
BOX CL29
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
IF CL28 - NOPHONE = 1/NoPhone OR CL28 -PHONAREA = RF, GO TO
BOX CL29.
ELSE GO TO CL29 - SAMENAME.
code 1
verbatim text
Under what name is the second telephone number likely to to be listed?
OTHER NAME (SPECIFY)
routing
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP'S PREVIOUS ROUND
INTERVIEW WAS IN A FACILITY) OR (IF SECOND CONTACT WAS NOT
REPORTED IN THE PREVIOUS ROUND), GO TO CL38 REPORT_CONTACT2.
ELSE (IF THE SECOND CONTACT PERSON REPORTED IN THE
PREVIOUS ROUND LIVES WITH THE SP IN THE CURRENT ROUND) OR
(IF IT'S A PROXY INTERVIEW AND THE PROXY WAS THE SECOND
CONTACT PERSON REPORTED IN THE PREVIOUS ROUND) OR (IF THE
SECOND CONTACT PERSON REPORTED IN THE PREVIOUS ROUND
WAS SELECTED AS CONTACT ONE IN THE CURRENT ROUND), GO TO
CL38 - REPORT_CONTACT2.
ELSE GO TO CL30 - CON2INFO.
You also named [READ NAME BELOW] as someone who would know where
[you/(SP)] could be contacted in case we have trouble arranging for the next
inteview.
[READ INFORMATION BELOW] Is this correct?
CONTACT 2: (SECOND CONTACT NAME FROM PREVIOUS ROUND)
STREET ADDRESS 1: (STREET ADDRESS LINE 1)
STREET ADDRESS 2: (STREET ADDRESS LINE 2)
CITY: (CITY) STATE: (STATE)
ZIPCODE: (ZIPCODE)
PHONE 1: (PRIMARY PHONE NUMBER)
PHONE 2: [(SECONDARY PHONE NUMBER)/NONE]
IS CONTACT TWO INFORMATION CORRECT?
CON2INFO
CL30
code 1
REFER TO INFORMATION SHEET AND VERIFY INFORMATION WITH
RESPONDENT.
(01) YES, CONTACT TWO INFORMATION CORRECT
(05) NO, NEED TO REPLACE CONTACT TWO
(06) NO, NEED TO CORRECT CONTACT TWO INFO
(07) NO, DELETE CONTACT TWO - NO REPLACEMENT
[you] respondent is SP
[(SP)] respondent is proxy
(01) BOX CL44
(05) CL39 - PERSON_CONTACT2
(06) CL31 - VERIFY
(07) BOX CL44
I'd like to verify (SECOND CONTACT NAME)' s address. I have it listed
as...[READ ADDRESS LISTED BELOW]. Is this correct?
[IF ANY INFORMATION IS MISSING (E.G., AN APARTMENT NUMBER),
SELECT “NO” TO ENTER THE MISSING DATA.]
STREET ADDRESS 1: (STREET ADDRESS LINE 1)
STREET ADDRESS 2: (STREET ADDRESS LINE 2)
CITY: (CITY) STATE: (STATE)
ZIPCODE: (ZIPCODE)
VERIFY
CL31
yes/no
STADDR1
CL32
address
ENTER CORRECT ADDRESS.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
STADDR2
CL32
address
ENTER CORRECT ADDRESS.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
CITY
CL32
address
ENTER CORRECT ADDRESS.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
STATE
CL32
address
ENTER CORRECT ADDRESS.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
ZIPCODE
CL32
address
ENTER CORRECT ADDRESS.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
routing
IF A PRIMARY PHONE HAS BEEN COLLECTED FOR THE SECOND
CONTACT PERSON, GO TO CL33 - VERIFY.
ELSE GO TO CL34 - PHONAREA.
BOX CL32
(01) YES
(02) NO
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX CL32
(02) CL32 - STADDR1
CL32 - STADDR2
CL32 - CITY
CL32 - STATE
CL32 - ZIPCODE
BOX CL32
Next, I would like to verify (SECOND CONTACT NAME)'s phone number(s).
I have them listed as ... [READ PHONE NUMBER(S) LISTED BELOW].
Are these correct?
PHONE 1: (PRIMARY PHONE NUMBER)
VERIFY
CL33
yes/no
PHONAREA
CL34
phone
PHONEXCH
CL34
phone
PHONLOCL
CL34
phone
NOPHONE
CL34
phone
BOX CL34
routing
(01) YES
PHONE 2: [(SECONDARY PHONE NUMBER)/NONE]
(02) NO
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
Please give me a phone number for contacting (SECOND CONTACT NAME). (-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
Please give me a phone number for contacting (SECOND CONTACT NAME). (-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
Please give me a phone number for contacting (SECOND CONTACT NAME). (-9) Refused
(01) PERSON DOES NOT HAVE PHONE
Please give me a phone number for contacting (SECOND CONTACT NAME). (-7) Empty
IF CL34 - NOPHONE = 1/NoPhone OR CL34 - PHONAREA = RF, GO TO
BOX CL44.
ELSE GO TO CL35 - SAMENAME.
[(SECONDARY PHONE NUMBER)] secondary phone number
previously provided
[NONE] secondary phone number not previously provided
(01) BOX CL44
(02) CL34 - PHONAREA
(01) CL34 - PHONEXCH
(-7) CL34 - PHONEXCH
(-8) CL34 - PHONEXCH
(-9) BOX CL34
CL34 - PHONLOCL
CL34 - NOPHONE
BOX CL34
SAMENAME
NAMEOS
CL35
CL35
code 1
verbatim text
Under what name is that telephone number likely to be listed?
OTHER NAME (SPECIFY)
Is there a second phone number for contacting (SECOND CONTACT
NAME)?
PHONAREA
CL36
phone
[PROBE: What is that number?]
Is there a second phone number for contacting (SECOND CONTACT
NAME)?
PHONEXCH
CL36
phone
[PROBE: What is that number?]
Is there a second phone number for contacting (SECOND CONTACT
NAME)?
PHONLOCL
CL36
phone
[PROBE: What is that number?]
Is there a second phone number for contacting (SECOND CONTACT
NAME)?
NOPHONE
CL36
phone
BOX CL36
routing
SAMENAME
NAMEOS
REPORT_CONTACT2
PERSON_CONTACT2
STADDR1
STADDR2
CITY
STATE
ZIPCODE
PHONAREA
PHONEXCH
PHONLOCL
CL37
CL37
CL38
CL39
CL40
CL40
CL40
CL40
CL40
CL41
CL41
CL41
(01) SAME AS CONTACT NAME LISTED ABOVE
(91) OTHER NAME
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) CL36 - PHONAREA
(91) CL35 - NAMEOS
(-8) CL36 - PHONAREA
(-9) CL36 - PHONAREA
CL36 - PHONAREA
(01) CL36 - PHONEXCH
(-7) CL36 - PHONEXCH
(-8) CL36 - PHONEXCH
(-9) BOX CL36
CL36 - PHONLOCL
CL36 - NOPHONE
(01) PERSON DOES NOT HAVE PHONE
[PROBE: What is that number?]
(-7) Empty
IF CL34 - NOPHONE = 1/NoPhone OR CL34 - PHONAR2 = RF, GO TO BOX
CL44.
ELSE GO TO CL37 - SAMENAME.
BOX CL36
(01) SAME AS CONTACT NAME LISTED ABOVE
(91) OTHER NAME
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) BOX CL44
(91) CL37 - NAMEOS
(-8) BOX CL44
(-9) BOX CL44
BOX CL44
code 1
verbatim text
Under what name is the second telephone number likely to be listed?
OTHER NAME (SPECIFY)
code 1
[Besides yourself, please/Please] give me another name, address, and
telephone number of a relative or close friend who would know where
(you/(SP)] would be in case we have trouble arranging for the next interview.
Again, please give me the name of someone who is not living with [you/(SP)].
[PROXIES AND HOUSEHOLD MEMBERS SHOULD NOT BE USED AS
CONTACTS. IF YOU USED A PROXY RESPONDENT, IF POSSIBLE TRY
TO GET SOMEONE WHO IS RELATED TO BOTH THE RESPONDENT AND
THE PROXY. IF THE RESPONDENT AND PROXY ARE NOT RELATED,
TRY TO GET A RELATIVE OF THE RESPONDENT.]
roster
[Please give me the name of another relative or close friend who would know
where [you/(SP)] would be. Again, please give me the name of someone
who is not living with [you/(SP)].]
(01) [Continuous answer.]
address
[Please give me an address for contacting (SECOND CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CL40 - STADDR2
address
[Please give me an address for contacting (SECOND CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL40 - CITY
address
[Please give me an address for contacting (SECOND CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CL40 - STATE
address
[Please give me an address for contacting (SECOND CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CL40 - ZIPCODE
address
[Please give me an address for contacting (SECOND CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CL41 - PHONAREA
phone
(01) [Continuous answer.]
Please give me a phone number for contacting (SECOND CONTACT NAME). (-7) Empty
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
(-8) Don't Know
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(-9) Refused
(01) CL41 - PHONEXCH
(-7) CL41 - PHONEXCH
(-8) CL41 - PHONEXCH
(-9) BOX CL41
phone
(01) [Continuous answer.]
Please give me a phone number for contacting (SECOND CONTACT NAME). (-7) Empty
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
(-8) Don't Know
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(-9) Refused
CL41 - PHONLOCL
phone
(01) [Continuous answer.]
Please give me a phone number for contacting (SECOND CONTACT NAME). (-7) Empty
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
(-8) Don't Know
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(-9) Refused
CL41 - NOPHONE
(01) RESPONDENT REPORTS A CONTACT NAME
(02) RESPONDENT DID NOT REPORT A CONTACT NAME
(-8) Don't Know
(-9) Refused
[Besides yourself, please] respondent is SP proxy
[Please] respondent is proxy SP
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
(01) CL39 - PERSON_CONTACT2
(02) BOX CL44
(-8) BOX CL44
(-9) BOX CL44
CL40 - STADDR1
NOPHONE
SAMENAME
NAMEOS
CL41
phone
BOX CL41
routing
Please give me a phone number for contacting (SECOND CONTACT NAME).
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
(01) PERSON DOES NOT HAVE PHONE
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(-7) Empty
If CL41 - NOPHONE = 1/NoPhone OR CL41 - PHONAREA = RF, GO TO
BOX CL44.
ELSE GO TO CL42 - SAMENAME.
code 1
Under what name is that telephone number likely to be listed?
FOR UNLISTED NUMBERS, SELECT "OTHER NAME" AND ENTER
"UNLISTED" IN THE FIELD PROVIDED.
(01) SAME AS CONTACT NAME LISTED ABOVE
(91) OTHER NAME
(-8) Don't Know
(-9) Refused
(01) CL43 - PHONAREA
(91) CL42 - NAMEOS
(-8) CL43 - PHONAREA
(-9) CL43 - PHONAREA
verbatim text
OTHER NAME (SPECIFY)
FOR UNLISTED NUMBERS, SELECT "OTHER NAME" AND ENTER
"UNLISTED" IN THE FIELD PROVIDED.
(01) [Continuous answer.]
CL43 - PHONAREA
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) CL43 - PHONEXCH
(-7) CL43 - PHONEXCH
(-8) CL43 - PHONEXCH
(-9) BOX CL43
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL43 - PHONLOCL
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL43 - NOPHONE
CL42
CL42
BOX CL41
Is there a second phone number for contacting (SECOND CONTACT
NAME)?
PHONAREA
CL43
phone
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
Is there a second phone number for contacting (SECOND CONTACT
NAME)?
PHONEXCH
CL43
phone
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
Is there a second phone number for contacting (SECOND CONTACT
NAME)?
PHONLOCL
CL43
phone
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
Is there a second phone number for contacting (SECOND CONTACT
NAME)?
NOPHONE
SAMENAME
NAMEOS
CL43
phone
BOX CL43
routing
CL44
CL44
code 1
verbatim text
BOX CL44
routing
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
(01) PERSON DOES NOT HAVE PHONE
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(-7) Empty
If CL43 - NOPHONE = 1/NoPhone OR CL43 - PHONAR2 = RF, GO TO BOX
CL44.
ELSE GO TO CL44 - SAMENAME.
Under what name is the second phone number likely to be listed?
OTHER NAME (SPECIFY)
IF A VACATION HOME HAS BEEN COLLECTED FOR THE SP, GO TO
CL48 - VERIFY.
ELSE GO TO CL45 - ANOTHHOM.
BOX CL43
(01) SAME AS CONTACT NAME LISTED ABOVE
(91) OTHER NAME
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) BOX CL44
(91) CL44 - NAMEOS
(-8) BOX CL44
(-9) BOX CL44
BOX CL44
(01) CL46 - STADDR1
(02) BOX CL51
(-8) BOX CL51
(-9) BOX CL51
ANOTHHOM
CL45
yes/no
[Do you/Does (SP)] spend more than one month away, during the year, at
another home other than your primary home?
STADDR1
CL46
address
[Please give me an address for this home.]
STADDR2
CL46
address
[Please give me an address for this home.]
CITY
CL46
address
[Please give me an address for this home.]
STATE
CL46
address
[Please give me an address for this home.]
ZIPCODE
CL46
address
[Please give me an address for this home.]
PHONAREA
CL47
code 1
Please give me a phone number for this home
PHONEXCH
CL47
code 1
Please give me a phone number for this home
PHONLOCL
CL47
code 1
Please give me a phone number for this home
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
NOPHONE
CL47
code 1
Please give me a phone number for this home
(01) PERSON DOES NOT HAVE PHONE
(-7) Empty
[Do you] respondent is SP
[Does (SP)] respondent is proxy
CL46 - STADDR2
CL46 - CITY
CL46 - STATE
CL46 - ZIPCODE
CL47 - PHONAREA
(01) CL47 - PHONEXCH
(-7) CL47 - PHONEXCH
(-8) CL47 - PHONEXCH
(-9) BOX CL51
CL47 - PHONLOCL
CL47 - NOPHONE
BOX CL51
CODE "YES" IF ALREADY KNOWN, OTHERWISE ASK.
I would like to verify the address of the place where [you/(SP)]
(spend/spends) some portion of the year. I have it listed as… [READ
ADDRESS LISTED BELOW].
Is this correct?
STREET ADDRESS 1: (VACATION HOME ADDRESS LINE 1)
STREET ADDRESS 2: (VACATION HOME ADDRESS LINE 2)
VERIFY
CL48
yes/no
CITY: (VACATION HOME CITY) STATE: (VACATION HOME STATE)
ZIPCODE: (VACATION HOME ZIPCODE)
[IF ANY INFORMATION IS MISSING (E.G., AN APARTMENT NUMBER),
SELECT “NO” TO ENTER THE MISSING DATA.]
STADDR1
CL49
address
[What is the correct address of that place?]
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
STADDR2
CL49
address
[What is the correct address of that place?]
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
CITY
CL49
address
[What is the correct address of that place?]
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
STATE
CL49
address
[What is the correct address of that place?]
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
ZIPCODE
CL49
address
[What is the correct address of that place?]
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.
routing
IF A PHONE NUMBER HAS BEEN COLLECTED FOR SP'S VACATION
HOME, GO TO CL50 - VERIFY.
ELSE GO TO CL51 - PHONAREA.
BOX CL49
(01) YES
(02) NO
(03) SP NO LONGER HAS 2ND HOME
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CODE "YES" IF ALREADY KNOWN. OTHERWISE ASK:
I would like to verify the phone number of the place where [you/(SP)]
(spend/spends) some portion of the year.
VERIFY
CL50
yes/no
PHONE NUMBER: (VACATION HOME PHONE NUMBER)
PHONAREA
CL51
phone
Please give me a phone number for this home.
PHONEXCH
CL51
phone
Please give me a phone number for this home.
PHONLOCL
CL51
phone
Please give me a phone number for this home.
NOPHONE
FUTRPROX
PERSON_FUTRPROXY
STADDR1
CL51
BOX CL51
CL52
CL53
phone
routing
code 1
roster
Please give me a phone number for this home.
GO TO CL52 - FUTRPROX.
During our remainng interviews, we will continue to collect information about
health care visits and the costs of any health care [you/(SP)] may receive. If
for some reason you could not do the interview, please give me the name of
someone who would be able to provide the information for [you/SP)].
[Please give me the name of someone who would be able to provide this
information for [you/(SP)].]
ENTER ONLY ONE PERSON.
BOX CL53
routing
BOX CL53B
routing
IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO BOX CL53B.
IF AN ADDRESS HAS BEEN COLLECTED FOR THE FUTURE PROXY
SELECTED AT CL53 IN THE CURRENT OR PREVIOUS ROUND, GO TO
BOX CL58.
ELSE GO TO CL54 - STADDR1.
IF THE FUTURE PROXY LIVES IN THE HOUSEHOLD WITH THE SP, GO
TO BOX CL58.
ELSE GO TO CL54 - STADDR1.
address
[Please give me an address for contacting (FUTURE PROXY NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
CL54
(01) YES
(02) NO
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) BOX CL49
(02) CL49 - STADDR1
(03) BOX CL51
CL49 - STADDR2
CL49 - CITY
CL49 - STATE
CL49 - ZIPCODE
BOX CL49
[you] respondent is SP
[(SP)] respondent is proxy
[spend] respondent is SP
[spends] respondent is proxy
(01) BOX CL51
(02) CL51 - PHONAREA
(01) CL51 - PHONEXCH
(-7) CL51 - PHONEXCH
(-8) CL51 - PHONEXCH
(-9) BOX CL51
CL51 - PHONLOCL
CL51 - NOPHONE
(01) PERSON DOES NOT HAVE PHONE
(-7) Empty
BOX CL51
(01) SOMEONE NAMED
(02) NO ONE NAMED
(03) REFUSED TO NAME SOMEONE
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
(01) CL53 PERSON_FUTRPROXY
(02) BOX CL58
(03) BOX CL58
(-8) BOX CL58
(-9) BOX CL58
(01) [Continuous answer.]
[you] respondent is SP
[(SP)] respondent is proxy
BOX CL53
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CL54 - STADDR2
STADDR2
CITY
STATE
ZIPCODE
PHONAREA
PHONEXCH
PHONLOCL
NOPHONE
SAMENAME
NAMEOS
CL54
CL54
CL54
CL54
CL55
CL55
CL55
address
[Please give me an address for contacting (FUTURE PROXY NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL54 - CITY
address
[Please give me an address for contacting (FUTURE PROXY NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CL54 - STATE
address
[Please give me an address for contacting (FUTURE PROXY NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CL54 - ZIPCODE
address
[Please give me an address for contacting (FUTURE PROXY NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
CL55 - PHONAREA
phone
Please give me a phone number for contacting (FUTURE PROXY NAME).
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) CL55 - PHONEXCH
(-7) CL55 - PHONEXCH
(-8) CL55 - PHONEXCH
(-9) BOX CL55
phone
Please give me a phone number for contacting (FUTURE PROXY NAME).
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL55 - PHONLOCL
phone
Please give me a phone number for contacting (FUTURE PROXY NAME).
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL55 - NOPHONE
(01) PERSON DOES NOT HAVE PHONE
(-7) Empty
BOX CL55
(01) SAME AS CONTACT NAME LISTED ABOVE
(91) OTHER NAME
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) CL57 - PHONAREA
(91) CL56 - NAMEOS
(-8) CL57 - PHONAREA
(-9) CL57 - PHONAREA
CL57 - PHONAREA
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) CL57 - PHONEXCH
(-7) CL57 - PHONEXCH
(-8) CL57 - PHONEXCH
(-9) BOX CL57
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL57 - PHONLOCL
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
CL57 - NOPHONE
CL55
phone
BOX CL55
routing
CL56
CL56
code 1
verbatim text
Please give me a phone number for contacting (FUTURE PROXY NAME).
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
IF CL55 - NOPHONE = 1/NoPhone OR CL55 - PHONAREA = RF, GO TO
BOX CL58.
ELSE GO TO CL56 - SAMENAME.
Under what name is that telephone number likely to be listed?
OTHER NAME (SPECIFY)
Is there a second phone number for contacting (FUTURE PROXY NAME)?
PHONAREA
CL57
phone
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
Is there a second phone number for contacting (FUTURE PROXY NAME)?
PHONEXCH
CL57
phone
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
Is there a second phone number for contacting (FUTURE PROXY NAME)?
PHONLOCL
CL57
phone
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
LETTERS, ETC., FOR COMPLETE INFORMATION.]
Is there a second phone number for contacting (FUTURE PROXY NAME)?
NOPHONE
SAMENAME
NAMEOS
CL57
phone
BOX CL57
routing
CL58
CL58
BOX CL58
[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS,
(01) PERSON DOES NOT HAVE PHONE
LETTERS, ETC., FOR COMPLETE INFORMATION.]
(-7) Empty
IF CL57 - NOPHONE = 1/NoPhone OR CL57 - PHONAR2 = RF, GO TO BOX
CL58.
ELSE GO TO CL58 - SAMENAME.
code 1
verbatim text
Under what name is the second telephone number likely to be listed?
OTHER NAME (SPECIFY)
routing
IF (SP IS IN THE SUPPLEMENTAL SAMPLE), GO TO CL60 THANK_SUPP.
ELSE IF (SP IS THE RESPONDENT), GO TO CL59 - THANK_SP.
ELSE GO TO CL61 - THANK_PROXYPLANNER.
(01) SAME AS CONTACT NAME LISTED ABOVE
(91) OTHER NAME
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
BOX CL57
(01) BOX CL58
(91) CL58 - NAMEOS
(-8) BOX CL58
(-9) BOX CL58
BOX CL58
THANK_SP
CL59
no entry
[I would like to thank you for keeping the planner for this interview.] I would
[also] appreciate it if you would [continue to] record health care visits and
keep information about medical expenses for the next interview. Thank you
for your time and cooperatoin during this interview.
CIRCLE TODAY'S DATE IN THE PLANNER AS A REFERENCE FOR THE
RESPONDENT. EXPLAIN PLANNER SECTIONS AS NECESSARY.
(01) CONTINUE
[I would like to thank you for keeping the planner for this
interview.] SP kept planner
[also] SP kept planner
[continue to] SP kept planner
BOX CLEND
[you have] respondent is SP
[(SP) has] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
BOX CLEND
I would like to give you this planner [HAND PLANNER TO RESPONDENT] to
record any health care visits [you have/(SP) has] with any kind of medical
professional or facility.
THANK_SUPP
CL60
THANK_PROXYPLANNER CL61
THANK_PROXY
CL62
BOX CLEND
no entry
Here is a folder to keep any medical bills, receipts, Medicare statements, and
insurance statements that would be connected to [your/(SP)'s] health care
visits and other medical expenses so that we can talk about them during the
next interview. I'd like to thank you for your time and cooperation and I look
forward to seeing you soon.
CIRCLE TODAY'S DATE IN PLANNER AS A REFERENCE FOR THE
RESPONDENT. EXPLAIN PLANNER SECTIONS IN DETAIL TO
RESPONDENT.
(01) CONTINUE
no entry
I would like to make sure you are aware of the planner we use to record
health care visits as well as the folder for keeping information about medical
expenses for the next interview.
CIRCLE TODAY'S DATE IN PLANNER AS A REFERENCE FOR THE
RESPONDENT. EXPLAIN PLANNER SECTIONS IN DETAIL TO
RESPONDENT.
no entry
routing
I would like to thank you for your time and cooperation during this interview.
We may be contacting you in the future for further information.
GO TO NEXT SECTION
(01) CONTINUE
BOX CLEND
(01) CONTINUE
BOX CLEND
Enumeration Summary (ENS)
Variable Name
ENSINT
MR Screen Name
BOX ENSBEG
ENSINTRO
BOX ENS1
Question type
routing
Question text/description)
GO TO ENSINTRO - ENSINT.
no entry
Now I’d like to [review with you who was living in the household/ask
you a few questions about [your/(SP's)] home and any other people
who may live in the household.].
routing
IF AT LEAST ONE PERSON LIVED IN THE HOUSEHOLD WITH
THE SP AT THE TIME OF THE PREVIOUS ROUND INTERVIEW,
GO TO ENS1 - HHSTILL.
ELSE GO TO ENS3 - HHNEW.
HHSTILL
ENS1
yes/no
HOUSEHOLD_NOT
ENS2
roster
From our last interview on (REFERENCE DATE), we have listed
that [(READ NAME(S) LISTED BELOW)] lived in the same
household as [you/(SP)].
[As of (DATE OF DEATH/DATE OF INSTITUTIONALIZATION),
did/Do/Does] [READ NAME(S) LISTED BELOW] still live in the
same household as [you/(SP)]?
[A SEPARATE QUESTION WILL ASK YOU IF ANYONE ELSE
SHOULD BE ADDED. THIS QUESTION ONLY REFERS TO THE
LISTED PERSONS.]
PROBE FOR AND SELECT THOSE PEOPLE WHO ARE NO
LONGER IN THE HOUSEHOLD.
Code list
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Text Fill Logic
[review with you who was living in the household] respondent
is proxy, SP deceased or institutionalized
[ask you a few questions about [your] home and any other
people who may live in the household] respondent is SP
[ask you a few questions about [(SP's)] home and any other
people who may live in the household] respondent is proxy,
SP not deceased or institutionalized
BOX ENS1
[you] respondent is SP
[(SP)] respondent is proxy
[As of (DATE OF DEATH) did] respondent is proxy, SP
deceased
[As of (DATE OF INSTITUTIONALIZATION) did] respondent is
proxy, SP institutionalized
[Do] more than one name listed as living in same household,
SP not deceased or institutionalized
[Does] only one name listed as living in same household, SP
not deceased or institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
(01) ENS3 - HHNEW
(02) ENS2 - HOUSEHOLD_NOT
(-8) ENS3 - HHNEW
(-9) ENS3 - HHNEW
ENS2_IN - NAVIGATOR
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
NAVIGATOR
NOTHHRSN
NOTHHROS
ENS2_IN
ENS2A
ENS2A
BOX ENS2
code 1
verbatim text
routing
(01) DECEASED
(02) INSTITUTIONALIZED, HEALTH CARE FACILITY
(03) INSTITUTIONALIZED, OTHER
(04) PERSON MOVED
(05) SP MOVED
(06) PERSON NOT IN HOUSEHOLD - PREVIOUS
ROUND ERROR
(91) OTHER REASON
(-8) Don't Know
(-9) Refused
[is] SP is not deceased or institutionalized
[was] SP is deceased or institutionalized
[as of (DATE OF DEATH)] SP is deceased
[as of (DATE OF INSTITUTIONALIZATION)] SP is
institutionalized
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[At the time of the last interview, you were living by yourself]
respondent is SP and INTTYPE in(1,4,5,7,8,9,10,12) and was
living by themselves last interview
[At the time of the last interview, (SP) was living by himself]
respondent is proxy, SP male and INTTYPE
in(1,4,5,7,8,9,10,12) and was living by themselves last
interview
[At the time of the last interview, (SP) was living by herself]
respondent is proxy, SP female and INTTYPE
in(1,4,5,7,8,9,10,12) and was living by themselves last
interview
[you] respondent is SP
[(SP)] respondent is proxy
[is] respondent is SP or proxy, SP not deceased or
institutionalized
[was] respondent is proxy, SP deceased or institutionalized
[as of (DATE OF DEATH)] respondent is proxy, SP deceased
[as of (DATE OF INSTITUTIONALIZATION)] respondent is
proxy, SP institutionalized
[are] respondent is SP or proxy, SP not deceased or
institutionalized
[were] respondent is proxy, SP deceased or institutionalized
[may live] respondent is SP or proxy, SP not deceased or
institutionalized
[may have lived] respondent is proxy, SP deceased or
institutionalized
(01) ENS4 - HOUSEHOLD_ENS
(02) BOX ENS4
(-8) BOX ENS4
(-9) BOX ENS4
[is] respondent is SP or proxy, SP not deceased or institutionalized
[was] respondent is proxy, SP deceased or institutionalized
ENS4A - HHMISS
[At the time of the last interview, [you were living by yourself/(SP)
was living by [himself/herself]]].
HHNEW
HOUSEHOLD_ENS
ENS3
ENS4
(01) ENS2A - NOTHHRSN
(02) ENS3 - HHNEW
instance navigator
Why [is/was] (HOUSEHOLD MEMBER NAME) no longer in the
household [as of (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?
OTHER REASON (SPECIFY)
GO TO ENS2_IN - NAVIGATOR.
yes/no
[Besides [you/(SP)], (is/was)/(Is/Was)] there anyone else living or
staying in the household [as of (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]? Remember to include people who
[are/were] temporarily absent and any children who [may live/may
have lived] in the household.
roster
Who else [is/was] living or staying in the household?
SELECT OR ADD ALL PERSONS LIVING IN THE HOUSEHOLD.
Input mask Routing
(01) BOX ENS2
(02) BOX ENS2
(03) BOX ENS2
(04) BOX ENS2
(05) BOX ENS2
(06) BOX ENS2
(91) ENS2A - NOTHHROS
(-8) BOX ENS2
(-9) BOX ENS2
BOX ENS2
Now I want to make sure I have everyone who [lives/lived] in the
household [as of (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]. I have listed (READ NAME(S) LISTED
BELOW).
HHMISS
ENS4A
yes/no
Have I missed any lodgers, boarders, or anyone else who usually
[lives or stays/lived or stayed] in the household but [is/was] away
from home traveling or in the hospital?
HHPSEX
ENS5
grid
Is (HOUSEHOLD MEMBER NAME) male or female?
grid
What is (HOUSEHOLD MEMBER NAME'S) date of birth?
[ENTER DATE.]
grid
What is (HOUSEHOLD MEMBER NAME'S) date of birth?
[ENTER DATE.]
EHHDOBMM
EHHDOBDD
ENS5
ENS5
EHHDOBYY
ENS5
grid
What is (HOUSEHOLD MEMBER NAME'S) date of birth?
[ENTER DATE.]
HHPAGE
ENS5
grid
How old is (HOUSEHOLD MEMBER NAME)?
routing
IF AT LEAST ONE PERSON LIVING IN THE HOUSEHOLD WITH
THE SP IN THE CURRENT ROUND, WAS ALSO LIVING IN THE
HOUSEHOLD AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW AND (WAS MISSING ANY PART OF THEIR DATE OF
BIRTH IN THE PREVIOUS ROUND) AND (HAS NEVER BEEN
ASKED ENS10 IN ANY PREVIOUS ROUND), GO TO ENS10 EHHDOBMM.
ELSE GO TO BOX ENS4A
BOX ENS4
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) MALE
(02) FEMALE
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
[lives] respondent is SP or proxy, SP not deceased or
institutionalized
[lived] respondent is proxy, SP deceased or institutionalized
[as of (DATE OF DEATH)] respondent is proxy, SP deceased
[as of (DATE OF INSTITUTIONALIZATION)] respondent is
proxy, SP institutionalized
[lives or stays] respondent is SP or proxy, SP not deceased or
institutionalized
[lived or stayed] respondent is proxy, SP deceased or
institutionalized
[is] respondent is SP or proxy, SP not deceased or
institutionalized
[was] respondent is proxy, SP deceased or institutionalized
(01) ENS4 - HOUSEHOLD_ENS
(02) ENS5 - HHPSEX
(-8) ENS5 - HHPSEX
(-9) ENS5 - HHPSEX
ENS5 - EHHDOBMM
MM
ENS5 - EHHDOBDD
DD
ENS5 - EHHDOBYY
YY
ENS5 - HHPAGE (01) BOX ENS4
(-8) ENS5 -HHPAGE
(-9) ENS5-HHPAGE
BOX ENS4
ASK THE RESPONDENT TO PROVIDE INFORMATION FOR ALL
"DK" AND "RF" ENTRIES LISTED BELOW. DO NOT CHANGE
THE ENTRIES IF THE RESPONDENT STILL DOES NOT KNOW
THE INFORMATION.
EHHDOBMM
ENS10
grid
(HOUSEHOLD MEMBER NAME'S) DATE OF BIRTH.
[ENTER DATE.]
(01)[Continuous answer.]
(-8) Don't Know
(-9) Refused
MM
ENS10 - EHHDOBDD
(01)[Continuous answer.]
(-8) Don't Know
(-9) Refused
DD
ENS10 - EHHDOBYY
(01)[Continuous answer.]
(-8) Don't Know
(-9) Refused
YY
ENS10 - HHPAGE
ASK THE RESPONDENT TO PROVIDE INFORMATION FOR ALL
"DK" AND "RF" ENTRIES LISTED BELOW. DO NOT CHANGE
THE ENTRIES IF THE RESPONDENT STILL DOES NOT KNOW
THE INFORMATION.
EHHDOBDD
ENS10
grid
(HOUSEHOLD MEMBER NAME'S) DATE OF BIRTH.
[ENTER DATE.]
ASK THE RESPONDENT TO PROVIDE INFORMATION FOR ALL
"DK" AND "RF" ENTRIES LISTED BELOW. DO NOT CHANGE
THE ENTRIES IF THE RESPONDENT STILL DOES NOT KNOW
THE INFORMATION.
EHHDOBYY
ENS10
grid
(HOUSEHOLD MEMBER NAME'S) DATE OF BIRTH.
[ENTER DATE.]
ASK THE RESPONDENT TO PROVIDE INFORMATION FOR ALL
"DK" AND "RF" ENTRIES LISTED BELOW. DO NOT CHANGE
THE ENTRIES IF THE RESPONDENT STILL DOES NOT KNOW
THE INFORMATION.
HHPAGE
ENS10
grid
BOX ENS4A
routing
(HOUSEHOLD MEMBER NAME'S) AGE.
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP'S
PREVIOUS ROUND INTERVIEW WAS IN A FACILITY), GO TO
BOX ENS4B.
ELSE GO TO BOX ENS5
routing
IF AT LEAST ONE PERSON LIVES IN THE HOUSEHOLD WITH
THE SP, GO TO ENS10A - HOUSEHOLD_OWNS.
ELSE SET SP AS PERSON WHO OWNS/RENTS HOME AND GO
TO BOX ENS4C
BOX ENS4B
(01)[Continuous answer.]
(-8) Don't Know
(-9) Refused
BOX ENS4A
HOUSEHOLD_OWNS
ASKWORK
ENS10A
roster
BOX ENS4C
routing
ENS10AA
BOX ENS5
JOBSTAT
NAVIGATOR
HHJBSTAT
ENS11
BOX ENS5A
ENS11A_IN
ENS11A
BOX ENS6
BOX ENS7
[this] respondent is SP
[(SP's)] respondent is proxy
[here] respondent is SP or proxy, SP not deceased or
institutionalized
[there] respondent is proxy, SP deceased or institutionalized
BOX ENS4C
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
BOX ENS5
[Before I continue with the next set of questions, I need to collect
information about [your/(SP’s)] job status.] [Are you/Is (SP)]
currently working at a job or business?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Before I continue with the next set of questions, I need to
collect information about [your] job status.] respondent is SP,
SP is not in supplemental sample
[Before I continue with the next set of questions, I need to
collect information about [(SP)'s] job status.] respondent is
proxy, SP is not in supplemental sample
[Are you] respondent is SP
[Is (SP)] respondent is proxy
BOX ENS5A
IF AT LEAST ONE PERSON WHO LIVES IN THE HOUSEHOLD
WITH THE SP IS AGE 16 OR OLDER, OR AGE = DK OR RF AND
((THIS PERSON IS A NEW HOUSEHOLD MEMBER IN THE
CURRENT ROUND) OR (IT IS A FALL ROUND)), GO TO
ENS11A_IN - NAVIGATOR.
ELSE GO TO BOX ENS7.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
Who owns or rents [this/(SP’s)] home? (PROBE: Of the people
living [here/there] now, who is the person who is the head of the
household?)
SELECT ONLY ONE.
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) AND (SP'S AGE IS
16 OR OLDER, OR AGE = DK OR RF), GO TO ENS10AA ASKWORK.
ELSE GO TO BOX ENS5.
yes/no
Since (REFERENCE DATE), did [you/(SP)] work at any time at a
job or business?
routing
IF (SP IS IN THE SUPPLEMENTAL SAMPLE AND ENS10AA ASKWORK = 1/Yes) OR (IF SP IS NOT IN THE SUPPLEMENTAL
SAMPLE AND ((IT IS A FALL ROUND) AND (SP IS ALIVE AND
NOT INSTITUTIONALIZED) AND (SP'S AGE IS 16 OR OLDER, OR
AGE = DK OR RF))), GO TO ENS11 - JOBSTAT.
ELSE GO TO BOX ENS5A.
routing
routing
instance navigator
yes/no
routing
([Before I continue with the next set of questions, I need to update
information about [your/(HOUSEHOLD MEMBER NAME'S)] job
status.)] [Are you/Is (HOUSEHOLD MEMBER NAME)] currently
working at a job or business?
GO TO ENS11A_IN - NAVIGATOR.
routing
IF ((SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW
FROM THE FACILITY)) AND SP'S AGE IS 17 OR OLDER OR AGE
= DK OR RF, GO TO ENS12 - SPAFEVER.
ELSE GO TO BOX ENSEND.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
Did [you/(SP)] ever serve in the Armed Forces of the United States? (-9) Refused
(01) ENS11A - HHJBSTAT
(02) BOX ENS7
[Before I continue with the next set of questions, I need to
update information about [your] job status.] respondent is
HOUSEHOLD MEMBER NAME if proxy or SP if not a proxy
[Before I continue with the next set of questions, I need to
update information abo
BOX ENS6
[you] respondent is SP
[(SP)] respondent is proxy
(01) ENS13 - SPAFTIME
(02) ENS14 - SPNGEVER
(-8) ENS14 - SPNGEVER
(-9) ENS14 - SPNGEVER
Now we have a few questions about military service.
SPAFEVER
SPAFTIME
SPNGEVER
SPNGALL
SPNGDSBL
ENS12
yes/no
ENS14
yes/no
(07) IRAQ OR AFGHANISTAN CONFLICT (2001present)
(06) PERSIAN GULF WAR/OPERATION DESERT
STORM (Aug 1990 - March 1991)
(01) VIETNAM ERA (Aug 1964 - May 1975)
(02) KOREAN CONFLICT (June 1950 - Jan 1955)
(03) WORLD WAR II (Sept 1940 - July 1947)
SHOW CARD ENS1
(04) WORLD WAR I (1917 - 1918)
Looking at this card, in which of these time periods did [you/(SP)]
(05) PEACE TIME (ALL OTHER TIMES)
serve in the Armed Forces?
(-8) Don't Know
CHECK ALL THAT APPLY.
(-9) Refused
(01) YES
(02) NO
[Were you/Was (SP)] ever an active member of a National Guard or (-8) Don't Know
military reserve unit of the United States?
(-9) Refused
BOX ENS14
routing
IF ENS12 - SPAFEVER = 1/Yes, GO TO ENS16 - SPNGDSBL.
ELSE GO TO BOX ENSEND.
ENS15
yes/no
Was all of [your/(SP’s)] active duty related to National Guard or
military reserve training?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
yes/no
[Do you/Does (SP)/Did (SP)] have a disability related to service in
the Armed Forces of the United States?
[PROBE: ‘Have you received a V.A. disability rating?’ IF THE
RESPONDENT HAS A V.A. DISABILITY RATING, SELECT "YES";
IF HE OR SHE DOES NOT, SELECT "NO"]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
ENS13
ENS16
code all
[you] respondent is SP
[(SP)] respondent is proxy
[Were you] respondent is SP
[Was (SP)] respondent is proxy
ENS14 - SPNGEVER
(01) ENS15 - SPNGALL
(02) BOX ENS14
(-8) BOX ENS14
(-9) BOX ENS14
[your] respondent is SP
[(SP's)] respondent is proxy
ENS16 - SPNGDSBL
[Do you] respondent is SP
[Does (SP)] respondent is proxy, SP alive
[Did (SP)] respondent is proxy, SP deceased
(01) ENS17 - SPVARATE
(02) BOX ENSEND
(-8) BOX ENSEND
(-9) BOX ENSEND
SPVARATE
ENS17
BOX ENSEND
numeric
routing
What [is [your/(SP’s)]/was (SP's)] (current) V.A. disability rating?
THE VA DISABILITY RATING IS A PERCENTAGE IN MULTIPLES
OF 10 (I.E., 10%, 20%, ETC.). ENTER THE NUMBER AS A
WHOLE NUMBER. YOU DO NOT NEED TO ENTER THE "%"
SIGN.
GO TO NEXT SECTION
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[is [your]] respondent is SP
[is [(SP's)] respondent is proxy, SP alive
[was (SP's)] respondent is proxy, SP deceased
BOX ENSEND
Housing Characteristics (HAQ)
Variable Name
HAINT
MR Screen Name
Question type
BOX HA1
routing
HAINTRO
no entry
Question text/description
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP DID NOT RECEIVE THE HA
SECTION IN THE PREVIOUS YEAR) OR (SP MOVED IN THE PREVIOUS YEAR)
OR (THE TYPE OF DWELLING REPORTED IN THE PREVIOUS YEAR WAS
UNKNOWN) OR (MOST RECENT TYPE OF DWELLING COLLECTED IN A
PREVIOUS ROUND = 96/HomelessJail), GO TO HAINTRO - HAINT.
ELSE IF (SP DID NOT PREVIOUSLY REPORT THAT THIS RESIDENCE HAD
RAMPS AT ENTRANCES) OR (SP DID NOT PREVIOUSLY REPORT THAT THIS
RESIDENCE HAD MODIFICATIONS TO ANY BATHROOM) OR (SP DID NOT
PREVIOUSLY REPORT THAT THIS RESIDENCE HAS SPECIAL RAILINGS), GO
TO HAINTRO2A - HAINT2.
ELSE GO TO BOX HA1B.
IF THE SP IS HOMELESS, IS TRANSIENT WITH NO PERMANENT HOME, OR IS
IN JAIL OR PRISON, SELECT NEXT PAGE WITHOUT READING THIS
INTRODUCTION.
I would like to ask a few questions about [your/(SP’s)] housing situation or living
arrangements.
SHOW CARD HA1
DWELLING
DWELLOS
HLEVELS
HELEVTR
HONELEVL
HA1
HA1
HA2
HA3
HA4
code one
verbatim text
IF TYPE OF HOUSING IS OBVIOUS, CODE WITHOUT ASKING. SELECT "SP IS
HOMELESS/TRANSIENT/IN JAIL OR PRISON" WITHOUT ASKING.
[IF HOUSING TYPE IS NOT OBVIOUS, ASK:] Which of these best describes
[your/(SP’s)] home?
SOMETHING ELSE (SPECIFY)
HAINT1
HAINT2
HA5
HAINTRO2
HAINTRO2A
BOX HA1AB
Text Fill Logic
Input Mask Routing
[your] respondent is SP
[(SP's)] respondent is proxy
(01) ONE-FAMILY, DETACHED
(02) TWO-FAMILY OR DUPLEX
(03) APARTMENT OR CONDOMINIUM BUILDING
(04) MOBILE HOME, TRAILER
(05) ROWHOUSE, TOWNHOUSE
(06) "MOTHER-IN-LAW" APARTMENT
(91) SOMETHING ELSE
(96) SP IS HOMELESS/TRANSIENT/IN JAIL OR PRISON
(-8) Don't Know
(01) continuous answer
[your] respondent is SP
[(SP's)] respondent is proxy
(01) HA2 - HLEVELS
(02) HA2 - HLEVELS
(03) HA2 - HLEVELS
(04) HAINTRO2 - HAINT1
(05) HA2 - HLEVELS
(06) HA2 - HLEVELS
(91) HA1 - DWELLOS
(96) BOX HA4
(-8) HA2 - HLEVELS
HA2 - HLEVELS
(01) ONE
(02) TWO
(03) THREE OR MORE
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
[house] (TYPE OF HOUSING) = 01 or 02
[apartment or condominium building] (TYPE OF
HOUSING) = 03
[place of residence] (TYPE OF HOUSING) = = not
equal to 01,02,03
(01) HAINTRO2 - HAINT1
(02) HA3 - HELEVTR
(03) HA3 - HELEVTR
(-8) HA3 - HELEVTR
(-9) HA3 - HELEVTR
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
[house] (TYPE OF HOUSING) = 01 or 02
[apartment or condominium building] (TYPE OF
HOUSING) = 03
[place of residence] (TYPE OF HOUSING) = = not
equal to 01,02,03
HA4 - HONELEVL
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
[house] (TYPE OF HOUSING) = 01 or 02
[own apartment or condominium building] (TYPE OF
HOUSING) = 03
[place of residence] (TYPE OF HOUSING) = = not
equal to 01,02,03
(01) HAINTRO2 - HAINT1
(02) HA5 - HBTHLEVL
(-8) HA5 - HBTHLEVL
(-9) HA5 - HBTHLEVL
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
[house] (TYPE OF HOUSING) = 01 or 02
[own apartment or condominium building] (TYPE OF
HOUSING) = 03
[place of residence] (TYPE OF HOUSING) = = not
equal to 01,02,03
HAINTRO2 - HAINT1
no entry
Next, I would like to ask about access or mobility modifications that [you/(SP)] may
have in (your/his/her) (house/apartment or condominium building/mobile home/place
of residence).
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[house] (TYPE OF HOUSING) = 01 or 02
[apartment or condominium building] (TYPE OF
HOUSING) = 03
[mobile home] (housing type) = 04
[place of residence] (TYPE OF HOUSING) = = not
equal to 01,02,03,04
BOX HA1AB
no entry
When we were here about a year ago, we asked about access or mobility
modifications that may have been a part of [your/(SP’s)] residence at that time.
Now, I would like to update our information about such modifications.
[your] respondent is SP
[(SP's)] respondent is proxy
BOX HA1AB
routing
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP DID NOT RECEIVE THE HA
SECTION IN THE PREVIOUS YEAR) OR (SP MOVED IN THE PREVIOUS YEAR)
OR (THE TYPE OF DWELLING REPORTED IN THE PREVIOUS YEAR WAS
UNKNOWN) OR (MOST RECENT TYPE OF DWELLING COLLECTED IN A
PREVIOUS ROUND = 96/HomelessJail) OR (SP DID NOT PREVIOUSLY REPORT
THAT THIS RESIDENCE HAD RAMPS AT ENTRANCES ), GO TO HA6 - HRAMPS.
ELSE GO TO BOX HA1AC.
code one
yes/no
yes/no
How many levels are in [your/(SP’s)] (house/apartment or condominium
building/place of residence)?
[THE NUMBER OF LEVELS REFERS TO THE TOTAL NUMBER OF FLOORS
INCLUDING BOTH FINISHED AND UNFINISHED BASEMENTS AND FINISHED
ATTICS. DO NOT INCLUDE UNFINISHED ATTICS OR ROOF TERRACES.]
Does [your/(SP’s)] (house/apartment or condominium building/place of residence)
have an elevator?
[DO NOT INCLUDE ESCALATORS, WHEELCHAIR LIFTS, OR STAIR LIFTS.]
Is the living space in [your/(SP’s)] (house/own apartment or condominium/place of
residence) all on one level?
Does [your/(SP’s)] (house/own apartment or condominium/place of residence) have
either a full bathroom or a half bathroom on all levels?
HBTHLEVL
Code list
yes/no
[PROBE: Bathroom facilities must contain at least a flush toilet, or a bathtub or
shower.]
HRAMPS
HA6
BOX HA1AC
HBATHRM
HA7
BOX HA1AD
HRAILING
HA8
BOX HA1B
HOUSTYPE
HCOMUNTY
HCOMUNOS
HA9
HA10
HA10
[your] respondent is SP
[(SP's)] respodnent is proxy
[house] (TYPE OF HOUSING) = 01 or 02
[mobile home] (TYPE OF HOUSING) = 04
[apartment or condominium building] (TYPE OF
HOUSING) = 03
[place of residence] (TYPE OF HOUSING) = = not
equal to 01,02,03,04
BOX HA1AC
[your] respondent is SP
[(SP's)] respodnent is proxy
[house] (TYPE OF HOUSING) = 01, or 02
[own apartment or condominium building] (TYPE OF
HOUSING) = 03
[mobile home] (TYPE OF HOUSING) = 04
[place of residence] (TYPE OF HOUSING) = = not
equal to 01,02,03,04
BOX HA1AD
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
[house] (TYPE OF HOUSING) = 01 or 02
[own apartment or condominium building] (TYPE OF
HOUSING) = 03
[mobile home] (TYPE OF HOUSING) = 04
[place of residence] (TYPE OF HOUSING) = = not
equal to 01,02,03,04
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
BOX HA1B
SHOW CARD HA2
Please look at this card. Is [your/(SP’s)] [house/own apartment or
condominium/mobile home/place of residence] a part of one of these
communities?[IF A RESPONDENT EXPLAINS THAT THE PLACE OF RESIDENCE
IS SIMILAR TO ONE LISTED ON THE CARD BUT CALLED BY ANOTHER NAME,
SELECT “YES”.]
(01) YES
(02) NO
(-8) Don't Know
(-9)
(01) Refused
RETIREMENT COMMUNITY
[your] respondent is SP
[(SP's)] respondent is proxy
[house] (TYPE OF HOUSING) = 01 or 02
[own apartment or condominium building] (TYPE OF
HOUSING) = 03
[mobile home] (TYPE OF HOUSING) = 04
[place of residence] (TYPE OF HOUSING) = = not
equal to 01,02,03,04
(01) HA10 - HCOMUNTY
(02) BOX HA3
(-8) HA10 - HCOMUNTY
(-9)
(01) BOX
HA11HA3
- HPERCARE
SHOW CARD HA2
[IF NECESSARY, ASK:] Which category best describes [your/(SP’s)] type of
housing?
OTHER (SPECIFY)
(02) SENIOR CITIZENS HOUSING
(03) ASSISTED LIVING FACILITY
(04) CONTINUING CARE COMMUNITY
(05) STAGED LIVING COMMUNITY
(06) RETIREMENT APARTMENTS
(07) CHURCH-PROVIDED HOUSING
(08) PERSONAL OR RESIDENTIAL CARE HOME
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) continuous answer
yes/no
(01) YES
(02) NO
Does [your/(SP’s)] (house/mobile home/apartment or condominium building/place of (-8) Don't Know
residence) have ramps at (any of) its entrance(s)?
(-9) Refused
routing
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP DID NOT RECEIVE THE HA
SECTION IN THE PREVIOUS YEAR) OR (SP MOVED IN THE PREVIOUS YEAR)
OR (THE TYPE OF DWELLING REPORTED IN THE PREVIOUS YEAR WAS
UNKNOWN) OR (MOST RECENT TYPE OF DWELLING COLLECTED IN A
PREVIOUS ROUND = 96/HomelessJail) OR (SP DID NOT PREVIOUSLY REPORT
THAT THIS RESIDENCE HAD MODIFICATIONS TO ANY BATHROOM ), GO TO
HA7 - HBATHRM.
ELSE GO TO BOX HA1AD.
yes/no
(01) YES
(02) NO
Does [your/(SP’s)] (house/own apartment or condominium/mobile home/place of
(-8) Don't Know
residence) have modifications to any bathroom such as grab bars or a shower seat? (-9) Refused
routing
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP DID NOT
RECEIVE THE HA SECTION IN THE PREVIOUS YEAR) OR (SP
MOVED IN THE PREVIOUS YEAR) OR (THE TYPE OF DWELLING
REPORTED IN THE PREVIOUS YEAR WAS UNKNOWN) OR (MOST RECENT
TYPE OF DWELLING COLLECTED IN A PREVIOUS ROUND = 96/HomelessJail)
OR (SP DID NOT PREVIOUSLY REPORT THAT THIS RESIDENCE HAS SPECIAL
RAILIINGS), GO TO HA8 - HRAILING.
ELSE GO TO BOX HA1B.
yes/no
Other than stair railings, does [your/(SP’s)] (house/own apartment or
condominium/mobile home/place of residence) have special railings to help
(you/him/her) move around?[DO NOT INCLUDE HANDRAILS IN BATHROOMS.]
routing
IF (THE SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP DID NOT RECEIVE THE
HA SECTION IN THE PREVIOUS YEAR) OR (SP MOVED IN THE PREVIOUS
YEAR) OR (MOST RECENT TYPE OF DWELLING COLLECTED IN A PREVIOUS
ROUND = 96/HomelessJail) OR (THE TYPE OF HOUSING REPORTED IN THE
PREVIOUS YEAR WAS UNKNOWN), GO TO HA9 - HOUSTYPE.
ELSE IF TYPE OF HOUSING WAS REPORTED LAST TIME IT WAS ASKED, GO
TO HAINTRO3 - HAINT3.
ELSE GO TO BOX HA4.
yes/no
code one
verbatim text
[your] respondent is SP
[(SP's)] respondent is proxy
(02) HA11 - HPERCARE
(03) HA11 - HPERCARE
(04) HA11 - HPERCARE
(05) HA11 - HPERCARE
(06) HA11 - HPERCARE
(07) HA11 - HPERCARE
(08) HA11 - HPERCARE
(91) HA10 - HCOMUNOS
(-8) HA11 - HPERCARE
(-9) HA11 - HPERCARE
HA11 - HPERCARE
HAINT3
HPERCARE
MEALPROB
MAIDPROB
WASHPROB
HELPPROB
TRANPROB
RECPROB
SERVINCL
HAINTRO3
HA11
HA12
HA12
HA12
HA12
HA12
no entry
The type of community [you/(SP)] [live/lives] in sometimes gives its residents access
to personal care services. Next, I would like to update our records regarding
[your/(SP’s)] access to such services.
[you] respondent is SP
[(SP)] respondent is proxy
[live] respondent is SP
[lives] respodnent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
HA11 - HPERCARE
yes/no
SHOW CARD HA3
Does [your/(SP’s)] place of residence give (you/him/her) access to personal care
services like any of those listed on this card?
[THE RESPONDENT ONLY HAS TO HAVE ONE PERSONAL CARE SERVICE
AVAILABLE TO HIM/HER TO QUALIFY AS A “YES” FOR THIS QUESTION.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[him] respondent is proxy, SP male
[her] respondent is proxy, SP female
(01) HA12 - MEALPROB
(02) BOX HA3
(-8) HA12 - MEALPROB
(-9) BOX HA3
list
We are interested in personal services that might be available here in addition to
housing. [In (this/these) (TYPE OF HOUSING)/In [your/(SP’s)] place of residence],
[do you/does (SP)] have access to…
prepared meals?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[In your place of residence] respondent is SP
[In (SP’s) place of residence] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
HA12 - MAIDPROB
list
We are interested in personal services that might be available here in addition to
housing. [In (this/these) (TYPE OF HOUSING)/In [your/(SP’s)] place of residence],
[do you/does (SP)] have access to…
housekeeping, maid, or cleaning services?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[In your place of residence] respondent is SP
[In (SP’s) place of residence] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
HA12 - WASHPROB
list
We are interested in personal services that might be available here in addition to
housing. [In (this/these) (TYPE OF HOUSING)/In [your/(SP’s)] place of residence],
[do you/does (SP)] have access to…
laundry services?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[In your place of residence] respondent is SP
[In (SP’s) place of residence] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
HA12 - HELPPROB
list
We are interested in personal services that might be available here in addition to
housing. [In (this/these) (TYPE OF HOUSING)/In [your/(SP’s)] place of residence],
[do you/does (SP)] have access to…
help with medications?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[In your place of residence] respondent is SP
[In (SP’s) place of residence] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
HA12 - TRANPROB
list
We are interested in personal services that might be available here in addition to
housing. [In (this/these) (TYPE OF HOUSING)/In [your/(SP’s)] place of residence],
[do you/does (SP)] have access to…
transportation?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[In your place of residence] respondent is SP
[In (SP’s) place of residence] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
HA12 - RECPROB
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[In your place of residence] respondent is SP
[In (SP’s) place of residence] respondent is proxy
[do you] respondent is SP
[does (SP)] respondent is proxy
BOX HA2
(01) ALL INCLUDED
(02) SOME INCLUDED/SOME SEPARATE
(03) ALL SEPARATE
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
BOX HA2A
[you] respondent is SP
[(SP)] respondent is proxy
[live] respondent is SP
[lives] respondent is proxy
[he] respondent is proxy, SP male
[she] respodnent is proxy, SP female
[house] (TYPE OF HOUSING) = 01 or 02
[apartment or condominium building] (TYPE OF
HOUSING) = 03
[mobile home] (TYPE OF HOUSING) = 04
[place of residence] (TYPE OF HOUSING) = = not
equal to 01,02,03,04
(01) HA16 - REQAGE
(02) HA15 - CAREPART
(-8) HA16 - REQAGE
(-9) HA16 - REQAGE
HA12
list
BOX HA2
routing
We are interested in personal services that might be available here in addition to
housing. [In (this/these) (TYPE OF HOUSING)/In [your/(SP’s)] place of residence],
[do you/does (SP)] have access to…
recreational services, such as exercise facilities, movies, activities programs, library,
card rooms, pool tables, etc.?
IF SP HAD ACCESS TO AT LEAST ONE PERSONAL SERVICE LISTED AT HA12,
GO TO HA13 - SERVINCL.
ELSE GO TO BOX HA2A.
HA13
code one
Are these services included as part of the cost of [your/(SP’s)] housing or is there a
separate charge for them?
routing
IF (THE SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP DID NOT RECEIVE THE
HA SECTION IN THE PREVIOUS YEAR) OR (SP MOVED IN THE PREVIOUS
YEAR) OR (MOST RECENT TYPE OF DWELLING COLLECTED IN A PREVIOUS
ROUND = 96/HomelessJail) OR (WHETHER OR NOT SP IS ALLOWED TO
CONTINUE LIVING IN HOME IF SUBSTANTIAL CARE IS NEEDED IS UNKNOWN),
GO TO HA14 - STAYPUT.
ELSE GO TO BOX HA4.
BOX HA2A
Would the (TYPE OF HOUSING)/place where [you/(SP)] currently (live/lives) allow
(you/him/her) to continue living in (your/his/her) (house/apartment or
condominium/mobile home/place of residence) if (you/he/she) needed substantial
care?
STAYPUT
HA14
yes/no
CAREPART
HA15
yes/no
REQAGE
HA16
yes/no
BOX HA3
routing
(01) YES
(02) NO
[PROBE: Could [you/(SP)] stay where (you/he/she) (live/lives) now if (you/he/she)
(-8) Don't Know
needed a much greater level of care?]
(-9) Refused
(01) YES
(02) NO
If (you/he/she) needed substantial care, would that care be provided in another part (-8) Don't Know
of (this/these) same (TYPE OF HOUSING)/this same place of residence?
(-9) Refused
(01) YES
(02) NO
Does the place where [you/(SP)] (live/lives) now require residents to be a certain age (-8) Don't Know
to live there or receive services?
(-9) Refused
IF HA5 - HBTHLEVL = 1/Yes OR HA7 - HBATHRM = 1/Yes, GO TO HA18 NBRROOMS.
ELSE GO TO HA17 - PERSBATH.
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respodnent is proxy
[live] respondent is SP
[lives] respondent is proxy
HA16 - REQAGE
BOX HA3
Now I have a few questions about the rooms in [your/(SP’s)] place of residence.
[Do you/Does (SP)] have (your/his/her) own bathroom facilities?
PERSBATH
NBRROOMS
HA17
HA18
yes/no
numeric
[EXPLAIN IF NECESSARY: Own bathroom facilities may be defined as the sink,
flush toilet, and bathtub or shower used primarily by [you/(SP)] and is not used on a
regular basis by someone not living in the household.]
How many rooms are there in [your/(SP’s)] (house/own apartment or
condominium/mobile home/place of residence), not counting bathrooms, hallways,
or unfinished basements?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
[Do you/Does (SP)] have (your/his/her) own kitchen?
PERKITCH
HA19
BOX HA4
yes/no
routing
[EXPLAIN IF NECESSARY: Own kitchen is defined as an area with a sink, nonportable cooking equipment and a refrigerator used primarily by [you/(SP)] and not
on a regular basis by someone not living in the household. Also includes
kitchenettes.]
GO TO NEXT SECTION
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[house] (TYPE OF HOUSING) = 01 or 02
[own apartment or condominium building] (TYPE OF
HOUSING) = 03
[mobile home] (TYPE OF HOUSING) = 04
[place of residence] (TYPE OF HOUSING) = = not
equal to 01,02,03,04
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[you] respondent is SP
[(SP)] respondent is proxy
HA18 - NBRROOMS
HA19 - PERKITCH
BOX HA4
Health Insurance Summary (HIS)
Variable Name
MR Screen Name
Question type
Question text/description
HISINT
HISINTRO
no entry
Now I'd like to review with you the information that we have about health insurance plans that [you/(SP)] had at the time of the last interview.
HISCORRB
HIS1
code one
[Let’s see if there are any other changes we need to make to the health insurance coverage [you/(SP)] had as of (REFERENCE DATE).] [(You/(SP)] had Medicare coverage
(through a managed care plan) and (you were/he was/she was) also covered by [READ PLAN NAMES BELOW]./The only health insurance coverage [you/(SP)] had was
Medicare (through a managed care plan)] on (REFERENCE DATE). Is that correct?
(01) YES, ALL CORRECT AS SHOWN
(02) NO, PLAN MISSING
(03) NO, PLAN NAME INCORRECT
(04) NO, PLAN NEEDS DELETION
(05) NO, PLAN STOPPED PRIOR TO (REFERENCE DATE)
(-8) Don't Know
(-9) Refused
PLAN_DELETION
HIS2
roster
(01) continuous answer
PLANDVB
HIS2A
verbatim text
What is the name of the plan that needs deletion?
SELECT ONLY ONE PLAN FOR DELETION AT THIS ROSTER.
BRIEFLY EXPLAIN WHY THE PLAN NEEDS TO BE DELETED.
IF THE SP WAS EVER COVERED BY THIS INSURANCE PLAN, PRESS [PgUp] SHIFT/ENTER TO GO BACK ONE SCREEN AND SELECT A DIFFERENT RESPONSE.
(01) continuous answer
HIS1 - HISCORRB
PLAN_CORRECT
HIS2B
roster code one
(01) continuous answer
HIS1 - HISCORRB PLAN_CORRECT_NAME
PLAN_CORRECT_NAME
PLAN_STOPPED
HIS2C
verbatim text
roster
What is the name of the plan that is incorrect?
EDIT ALL PLAN NAMES AT THIS ROSTER.
What is the name of the plan that is incorrect? What is the correct name of the plan listed below?
What is the name of the plan that (you were/he was/she was) no longer covered by as of (REFERENCE DATE)?
SELECT ONLY ONE PLAN TO STOP IN THE PREVIOUS ROUND AT THIS ROSTER.
HISSTPMM
HIS2D
date
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] coverage stop?
HISSTPDD
HIS2D
date
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] coverage stop?
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
HISSTPYY
HIS2D
date
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] coverage stop?
PLANSVB
HIS2E
verbatim text
BRIEFLY EXPLAIN WHY THE PLAN SHOULD BE STOPPED.
IF DATE WHEN PLAN STOPPED IS NOT KNOWN, PROVIDE ANY ADDITIONAL INFORMATION ABOUT WHEN THE PLAN STOPPED.
ADDHITYPE
HIS3
code one
What type of insurance plan needs to be added?
PLAN_HISMHMO
HISMC1
roster
What is the name of the Medicare Advantage Plan that covered [you/(SP)]?
SELECT OR ADD ONLY ONE MEDICARE ADVANTAGE PLAN AT THIS ROSTER.
HISMHMOCURR
HISMHMOCHNG
MHMORX
MHMODENT
MHMOEYE
MHMONH
MHMOPAY
MHMOAMT
HISMC2
yes/no
[Were you/Was (SP)] covered by or enrolled in (MEDICARE MANAGED CARE PLAN NAME) on (REFERENCE DATE)?
BOX HISMC1
routing
HISMC3
yes/no
OTHER THAN THE PLAN SELECTED AT HISMC1, IF ANOTHER MEDICARE MANAGED CARE PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO HISMC3 - HISMHMOCHNG.
ELSE GO TO BOX HISMC2.
I recorded previously that (PREVIOUS ROUND CURRENT MEDICARE MANAGED CARE PLAN NAME) was [your/(SP’s)] current Medicare Advantage Plan on (REFERENCE
DATE). Has this information changed?
BOX HISMC2
routing
BOX HISMC2A
routing
HISMC4
yes/no
HISMC5
HISMC6
HISMC8
HISMC9
HISMC10
yes/no
yes/no
yes/no
yes/no
numeric
IF THE PLAN SELECTED AT HIMC1 HAS BEEN IDENTIFIED AS THE SP'S CURRENT MEDICARE MANAGED CARE PLAN AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, SET THE PREVIOUS ROUND STATUS OF THIS PLAN TO "CURRENT". OTHERWISE, SET THE PREVIOUS ROUND STATUS OF THIS PLAN TO "NOT
CURRENT"
GO TO BOX HISMC2A.
IF THIS MEDICARE MANAGED CARE PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO HISMC4 - MHMORX.
ELSE GO TO HIS1 - HISCORRB.
Code list
HISMC10
code one
MHMOUNOS
MHMOCOST
HISMC10
HISMC11
verbatim text
yes/no
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
MHMOWHO
HISMC12
code one
[DO NOT INCLUDE AMOUNTS PAID BY FAMILY MEMBERS.]
Who else paid all or some portion of the additional cost for [your/(SP’s)] (MEDICARE MANAGED CARE PLAN NAME) coverage?
MHMOWHOS
HISMC12
BOX HIS2AA
verbatim text
routing
COVTIME
HIS6
code one
OTHER (SPECIFY)
CREATE MEDICAID PLAN IN THE PREVIOUS ROUND
GO TO HIS6 - COVTIME.
[Were you/Was (SP)] covered by Medicaid the whole time between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), or only part of the time?
COVNOW
HIS7
yes/no
[Were you/Was (SP)] covered by Medicaid on (REFERENCE DATE)?
COVBEGMM
HIS8
date
On what date did [your/(SP’s)] Medicaid start between (SUMMARY REFERENCE DATE) and (REFERENCE DATE)?
COVBEGDD
HIS8
date
On what date did [your/(SP’s)] Medicaid start between (SUMMARY REFERENCE DATE) and (REFERENCE DATE)?
COVBEGYY
HIS8
date
On what date did [your/(SP’s)] Medicaid start between (SUMMARY REFERENCE DATE) and (REFERENCE DATE)?
COVENDMM
HIS9
date
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] Medicaid coverage stop?
COVENDDD
HIS9
date
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] Medicaid coverage stop?
COVENDYY
HIS9
date
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] Medicaid coverage stop?
[you were] respondent is SP
[he was] respondent is proxy, SP male
[she was] respondent is proxy, SP female
[your] respondent is SP
[(SP's)] respondent is proxy
(-9) Refused
(01) HISCLOSE - ENDHIS
(02) HIS3 - ADDHITYPE
(03) HIS2B - PLAN_CORRECT
(04) HIS2 - PLAN_DELETION
(05) HIS2C - PLAN_STOPPED
(-8) HISCLOSE - ENDHIS
(-9) HISCLOSE - ENDHIS
HIS2A - PLANDVB
HIS1 - HISCORRB
HIS2D - HISSTPMM
MM
HIS2D - HISSTPDD
DD
HIS2D - HISSTPYY
YY
HIS2E - PLANSVB
[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
HIS1 - HISCORRB
(01) MEDICAID/MEDICAID MANAGED CARE PLAN
(02) PUBLIC PLAN OTHER THAN MEDICAID
(03) PRIVATE HEALTH INSURANCE PLAN
(04) MEDICARE ADVANTAGE PLAN
(05) TRICARE
(06) MEDICARE PRESCRIPTION DRUG PLAN
(01) continuous answer
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Besides the cost of [your/(SP’s)] Medicare Part B premium, was there an additional cost for [your/(SP’s)] (MEDICARE MANAGED CARE PLAN NAME) coverage? Please do not (01) YES
include any amount that [you/(SP)] may have paid as a co-payment for an office visit or a prescribed medicine.
(02) NO
(-8) Don't Know
[EXPLAIN IF NECESSARY: Some managed care plans may charge a monthly premium to cover the cost of the deductibles and coinsurance for Medicare-covered services or (-9) Refused
because they provide services that are not covered by Medicare such as prescribed medicines, routine exams, and dental, eye, or hearing. Plans that have premiums typically
charge from $50 to $75 per month.]
OTHER (SPECIFY)
Did anyone else, such as an employer, a union or professional organization pay all or some portion of the additional cost for [your/(SP’s)] (MEDICARE MANAGED CARE PLAN
NAME) coverage?
[you] respondent is SP
[(SP)] respondent is proxy
[(You/(SP)] had Medicare coverage (through a managed care plan) and (you were/he was/she was) also covered by
[READ PLAN NAMES BELOW]. respondent is SP or proxy, SP is alive and not institutionalized, SP is alive and
institutionalized
[you were] respondent is SP
[he was] respondent is proxy, SP is male
[she was] respondent is proxy, SP is female
(01) continuous answer
(01) continuous answer
(01) continuous answer
(-8) Don't Know
(-9) Refused
[PROBE IF NECESSARY: Was that per year, per month, per week, or what?]
MHMOUNIT
Input mask Routing
HIS1 - HISCORRB
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), did [you/(SP)] have prescribed medicine coverage through (MEDICARE MANAGED CARE PLAN NAME)? (01) YES
(02) NO
[PROBE: I am asking about the type of insurance coverage that [you/(SP)] personally had, not what the plan offers everyone.]
(-8) Don't Know
(-9) Refused
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), did [you/(SP)] have dental coverage through (MEDICARE MANAGED CARE PLAN NAME)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Did [you/(SP)] have optical coverage through (MEDICARE MANAGED CARE PLAN NAME), that is, for eyeglasses or contact lenses?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Did [your/(SP’s)] (MEDICARE MANAGED CARE PLAN NAME) coverage include nursing home care over above and beyond what Medicare normally covers?
(01) YES
(02) NO
[EXPLAIN IF NECESSARY: Under regular fee-for-service, Medicare pays for limited skilled nursing facility (SNF) care during a benefit period. In 2013 2014, the first 20 days
(-8) Don't Know
are paid in full and the next 80 days require a copayment of up to $148152.00 per day.]
(-9) Refused
Not including the cost of [your/(SP’s)] Medicare Part B premium, what was the additional amount that [you/(SP)] paid for (your/his/her) (MEDICARE MANAGED CARE PLAN
NAME) coverage? [Please do not include any copayments or any amount that may be paid for anyone other than [you/(SP)].]
Text Fill Logic
(01) PER YEAR
(02) QUARTERLY/EVERY 3 MONTHS
(03) BIMONTHLY/EVERY 2 MONTHS
(04) PER MONTH
(05) PER WEEK
(06) SEMI-ANNUALLY/2 TIMES PER YEAR
(07) SEMI-MONTHLY/2 TIMES PER MONTH
(91) OTHER
(-8) Don't Know
(-9) Refused
(01)
continuous answer
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) [(SP's)/(MIP's)] CURRENT EMPLOYER
(02) (SP's/MIP's) FORMER EMPLOYER
(03) (SP's/MIP's) UNION
(04) SPOUSE'S CURRENT EMPLOYER
(05) SPOUSE'S FORMER EMPLOYER
(06) PROFESSIONAL/FRATERNAL ORGANIZATION
(07) MEDICAID/MEDICAL ASSISTANCE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01)
continuous answer
(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) BOX HIS2AA
(02) HIS12 - PLAN_HISPUBLIC
(03) HIS20 - PLAN_HISPRIVATE HIS18A - EXCHGCOV
(04) HISMC1 - PLAN_HISMHMO
(05) BOX HIST1A
(06) HIS34 - PLAN_HISMPDP
HISMC2 - HISMHMOCURR
[you] respondent is SP
[(SP)] respondent is proxy
[Were you] respondent is SP
[Was SP] respondent is proxy
(01) BOX HISMC1
(02) BOX HISMC2
(-8) BOX HISMC2
(-9) BOX HISMC2
BOX HISMC2
[your] respondent is SP
[(SP's)] respondent is proxy
HISMC5 - MHMODENT
[you] respondent is SP
[(SP)] respondent is proxy
HISMC6 - MHMOEYE
[you] respondent is SP
[(SP)] respondent is proxy
HISMC8 - MHMONH
[you] respondent is SP
[(SP)] respondent is proxy
HISMC9 - MHMOPAY
[your] respondent is SP
[(SP's)] respondent is proxy
(01) HISMC10 - MHMOAMT
(02) HIS1 - HISCORRB
(-8) HIS1 - HISCORRB
(-9) HIS1 - HISCORRB
[your] respondent is SP
[(SP's)] respondent is proxy
(01) HISMC10 - MHMOUNIT
(-8) HISMC11 - MHMOCOST
(-9) HISMC11 - MHMOCOST
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
(01) HISMC11 - MHMOCOST
(02) HISMC11 - MHMOCOST
(03) HISMC11 - MHMOCOST
(04) HISMC11 - MHMOCOST
(05) HISMC11 - MHMOCOST
(06) HISMC11 - MHMOCOST
(07) HISMC11 - MHMOCOST
(91) HISMC10 - MHMOUNOS
(-8) HISMC11 - MHMOCOST
(-9) HISMC11
- MHMOCOST
HISMC11
- MHMOCOST
(01) HISMC12 - MHMOWHO
(02) HIS1 - HISCORRB
(-8) HIS1 - HISCORRB
(-9) HIS1 - HISCORRB
(01) HIS1 - HISCORRB
(02) HIS1 - HISCORRB
(03) HIS1 - HISCORRB
(04) HIS1 - HISCORRB
(05) HIS1 - HISCORRB
(06) HIS1 - HISCORRB
(07) HIS1 - HISCORRB
(91) HISMC12 - MHMOWHOS
(-8) HIS1 - HISCORRB
(-9) HIS1
- HISCORRB
HIS1
- HISCORRB
[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[Were you] respondent is SP
[Was SP] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
MM
(01) HIS10A - MCAIDHMO
(02) HIS7 - COVNOW
(-8) HIS7 - COVNOW
(-9) HIS7 - COVNOW
(01) HIS8 - COVBEGMM
(02) HIS9 - COVENDMM
(-8) HIS10A - MCAIDHMO
(-9) HIS10A - MCAIDHMO
HIS8 - COVBEGDD
[your] respondent is SP
[(SP's)] respondent is proxy
DD
HIS8 - COVBEGYY
[your] respondent is SP
[(SP's)] respondent is proxy
YY
HIS10A - MCAIDHMO
[your] respondent is SP
[(SP's)] respondent is proxy
MM
HIS9 - COVENDDD
[your] respondent is SP
[(SP's)] respondent is proxy
DD
HIS9 - COVENDYY
[your] respondent is SP
[(SP's)] respondent is proxy
YY
HIS10A - MCAIDHMO
[Were you] respondent is SP
[Was SP] respondent is proxy
MCAIDHMO
HIS10A
yes/no
Some states now use managed care plans, such as HMOs (Health Maintenance Organizations), to provide some or all health care for Medicaid beneficiaries. [Were you/Was
(SP)] enrolled in a Medicaid Managed Care Plan on [(REFERENCE DATE)/(PLAN COVERAGE STOP DATE)/the date [your/(SP’s)] Medicaid coverage stopped]?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Were you] respondent is SP
[Was SP] respondent is proxy
BOX HIS2C
BOX HIS2C
routing
IF THERE IS A MEDICARE PRESCRIPTION DRUG PLAN THAT WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO HIS1 - HISCORRB.
ELSE GO TO HIS10B1 - HISMPDCOVER.
HISMPDCOVER
HIS10B1
yes/no
Some people who receive Medicaid benefits are also enrolled in a Medicare Prescription Drug plan, or Medicare Part D plan, that pays for some or all of their prescribed
medicines. The Medicare program automatically enrolls such beneficiaries into a Prescription Drug plan, although the beneficiary may choose to switch to a different plan.
(01) YES
(02) NO
(-8) Don't Know
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), [were you/was (SP)] enrolled in a Medicare Prescription Drug plan that covered medicines prescribed by (-9) Refused
a doctor?
[Were you] respondent is SP
[Was SP] respondent is proxy
(01) HIS34 - PLAN_HISMPDP
(02) HIS10C - MCDRXCOV
(-8) HIS10C - MCDRXCOV
(-9) HIS10C - MCDRXCOV
MCDRXCOV
HIS10C
yes/no
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), did [your/(SP’s)] Medicaid plan cover medicines prescribed by a doctor?
[your] respondent is SP
[(SP's)] respondent is proxy
HIS1 - HISCORRB
BOX HIST1A
routing
COVTIME
HIST1
code one
CREATE TRICARE PLAN IN THE PREVIOUS ROUND
GO TO HIST1 - COVTIME.
[Were you/Was (SP)] covered by TRICARE the whole time between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), or only part of the time?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Were you] respondent is SP
[Was (SP)] respondent is proxy
COVNOW
HIST2
yes/no
[Were you/Was (SP)] covered by TRICARE on (REFERENCE DATE)?
(01) HIST3 - TRIRXCOV
(02) HIST2 - COVNOW
(-8) HIST2 - COVNOW
(-9) HIST2 - COVNOW
HIST3 - TRIRXCOV
TRIRXCOV
HIST3
yes/no
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), did [your/(SP’s)] TRICARE plan cover medicines prescribed by a doctor?
(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) A TRICARE MAIL ORDER PHARMACY (TMOP)
(02) A TRICARE RETAIL PHARMACY NETWORK PHARMACY (TRRX)
(03) A MILITARY TREATMENT FACILITY PHARMACY (MTF)
(04) A NON-NETWORK RETAIL PHARMACY
(91) SOMEWHERE ELSE
(-8) Don't Know
(-9) Refused
(01) continuous answer
(01) continuous answer
[PROBE: I am asking about the type of insurance coverage that [you/(SP)] personally had, not what the plan offers everyone.]
TRIMEDS
HIST3AA
code one
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), where did [you/(SP)] usually obtain (your/his/her) medicines? Did [you/(SP)] usually obtain them at a
TRICARE mail order pharmacy (TMOP), a TRICARE retail pharmacy network pharmacy (TRRx), a military treatment facility pharmacy (MTF), a non-network retail pharmacy, or
somewhere else?
TRIMEDOS
PLAN_HISPUBLIC
HIST3AA
HIS12
verebatim text
roster
SOMEWHERE ELSE (SPECIFY)
What is the name of the public program that covered [you/(SP)]?
SELECT OR ADD ALL PUBLIC PROGRAM NAMES AT THIS ROSTER.
NAVIGATOR
HIS12_IN
instance navigator
COVTIME
HIS13
code one
[Were you/Was (SP)] covered by (PUBLIC PLAN NAME) the whole time between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), or only part of the time?
COVNOW
HIS14
yes/no
[Were you/Was (SP)] covered by (PUBLIC PLAN NAME) on (REFERENCE DATE)?
COVBEGMM
HIS15
date
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start between (SUMMARY REFERENCE DATE) and (REFERENCE DATE)?
COVBEGDD
HIS15
date
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start between (SUMMARY REFERENCE DATE) and (REFERENCE DATE)?
COVBEGYY
HIS15
date
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start between (SUMMARY REFERENCE DATE) and (REFERENCE DATE)?
COVENDMM
HIS16
date
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] (PUBLIC PLAN NAME) coverage stop?
COVENDDD
HIS16
date
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] (PUBLIC PLAN NAME) coverage stop?
COVENDYY
HIS16
date
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] (PUBLIC PLAN NAME) coverage stop?
PUBRXCOV
BOX HIS2B1
HIS16A
routing
yes/no
GO TO HIS16A - PUBRXCOV.
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), did [your/(SP’s)] (PUBLIC PLAN NAME) plan cover medicines prescribed by a doctor?
EXCHGCOV
BOX HIS3
HIS18A
routing
yes/no
GO TO HIS12_IN - NAVIGATOR.
SHOW CARD HI5
As you may know, every state now offers a health insurance marketplace, also referred to as an exchange.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
The marketplace [, known as (STATE MARKETPLACE NAME),] allows residents to compare and purchase available health insurance options that meet their needs. While most (-9) Refused
Medicare beneficiaries are not eligible for insurance from a health insurance marketplace, there are some special circumstances that allow enrollment.
[Were you] respondent is SP
[Was (SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
(01) HIST3AA - TRIMEDS
(02) HIS1 - HISCORRB
(-8) HIS1 - HISCORRB
(-9) HIS1 - HISCORRB
(01) HIS1 - HISCORRB
(02) HIS1 - HISCORRB
(03) HIS1 - HISCORRB
(04) HIS1 - HISCORRB
(91) HIST3AA - TRIMEDOS
(-8) HIS1 - HISCORRB
(-9) HIS1 - HISCORRB
HIS1 - HISCORRB
HIS12_IN - NAVIGATOR
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
MM
(01) HIS13 - COVTIME
(02) HIS1 - HISCORRB
(01) BOX HIS2B1
(02) HIS14 - COVNOW
(-8) HIS14 - COVNOW
(-9) HIS14 - COVNOW
(01) HIS15 - COVBEGMM
(02) HIS16 - COVENDMM
(-8) BOX HIS2B1
(-9) BOX HIS2B1
HIS15 - COVBEGDD
[your] respondent is SP
[(SP's)] respondent is proxy
DD
HIS15 - COVBEGYY
[your] respondent is SP
[(SP's)] respondent is proxy
YY
BOX HIS2B1
[your] respondent is SP
[(SP's)] respondent is proxy
MM
HIS16 - COVENDDD
[your] respondent is SP
[(SP's)] respondent is proxy
DD
HIS16 - COVENDYY
[your] respondent is SP
[(SP's)] respondent is proxy
YY
BOX HIS2B1
[Were you] respondent is SP
[Was SP] respondent is proxy
[Were you] respondent is SP
[Was SP] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
BOX HIS3
[, known as (STATE MARKETPLACE NAME),] i State's price comparison website for subsidized health insurance
[were you] respondent is SP
[was (SP)] respondent is proxy
HIS20 - PLAN_HISPRIVATE
[your] respondent is SP
[(SP's)] respondent is proxy
HIS20_IN - NAVIGATOR
Please look at this card. At any time between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) [were you/was (SP)] enrolled in or covered by one of these exchange
plans?
What is the name of each of the (other) private plans that provided [your/(SP’s)] medical insurance coverage between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE)?
SELECT OR ADD ALLONE PRIVATE PLAN NAMESNAME AT THIS ROSTER.
PLAN_HISPRIVATE
HIS20
roster
NAVIGATOR
HIS20_IN
instance navigator
COVTIME
HIS21
code one
[Were you/Was (SP)] covered by (PRIVATE PLAN NAME) the whole time between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), or only part of the time?
COVNOW
HIS22
yes/no
[Were you/Was (SP)] covered by (PRIVATE PLAN NAME) on (REFERENCE DATE)?
COVBEGMM
HIS23
date
On what date did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) start between (SUMMARY REFERENCE DATE) and (REFERENCE DATE)?
COVBEGDD
HIS23
date
On what date did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) start between (SUMMARY REFERENCE DATE) and (REFERENCE DATE)?
COVBEGYY
HIS23
date
On what date did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) start between (SUMMARY REFERENCE DATE) and (REFERENCE DATE)?
COVENDMM
HIS24
date
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) stop?
COVENDDD
HIS24
date
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) stop?
COVENDYY
HIS24
date
On what date between (SUMMARY REFERENCE DATE) and (REFERENCE DATE) did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) stop?
PPRVHMO
BOX HIS3A1
HIS25
routing
yes/no
GO TO HIS25 - PPRVHMO.
CODE WITHOUT ASKING IF VOLUNTEERED.
Was this a managed care plan, such as an HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization)?
[EXPLAIN IF NECESSARY: Managed care plans generally provide a full range of health care services for a prepaid fee. Health care is generally provided by primary care
doctors, specialists, or hospitals on the plan’s list (network) except in an emergency.]
Who was listed as the main insured person on the (PRIVATE PLAN NAME) policy or contract?
SELECT OR ADD ONLY ONE PERSON.
For the (PRIVATE PLAN NAME) plan, did [you/(MIP)] sign up directly with the (insurance company/managed care plan), or did [you/(MIP)] get this insurance through a current
employer, a former employer, a union, a family business, AARP, or some other way?
(01) continuous answer
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM
[your] respondent is SP
[(SP's)] respondent is proxy
DD
HIS23 - COVBEGYY
[your] respondent is SP
[(SP's)] respondent is proxy
YY
BOX HIS3A1
[your] respondent is SP
[(SP's)] respondent is proxy
MM
HIS24 - COVENDDD
[your] respondent is SP
[(SP's)] respondent is proxy
DD
HIS24 - COVENDYY
[your] respondent is SP
[(SP's)] respondent is proxy
YY
BOX HIS3A1
[Were you] respondent is SP
[Was SP] respondent is proxy
[Were you] respondent is SP
[Was SP] respondent is proxy
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HIS26 - PERS_HISMIPNUM
(01) continuous answer
HIS27 - PPRVGET
PERS_HISMIPNUM
HIS26
roster
PPRVGET
HIS27
code one
PPRVGTOS
PRVNMCOV
HIS27
HIS29
verbatim text
numeric
OTHER (SPECIFY)
How many family members, including [yourself/(SP)], were covered by [your/(MIP’s)] (PRIVATE PLAN NAME) between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE)?
PRVRXCOV
HIS31A
list
Supplemental insurance plans may cover a variety of services or may be specific to only certain services, such as prescribed medicines or dental coverage. I’d like to know what (01) YES
[your/(SP’s)] (PRIVATE PLAN NAME) coverage included between (SUMMARY REFERENCE DATE) and (REFERENCE DATE).
(02) NO
(-8) Don't Know
[PROBE: I am asking about the type of insurance coverage that [you/(SP)] personally had, not what the plan offered everyone.]
(-9) Refused
Did [your/(MIP’s)] (PRIVATE PLAN NAME) cover...
prescribed medicines?
[your] respondent is SP
[(SP's)] respondent is proxy
(01) HIS21 - COVTIME
(02) HIS1 - HISCORRB
(01) BOX HIS3A1
(02) HIS22 - COVNOW
(-8) HIS22 - COVNOW
(-9) HIS22 - COVNOW
(01) HIS23 - COVBEGMM
(02) HIS24 - COVENDMM
(-8) BOX HIS3A1
(-9) BOX HIS3A1
HIS23 - COVBEGDD
(01) DIRECTLY
(02) (MIP'S) CURRENT EMPLOYER
(03) (MIP'S) FORMER EMPLOYER
(04) (MIP'S) UNION
(05) (MIP'S) FAMILY BUSINESS
(06) AARP
(07) DECEASED SPOUSE'S EMPLOYER
(08) DECEASED SPOUSE'S UNION
(09) PROFESSIONAL/FRATERNAL ORGANIZATION
(91) SOME OTHER WAY
(-8) Don't Know
(-9) Refused
(01)
continuous answer
(01) continuous answer
(-8) Don't Know
(-9) Refused
[you] respondent is MIP
[MIP] respondent is not MIP
[yourself] respondent is MIP
(SP) respondent is proxy
[your] respondent is MIP
[MIP's] respondent is not MIP
[your]respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is MIP
[MIP's] respondent is not MIP
(01) HIS29 - PRVNMCOV
(02) HIS29 - PRVNMCOV
(03) HIS29 - PRVNMCOV
(04) HIS29 - PRVNMCOV
(05) HIS29 - PRVNMCOV
(06) HIS29 - PRVNMCOV
(07) HIS29 - PRVNMCOV
(08) HIS29 - PRVNMCOV
(09) HIS29 - PRVNMCOV
(91) HIS27 - PPRVGTOS
(-8) HIS29 - PRVNMCOV
(-9) HIS29
- PRVNMCOV
HIS29
- PRVNMCOV
HIS31A - PRVRXCOV
HIS31A - PRVMSCOV
PRVMSCOV
HIS31A
list
Supplemental insurance plans may cover a variety of services or may be specific to only certain services, such as prescribed medicines or dental coverage. I’d like to know what (01) YES
[your/(SP’s)] (PRIVATE PLAN NAME) coverage included between (SUMMARY REFERENCE DATE) and (REFERENCE DATE).
(02) NO
(-8) Don't Know
[PROBE: I am asking about the type of insurance coverage that [you/(SP)] personally had, not what the plan offered everyone.]
(-9) Refused
Did [your/(MIP’s)] (PRIVATE PLAN NAME) cover...
doctor visits or lab work?
PRVIPCOV
HIS31A
list
Supplemental insurance plans may cover a variety of services or may be specific to only certain services, such as prescribed medicines or dental coverage. I’d like to know what (01) YES
[your/(SP’s)] (PRIVATE PLAN NAME) coverage included between (SUMMARY REFERENCE DATE) and (REFERENCE DATE).
(02) NO
(-8) Don't Know
[PROBE: I am asking about the type of insurance coverage that [you/(SP)] personally had, not what the plan offered everyone.]
(-9) Refused
Did [your/(MIP’s)] (PRIVATE PLAN NAME) cover...
inpatient hospital care?
PRVNHCOV
HIS31A
list
Supplemental insurance plans may cover a variety of services or may be specific to only certain services, such as prescribed medicines or dental coverage. I’d like to know what (01) YES
[your/(SP’s)] (PRIVATE PLAN NAME) coverage included between (SUMMARY REFERENCE DATE) and (REFERENCE DATE).
(02) NO
(-8) Don't Know
[PROBE: I am asking about the type of insurance coverage that [you/(SP)] personally had, not what the plan offered everyone.]
(-9) Refused
Did [your/(MIP’s)] (PRIVATE PLAN NAME) cover...
nursing home or long term care?
MHMODENT
HIS31A
list
Supplemental insurance plans may cover a variety of services or may be specific to only certain services, such as prescribed medicines or dental coverage. I’d like to know what (01) YES
[your/(SP’s)] (PRIVATE PLAN NAME) coverage included between (SUMMARY REFERENCE DATE) and (REFERENCE DATE).
(02) NO
(-8) Don't Know
[PROBE: I am asking about the type of insurance coverage that [you/(SP)] personally had, not what the plan offered everyone.]
(-9) Refused
Did [your/(MIP’s)] (PRIVATE PLAN NAME) cover...
dental care?
MIPPINS
HIS32
yes/no
Was there a premium or cost for the (PRIVATE PLAN NAME) coverage?
[Do not include the cost of any deductibles [you/(SP)] or [your/(SP’s)] family may have had to pay.]
MIPPAMT
HIS33
numeric
How much did [you/(MIP)] pay for the (PRIVATE PLAN NAME) coverage?
[Please do not include any amount that may be paid for anyone other than [you/(SP)].]
MIPPUNIT
HIS33
code one
MIPPUNOS
MHMOCOST
HIS33
HIS33A
verbatim text
yes/no
MHMOWHO
HIS33B
code one
MHMOWHOS
HIS33B
BOX HIS3B
verbatim text
routing
MHMOPOS
HIS33C
yes/no
[PROBE IF NECESSARY: Was that per year, per month, per week, or what?]
OTHER (SPECIFY)
Between (SUMMARY REFERENCE DATE) and (REFERENCE DATE), did anyone else, such as an employer, a union or professional organization pay all or some portion of
the premium or cost for [your/(MIP’s)] (PRIVATE PLAN NAME) coverage?
[DO NOT INCLUDE AMOUNTS PAID BY FAMILY MEMBERS.]
Who else paid all or some portion of the cost for [your/[MIP’s)] (PRIVATE PLAN NAME) coverage?
OTHER (SPECIFY)
IF THIS PRIVATE PLAN IS A MANAGED CARE PLAN, GO TO HIS33C - MHMOPOS.
ELSE GO TO BOX HIS4.
Some managed care plans offer a point-of-service option which allows members to receive services from out-of-plan providers even in non-emergency situations. Between
(SUMMARY REFERENCE DATE) and (REFERENCE DATE), [were you/was (SP)] enrolled in a point-of-service option offered by (PRIVATE PLAN NAME)?
[EXPLAIN IF NECESSARY: In a point-of-service option, the member typically pays a higher copayment when seeing an out-of-plan provider. For example, if a member sees
an in-plan provider, there may only be a $10 copayment. However, the member may have to pay 20 percent of the cost and the managed care plan will pay 80 percent of the
cost to receive the same service from an out-of-plan provider.]
PLAN_HISMPDP
BOX HIS4
HIS34
routing
roster
HISMPDPCURR
HIS35
yes/no
BOX HIS5A
routing
HIS36
yes/no
BOX HIS6
routing
BOX HIS6A
routing
PDPYSTOP
HIS37
code one
PDPYSTOS
ENDHIS
HIS37
HISCLOSE
verbatim text
no entry
OTHER (SPECIFY)
That covers the health insurance [you/(SP)] had at the time of the last interview. The next questions are about [your/(SP’s)] insurance coverage between (REFERENCE DATE)
and (today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION).
BOX HIS5
routing
GO TO NEXT SECTION
HISMPDPCHNG
GO TO HIS20_IN - NAVIGATOR.
What is the name of the Medicare Prescription Drug plan that covered [you/(SP)]?
SELECT OR ADD ONLY ONE MEDICARE PRESCRIPTION DRUG PLAN AT THIS ROSTER.
[Were you/Was (SP)] covered by or enrolled in (MEDICARE PRESCRIPTION DRUG PLAN NAME) on (REFERENCE DATE)?
OTHER THAN THE PLAN SELECTED AT HIS34, IF ANOTHER MEDICARE PRESCRIPTION DRUG PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO HIS36 - HISMPDPCHNG.
ELSE GO TO BOX HIS6.
I recorded previously that (PREVIOUS ROUND CURRENT MEDICARE PRESCRIPTION DRUG PLAN NAME) was [your/(SP’s)] current Medicare Prescription Drug Plan on
(REFERENCE DATE). Has this information changed?
IF THE PLAN SELECTED AT HIS34 HAS BEEN IDENTIFIED AS THE SP'S CURRENT MEDICARE PRESCRIPTION DRUG PLAN AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, SET THE PREVIOUS ROUND STATUS OF THIS PLAN TO "CURRENT". OTHERWISE, SET THE PREVIOUS ROUND STATUS OF THIS PLAN TO "NOT
CURRENT"
GO TO BOX HIS6A.
IF ((HIS35 - HISMPDPCURR = 2/No) OR (HIS36 - HISMPDPCHNG = 2/No)), GO TO HIS37 - PDPYSTOP.
ELSE GO TO HIS1 - HISCORRB.
What is the most important reason [you/(SP)] stopped the (MEDICARE PRESCRIPTION DRUG PLAN NAME) coverage?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) PER YEAR
(02) QUARTERLY/EVERY 3 MONTHS
(03) BIMONTHLY/EVERY 2 MONTHS
(04) PER MONTH
(05) PER WEEK
(06) SEMI-ANNUALLY/2 TIMES PER YEAR
(07) SEMI-MONTHLY/2 TIMES PER MONTH
(91) OTHER
(-8) Don't Know
(-9)
(01) Refused
continuous answer
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) [(SP's)/(MIP's)] CURRENT EMPLOYER
(02) (SP's/MIP's) FORMER EMPLOYER
(03) (SP's/MIP's) UNION
(04) SPOUSE'S CURRENT EMPLOYER
(05) SPOUSE'S FORMER EMPLOYER
(06) PROFESSIONAL/FRATERNAL ORGANIZATION
(07) MEDICAID/MEDICAL ASSISTANCE
(91) OTHER
(-8) Don't Know
(-9)
(01) Refused
continuous answer
[your]respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is MIP
[MIP's] respondent is not MIP
HIS31A - PRVIPCOV
[your]respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is MIP
[MIP's] respondent is not MIP
HIS31A - PRVNHCOV
[your]respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is MIP
[MIP's] respondent is not MIP
HIS31A - MHMODENT
[your]respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is MIP
[MIP's] respondent is not MIP
HIS32 - MIPPINS
[you] respondent is SP
(SP]respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is MIP
[MIP] respondent is not MIP
[you] respondent is SP
[(SP)] respondent is proxy
(01) HIS33 - MIPPAMT
(02) HIS33A - MHMOCOST
(-8) HIS33A - MHMOCOST
(-9) HIS33A - MHMOCOST
(01) HIS33 - MIPPUNIT
(-8) HIS33A - MHMOCOST
(-9) HIS33A - MHMOCOST
[your] respondent is MIP
[MIP's] respondent is not MIP
[your] respondent is MIP
[MIP's] respondent is not MIP
(01) HIS33A - MHMOCOST
(02) HIS33A - MHMOCOST
(03) HIS33A - MHMOCOST
(04) HIS33A - MHMOCOST
(05) HIS33A - MHMOCOST
(06) HIS33A - MHMOCOST
(07) HIS33A - MHMOCOST
(91) HIS33 - MIPPUNOS
(-8) HIS33A - MHMOCOST
(-9)
HIS33A
- MHMOCOST
HIS33A
- MHMOCOST
(01) HIS33B - MHMOWHO
(02) BOX HIS3B
(03) BOX HIS3B
(04) BOX HIS3B
(01) BOX HIS3B
(02) BOX HIS3B
(03) BOX HIS3B
(04) BOX HIS3B
(05) BOX HIS3B
(06) BOX HIS3B
(07) BOX HIS3B
(91) HIS33B - MHMOWHOS
(-8) BOX HIS3B
(-9)
HIS3B
BOXBOX
HIS3B
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Were you] respondent is SP
[Was (SP)] respondent is proxy
BOX HIS4
(01) continuous answer
[you] respondent is SP
[(SP)] respondent is proxy
[Were you] respondent is SP
[Was (SP)] respondent is proxy
HIS35 - HISMPDPCURR
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
BOX HIS6
(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH PLAN'S COVERAGE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET DIFFERENT HEALTH CARE COVERAGE
(05) PLAN NO LONGER CONTRACTS FOR MEDICARE RX COVERAGE
(06) PLAN NAME CHANGED OR PLAN WAS BOUGHT BY/MERGED WITH ANOTHER PLAN
(07) SP MOVED OUT OF PLAN AREA
(91) OTHER
(-8) Don't Know
(-9)
(01) Refused
continuous answer
[you] respondent is SP
[(SP)] respondent is proxy
(01) HIS1 - HISCORRB
(02) HIS1 - HISCORRB
(03) HIS1 - HISCORRB
(04) HIS1 - HISCORRB
(05) HIS1 - HISCORRB
(06) HIS1 - HISCORRB
(07) HIS1 - HISCORRB
(91) HIS37 - PDPYSTOS
(-8) HIS1 - HISCORRB
(-9)
- HISCORRB
HIS1HIS1
- HISCORRB
BOX HIS5
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
(01) BOX HIS5A
(02) BOX HIS6
(-8) BOX HIS6
(-9) BOX HIS6
Health Insurance (HIQ)
Variable Name
MR Screen Name
Question type
BOX HIBEG
routing
Question text/description)
Code list
IF (SP IS IN THE SUPPLEMENTAL SAMPLE), GO TO HIMCINTR HIINTR1.
ELSE GO
TO BOX
MC1AA.
SHOW
CARD
HI1 HIMC
The next questions are about [your/(SP's)] health insurance
benefits. This card outlines the types of health insurance that I’ll be
asking you about. [INTERVIEWER SHOULD POINT TO HEALTH
INSURANCE OPTIONS ON FRONT OF SHOWCARD HIMC1.]
Please refer to this card as we talk about [your/(SP’s)] health
insurance coverage.
Text Fill Logic
Input mask
Routing
It would also be helpful if I could look at a health plan card or
something with the plan name on it. These materials will ensure
that I record the information accurately.
HIINTR1
LOADCORR
WHATWRNG
HIMCINTR
no entry
BOX MC1AA
routing
MC1
MC2
yes/no
code 1
YDISNROL
MC2B
code 1
YDISNROS
MC2B
verbatim text
BOX MC1A
routing
PRIMPHYS
MC3
yes/no
SAMEPLAN
MC4
code 1
PLAN_MHMOMCA
MC5
roster
(EXPAIN IF NECESSARY: We ask about health insurance
coverage because it is important to understand how beneficiaries
cover the costs of their medical care, such as doctor visits,
prescribed medicines, and hospital stays.)
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) AND (SP HAS A
LOADED CMS MEDICARE MANAGED CARE PLAN), GO TO MC1 LOADCORR.
ELSE IF (SP IS NOT IN THE SUPPLEMENTAL SAMPLE) AND (SP
HAS A MEDICARE MANAGED CARE PLAN THAT WAS
"CURRENT" AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW), GO TO HIMC1A - MHMOSAME.
ELSE GO TO HIMC1 - MHMOCOV.
As you (may) know, Medicare allows beneficiaries in certain parts
of the country tocan enroll in either Original Medicare or a Medicare
Advantage plansplan, such as HMOsan HMO (Health Maintenance
OrganizationsOrganization) and PPOsPPO (Preferred Provider
Organizations), to receive their Medicare-covered health care.
Organization).
According to Medicare records, [you are/(SP) is] currently enrolled
in a Medicare Advantage Plan called (CMS MEDICARE MANAGED
CARE PLAN NAME). Is this information correct?
(01) YES
(02) NO
[PROBE IF NECESSARY: Do you have a health plan card or
(-8) Don't Know
something with the plan name on it?]
(-9) Refused
(01)
SP DISENROLLED FROM (CMS MHMO PLAN
How is this information incorrect?
SELECT ONLY ONE. IF MORE THAN ONE RESPONSE IS
APPLICABLE, SELECT THE RESPONSE THAT IS CLOSEST TO
THE TOP OF THE LIST.
What is the most important reason [you/(SP)] stopped the (CMS
MEDICARE MANAGED CARE PLAN NAME) coverage?
OTHER (SPECIFY)
IF MC2 - WHATWRNG = 1/EnrolledNewPlan, GO TO MC5 PLAN_MHMOMCA.
ELSE GO TO HIMC16 - MHMOMORE.
In many Medicare Advantage Plans, such as HMOs or PPOs, the
health plan gives the patient a list of doctors from which he
chooses a primary care physician. This primary care physician
provides the patient’s usual medical care and can refer the patient
to specialists, if necessary. [Do you/Does (SP)] have a primary
care physician?
[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
BOX MC1AA
[you are] respondent is SP
[(SP) is] respondent is proxy
(01) BOX HIMC1
(02) MC2 - WHATWRNG
(-8) MC11 - REFERMED
(-9) BOX HIMC4
NAME), ENROLLED IN NEW MEDICARE
ADVANTAGE PLAN
(02) SP HAS PLAN CALLED (CMS MHMO PLAN
NAME), R DOESN'T THINK IT'S A MEDICARE
ADVANTAGE PLAN
(03) SP NOW DISENROLLED FROM (CMS MHMO
PLAN NAME), NO LONGER IN ANY MEDICARE
ADVANTAGE PLAN
(04) SP ENROLLED IN MEDICARE ADVANTAGE
PLAN, BUT NEVER (CMS MHMO PLAN NAME)
(05) SP NEVER COVERED BY OR ENROLLED IN
(CMS MHMO PLAN NAME)
(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH QUALITY OF CARE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET BENEFIT COVERAGE OTHER THAN RX
(05) PLAN WENT OUT OF BUSINESS/STOPPED
MEDICARE COVERAGE
(06) PLAN NAME CHANGED OR PLAN WAS BOUGHT
BY/MERGED WITH ANOTHER PLAN
(07) DOCTOR LEFT PLAN/DIED/RETIRED
(08) DIFFICULTIES GETTING APPTS OR SEEING
PARTICULAR PROVIDERS
(09) SP MOVED OUT OF PLAN AREA
(10) SP DIDN'T LIKE CHOICE OF DOCTORS
(11) SP WANTED CHOICE OF DOCTORS
(91) OTHER
(-8) Don't Know
[you] respondent is SP
(-9) Refused
[(SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) SAME PLANS
Is it possible that [your/(SP’s)] current insurance plan is just another (02) NOT THE SAME PLANS
name for (CMS MEDICARE MANAGED CARE PLAN NAME), or
(-8) Don't Know
are they not the same plans?
(-9) Refused
What is the name of the Medicare Advantage Plan that provides
[your/(SP’s)] health care benefits?
[Do you] respondent is SP
[Does (SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
(01) MC2B - YDISNROL
(02) MC3 - PRIMPHYS
(03) MC2B - YDISNROL
(04) MC4 - SAMEPLAN
(05) MC11 - REFERMED
(01) BOX MC1A
(02) BOX MC1A
(03) BOX MC1A
(04) BOX MC1A
(05) BOX MC1A
(06) BOX MC1A
(07) BOX MC1A
(08) BOX MC1A
(09) BOX MC1A
(10) BOX MC1A
(11) BOX MC1A
(91) MC2B - YDISNROS
(-8) BOX MC1A
(-9) BOX MC1A
BOX MC1A
BOX HIMC1
(01) BOX HIMC1
(02) MC5 - PLAN_MHMOMCA
(-8) MC5 - PLAN_MHMOMCA
(-9) MC5 - PLAN_MHMOMCA
BOX HIMC1
Do you refer to [your/(SP’s)] Medicare coverage by any name
besides Medicare?
REFERMED
PLAN_MHMOMCB
MC11
MC12
code 1
roster
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]
What do you call [your/(SP’s)] coverage?
SELECT OR ADD ONLY ONE MEDICARE ADVANTAGE PLAN AT
THIS ROSTER.
(01) MEDICARE ONLY
(02) OTHER NAME
(-8) Don't Know
(-9) Refused
At the time of the last interview [you were/(SP) was] covered by the
Medicare Advantage Plan named (MEDICARE MANAGED CARE
PLAN NAME).
MHMOSAME
YDISNROL
YDISNROS
MHMOOTHR
HIMC1A
HIMC1B1
HIMC1B1
HIMC1C
yes/no
code 1
verbatim text
yes/no
[[Are you/Is (SP)] now covered by (MEDICARE MANAGED CARE
PLAN NAME)?] [Was (SP) covered by (MEDICARE MANAGED
CARE PLAN NAME) on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)?]
[IF THE RESPONDENT DROPPED THE INDICATED COVERAGE
SINCE THE PREVIOUS INTERVIEW DATE, BUT PICKED UP THE
COVERAGE AGAIN AND CURRENTLY IS COVERED BY THE
NAMED PLAN, SELECT “YES” FOR THIS QUESTION.]
What is the most important reason [you/(SP)] stopped the
(MEDICARE MANAGED CARE PLAN NAME) coverage?
OTHER (SPECIFY)
HIMC1SHOW CARD HI2
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/INSTITUTIONALIZATION)], [have you/has (SP)
been/was (SP)] covered by any other Medicare Advantage Plans
besidesCARD
(MEDICARE
MANAGED CARE PLAN)?
SHOW
HI2 HIMC1
As you (may) know, Medicare allows beneficiaries in certain parts
of the country to can enroll in either Original Medicare or a
Medicare Advantage plans plan, such as HMOs an HMO (Health
Maintenance Organizations Organization) and PPOs
PPO(Preferred Provider Organizations), to receive their Medicarecovered health care. Organization).
(Please look at this card.) At any time [since (REFERENCE
DATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION),] [have you/has
(SP)/had (SP)] been enrolled in or covered by [any/(one of
these/any)] Medicare Advantage plans?
MHMOCOV
MHMOCURR
PLAN_MHMO
HIMC1
HIMC3
yes/no
yes/no
HIMC5
roster
BOX HIMC1
routing
[your] respondent is SP
[(SP's)] respondent is proxy
BOX HIMC1
[you were] respondent is SP
[(SP) was] respondent is proxy
[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP not deceased or
institutionalized
[Was (SP) covered by (MEDICARE MANAGED CARE
PLAN NAME) on (DATE OF DEATH)?] respondent is proxy,
SP deceased
[Was (SP) covered by (MEDICARE MANAGED CARE
PLAN NAME) on (DATE OF INSTITUTIONALIZATION)?]
respondent is proxy, SP institutionalized
(01) BOX HIMC1
(02) HIMC1B1 - YDISNROL
(-8) HIMC1C - MHMOOTHR
(-9) BOX HIMC4
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH QUALITY OF CARE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET BENEFIT COVERAGE OTHER THAN RX
(05) PLAN WENT OUT OF BUSINESS/STOPPED
MEDICARE COVERAGE
(06) PLAN NAME CHANGED OR PLAN WAS BOUGHT
BY/MERGED WITH ANOTHER PLAN
(07) DOCTOR LEFT PLAN/DIED/RETIRED
(08) DIFFICULTIES GETTING APPTS OR SEEING
PARTICULAR PROVIDERS
(09) SP MOVED OUT OF PLAN AREA
(10) SP DIDN'T LIKE CHOICE OF DOCTORS
(11) SP WANTED CHOICE OF DOCTORS
(91) OTHER
(-8) Don't Know
[you] respondent is SP
(-9) Refused
[(SP)] respondent is proxy
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Are you/Is (SP)/Was (SP)] (currently) covered by or enrolled in a
Medicare Advantage Plan [on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
What is the name of the Medicare Advantage Plan that [currently
covers/covered] [you/(SP)] [on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?]
SELECT OR ADD ONLY ONE MEDICARE ADVANTAGE PLAN AT
THIS ROSTER.
THIS PLAN IS THE SP'S CURRENT MEDICARE MANAGED
CARE PLAN
IF (THIS MEDICARE MANAGED CARE PLAN IS NEW OR HAS
BEEN "RESTARTED") OR THIS IS A FALL ROUND GO TO
HIMC6A - MHMORXTM.
ELSE GO TO BOX HIMC1CC1
[your] respondent is SP
[(SP's)] respondent is proxy
(01) BOX HIMC4
(02) MC12 - PLAN_MHMOMCB
(-8) BOX HIMC4
(-9) BOX HIMC4
[Since (REFERENCE DATE)] respondent is SP or proxy,
SP not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you] respondent is SP
[has (SP) been] respondent is proxy, SP alive
[was (SP)] respondent is proxy, SP deceased
[Since (REFERENCE DATE)] respondent is SP or proxy,
SP not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased
[any] only one Medicare Advantage plan
[one of these] more than one Medicare Advantage plan
[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP alive and not
insitutionalized
[currently] SP is not deceased or institutionalized
[Was (SP)] respondent is proxy, SP deceased
[on (DATE OF DEATH)] SP deceased
[on (DATE OF INSTITUTIONALIZATION)] SP
institutionalize
[currently covers] SP alive
[covered] SP deceased or institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
[on (DATE OF DEATH)] SP is deceased
[on (DATE OF INSTITUTIONALIZATION)] SP is
institutionalized
(01) HIMC1C - MHMOOTHR
(02) HIMC1C - MHMOOTHR
(03) HIMC1C - MHMOOTHR
(04) HIMC1C - MHMOOTHR
(05) HIMC1C - MHMOOTHR
(06) HIMC1C - MHMOOTHR
(07) HIMC1C - MHMOOTHR
(08) HIMC1C - MHMOOTHR
(09) HIMC1C - MHMOOTHR
(10) HIMC1C - MHMOOTHR
(11) HIMC1C - MHMOOTHR
(91) HIMC1B1 - YDISNROS
(-8) HIMC1C - MHMOOTHR
(-9) HIMC1C - MHMOOTHR
HIMC1C - MHMOOTHR
(01) HIMC3 - MHMOCURR
(02) BOX HIMC4
(-8) BOX HIMC4
(-9) BOX HIMC4
(01) HIMC3 - MHMOCURR
(02) BOX HIMC4
(-8) BOX HIMC4
(-9) BOX HIMC4
(01) HIMC5 - PLAN_MHMO
(02) BOX HIMC2
(-8) BOX HIMC2
(-9) BOX HIMC2
BOX HIMC1
[Do you/Does (SP)/Did (SP)] have prescribed medicine coverage
through (CURRENT MEDICARE MANAGED CARE PLAN)?
MHMORXTM
MHMODENT
MHMOEYE
HIMC6A
yes/no
BOX HIMC1CC1
routing
HIMC7
HIMC8
[PROBE: I am asking about the type of insurance coverage that
[you personally have/(SP) personally has/(SP) personally had], not
what the plan offers everyone.]
IF (THIS MEDICARE MANAGED CARE PLAN IS NEW OR HAS
BEEN "RESTARTED"), GO TO HIMC7 - MHMODENT.
ELSE GO TO BOX HIMC2.
yes/no
[Do you/Does (SP)/Did (SP)] have dental coverage through
(CURRENT MEDICARE MANAGED CARE PLAN NAME)?
yes/no
[Do you/Does (SP)/Did (SP)] have optical coverage through
(CURRENT MEDICARE MANAGED CARE PLAN NAME), that is,
for eyeglasses or contact lenses?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Do you] respondent is SP
[Does (SP)] respondent is proxy, SP alive
[Did (SP)] respondent is proxy, SP deceased
[you personally have] respondent is SP
[(SP) personally has] respondent is proxy, SP alive
[(SP personally had] respondent is proxy, SP deceased
BOX HIMC1CC1
[Do you] respondent is SP
[Does (SP)] respondent is proxy, SP alive
[Did (SP)] respondent is proxy, SP deceased
HIMC8 - MHMOEYE
[Do you] respondent is SP
[Does (SP)] respondent is proxy, SP alive
[Did (SP)] respondent is proxy, SP deceased
HIMC10 - MHMONH
[Does your] respondent is SP
[Does (SP's)] respondent is proxy, SP alive
[Did (SP's)] respondent is proxy, SP deceased
HIMC11 - MHMOPAY
[Does your/Does (SP’s)/Did (SP’s)] (CURRENT MEDICARE
MANAGED CARE PLAN NAME) coverage include nursing home
care over above and beyond what Medicare normally covers?
MHMONH
HIMC10
yes/no
(EXPLAIN IF NECESSARY: Under regular fee-for-service,
Medicare pays for limited skilled nursing facility (SNF) care during a
benefit period. In 2013 2014, the first 20 days are paid in full and
the next 80 days require a copayment of up to $148152.00 per
day.)
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Besides the cost of [your/(SP’s)] Medicare Part B premium, [is/was]
there an additional cost for [your/(SP’s)] (CURRENT MEDICARE
MANAGED CARE PLAN NAME) coverage? Please do not include
any amount that [you/(SP)] may (pay/have paid) as a co-payment
for an office visit or a prescribed medicine.
MHMOPAY
HIMC11
yes/no
[EXPLAIN IF NECESSARY: Some managed care plans may
charge a monthly premium to cover the cost of the deductibles and
coinsurance for Medicare-covered services or because they provide
services that are not covered by Medicare such as prescribed
medicines, routine exams, and dental, eye, or hearing. Plans that
have premiums typically charge from $50 to $75 per month.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Not including the cost of [your/(SP’s)] Medicare Part B premium,
what [is/was] the additional amount that [you pay/(SP) pays/(SP)
paid] for [your/his/her] (CURRENT MEDICARE MANAGED CARE
PLAN NAME) coverage? (Please do not include any copayments
or any amount that may [be/have been] paid for anyone other than
[you/(SP)].)
MHMOAMT
HIMC12
(01) [Continuous answer.]
[PROBE IF NECESSARY: Is that per year, per month, per week, or (-8) Don't Know
quantity unit hybrid what?]
(-9) Refused
(01) PER YEAR
(02) QUARTERLY/EVERY 3 MONTHS
(03) BIMONTHLY/EVERY 2 MONTHS
(04) PER MONTH
(05) PER WEEK
(06) SEMI-ANNUALLY/2 TIMES PER YEAR
(07) SEMI-MONTHLY/2 TIMES PER MONTH
(91) OTHER
[PROBE IF NECESSARY: Is that per year, per month, per week, or (-8) Don't Know
quantity unit hybrid what?]
(-9) Refused
verbatim text
OTHER (SPECIFY)
[Does/Did] anyone else, such as an employer, a union or
(01) YES
professional organization pay all or some portion of the additional
(02) NO
cost for [your/(SP’s)] (CURRENT MEDICARE MANAGED CARE
(-8) Don't Know
yes/no
PLAN NAME) coverage?
(-9) Refused
Not including the cost of [your/(SP’s)] Medicare Part B premium,
what [is/was] the additional amount that [you pay/(SP) pays/(SP)
paid] for [your/his/her] (CURRENT MEDICARE MANAGED CARE
PLAN NAME) coverage? (Please do not include any copayments
or any amount that may [be/have been] paid for anyone other than
[you/(SP)].)
MHMOUNIT
MHMOUNOS
MHMOCOST
MHMOWHO
MHMOWHOS
HIMC12
HIMC12
HIMC12A
HIMC12B
HIMC12B
code 1
verbatim text
Who else [pays/paid] all or some portion of the additional cost for
[your/(SP’s)] (CURRENT MEDICARE MANAGED CARE PLAN
NAME) coverage?
OTHER (SPECIFY)
(01) [(SP's)/(MIP's)] CURRENT EMPLOYER
(02) (SP's/MIP's) FORMER EMPLOYER
(03) (SP's/MIP's) UNION
(04) SPOUSE'S CURRENT EMPLOYER
(05) SPOUSE'S FORMER EMPLOYER
(06) PROFESSIONAL/FRATERNAL ORGANIZATION
(07) MEDICAID/MEDICAL ASSISTANCE
(91) OTHER
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
[is] SP alive
[was] SP deceased
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[pay] SP alive
[have paid]
SP deceased
[your]
respondent
is SP
[(SP's)] respondent is proxy
[is] SP aluve
[was] SP deceased
[you pay] respondent is SP
[(SP) pays] respondent is proxy, SP alive
[(SP) paid] respondent is proxy, SP deceased
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[be] SP alive
[have been paid] SP deceased
[you] respondent is SP
[(SP)] respondent
respondent is
is SP
proxy
[your]
[(SP's)] respondent is proxy
[is] SP aluve
[was] SP deceased
[you pay] respondent is SP
[(SP) pays] respondent is proxy, SP alive
[(SP) paid] respondent is proxy, SP deceased
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[be] SP alive
[have been paid] SP deceased
[you] respondent is SP
[(SP)] respondent is proxy
[Does] SP alive
[Did] SP deceased
[your] respondent is SP
[(SP's)] respondent is proxy
[pays] SP alive
[paid] SP deceased
[your] respondent is SP
[(SP's)] respondent is proxy
(01) HIMC12 - MHMOAMT
(02) BOX HIMC2
(-8) BOX HIMC2
(-9) BOX HIMC2
(01) HIMC12 - MHMOUNIT
(-8) HIMC12A - MHMOCOST
(-9) HIMC12A - MHMOCOST
HIMC12A - MHMOCOST
(01) HIMC12B - MHMOWHO
(02) BOX HIMC2
(-8) BOX HIMC2
(-9) BOX HIMC2
(01) BOX HIMC2
(02) BOX HIMC2
(03) BOX HIMC2
(04) BOX HIMC2
(05) BOX HIMC2
(06) BOX HIMC2
(07) BOX HIMC2
(91) HIMC12B - MHMOWHOS
(-8) BOX HIMC2
(-9) BOX HIMC2
BOX HIMC2
BOX HIMC2
routing
IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERING CPS, GO TO BOX CPS29A.
ELSE IF HIMC1A - MHMOSAME = 1/Yes, GO TO BOX HIMC4.
ELSE IF HIMC3 - MHMOCURR = 2/No, DK OR RF, GO TO
HIMC17 - PLAN_MHMOOTHER.
ELSE GO TO HIMC16 - MHMOMORE.
SHOW CARD HI2 HIMC1
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/ DATE OF INSTITUTIONALIZATION)], [have
you/has (SP)/had (SP)] been covered by any other Medicare
Advantage Plans besides (MEDICARE MANAGED CARE PLAN
and MEDICARE MANAGED CARE PLAN)?
MHMOMORE
HIMC16
yes/no
PLAN_MHMOOTHER
HIMC17
roster
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]
[Besides (MEDICARE MANAGED CARE PLAN and MEDICARE
MANAGED CARE PLAN), what other/What] Medicare Advantage
Plans provided [your/(SP’s)] health care since (REFERENCE
DATE)?
SELECT OR ADD MEDICARE ADVANTAGE PLAN NAMES AT
THIS ROSTER.
routing
IF FALL ROUND AND (SP IS ALIVE AND NOT
INSTITUTIONALIZED) AND (SP HAS A MEDICARE MANAGED
CARE PLAN THAT IS "CURRENT"), GO TO HIMC19 - RECMHMO.
ELSE GO TO BOX HI1.
BOX HIMC4
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HIMC19
yes/no
BOX HIMC5
routing
HMONUMYR
HIMC24
numeric
HMONUM96
HIMC24
numeric
(01) YES
(02) NO
Would you recommend (CURRENT MEDICARE MANAGED CARE (-8) Don't Know
PLAN NAME) to your family or friends?
(-9) Refused
IF (SP HAS A MEDICARE MANAGED CARE PLAN THAT IS
"CURRENT") AND (THE NUMBER OF YEARS THE SP WAS
COVERED BY A MANAGED CARE PLAN HAS NEVER BEEN
COLLECTED), GO TO HIMC24 - HMONUMYR.
ELSE GO TO BOX HI1.
How many years [have you/has (SP)] been enrolled in a managed
care Medicare Advantage plan?
[IF THE RESPONDENT HAS BEEN ENROLLED IN MORE THAN
(01) [Continuous answer.]
ONE MEDICARE ADVANTAGE PLAN, THEN ENTER THE TOTAL (-7) Empty
NUMBER OF YEARS THAT HE/SHE HAS BEEN ENROLLED IN
(-8) Don't Know
ALL MEDICARE ADVANTAGE PLANS.]
(-9) Refused
How many years [have you/has (SP)] been enrolled in a managed (01) LESS THAN ONE YEAR
care plan?
(-7) Empty
routing
IF A MEDICAID PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO HI6 - COVTIME.
ELSE GO TO HI5INTRO - MCAIDINT.
RECMHMO
BOX HI1
[Since (REFERENCE DATE)] respondent is SP or proxy,
SP not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased
[Besides (MEDICARE MANAGED CARE PLAN and
MEDICARE MANAGED CARE PLAN) what other] second
or more time through loop
[What] first time through loop
[your] respondent is SP
[(SP's)] respondent is proxy
(01) HIMC17 - PLAN_MHMOOTHER
(02) BOX HIMC4
(-8) BOX HIMC4
(-9) BOX HIMC4
BOX HIMC4
BOX HIMC5
[have you] respondent is SP
[has (SP)] respondent is proxy
[have you] respondent is SP
[has (SP)] respondent is proxy
HIMC24 - HMONUM96
BOX HI1
SHOW CARD HI3
MCAIDINT
MCAIDINTB
HI5INTRO
no entry
BOX HI1B
routing
HI5INTRB
no entry
PLEASE READ THIS INTRODUCTION SLOWLY AND CLEARLY:
Medicaid (, also known as [READ FROM ABOVE],) is a state
program for low income persons or for persons on public
assistance. Sometimes persons with very large medical bills are
also covered by Medicaid. People covered by Medicaid usually
have a card that looks like this
IF STATE IN WHICH SP LIVES DOES NOT OFFER A MEDICAID
MANAGED CARE PLAN, GO TO HI5 - AIDCOVER.
ELSE GO TO HI5INTRB - MCAIDINTB.
SHOW CARD HI4
Some people receive their Medicaid benefits from plans that have
names like those listed on this card.
At any time [since (REFERENCE DATE)/between (REFERENCE
DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], [have you/has (SP) been/was (SP)]
covered by Medicaid?
AIDCOVER
COVTIME
COVNOW
HI5
HI6
HI7
BOX HI1B
yes/no
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
code 1
(At the time of the last interview [you were/(SP) was] covered by
Medicaid, (also known as [READ FROM ABOVE].) [Were you/Was
(SP)] covered by Medicaid the whole time between (REFERENCE
DATE) and [(today/DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], or only part of the time?
(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
yes/no
(01) YES
[[Are you/Is (SP)] now covered by Medicaid?] [Was (SP) covered by (02) NO
Medicaid on (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)?]
(-9) Refused
[Since (REFERENCE DATE)] respondent is SP or proxy,
SP not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you] respondent is SP
[has (SP) been] respondent is proxy, SP alive
[was (SP)] respondent is proxy, SP deceased
[you were] respondent is SP
[(SP) was] respondent is proxy
[Were you] respondent is SP
[Was (SP)] respondent is proxy
[today] respondent is SP or proxy, SP not deceased or
institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[Are you] now covered by Medicaid?] respondent is SP
[Is (SP)] now covered by Medicaid?] respondent is proxy,
SP not deceased or institutionalized
[Was (SP) covered by Medicaid on (DATE OF DEATH)?]
respondent is proxy, SP deceased
[Was (SP) covered by Medicaid on (DATE OF
INSTITUTIONALIZATION)?] respondent is proxy, SP
institutionalized
HI5 - AIDCOVER
(01) HI6 - COVTIME
(02) BOX HIT1
(-8) BOX HIT1
(-9) BOX HIT1
(01) HI10A - MCAIDHMO
(02) HI7 - COVNOW
(-8) HI7 - COVNOW
(-9) HI7 - COVNOW
(01) BOX HI4
(02) HI9 - COVENDMM
(-8) HI10A - MCAIDHMO
(-9) HI10A - MCAIDHMO
BOX HI4
COVBEGMM
COVBEGDD
COVBEGYY
COVENDMM
COVENDDD
COVENDYY
MCAIDHMO
HI8
HI8
HI8
HI9
HI9
HI9
HI10A
routing
IF THIS MEDICAID PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO HI10A - MCAIDHMO.
ELSE GO TO HI8 - COVBEGMM.
date
On what date did [your/(SP’s)] Medicaid start between
(REFERENCE DATE) and [today/(DATE OF DEATH)/(DATE OF
INSTITUTIONALIZATION)]?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
date
On what date did [your/(SP’s)] Medicaid start between
(REFERENCE DATE) and [today/(DATE OF DEATH)/(DATE OF
INSTITUTIONALIZATION)]?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
date
On what date did [your/(SP’s)] Medicaid start between
(REFERENCE DATE) and [today/(DATE OF DEATH)/(DATE OF
INSTITUTIONALIZATION)]?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
date
date
date
yes/no
[your] respondent is SP
[(SP's)] respondent is proxy
[today] respondent is SP or proxy, SP not deceased or
institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
MM
[your] respondent is SP
[(SP's)] respondent is proxy
[today] respondent is SP or proxy, SP not deceased or
institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
DD
[your] respondent is SP
[(SP's)] respondent is proxy
[today] respondent is SP or proxy, SP not deceased or
institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP
institutionalized
YY
[since
(REFERENCE DATE)] respondent is SP or proxy,
HI8 - COVBEGDD
HI8 - COVBEGYY
HI10A - MCAIDHMO
On what date [since (REFERENCE DATE)/between (REFERENCE
DATE) and (DATE OF DEATH/
(01) [Continuous answer.]
DATE OF INSTITUTIONALIZATION)], did [your/(SP’s)] Medicaid
(-8) Don't Know
coverage [most recently/last] stop?
(-9) Refused
SP not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[most recently] SP alive
[last]
deceased DATE)] respondent is SP or proxy,
[sinceSP
(REFERENCE
MM
HI9 - COVENDDD
On what date [since (REFERENCE DATE)/between (REFERENCE
DATE) and (DATE OF DEATH/
(01) [Continuous answer.]
DATE OF INSTITUTIONALIZATION)], did [your/(SP’s)] Medicaid
(-8) Don't Know
coverage [most recently/last] stop?
(-9) Refused
SP not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[most recently] SP alive
[last]
deceased DATE)] respondent is SP or proxy,
[sinceSP
(REFERENCE
DD
HI9 - COVENDYY
On what date [since (REFERENCE DATE)/between (REFERENCE
DATE) and (DATE OF DEATH/
(01) [Continuous answer.]
DATE OF INSTITUTIONALIZATION)], did [your/(SP’s)] Medicaid
(-8) Don't Know
coverage [most recently/last] stop?
(-9) Refused
SP not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[most recently] SP alive
[last] SP deceased
YY
(Some states now use managed care plans, such as HMOs (Health
Maintenance Organizations), to provide some or all health care for
Medicaid beneficiaries.) [At the time of the last interview [you
were/(SP) was] enrolled in a Medicaid Managed Care Plan.] [Are
you now/Is (SP) now/Were you/Was (SP)] enrolled in a Medicaid
Managed Care Plan [as of (DATE OF DEATH)/(DATE OF
INSTITUTIONALIZATION)/(MEDICAID COVERAGE STOP
DATE)/the date [your/(SP’s)] Medicaid coverage stopped]?
[ONLY SELECT “YES” IF THE RESPONDENT IS ACTUALLY
ENROLLED IN THE PLAN; SOME STATES MAY OFFER
MANAGED CARE, BUT NOT REQUIRE ENROLLMENT.]
(01) YES
(02) NO
[PROBE IF NECESSARY: Do you have a health plan card or
(-8) Don't Know
something with the plan name on it?]
(-9) Refused
[At the time of the last interview [you were] enrolled in a
Medicaid Managed Care Plan] respondent is SP, second or
more time through loop, indicated plan already existed
[At the time of the last interview [(SP) was] enrolled in a
Medicaid Managed Care Plan] respondent is proxy, second
or more time through loop, indicated plan already existed
[Are you now] enrolled in a Medicaid Managed Care Plan
[as of the date [your] Medicaid coverage stopped]
respondent is SP, plan is beginning
[Is (SP) now] enrolled in a Medicaid Managed Care Plan
[as of the date [(SP's)] Medicaid coverage stopped]
respondent is proxy, SP alive, plan is beginning
[Were you] enrolled in a Medicaid Managed Care Plan [as
of (MEDICAID COVERAGE STOP DATE)] respondent is
SP, indicated that plan ended
[Were you] enrolled in a Medicaid Managed Care Plan [as
of the date [your] Medicaid coverage stopped] respondent
is SP, indicated that plan is beginning
[Was (SP)] enrolled in a Medicaid Managed Care Plan [as
of (DATE OF DEATH)] respondent is proxy, SP deceased
[Was (SP)] enrolled in a Medicaid Managed Care Plan [as
of (DATE OF INSTITUTIONALIZATION)] respondent is
proxy, SP institutionalized
[Was (SP)] enrolled in a Medicaid Managed Care Plan [as
of (MEDICAID COVERAGE STOP DATE)] respondent is
proxy, indicated that plan ended
BOX HI5D
BOX HI5D
yes/no
IF ((ADMINISTERING ST, NS OR CPS) AND SP WAS COVERED
BY A MEDICARE PRESCRIPTION DRUG PLAN ANYTIME
DURING THE CURRENT ROUND) OR (ADMINSTERING HI AND
THERE WAS A MEDICARE PRESCRIPTION DRUG PLAN THAT
WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW), GO TO BOX HIT1.
ELSE IF (ADMINISTERING ST, NS OR CPS) AND SP WAS NOT
COVERED BY A MEDICARE PRESCRIPTION DRUG PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO HI10D MCDRXCOV.
ELSE
TO HI10C1
- MPDCOVER.
(SomeGO
people
who receive
Medicaid benefits are also enrolled in a
Medicare Prescription Drug plan, or Medicare Part D plan, that
pays for some or all of their prescribed medicines. The Medicare
program automatically enrolls such beneficiaries into a Medicare
Prescription Drug plan, although the beneficiary may choose to
switch to a different prescription plan.)
At any time [since (REFERENCE DATE)/between (REFERENCE
DATE) AND (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], [have you been/has (SP) been/was
(SP)] enrolled in a Medicare Prescription Drug plan that
[covers/covered] medicines prescribed by a doctor?
MPDCOVER
PDPCURR
PLAN_CAIDMPDP
HI10C1
HI10C2
HI10C3
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[since (REFERENCE DATE)] respondent is SP or proxy,
SP not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you been] respondent is SP
[has (SP) been] respondent is proxy, SP alive
[was (SP)] respondent is proxy, SP deceased
[covers] SP alive
[covered] SP deceased
[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP alive
[Was (SP)] respondent is proxy, SP deceased
[currently] SP is not deceased or institutionalized
[on (DATE OF DEATH)] SP deceased
[on (DATE OF INSTITUTIONALIZATION)] SP
institutionalized
[currently covers] SP alive
[covered] SP deceased or institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
[on (DATE OF DEATH)] SP is deceased
[on (DATE OF INSTITUTIONALIZATION)] SP is
institutionalized
[Since
(REFERENCE DATE)] respondent is SP or proxy,
SP not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased
[you were] respondent is SP
[(SP) was] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she]
respondent
female
[the other]
secondisorproxy,
moreSP
time
through loop
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[all] first time through loop
[you have] respondent is SP
[he has] respondent is proxy, SP male
[she has] respondent is proxy, SP female
[you were] respondent is SP
[(SP) was] respondent is proxy
[you] respondent is SP
[he] respondent is proxy, SP male
[she] respondent is proxy, SP female
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[Does] SP alive
[Did] SP deceased
[your] respondent is SP
[(SP's)] respondent is proxy
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
yes/no
[Are you/Is (SP)/Was (SP)] [(currently)] covered by or enrolled in a
Medicare Prescription Drug plan [on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
roster
[What is the name of the Medicare Prescription Drug plan that
(currently covers/covered) [you/(SP)] [on (DATE OF DEATH)/(DATE
OF INSTITUTIONALIZATION)]?]
SELECT OR ADD ONLY ONE MEDICARE PRESCRIPTION DRUG
PLAN AT THIS ROSTER.
yes/no
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/INSTITUTIONALIZATION)], [have you/has
(SP)/had (SP)] been covered by any other Medicare Prescription
Drug plans besides (CURRENT MEDICARE PRESCRIPTION
DRUG PLAN)?
(PROBE IF NECESSARY: Please include Medicare Prescription
Drug plans [you were/(SP) was] automatically enrolled in through
Medicaid as well as any [you/he/she] enrolled in on [your/his/her]
own.)
PDPMORE
HI10C4
Yes/No
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]
Please tell me the names of [the other/all] Medicare Prescription
Drug plans that [you have/he has/she has] been enrolled in since
(REFERENCE DATE) [besides (CURRENT MEDICARE
PRESCRIPTION DRUG PLAN)].
PLAN_CAIDMPDPOTHR
MCDRXCOV
HI10C5
HI10D
BOX HIT1
roster
[PROBE IF NECESSARY: Please include Medicare Prescription
Drug plans [you were/(SP) was] automatically enrolled in through
Medicaid as well as any [you/he/she] enrolled in on [your/his/her)
own.]
SELECT OR ADD MEDICARE PRESCRIPTION DRUG PLAN
NAMES AT THIS ROSTER.
yes/no
(Does/Did) [your/(SP’s)] Medicaid plan cover medicines prescribed
by a doctor?
routing
IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERIGN CPS, GO TO BOX CPS29A.
ELSE IF A TRICARE PLAN WAS "CURRENT" AT THE TIME OF
THE PREVIOUS ROUND INTERVIEW, GO TO HIT2 - COVTIME.
ELSE GO TO HIT1 - TRICOVER.
(01) HI10C2 - PDPCURR
(02) HI10D - MCDRXCOV
(-8) HI10D - MCDRXCOV
(-9) HI10D - MCDRXCOV
(01) HI10C3 - PLAN_CAIDMPDP
(02) HI10C5 - PLAN_CAIDMPDPOTHR
(-8) HI10C5 - PLAN_CAIDMPDPOTHR
(-9) HI10C5 - PLAN_CAIDMPDPOTHR
HI10C4 - PDPMORE
(01) HI10C5 - PLAN_CAIDMPDPOTHR
(02) BOX HIT1
(-8) BOX HIT1
(-9) BOX HIT1
BOX HIT1
BOX HIT1
SHOW CARD HIT1
As you (may) know, the Department of Defense sponsors a
regionally managed health care program called TRICARE for active
duty and retired members of the uniformed Armed Forces, their
families, and survivors.
Please look at this card. At any time [since (REFERENCE DATE)/
between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], [have you/has (SP)
been/was (SP)] enrolled in or covered by any of these TRICARE
plans?
TRICOVER
COVTIME
COVNOW
TRIRXCOV
TRIMEDS
TRIMEDOS
HIT1
HIT2
HIT3
HIT4
HIT4A1
HIT4A1
BOX HIT3
yes/no
(EXPLAIN IF NECESSARY: You may have received a reference
card that looks like this (BACK OF SHOWCARD HIT1).)
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
code1
[At the time of the last interview [you were/(SP) was] covered by
TRICARE.] [Were you/Was (SP)] covered by TRICARE the whole
time between [(REFERENCE DATE) and (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], or only part of the
time?
(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
yes/no
[[Are you/Is (SP)] now covered by TRICARE?] [Was (SP) covered
by TRICARE on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION?]
[Does/Did] [your/(SP’s)] TRICARE plan cover medicines prescribed
by a doctor?
HIT11
BOX HI20
VACOVER
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[[Are you] now covered by TRICARE?] respondent is SP
[[Is (SP)] now covered by TRICARE?] respondent is proxy,
SP not deceased or institutionalized
[Was (SP) covered by TRICARE on (DATE OF DEATH)?]
respondent is proxy, SP deceased
[Was (SP) covered by TRICARE on (DATE OF
INSTITUTIONALIZATION)?] respondent is proxy, SP
institutionalized
[Does] SP alive
[Did] SP deceased
[your] respondent is SP
[(SP's)] respondent is proxy
[you personally have] respondent is SP
[(SP) personally has] respondent is proxy, SP alive
yes/no
[PROBE: I am asking about the type of insurance coverage that
[you personally have/(SP) personally has], not what the plan offers
everyone.]
code 1
verbatim text
[do you] respondent is SP, SP still obtains medicines
[does (SP)] respondent is proxy, SP alive
[did you] respondent is SP, SP no longer obtains medicines
(01) A TRICARE MAIL ORDER PHARMACY (TMOP)
[did (SP)] respondent is proxy, SP deceased
(02) A TRICARE RETAIL PHARMACY NETWORK
[your] respondent is SP
SHOW CARD HIT2
PHARMACY (TRRX)
[his] respondent is proxy, SP male
Where [do you/does (SP)/did you/did (SP)] usually obtain
(03) A MILITARY TREATMENT FACILITY PHARMACY [her] respondent is proxy, SP female
[your/his/her] medicines? [Do you/Does (SP)/Did you/Did (SP)]
(MTF)
[Do you] respondent is SP, SP still obtains medicines
usually obtain them at a TRICARE mail order pharmacy (TMOP), a (04) A NON-NETWORK RETAIL PHARMACY
[Does (SP)] respondent is proxy, SP alive
TRICARE retail pharmacy network pharmacy (TRRx), a military
(91) SOMEWHERE ELSE
[Did you] respondent is SP, SP no longer obtains
treatment facility pharmacy (MTF), a non-network retail pharmacy, (-8) Don't Know
medicines
or somewhere else?
(-9) Refused
[Did (SP)] respondent is proxy, SP deceased
SOMEWHERE
ELSE
(SPECIFY)
(01)
[Continuous
Answer]
IF ADMINISTERING ST, GO TO BOX ST69A.
routing
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERING CPS, GO BOX CPS29A.
ELSE IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO BOX
HI7.
ELSE IF ((SP DID NOT REPORT RECEIVING HEALTH CARE
SERVICES FROM M.T.F IN THE PREVIOUS ROUND) AND ((SP
WAS COVERED BY TRICARE IN THE CURRENT OR PREVIOUS
ROUND) OR (SP SERVED IN THE ARMED FORCES)), GO TO
HIT11 - MTFCOVER.
ELSE GO TO BOX HI20.
[We recorded that [you/(SP)] served in the Armed Forces of the
United States.] Since (REFERENCE DATE), [have you/has (SP)
received/did (SP) receive] health care or health services or
prescribed medicines at a Military Treatment Facility or MTF?
MTFCOVER
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[since (REFERENCE DATE)] respondent is SP or proxy,
SP not deceased or institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] respondent is proxy, SP deceased,
second or more time through loop
[between (PREVIOUS ROUND INTERVIEW) and (DATE
OF INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized, second or more time through loop
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[was
(SP)]
is proxy, SP
[At
the
timerespondent
of the last interview
[youdeceased
were] covered by
TRICARE] respondent is SP, second or more time through
loop
[At the time of the last interview [(SP)] was covered by
TRICARE] respondent is proxy, second or more time
through loop
[Were you] respondent is SP
[Was (SP)] respondent is proxy
[(REFERENCE DATE) and today] respondent is SP or
proxy, SP not institutionalized or deceased
[(REFERENCE DATE) and (DATE OF DEATH)] respondent
is proxy, SP deceased
[(REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
yes/no
routing
HI36
yes/no
BOX HI7
routing
[EXPLAIN IF NECESSARY: A Military Treatment Facility is any
military hospital, clinic, or NAVCARE clinic.]
IF (SP DID NOT REPORT RECEIVING HEALTH CARE SERVICES
THROUGH V.A. IN THE PREVIOUS ROUND) AND (SP SERVED
IN THE ARMED FORCES), GO TO HI36 - VACOVER.
ELSE GO TO BOX HI7.
[We recorded that [you/(SP)] served in the Armed Forces of the
United States.] Since (REFERENCE DATE), [have you/has (SP)
received/did (SP) receive] health care or health services or
prescribed medicines through the Department of Veterans Affairs
or V.A.?
IF AT LEAST ONE PUBLIC PLAN WAS "CURRENT" AT THE TIME
OF THE PREVIOUS ROUND INTERVIEW, GO TO HI11PREV PUBINTRO.
ELSE GO TO HI11 - PUBCOVER.
(01) HIT2 - COVTIME
(02) BOX HIT3
(-8) BOX HIT3
(-9) BOX HIT3
(01) HIT4 - TRIRXCOV
(02) HIT3 - COVNOW
(-8) HIT3 - COVNOW
(-9) HIT3 - COVNOW
HIT4 - TRIRXCOV
(01) HIT4A1 - TRIMEDS
(02) BOX HIT3
(-8) BOX HIT3
(-9) BOX HIT3
BOX HIT3
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[have you] respondent is SP
[has (SP) received] respondent is proxy, SP alive
[did (SP) receive] respondent is proxy, SP deceased
BOX HI20
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you] respondent is SP
[(SP)] respondent is proxy
[have you] respondent is SP
[has (SP) received] respondent is proxy, SP alive
[did (SP) receive] respondent is proxy, SP deceased
BOX HI7
PUBINTRO
HI11PREV
no entry
NAVIGATOR
HI11PREV_IN
instance navigator
BOX HI7A
routing
PUBCOVER
HI11
yes/no
PLAN_PUBLIC
HI12
roster
NAVIGATOR
HI12_IN
instance navigator
COVTIME
COVNOW
HI13
HI14
BOX HI10
COVBEGMM
COVBEGDD
COVBEGYY
HI15
HI15
HI15
code 1
The next questions are about public plans [you were/(SP) was]
covered by as of (REFERENCE DATE).
CREATE CURRENT ROUND PLRO FOR PUBLIC PLAN
GO
TO CARD
HI13 - COVTIME.
SHOW
HI6
At any time [since (REFERENCE DATE)/between (PREVIOUS
ROUND INTERVIEW DATE) and (DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)], [have you/has (SP) been/was
(SP)] covered by any public program other than Medicaid that pays
for medical care [for example, a public program that pays for
prescribed medicines/for example (STATE PHARMACEUTICAL
ASSISTANCE PROGRAM), a public program that pays for
prescribed medicines/
for example (STATE PHARMACEUTICAL ASSISTANCE
PROGRAM1) or (STATE PHARMACEUTICAL ASSISTANCE
PROGRAM2)/for example (STATE PHARMACEUTICAL
ASSISTANCE PROGRAM1), (STATE PHARMACEUTICAL
ASSISTANCE PROGRAM2), or (STATE PHARMACEUTICAL
ASSISTANCE PROGRAM3), public programs that pay for
prescribed medicines]?
What is the name of each of the public programs other than
Medicaid that covered [you/(SP)]?
SELECT OR ADD ALL PUBLIC PROGRAM NAMES AT THIS
ROSTER.
[WHEN YOU ENTER A PLAN, VERIFY WITH THE RESPONDENT
THAT IT IS A PUBLIC PLAN.]
[At the time of the last interview [you were/(SP) was] covered by
(PUBLIC PLAN NAME).] [Were you/Was (SP)] covered by
(PUBLIC PLAN NAME) the whole time between [(REFERENCE
DATE) and (today/DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], or only part of the time?
(01) CONTINUE
(-7) Empty
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
[you were] respondent is SP
[(SP) was] respondent is proxy
[since (REFERENCE DATE)] SP not deceased or
institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] SP institutionalized
[have you] respondent is SP
[has (SP) been] respondent is proxy, SP alive
[was (SP)] respondent is proxy, SP institutionalized
(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
(01) THE WHOLE TIME YES
(02) PART OF THE TIME NO
(-8) Don't Know
(-9) Refused
[[Are you] now covered by (PUBLIC PLAN NAME)?]
respondent is SP
[[Is (SP)] now covered by (PUBLIC PLAN NAME)?]
respondent is proxy, SP not deceased or institutionalized
[Was (SP) covered by (PUBLIC PLAN NAME) on (DATE
OF DEATH)?] respondent is proxy, SP deceased
[Was (SP) covered by (PUBLIC PLAN NAME) on (DATE
OF INSTITUTIONALIZATION)?] respondent is proxy, SP
institutionalized
yes/no
routing
IF THIS PUBLIC PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO HI16A - PUBRXCOV.
ELSE GO TO HI15 - COVBEGMM.
date
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage
start [between (REFERENCE DATE) and (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
date
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage
start between (REFERENCE DATE) and (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
date
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage
start between (REFERENCE DATE) and (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) HI12 - PLAN_PUBLIC
(02) BOX HI12AA
(-8) BOX HI12AA
(-9) BOX HI12AA
[you] respondent is SP
[(SP)] respondent is proxy
[you were] respondent is SP
[(SP) was] respondent is proxy
[Were you] respondent is SP
[Was (SP)] respondent is proxy
[between (REFERENCE DATE) and today] respondent is
SP or proxy, SP not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[[Are you/Is (SP)] now covered by (PUBLIC PLAN NAME)?] [Was
(SP) covered by (PUBLIC PLAN NAME) on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)?]
HI11PREV_IN - NAVIGATOR
(01) BOX HI7A
(02) HI11 - PUBCOVER
[your] respondent is SP
[(SP's)] respondent is proxy
[between (REFERENCE DATE) and today] respondent is
SP or proxy, SP not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[between (REFERENCE DATE) and today] respondent is
SP or proxy, SP not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[between (REFERENCE DATE) and today] respondent is
SP or proxy, SP not deceased or institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
HI12_IN - NAVIGATOR
(01) HI13 - COVTIME
(02) BOX HI12AA
(01) HI16A - PUBRXCOV
(02) HI14 - COVNOW
(-8) HI14 - COVNOW
(-9) HI14 - COVNOW
(01) BOX HI10
(02) HI16 - COVENDMM
(-8) HI16A - PUBRXCOV
(-9) HI16A - PUBRXCOV
MM
HI15 - COVBEGDD
DD
HI15 - COVBEGYY
YY
HI16A - PUBRXCOV
COVENDMM
COVENDDD
HI16
HI16
date
date
COVENDYY
HI16
date
PUBRXCOV
HI16A
yes/no
BOX HI12
routing
BOX HI12AA
routing
On what date [since (REFERENCE DATE)/between (PREVIOUS
ROUND INTERVIEW DATE) and (DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] (PUBLIC
PLAN NAME) coverage [most recently/last] stop?
On what date [since (REFERENCE DATE)/between (PREVIOUS
ROUND INTERVIEW DATE) and (DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] (PUBLIC
PLAN NAME) coverage [most recently/last] stop?
On what date [since (REFERENCE DATE)/between (PREVIOUS
ROUND INTERVIEW DATE) and (DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] (PUBLIC
PLAN NAME) coverage [most recently/last] stop?
(Does/Did) [your/(SP’s)] (PUBLIC PLAN NAME) plan cover
medicines prescribed by a doctor?
IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERIGN CPS, GO TO BOX CPS29A.
ELSE IF REVIEWING PUBLIC PLANS THAT WERE "CURRENT"
AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO
HI11PREV_IN - NAVIGATOR.
ELSE
TO
- NAVIGATOR.
IF
(SPGO
HAS
A HI12_IN
MEDICARE
PRESCRIPTION DRUG PLAN THAT
WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW), GO TO HI16AB - PDPSAME.
ELSE IF ((SP DOES NOT HAVE A MEDICARE PRESCRIPTION
DRUG PLAN THAT WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW) AND (SP DOES NOT HAVE A
"CURRENT" MEDICARE MANAGED CARE PLAN WITH RX
COVERAGE) AND (HI10C1 - MPDCOVER = empty)), GO TO
HI16B - PDPCOVER.
ELSE IF ((SP DOES NOT HAVE A MEDICARE PRESCRIPTION
DRUG PLAN THAT WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW) AND (SP DOES NOT HAVE A
"CURRENT" MEDICARE MANAGED CARE PLAN WITH RX
COVERAGE) AND (HI10C1 - MPDCOVER = 2/No)), GO TO
HI16B1 - PDPCOVER.
ELSE GO TO BOX HI12A.
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
[since (REFERENCE DATE)] SP not deceased or
institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[most recently] SP alive
[last] SP deceased
MM
HI16 - COVENDDD
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
[since (REFERENCE DATE)] SP not deceased or
institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[most recently] SP alive
[last] SP deceased
DD
HI16 - COVENDYY
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[since (REFERENCE DATE)] SP not deceased or
institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
[most recently] SP alive
[last] SP deceased
[Does] SP alive
[Did] SP deceased
[your] respondent is SP
[(SP's)] respondent is proxy
YY
HI16A - PUBRXCOV
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[you were] respondent is SP
[(SP) was] respondent is proxy
[[Are you] now covered by (MEDICARE PRESCRIPTION
DRUG PLAN NAME)?] respondent is SP
[[Is (SP)] now covered by (MEDICARE PRESCRIPTION
DRUG PLAN NAME)?] respondent is proxy, SP not
deceased or institutionalized
[Was (SP) covered by (MEDICARE PRESCRIPTION
DRUG PLAN NAME) on (DATE OF DEATH)?] respondent
is proxy, SP deceased
[Was (SP) covered by (MEDICARE PRESCRIPTION
DRUG PLAN NAME) on (DATE OF
INSTITUTIONALIZATION)?] respondent is proxy, SP
institutionalized
At the time of the last interview [you were/(SP) was] covered by a
Medicare Prescription Drug Plan named (MEDICARE
PRESCRIPTION DRUG PLAN NAME).
PDPSAME
PDPYSTOP
PDPYSTOS
HI16AB
HI16AC
HI16AC
yes/no
code 1
verbatim text
[[Are you/Is (SP)] now covered by (MEDICARE PRESCRIPTION
DRUG PLAN NAME)?] [Was (SP) covered by (MEDICARE
PRESCRIPTION DRUG PLAN NAME) on (DATE OF DEATH/DATE
OF INSTITUTIONALIZATION)?]
[IF THE RESPONDENT DROPPED THE INDICATED COVERAGE
SINCE THE PREVIOUS INTERVIEW DATE, BUT PICKED UP THE
COVERAGE AGAIN AND CURRENTLY IS COVERED BY THE
NAMED PLAN, SELECT “YES” FOR THIS QUESTION.]
What is the most important reason [you/(SP)] stopped the
(MEDICARE PRESCRIPTION DRUG PLAN NAME) coverage?
OTHER (SPECIFY)
(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH PLAN'S COVERAGE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET DIFFERENT HEALTH CARE COVERAGE
(05) PLAN NO LONGER CONTRACTS FOR
MEDICARE RX COVERAGE
(06) PLAN NAME CHANGED OR PLAN WAS BOUGHT
BY/MERGED WITH ANOTHER PLAN
(07) SP MOVED OUT OF PLAN AREA
(91) OTHER
(-8) Don't Know
[you] respondent is SP
(-9) Refused
[(SP)] respondent is proxy
BOX HI12
(01) BOX HI12A
(02) HI16AC - PDPYSTOP
(-8) BOX HI12A
(-9) HI16AD - PDPOTHER
(01) HI16AD - PDPOTHER
(02) HI16AD - PDPOTHER
(03) HI16AD - PDPOTHER
(04) HI16AD - PDPOTHER
(05) HI16AD - PDPOTHER
(06) HI16C - PDPCURR
(07) HI16AD - PDPOTHER
(91) HI16AC - PDPYSTOS
(-8) HI16AD - PDPOTHER
(-9) HI16AD - PDPOTHER
HI16AD - PDPOTHER
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/INSTITUTIONALIZATION)], [have you/has
(SP)/had (SP)] been covered by any other Medicare Prescription
Drug plans besides (MEDICARE PRESCRIPTION DRUG PLAN
CURRENT LAST ROUND)?
PDPOTHER
HI16AD
yes/no
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]
(Medicare beneficiaries can receive insurance coverage for
prescription drugs through Medicare Prescription Drug plans. These
plans are also called "Medicare Part D" plans.)
At any time since (REFERENCE DATE), [have you/has (SP)/had
(SP)] been enrolled in a Medicare Prescription Drug plan that
[covers/covered] medicines prescribed by a doctor?
PDPCOVER
HI16B
yes/no
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]
You mentioned that [you have/(SP) has/(SP) had] not been enrolled
in a Medicare Prescription Drug plan associated with [your/his/her]
Medicaid coverage.
At any time since (REFERENCE DATE), [have you/has (SP)/had
(SP)] been enrolled in a Medicare Prescription Drug plan in any
way other than through Medicaid?
PDPCOVER
PDPCURR
PLAN_MPDP
HI16B1
HI16C
HI16E
PLAN_MPDPOTHR
PRIVINTRO
NAVIGATOR
HI16F
(01) HI16C - PDPCURR
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased
[covers] SP alive
[covered] SP deceased
(01) HI16C - PDPCURR
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
yes/no
[Are you/Is (SP)/Was (SP)] ([currently]) covered by or enrolled in a
Medicare Prescription Drug plan [on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
roster
What is the name of the Medicare Prescription Drug plan that
[currently covers/covered] [you/(SP)] [on (DATE OF DEATH/DATE
OF INSTITUTIONALIZATION)]?]
SELECT OR ADD ONLY ONE MEDICARE PRESCRIPTION DRUG
PLAN AT THIS ROSTER.
yes/no
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/ INSTITUTIONALIZATION)], [have you/has
(SP)/had (SP)] been covered by any other Medicare Prescription
Drug plans besides (CURRENT MEDICARE PRESCRIPTION
DRUG PLAN)?
PDPMORE
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Since (REFERENCE DATE)] respondent is SP or proxy,
SP not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)], respondent is proxy, SP
institutionalized
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased
yes/no
HI16G
roster
BOX HI12A
routing
HI17PREV
no entry
HI17PREV_IN
instance navigator
BOX HI12B
routing
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Besides (CURRENT PRESCRIPTION DRUG PLAN), what
other/Besides (PREVIOUS ROUND PRESCRIPTION DRUG PLAN),
what other/What] Medicare Prescription Drug plans covered
[your/(SP’s)] medicines since (REFERENCE DATE)?
SELECT OR ADD MEDICARE PRESCRIPTION DRUG PLAN
NAMES AT THIS ROSTER.
IF AT LEAST ONE PRIVATE PLAN WAS "CURRENT" AT THE
TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO
HI17PREV - PRIVINTRO.
ELSE GO TO HI17 - PRVCOVER
The next questions are about private plans [you were/(SP) was]
(01) CONTINUE
covered by as of (REFERENCE DATE).
(-7) Empty
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
CREATE A CURRENT ROUND PLRO FOR PRIVATE PLAN
We’ve
reported being covered by [READ PLAN
GO TOtalked
HI21 -aboutYou
COVTIME.
NAME(S) AND PLAN TYPE(S) LISTED ABOVE].
(Now, I would like to ask about other typesanother type of health
insurance.) At any time [since (REFERENCE DATE)/between
(PREVIOUS ROUND INTERVIEW DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], [have you/has (SP)
been/was (SP)] covered by (any other) private health insurance or
private managed care (plan/?
Private plans)?
PRVCOVER
HI17
yes/no
By "private", I mean a include supplemental or Medigap plan, or a
planplans, plans that isare provided by a former or current
employer., and plans that you have directly purchased. Such plans (01) YES
cover the cost of hospital or doctor visits, prescribed medicines, or (02) NO
dental care.
(-8) Don't Know
(-9) Refused
[you have] respondent is SP
[(SP) has] respondent is proxy, SP alive
[(SP) had] respondent is proxy, SP deceased
[your] respondent is SP
[his] respondent is proxy, SP male
[her] respondent is proxy, SP female
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased
[Are you] respondent is SP
[Is (SP)] respondent is proxy, SP alive
[Was (SP)] respondent is proxy, SP deceased or
institutionalized
[currently] SP is alive
[on (DATE OF DEATH)] SP deceased
[on (DATE OF INSTITUTIONALIZATION)] SP
institutionalized
[currently covers] SP alive
[covered] SP deceased or institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
[on (DATE OF DEATH)] SP is deceased
[on (DATE OF INSTITUTIONALIZATION)] SP is
institutionalized
[Since (REFERENCE DATE)] respondent is SP or proxy,
SP not deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased
[Besides (CURRENT PRESCRIPTION DRUG PLAN), what
other] second or more time through the loop, SP enrolled in
prescription drug plan
[Besides (PREVIOUS ROUND PRESCRIPTION DRUG
PLAN), what other] second or more time through loop, SP
previously enrolled in prescription drug plan
[What] first time through loop
[your] respondent is SP
[(SP's)] respondent is proxy
(01) HI16C - PDPCURR
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A
(01) HI16E - PLAN_MPDP
(02) HI16G - PLAN_MPDPOTHR
(-8) HI16G - PLAN_MPDPOTHR
(-9) HI16G - PLAN_MPDPOTHR
HI16F - PDPMORE
(01) HI16G - PLAN_MPDPOTHR
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A
BOX HI12A
[you were] respondent is SP
[(SP) was] respondent is proxy
(01) BOX HI12B
(02) HI17 - PRVCOVER
[since (REFERENCE DATE)] respondent is SP or proxy,
SP not deceased or institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] respondent is proxy, SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[have you] respondent is SP
[has (SP) been] respondent is proxy, SP alive
[was (SP)] respondent is proxy, SP deceased
[any other] SP already covered by private health insurance
or private managed care plan
[plan] SP already covered by private health insurance or
private managed care plan
[plan] SP not already covered by private health insurance
or private managed care plan
(01) HI20 - PLAN_PRIVATEHI18A EXCHGCOV
(02) BOX HI13A
(-8) BOX HI13A
(-9) BOX HI13A
SHOW CARD MA PLANS
As you may know, every state now offers a health insurance
marketplace, also referred to as an exchange.
The marketplace [, known as (STATE MARKETPLACE NAME),]
allows residents to compare and purchase available health
insurance options that meet their needs. While most Medicare
beneficiaries are not eligible for insurance from a health insurance
marketplace, there are some special circumstances that allow
enrollment.
[STATE MARKETPLACE NAME] fill with name from table
here: "\\norc.org\Projects\7649\Common\NORC-SM\Data
Quality\Plan Name Lookup\State Marketplace Names.xlsx"
Please look at this card. At any time [since (REFERENCE
DATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION),] [have you/has
(SP)/had (SP)] been enrolled in or covered by one of these
exchange plans?
EXCHGCOV
HI18A
yes/no
BOX HI13A
routing
[MEDICARE BENEFICIARIES ARE NOT ELIGIBLE TO OBTAIN
INSURANCE THROUGH THESE PLANS. THE RESPONSE TO
THIS QUESTION SHOULD ALMOST ALWAYS BE “NO”.
HOWEVER, SOME RESPONDENTS MAY SIGN UP FOR THESE
PLANS DUE TO CONFUSION ABOUT THE PROGRAM.]
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW
FROM FACILITY), GO TO HI19 - GAPCOVER.
ELSE GO TO HI35 - PRVOCOV.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[since (REFERENCE DATE)] SP alive and not
institutionalized
[between (REFERENCE DATE) and (DATE OF DEATH)]
SP deceased
[(DATE OF INSTITUTIONALIZATION)] SP institutionalized
[have you] respondent is SP
[has (SP)] respondent is proxy, SP alive
[had (SP)] respondent is proxy, SP deceased
HI20 - PLAN_PRIVATE
Some people who are eligible for Medicare have additional
coverage through a private insurance carrier. This is sometimes
referred to as Medigap or Medicare Supplement -insurance. These
plans help pay some of the health care costs that Original Medicare
doesn't cover, like copayments, coinsurance and deductibles.
At any time since (REFERENCE DATE) did [you/(SP)] have this
type of health insurance coverage?
GAPCOVER
PLAN_PRIVATE
NAVIGATOR
COVTIME
COVNOW
COVBEGMM
COVBEGDD
COVBEGYY
HI19
HI20
HI20_IN
HI21
yes/no
[PROBE IF NECESSARY: Do you have a health plan card or
something with the plan name on it?]
roster
What is the name of each of the [other] private plans that
[provide/provided] [your/(SP’s)] medical insurance coverage?
SELECT OR ADD ALL PRIVATE PLAN NAMES AT THIS ROSTER.
[At the time of the last interview [you were/(SP) was] covered by a
private plan named (PRIVATE PLAN NAME).] [Were you/Was (SP)]
covered by (PRIVATE PLAN NAME) the whole time between
(REFERENCE DATE) and [today/ DATE OF DEATH/DATE OF
INSTITUTIONALIZATION], or only part of the time?
(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused
HI22
yes/no
BOX HI16
routing
(01) YES
[[Are you/Is (SP)] now covered by (PRIVATE PLAN NAME)?] [Was (02) NO
(SP) covered by (PRIVATE PLAN NAME) on (DATE OF DEATH/
(-8) Don't Know
DATE OF INSTITUTIONALIZATION)?]
(-9) Refused
IF THIS PRIVATE PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO BOX HI17.
ELSE GO TO HI23 - COVBEGMM.
date
On what date did [your/(SP’s)] coverage under (PRIVATE PLAN
NAME) start between (REFERENCE DATE) and [today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION]?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
date
On what date did [your/(SP’s)] coverage under (PRIVATE PLAN
NAME) start between (REFERENCE DATE) and [today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION]?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
date
On what date did [your/(SP’s)] coverage under (PRIVATE PLAN
NAME) start between (REFERENCE DATE) and [today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION]?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
HI23
HI23
HI23
[you] respondent is SP
[(SP)] respondent is proxy
[other] SP already covered by private plan
[provide] SP alive
[provided] SP deceased
[your] respondent is SP
[(SP's)] respondent is proxy
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
instance navigator
code 1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HI20 - PLAN_PRIVATE
(02) HI35 - PRVOCOV
(-8) HI35 - PRVOCOV
(-9) HI35 - PRVOCOV
HI20_IN - NAVIGATOR
(01) HI21 - COVTIME
(02) HI35 - PRVOCOV
[At the time of the last interview [you were] covered by
(PRIVATE PLAN NAME).] respondent is SP, second or
more time through loop
[At the time of the last interview [(SP) was] covered by
(PRIVATE PLAN NAME).] respondent is proxy, second or
more time through loop
[Were you] respondent is SP
[Was (SP)] respondent is proxy
[today] SP not deceased or institutionalized
[(DATE OF DEATH)] SP deceased
[(DATE OF INSTITUTIONALIZATION)] SP institutionalized
(01) BOX HI17
(02) HI22 - COVNOW
(-8) HI22 - COVNOW
(-9) HI22 - COVNOW
[[Are you] now covered by (PRIVATE PLAN NAME)?]
respondent is SP
[[Is (SP)] now covered by (PRIVATE PLAN NAME)?]
respondent is proxy, SP not deceased or institutionalized
[Was (SP) covered by (PRIVATE PLAN NAME) on (DATE
OF DEATH)?] respondent is proxy, SP deceased
[Was (SP) covered by (PRIVATE PLAN NAME) on (DATE
OF INSTITUTIONALIZATION)?] respondent is proxy, SP
institutionalized
(01) BOX HI16
(02) HI24 - COVENDMM
(-8) BOX HI17
(-9) BOX HI17
[your] respondent is SP
[(SP's)] respondent is proxy
[today] respondent is SP or proxy, SP not deceased or
institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
MM
[your] respondent is SP
[(SP's)] respondent is proxy
[today] respondent is SP or proxy, SP not deceased or
institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
DD
[your] respondent is SP
[(SP's)] respondent is proxy
[today] respondent is SP or proxy, SP not deceased or
institutionalized
[(DATE OF DEATH)] respondent is proxy, SP deceased
[(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
YY
HI23 - COVBEGDD
HI23 - COVBEGYY
BOX HI17
COVENDMM
COVENDDD
COVENDYY
HI24
HI24
HI24
BOX HI17
EXCHGPLN
HI25AA
date
On what date [since (REFERENCE DATE)/between (PREVIOUS
ROUND INTERVIEW DATE) and (DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] coverage
under (PRIVATE PLAN NAME) stop?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
date
On what date [since (REFERENCE DATE)/between (PREVIOUS
ROUND INTERVIEW DATE) and (DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] coverage
under (PRIVATE PLAN NAME) stop?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
date
On what date [since (REFERENCE DATE)/between (PREVIOUS
ROUND INTERVIEW DATE) and (DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)] did [your/(SP’s)] coverage
under (PRIVATE PLAN NAME) stop?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
routing
yes/no
[since (REFERENCE DATE)] respondent is SP or proxy,
SP not deceased or institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] respondent is proxy, SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
MM
[since (REFERENCE DATE)] respondent is SP or proxy,
SP not deceased or institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] respondent is proxy, SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
DD
[since (REFERENCE DATE)] respondent is SP or proxy,
SP not deceased or institutionalized
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF DEATH)] respondent is proxy, SP deceased
[between (PREVIOUS ROUND INTERVIEW DATE) and
(DATE OF INSTITUTIONALIZATION)] respondent is proxy,
SP institutionalized
[your] respondent is SP
[(SP's)] respondent is proxy
YY
HI24 - COVENDDD
HI24 - COVENDYY
BOX HI17
IF THIS PRIVATE PLAN IS NEW OR HAS BEEN "RESTARTED",
GO TO HI25 - PPRVHMO HI25AA-EXCHGPLN.
ELSE IF THIS PRIVATE PLAN WAS "CURRENT" AT THE TIME OF
THE PREVIOUS ROUND INTERVIEW AND IS STILL "CURRENT",
AND IT IS A FALL ROUND, GO TO HI26 - PERS_MIPNUM.
ELSE GO TO HI30 - PRVRXCOV.
DID THE SP INDICATE THAT THIS PLAN WAS PURCHASED
THROUGH A HEALTH MARKETPLACE OR EXCHANGE?
[MOST MEDICARE BENEFICIARIES ARE NOT ELIGIBLE FOR
INSURACE FROM A HEALTH INSURANCE MARKETPLACE.
UNLESS THE SP SPECIFICALLY MENTIONED THE PLAN WAS
OBTAINED THROUGH HEALTH EXCHANGE, SELECT "NO". IF
NECESSARY, REFER TO SHOWCARD HI5 TO VERIFY PLAN
NAME IS LISTED ON SHOWCARD PRIOR TO SELECTING
"YES".]
[UNLESS THE SP HAS SPECIFICALLY MENTIONED THAT THIS
PLAN WAS PURCHASED THROUGH A HEALTH EXCHANGE
AND INDICATED A PLAN LISTED ON SHOWCARD HI5, THE
RESPONSE TO THIS QUESTION SHOULD ALWAYS BE “NO”.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HI25 - PPRVHMO
CODE WITHOUT ASKING IF VOLUNTEERED.
[Is/Was] this a managed care plan, such as an HMO (Health
Maintenance Organization) or PPO (Preferred Provider
Organization)?
PPRVHMO
HI25
yes/no
PERS_MIPNUM
HI26
roster
PPRVGET
PPRVGTOS
HI27
HI27
code 1
verbatim text
PRVNMCOV
HI29
numeric
[EXPLAIN IF NECESSARY: Managed care plans generally provide
a full range of health care services for a prepaid fee. Health care is
generally provided by primary care doctors, specialists, or hospitals
on the plan’s list (network) except in an emergency.]
Who [is/was] listed as the main insured person on the (PRIVATE
PLAN NAME) policy or contract?
SELECT OR ADD ONLY ONE PERSON.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) DIRECTLY
(02) (MIP'S) CURRENT EMPLOYER
(03) (MIP'S) FORMER EMPLOYER
(04) (MIP'S) UNION
(05) (MIP'S) FAMILY BUSINESS
(06) AARP
(07) DECEASED SPOUSE'S EMPLOYER
(08) DECEASED SPOUSE'S UNION
For the (PRIVATE PLAN NAME) plan, did [you/(MIP)] sign up
(09) PROFESSIONAL/FRATERNAL ORGANIZATION
directly, or did [you/(MIP)] get this insurance through a current
(91) SOME OTHER WAY
employer, a former employer, a union, a family business, AARP, or (-8) Don't Know
some other way?
(-9) Refused
OTHER (SPECIFY)
How many family members, including [yourself/(SP)], [are/were]
covered by [your/(MIP’s)] (PRIVATE PLAN NAME)?
[INCLUDE ALL FAMILY MEMBERS COVERED BY THE PLAN
REGARDLESS OF WHETHER OR NOT THEY LIVE WITH THE
(01) [Continuous answer.]
RESPONDENT. MAKE SURE THE RESPONDENT INCLUDES
(-8) Don't Know
HIM/HERSELF IN THE COUNT.]
(-9) Refused
[Is] plan still current
[Was] plan no longer current
HI26 - PERS_MIPNUM
[is] plan still current
[was] plan no longer current
HI27 - PPRVGET
[your] respondent is SP, SP is MIP
[(MIP)] respondent is SP or proxy, SP is not MIP
[your] respondent is SP, SP is MIP
[(MIP)] respondent is SP or proxy, SP is not MIP
[yourself] respondent is SP
[(SP)] respondent is proxy
[are] SP alive
[were] SP deceased
[your] respondent is SP, SP is MIP
[(MIP's)] respondent is SP or proxy, SP is not MIP
(01) HI29 - PRVNMCOV
(02) HI29 - PRVNMCOV
(03) HI29 - PRVNMCOV
(04) HI29 - PRVNMCOV
(05) HI29 - PRVNMCOV
(06) HI29 - PRVNMCOV
(07) HI29 - PRVNMCOV
(08) HI29 - PRVNMCOV
(09) HI29 - PRVNMCOV
(91) HI27 - PPRVGTOS
(-8) HI29 - PRVNMCOV
(-9) HI29 - PRVNMCOV
HI29 - PRVNMCOV
HI30 - PRVRXCOV
Supplemental insurance plans may cover a variety of services or
may be specific to only certain services, such as prescribed
medicines or dental coverage. I’d like to know what [your/(SP’s)]
(PLAN NAME) coverage [includes/included].
[PROBE: I am asking about the type of insurance coverage that
[you/(SP)] personally [have/has/had], not what the plan offers
everyone.]
PRVRXCOV
HI30
BOX HI17AB
yes/no
[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) plan cover
prescribed medicines?
[IF THE RESPONDENT IS COVERED BY A DELTA DENTAL PLAN
THAT PROVIDES ONLY DENTAL COVERAGE, THE
INTERVIEWER SHOULD VERIFY AND SELECT “NO” THAT THE
PLAN DOES NOT COVER OTHER TYPES PRESCRIBED
MEDICINES.]
routing
IF (THIS PRIVATE PLAN IS NEW OR HAS BEEN "RESTARTED")
OR (THIS PRIVATE PLAN WAS "CURRENT" AT THE TIME OF
THE PREVIOUS ROUND INTERVIEW AND IS STILL "CURRENT",
AND IT IS A FALL ROUND), GO TO HI31A - PRVMSCOV.
ELSE GO TO BOX HI19.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) cover…
doctor visits or lab work?
[PROBE IF NECESSARY: I am asking about the type of insurance
coverage that [you/(SP)] personally [have/has/had], not what the
plan offers everyone.]
PRVMSCOV
HI31A
list
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) cover…
inpatient hospital care?
PRVIPCOV
HI31A
list
[PROBE IF NECESSARY: I am asking about the type of insurance
coverage that [you/(SP)] personally [have/has/had], not what the
plan offers everyone.]
[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) cover…
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
nursing home or long term care?
[PROBE IF NECESSARY: I am asking about the type of insurance
coverage that [you/(SP)] personally [have/has/had], not what the
plan offers everyone.]
PRVNHCOV
HI31A
list
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Does/Did] [your/(MIP’s)] (PRIVATE PLAN NAME) cover…
dental care?
[PROBE IF NECESSARY: I am asking about the type of insurance
coverage that [you/(SP)] personally [have/has/had], not what the
plan offers everyone.]
MHMODENT
HI31A
list
[Do/Does/Did] [you/(MIP)] pay any or all of the premium or cost for
the (PRIVATE PLAN NAME) coverage?
MIPPINS
HI32
yes/no
[Do not include the cost of any deductibles [you/(SP)] or
[your/(SP’s)] family may [have/have had] to pay.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
How much [do/does/did] [you/(MIP)] pay for the (PRIVATE PLAN
NAME) coverage?
[Please do not include any amount that may be paid for anyone
other than [you/(SP)].]
MIPPAMT
HI33
[PROBE IF NECESSARY: [Is/Was] that per year, per month, per
quantity unit hybrid week, or what?]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
[includes] SP alive
[included] SP deceased
[you] respondent is SP
[(SP)] respondent is proxy
[have] respondent is SP
[has] respondent is proxy, SP alive
[had] respondent is proxy, SP deceased
[Does] SP alive
[Did] SP deceased
[your] respondent is SP, SP is MIP
[(MIP)] respondent is SP or proxy, SP is not MIP
[Does] SP alive
[Did] SP deceased
[your] respondent is SP, SP is MIP
[(MIP's)] respondent is SP or proxy, SP not MIP
[you] respondent is SP
[(SP)] respondent is proxy
[have] respondent is SP
[has] respondent is proxy, SP alive
[had] respondent is proxy, SP deceased
[Does] SP alive
[Did] SP deceased
[your] respondent is SP, SP is MIP
[(MIP's)] respondent is SP or proxy, SP not MIP
[you] respondent is SP
[(SP)] respondent is proxy
[have] respondent is SP
[has] respondent is proxy, SP alive
[had] respondent is proxy, SP deceased
[Does] SP alive
[Did] SP deceased
[your] respondent is SP, SP is MIP
[(MIP's)] respondent is SP or proxy, SP not MIP
[you] respondent is SP
[(SP)] respondent is proxy
[have] respondent is SP
[has] respondent is proxy, SP alive
[had] respondent is proxy, SP deceased
[Does] SP alive
[Did] SP deceased
[your] respondent is SP, SP is MIP
[(MIP's)] respondent is SP or proxy, SP not MIP
[you] respondent is SP
[(SP)] respondent is proxy
[have] respondent is SP
[has] respondent is proxy, SP alive
[had] respondent is proxy, SP deceased
[Do] respondent is SP, SP is MIP
[Does] respondent is SP or proxy, SP is not MIP
[Did] respondent is proxy, SP deceased
[Do] respondent is SP, SP is MIP; or respondent is proxy,
proxy is MIP
[Does] respondent is SP, SP is not MIP; ot respondent is
proxy, SP is MIP
[Did] respondent is proxy, SP deceased; or plan is no
longer current
[you] respondent is SP, SP is MIP
[(MIP)] respondent is SP or proxy, SP is not MIP
[you] respondent is SP
[(SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[have]
SP alive is SP, SP is MIP
[do]
respondent
[does] respondent is SP or proxy, SP is not MIP
[did] respondent is proxy, SP deceased
[Do] respondent is SP, SP is MIP; or respondent is proxy,
proxy is MIP
[Does] respondent is SP, SP is not MIP; ot respondent is
proxy, SP is MIP
[Did] respondent is proxy, SP deceased; or plan is no
longer current
[you] respondent is SP, SP is MIP
[(MIP)] respondent is SP or proxy, SP is not MIP
[you] respondent is SP
[(SP)] respondent is proxy
[Is] SP alive
[Was] SP deceased
BOX HI17AB
HI31A - PRVIPCOV
HI31A - PRVNHCOV
HI31A - MHMODENT
HI32 - MIPPINS
(01) HI33 - MIPPAMT
(02) HI33A - MHMOCOST
(-8) HI33A - MHMOCOST
(-9) HI33A - MHMOCOST
(01) HI33 - MIPPUNIT
(-8) HI33A - MHMOCOST
(-9) HI33A - MHMOCOST
How much [do/does/did] [you/(MIP)] pay for the (PRIVATE PLAN
NAME) coverage?
[Please do not include any amount that may be paid for anyone
other than [you/(SP)].]
MIPPUNIT
MIPPUNOS
MHMOCOST
MHMOWHO
MHMOWHOS
HI33
HI33
HI33A
[PROBE IF NECESSARY: [Is/Was] that per year, per month, per
quantity unit hybrid week, or what?]
verbatim text
OTHER (SPECIFY)
yes/no
HI33B
HI33B
code 1
verbatim text
BOX HI17B
routing
(01) PER YEAR
(02) QUARTERLY/EVERY 3 MONTHS
(03) BIMONTHLY/EVERY 2 MONTHS
(04) PER MONTH
(05) PER WEEK
(06) SEMI-ANNUALLY/2 TIMES PER YEAR
(07) SEMI-MONTHLY/2 TIMES PER MONTH
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) YES
[Does/Did] anyone else, such as an employer, a union or
(02) NO
professional organization pay all or some portion of the premium or (-8) Don't Know
cost for [your/(MIP’s)] (PRIVATE PLAN NAME) coverage?
(-9) Refused
Who else [pays/paid] all or some portion of the cost for
[your/(MIP’s)] (PRIVATE PLAN NAME) coverage?
OTHER (SPECIFY)
IF THIS PRIVATE PLAN IS A MANAGED CARE PLAN, GO TO
HI33C - MHMOPOS.
ELSE GO TO BOX HI19.
MHMOPOS
PRVOCOV
OTHNHCOV
HI33C
yes/no
BOX HI19
routing
[pays] SP still has private plan
[paid] SP no longer has private plan
[your] respondent is SP, SP is MIP
[(MIP's)] respondent is SP or proxy, SP not MIP
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Are] respondent is SP, SP currently enrolled in private
plan
[Were] respondent is SP, SP not currently enrolled in
private plan
[Is] respondent is proxy, SP alive, SP currently enrolled in
private plan
[Was] respondent is proxy, SP deceased or SP not
currently enrolled in private plan
[you] respondent is SP
[(SP)] respondent is proxy
BOX HI19
[Do you] respondent is SP
[Does (SP)] respondent is proxy, SP alive
[Did (SP)] respondent is proxy, SP deceased
(01) HI20 - PLAN_PRIVATE
(02) BOX HI19B
(-8) BOX HI19B
(-9) BOX HI19B
[Other than the plans you have already told me about, [do
you]] respondent is SP, SP has plans
[Other than the plans you have already told me about,
[does (SP)]] respondent is proxy, SP alive, SP has other
plans
[Other than the plans you have already told me abouy, [did
(SP)]] respondent is proxy, SP deceased, SP had other
plans
[Do you] respondent is SP, SP has no other plans
[Does (SP)] respondent is proxy, SP alive, SP has no other
plans
[Did (SP)] respondent is proxy, SP deceased, SP had no
other plans
[pays] SP alive
[paid] SP deceased
BOX HI21A
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HI35
yes/no
BOX HI19B
routing
We’ve talked about [READ PLAN(S) LISTED ABOVE]. [Do
you/Does (SP)/Did (SP)] have medical coverage under any (other)
private insurance plans we haven’t talked about?
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW
FROM FACILITY), GO TO HI34 - OTHNHCOV.
ELSE GO TO BOX HI21A.
yes/no
routing
(01) YES
[Other than the plans you have already told me about, [do you/does (02) NO
(SP)/did (SP)]/[Do you/Does (SP)/Did (SP)]] have any insurance
(-8) Don't Know
that [pays/paid] just for nursing home care or other long term care? (-9) Refused
GO TO NEXT SECTION
HI34
BOX HI21A
[Does] SP still has private plan
[Did] SP no longer has private plan
[your] respondent is SP, SP is MIP
[(MIP's)] respondent is SP or proxy, SP not MIP
(01) [(SP's)/(MIP's)] CURRENT EMPLOYER
(02) (SP's/MIP's) FORMER EMPLOYER
(03) (SP's/MIP's) UNION
(04) SPOUSE'S CURRENT EMPLOYER
(05) SPOUSE'S FORMER EMPLOYER
(06) PROFESSIONAL/FRATERNAL ORGANIZATION
(07) MEDICAID/MEDICAL ASSISTANCE
(91) OTHER
(-8) Don't Know
(-9) Refused
Some managed care plans offer a point-of-service option which
allows members to receive services from out-of-plan providers even
in non-emergency situations. [Are/Were/Is/Was] [you/(SP)] enrolled
in a point-of-service option offered by (PRIVATE PLAN NAME)?
[EXPLAIN IF NECESSARY: In a point-of-service option, the
member typically pays a higher copayment when seeing an out-ofplan provider. For example, if a member sees an in-plan provider,
there may only be a $10 copayment. However, the member may
have to pay 20 percent of the cost and the managed care plan will
pay 80 percent of the cost to receive the same service from an outof-plan provider.]
IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERING CPS, GO TO BOX CPS29A.
ELSE IF REVIEWING PRIVATE PLANS THAT WERE "CURRENT"
AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO
HI17PREV_IN - NAVIGATOR.
ELSE GO TO HI20_IN - NAVIGATOR.
[do] respondent is SP, SP is MIP
[does] respondent is SP or proxy, SP is not MIP
[did] respondent is proxy, SP deceased
[you] respondent is SP, SP is MIP
[(MIP)] respondent is SP or proxy, SP is not MIP
[you] respondent is SP
[(SP)] respondent is proxy
[Is] SP alive
[Was] SP deceased
(01) HI33A - MHMOCOST
(02) HI33A - MHMOCOST
(03) HI33A - MHMOCOST
(04) HI33A - MHMOCOST
(05) HI33A - MHMOCOST
(06) HI33A - MHMOCOST
(07) HI33A - MHMOCOST
(91) HI33 - MIPPUNOS
(-8) HI33A - MHMOCOST
(-9) HI33A - MHMOCOST
HI33A - MHMOCOST
(01) HI33B - MHMOWHO
(02) BOX HI17B
(-8) BOX HI17B
(-9) BOX HI17B
(01) BOX HI17B
(02) BOX HI17B
(03) BOX HI17B
(04) BOX HI17B
(05) BOX HI17B
(06) BOX HI17B
(07) BOX HI17B
(91) HI33B - MHMOWHOS
(-8) BOX HI17B
(-9) BOX HI17B
BOX HI17B
Dental Utilization (DUQ)
Variable Name
MR Screen Name Question type Question text/description
The next questions are about any medical care
[you/(SP)] may have had between (REFERENCE
DATE) and (today/DATE OF DEATH/DATE OF
INSTITUTIONALIZATION).
DUINT
DUINTRO
no entry
Code list
(Now would be a good time to get out the planner
that [you/(SP)] may have used to record health care
visits or other medical expenses. We will also refer
to any statements you may have received since the
last interview.)
Text Fill Logic
Input mask
Routing
[you] respondent is SP
[(SP)] respondent is proxy
[today] respondent is SP or proxy, SP alive and not institutionalized
[DATE OF DEATH] respondent is proxy, SP deceased
[DATE OF INSTITUTIONALIZATION] respondent is proxy, SP
institutionalized
DU1 - DUPROBE
(01) DU2 PROVIDER_DU
(02) BOX DU6 DU15 DVNEED
(03) DO NOT
DISPLAY. DATA
EDITING ONLY.
(-8) BOX DU6
(-9) BOX DU6
(01-N) BOX DU1
(N+1) DU2BPROVNAME
First we’ll talk about dental care.
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
[Since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not
institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is
proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)]
respondent is proxy, SP institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
(01-N) LIST ALL PROVIDERS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
[you] respondent is SP
[(SP)] respondent is proxy
DUPROBE
DU1
yes/no
[Since (REFERENCE DATE)/Between (REFERENCE
DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], did [you/(SP)] go to a
dentist or any other person for dental care? [Dental
providers include dentists, dental surgeons,
endodontists, periodontists, and dental hygienists.]
PROVIDER_DU
DU2
roster
Who did [you/(SP)] see?
SELECT OR ADD ONLY ONE PROVIDER.
DU2B - GRPNAME
PROVSPEC
PROVNAME
DU2B
verbatim text
ENTER THE NAME OF THE PROVIDER AND THE
BILLING GROUP OR PRACTICE NAME BELOW.
NAME:
GRPNAME
DU2B
verbatim text
GROUP:
PROVSPEC
DU2C
code one
What kind of (health practitioner/mental health
professional/therapist/medical person) dental
provider is [PROVNAME]?
(01) GENERAL DENTIST
(02) DENTAL HYGIENIST
(03) DENTAL TECHNICIAN
(04) DENTAL/ORAL SURGEON
(05) ORTHODONTIST
(06) ENDODONTIST
(07) PERIDONTIST
(08) PROSTHODONTIST
(09) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX DU2
(02) BOX DU2
(03) BOX DU2
(04) BOX DU2
(05) BOX DU2
(06) BOX DU2
(07) BOX DU2
(08) BOX DU2
(09) DU2C PROVSPECOTH
(01) DENTIST/DENTAL PROVIDER (DO NOT DISPLAY
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(01) DO NOT DISPLAY
(02) BOX DU2
(03) BOX DU2
(04) BOX DU2
(05) BOX DU2
(06) BOX DU2
(07) BOX DU2
(08) BOX DU2
(09) BOX DU2
(10) BOX DU2
(11) BOX DU2
(12) BOX DU2
(13) BOX DU2
(14) BOX DU2
(15) BOX DU2
(16) BOX DU2
(17) BOX DU2
(18) BOX DU2
(19) BOX DU2
(20) BOX DU2
(21) BOX DU2
(22) BOX DU2
(23) BOX DU2
(24) BOX DU2
(25) BOX DU2
(26) BOX DU2
(27) BOX DU2
(28) BOX DU2
(29) BOX DU2
(01) [Continuous answer.]
BOX DU2
PROVSPECOTH
DU2C
code one
What kind of (health practitioner/mental health
professional/therapist/medical person) is
[PROVNAME]?
PROVSPOS
DU2D
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
BOX DU1
VAPLACE
DU3
BOX DU2
HMOASSOC
HMOREFER
EVENT_DU
NAVIGATOR
DU4
DU5
DU6
DU6_IN
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES
THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND) AND (IF THIS PROVIDER IS
ASSOCIATED WITH V.A. IS UNKNOWN), GO TO DU3 VAPLACE.
ELSE GO TO BOX DU2.
yes/no
(01) YES
Is (PROVIDER NAME) associated with a Department (02) NO
of Veterans Affairs, or V.A., facility?
(-8) Don't Know
(-9) Refused
routing
IF (SP COVERED BY A MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND) AND (IF
THIS PROVIDER IS ASSOCIATED WITH A MANAGED
CARE PLAN IS UNKNOWN), GO TO DU4 HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND) AND (THIS
PROVIDER IS NOT ASSOCIATED WITH A MANAGED
CARE PLAN), GO TO DU5 - HMOREFER.
ELSE GO TO DU6 - EVENT_DU.
BOX DU2
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)]
[READ MANAGED CARE PLAN NAME(S) BELOW]
plan?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[your] respondent is SP
[(SP's)] respondent is proxy
(01) DU6 - EVENT_DU
(02) DU5 HMOREFER
(-8) DU5 HMOREFER
(-9) DU5 HMOREFER
yes/no
[Were you/Was (SP)] referred to (PROVIDER NAME)
by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S
PRIMARY CARE PHYSICIAN (PCP).]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Were you] respondent is SP
[Was (SP)] respondent is proxy
DU6 - EVENT_DU
roster
When did [you/(SP)] see (PROVIDER NAME)? Please
tell me all the dates [since (REFERENCE
DATE)/between (REFERENCE DATE) and (DATE OF
(01) continuous answer
DEATH/DATE OF INSTITUTIONALIZATION)].
(-8) Don't Know
ENTER ALL DATES.
(-9) Refused
[IF THE RESPONDENT SAW THE SAME PROVIDER
TWICE ON THE SAME DAY, ENTER THE DATE ONLY
ONCE.]
[you] respondent is SP
[(SP)] respondent is proxy
[Since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not
institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is
proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)]
respondent is proxy, SP institutionalized
DU6_IN NAVIGATOR
instance
navigator
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) DU9 PRESMDCN DU7 DVPROCDR
(02) DU14 - DUMORE
SHOW CARD DU1
DVPROCDR
DU7
code all
For [your/(SP’s)] [VISIT ON EVENT DATE], what did
[you/(SP)] have done?
CHECK ALL THAT APPLY.
EVOSTEXT
PRESMDCN
PRESFILL
DU7A
DU9
DU10
BOX DU3B
DUPMMEDS
DU10A
(01) GENERAL EXAM, CHECKUP OR CONSULTATION
(02) CLEANING, PROPHYLAXIS, OR POLISHING
(03) X-RAYS, RADIOGRAPHS, OR BITEWINGS
(04) FLUORIDE TREATMENT
(05) SEALANT (PLASTIC COATINGS ON BACK TEETH)
(06) FILLINGS
(07) INLAYS
(08) CROWNS OR CAPS
(09) ROOT CANAL
(10) PERIODONTAL SCALING, ROOT PLANING, OR
GUM SURGERY
(11) PERIODONTAL RECALL VISIT (PERIODIC OR
REGULAR)
(12) EXTRACTION, TOOTH PULLED
(13) IMPLANTS
(14) ABSCESS OR INFECTION TREATMENT
(15) OTHER ORAL SURGERY
(16) FIXED BRIDGES
(17) DENTURES OR REMOVABLE PARTIAL DENTURES
(18) RELINING OR REPAIR OF BRIDGES OR
DENTURES
(19) ORTHODONTIA, BRACES, OR RETAINERS
(20) BOND, WHITEN, OR BLEACH
(21) TREATMENT FOR TMD OR TMJ
(95) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
OTHER PROCEDURE OR REASON DURING VISIT
(SPECIFY)
(01) [CONTINUOUS ANSWER]
yes/no
Were any medicines prescribed for [you/(SP)]
during (this visit/any of these visits)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
yes/no
Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF
WHO OBTAINED IT FOR THE RESPONDENT,
WHETHER OR NOT THE PRESCRIPTION COST
ANYTHING, AND WHETHER OR NOT THE
RESPONDENT ACTUALLY TOOK THE MEDICINE.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
verbatim text
routing
no entry
IF THE PROBE FOR PRESCRIPTION MEDICINE
BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO DU10A - DUPMMEDS.
ELSE GO TO DU11 - MEDICINE_DU.
It would be helpful if I could look at any medicine
bottle(s), container(s), or bag(s) that you have so
that I can spell the medicine name correctly and
enter the strength of the medicine. [Also, please
take out [your/(SP's)] (MEDICARE PRESCRIPTION
DRUG PLAN NAME) medicine statements, which
should have that same information on them.]
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that
same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get
those bottles, too.
(01) INSTRUCTION WAS READ
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
(01) DU9-PRESMDCN
(02) DU9-PRESMDCN
(03) DU9-PRESMDCN
(04) DU9-PRESMDCN
(05) DU9-PRESMDCN
(06) DU9-PRESMDCN
(07) DU9-PRESMDCN
(08) DU9-PRESMDCN
(09) DU9-PRESMDCN
(10) DU9-PRESMDCN
(11) DU9-PRESMDCN
(12) DU9-PRESMDCN
(13) DU9-PRESMDCN
(14) DU9-PRESMDCN
(15) DU9-PRESMDCN
(16) DU9-PRESMDCN
(17) DU9-PRESMDCN
(19) DU9-PRESMDCN
(20) DU9-PRESMDCN
(21) DU9-PRESMDCN
(22) DU9-PRESMDCN
(95) DU7A-EVOSTEXT
(01) DU9-PRESMDCN
(02) DU9-PRESMDCN
(03) DU9-PRESMDCN
(04) DU9-PRESMDCN
(05) DU9-PRESMDCN
(06) DU9-PRESMDCN
(07) DU9-PRESMDCN
(08) DU9-PRESMDCN
(09) DU9-PRESMDCN
(10) DU9-PRESMDCN
(11) DU9-PRESMDCN
(12) DU9-PRESMDCN
(13) DU9-PRESMDCN
(14) DU9-PRESMDCN
(15) DU9-PRESMDCN
(16) DU9-PRESMDCN
(17) DU9-PRESMDCN
(18) DU9-PRESMDCN
(19) DU9-PRESMDCN
(20) DU9-PRESMDCN
(21) DU9-PRESMDCN
(95) DU7A-EVOSTEXT
(-8) DU9-PRESMDCN
(-9) DU9-PRESMDCN
DU9 - PRESMDCN
[you] respondent is SP
[(SP)] respondent is proxy
[this visit] one visit to provider
[any of these visits] two or more visits to provider
(01) DU10 - PRESFILL
(02) BOX DU4
(-8) BOX DU4
(-9) BOX DU4
(01) BOX DU3B
(02) BOX DU4
(-8) BOX DU4
(-9) BOX DU4
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
DU11 MEDICINE_DU
MEDICINE_DU
DUMORE
DVNEED
DU11
roster
BOX DU4
routing
DU14
DU15
Please tell me the names of these medicines.
ENTER ALL MEDICINES.
CHECK STATEMENT OR MEDICINE BOTTLE FOR
SPELLING.
INCLUDE STRENGTH WITH NAME.
GO TO DU6_IN - NAVIGATOR.
(01) continuous answer
yes/no
[Since (REFERENCE DATE)/Between (REFERENCE
DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], did [you/(SP)] have any
other dental care visits to this or any other
provider?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
yes/no
Since (REFERENCE DATE), was there a time when
{you/SP} needed dental care but could not get it at
that time?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
DVNDRS
DU16
code all
(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DENTAL OFFICE IS TOO FAR AWAY
(05) DENTAL OFFICE IS NOT OPEN AT CONVENIENT
TIMES
(06) ANOTHER DENTIST RECOMMENDED NOT
What were the reasons that {you/SP} could not get DOING IT
the dental care {you/she/he} needed?
(07) AFRAID OR DO NOT LIKE DENTISTS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED DENTAL PROBLEMS TO GO
AWAY
(95) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
DVNDRSOS
DU16A
verbatim text
WHAT OTHER REASON (SPECIFY)
(01) continuous answer
[Since (REFERENCE DATE)] respondent is SP or proxy, SP alive and not
institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)] respondent is
proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF INSTITUTIONALIZATION)]
respondent is proxy, SP institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
(01) DU2 PROVIDER_DU
(02) BOX DU6
(-8) BOX DU6
(-9) BOX DU6
[you] respondent is SP
[(SP)] respondent is proxy
(01) DU16 - DVNDRS
(02) BOX DU6
(-8) BOX DU6
(-9) BOX DU6
[you] respondent is SP
[(SP)] respondent is proxy
[you] respondent is SP
[she] respondent is proxy, SP is female
[he] respondent is proxy, SP is male
(01) BOX DU6
(02) BOX DU6
(03) BOX DU6
(04) BOX DU6
(05) BOX DU6
(06) BOX DU6
(07) BOX DU6
(08) BOX DU6
(09) BOX DU6
(10) BOX DU6
(95) DU16A DVNDRSOS
(-8) BOX DU6
(-9) BOX DU6
BOX DU6
Emergency Room Utilization (ERQ)
Variable Name
MR Screen Name
Question type
Question text/description
Code list
ERPROBE
ER1
yes/no
PROVIDER_ER
ER2
roster
(01) YES
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (02) NO
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have you (03) INDICATED YES BY DATAPREP
gone/has (SP) gone/did (SP) go] to a hospital emergency room for (-8) Don't Know
medical care?
(-9) Refused
Where did [you/(SP)] go (to which hospital)?
SELECT OR ADD ONLY ONE HOSPITAL.
(01) continuous answer
[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF (-8) Don't Know
THE HOSPITAL.]
(-9) Refused
BOX ER1
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES
THROUGH V.A. IN THE CURRENT ROUND OR ANY PREVIOUS
ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS
UNKNOWN), GO TO ER3 - VAPLACE.
ELSE GO TO BOX ER1B.
ER3
yes/no
BOX ER1B
routing
ER3A
yes/no
VAPLACE
HMOASSOC
HMOREFER
ER3B
yes/no
Is (PROVIDER NAME) a Department of Veterans Affairs, or V.A.,
facility?
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND) AND (IF THIS PROVIDER IS
ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN),
GO TO ER3A - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND) AND (THIS PROVIDER IS NOT
ASSOCIATED WITH A MANAGED CARE PLAN), GO TO ER3B HMOREFER.
ELSE GO TO ER4 - EVENT_ER.
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ
MANAGED CARE PLAN NAME(S) BELOW] plan?
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ
MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY
CARE PHYSICIAN (PCP).]
EVENT_ER
ER4
roster
NAVIGATOR
ER4_IN
instance navigator
ERADMIT
ER6
yes/no
[Were you/Was (SP)] admitted to (PROVIDER NAME) from the
emergency room?
yes/no
During [your/(SP’s)] visit to the emergency room, were any
medicines prescribed for [you/(SP)]?
PRESMDCN
PRESFILL
ER7
ER8
yes/no
BOX ER3A
routing
Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO
OBTAINED IT FOR THE RESPONDENT, WHETHER OR NOT THE
PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT
THE RESPONDENT ACTUALLY TOOK THE MEDICINE.]
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS
NOT BEEN ASKED IN THE CURRENT ROUND, GO TO ER8A ERPMMEDS.
ELSE
GO
ER9 if- MEDICINE_ER.
It would
beTO
helpful
I could look at any medicine bottle(s),
[you] respodnent is SP
[(SP)] respondent is proxy
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
When did [you/(SP)] go to the emergency room at (PROVIDER
NAME)?
Please tell me all the dates [since (REFERENCE DATE)/between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)].
ENTER ALL DATES.
[IF THE SAMPLE PERSON SAW THE SAME PROVIDER TWICE
ON THE SAME DAY, ENTER THE DATE ONLY ONCE.]
Text
Logic
[SinceFill
(REFERENCE
DATE)] respondent
is SP or proxy, SP alive and not
institutionalized
[Between (REFERENCE DATE) and
(DATE OF DEATH)] respondent is proxy,
SP deceased
[Between (REFERENCE DATE) and
(DATE OF INSTITUTIONALIZATION)]
respondent is proxy, SP institutionalized
[have you gone] respondent is SP
[has (SP) gone] respondent is proxy, SP
alive
[did (SP) go] respondent is proxy, SP
deceased
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Input mask Routing
(01) ER2 - PROVIDER_ER
(02)BOX ER6
(03) DO NOT DISPLAY. DATA
EDITING ONLY.
(-8) BOX ER6
(-9) BOX ER6
BOX ER1
BOX ER1B
[your] respondent is SP
[(SP's)] respondent is proxy
(01) ER4 - EVENT_ER
(02) ER3B - HMOREFER
(-8) ER3B - HMOREFER
(-9) ER3B - HMOREFER
[Were you] respondent is SP
[Was
(SP)] respondent
[you] respodnent
is SP is proxy
ER4 - EVENT_ER
[(SP)] respondent is proxy
[Since (REFERENCE DATE)] respondent
is SP or proxy, SP alive and not
institutionalized
[Between (REFERENCE DATE) and
(DATE OF DEATH)] respondent is proxy,
SP deceased
[Between (REFERENCE DATE) and
(DATE OF INSTITUTIONALIZATION)]
respondent is proxy, SP institutionalized
[Were you] respondent is SP
[Was (SP)] respondent is proxy
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
ER4_IN - NAVIGATOR
(01) ER6 - ERADMIT
(02) ER10 - ERMORE
(01) BOX ER4
(02) ER7 - PRESMDCN
(-8) ER7 - PRESMDCN
(-9) ER7 - PRESMDCN
(01) ER8 - PRESFILL
(02) BOX ER4
(-8) BOX ER4
(-9) BOX ER4
(01) BOX ER3A
(02) BOX ER4
(-8) BOX ER4
(-9) BOX ER4
container(s), or bag(s) that you have so that I can spell the
medicine name correctly and enter the strength of the medicine.
[Also, please take out [your/(SP's)] (MEDICARE PRESCRIPTION
DRUG PLAN NAME) medicine statements, which should have that
same information on them.]
ERPMMEDS
MEDICINE_ER
ER8A
ER9
no entry
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same
information for all of the medicines [you/(SP)] obtained since the
last interview, if you’d like to get those bottles, too.
roster
Please tell me the names of these medicines.
ENTER ALL MEDICINES.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
INCLUDE STRENGTH WITH NAME.
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
(01) continuous answer
ER9 - MEDICINE_ER
BOX ER4
SOFT EDIT
BOX ER4
ERMORE
routing
ER10
yes/no
BOX ER5
BOX ER6
routing
routing
GO TO ER4_IN - NAVIGATOR.
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to the emergency room at this or
any other hospital?
IF FALL ROUND AND ((SP REPORTED AN EMERGENCY ROOM
VISIT AT ER2) AND (SP IS ALIVE AND NOT
INSTITUTIONALIZED)), GO TO AC6A - EWAITUNT.
ELSE GO TO BOX ER6.
GO TO NEXT SECTION
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Since (REFERENCE DATE)] respondent
is SP or proxy, SP alive and not
institutionalized
[Between (REFERENCE DATE) and
(DATE OF DEATH)] respondent is proxy,
SP deceased
[Between (REFERENCE DATE) and
(DATE OF INSTITUTIONALIZATION)]
respondent is proxy, SP institutionalized
[you] respondent is SP
[(SP)] respondent is proxy
(01) ER2 - PROVIDER_ER
(02) BOX ER5
(-8) BOX ER5
(-9) BOX ER5
Inpatient Utilization (IPQ)
Variable Name
MR Screen Name
BOX IP1
EVENDMM
EVENDDD
IPS1
IPS1
Question type
Question text/description)
routing
IF THE SP WAS STILL IN A HOSPTIAL AT THE TIME OF THE PREVIOUS
ROUND INTERVIEW, GO TO IPS1 - EVENDMM.
ELSE IF SP IS IN THE EXIT SAMPLE AND PREVIOUS ROUND INTERVIEW
WAS NOT SKIPPED, GO TO BOX IP6.
ELSE GO TO BOX IP1AB.
date
Last time [you/(SP)] had been admitted to (HOSPITAL NAME) on
(ADMISSION DATE) and [were/was] still a patient there on (REFERENCE
DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for
that stay?
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
date
Last time [you/(SP)] had been admitted to (HOSPITAL NAME) on
(ADMISSION DATE) and [were/was] still a patient there on (REFERENCE
DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for
that stay?
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
Last time [you/(SP)] had been admitted to (HOSPITAL NAME) on
(ADMISSION DATE) and [were/was] still a patient there on (REFERENCE
DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for
that stay?
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) SP IS STILL IN HOSPITAL
(-7) Empty
Code list
Text Fill Specifications
[you] respondent is SP
[(SP)] respondent is proxy
[were] respondent is SP
[was] respondent is proxy
[were you] respondent is SP
[was (SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[were] respondent is SP
[was] respondent is proxy
[were you] respondent is SP
[was (SP)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
[were] respondent is SP
[was] respondent is proxy
[were you] respondent is SP
[was (SP)] respondent is proxy
Input mask
Routing
MM
IPS1 - EVENDDD
DD
IPS1 - EVENDYY
YY
IPS1 - STILLHOSP
EVENDYY
IPS1
date
STILLHOSP
IPS1
date
BOX IP1A
routing
IF SP WAS REPORTED AS STILL IN THE HOSPITAL AT IPS1, GO TO BOX
IP6.
ELSE GO TO IP7 - ANYOPERS.
routing
IF THE SP HAD AT LEAST ONE EMERGENCY ROOM VISIT IN THE
CURRENT ROUND THAT RESULTED IN THE SP BEING ADMITTED TO A
HOSPITAL, GO TO BOX IP1AA.
ELSE GO TO IP1 - IPPROBE.
routing
CREATE EVENT FOR FIRST/NEXT ER VISIT ADDED WHERE SP WAS
ADMITTED TO HOSPITAL
GO TO IP1A - EVENDMM.
date
You told me [you were/(SP) was] admitted to (HOSPITAL NAME) from the
emergency room on (ADMISSION DATE). When [were you/was (SP)]
discharged from (HOSPITAL NAME) for the stay that started on (ADMISSION
DATE)?
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
[you were] respondent is SP
[(SP) was] respondent is proxy
[were you] respondent is SP
[was (SP)] respondent is proxy
MM
IP1A - EVENDDD
date
You told me [you were/(SP) was] admitted to (HOSPITAL NAME) from the
emergency room on (ADMISSION DATE). When [were you/was (SP)]
discharged from (HOSPITAL NAME) for the stay that started on (ADMISSION
DATE)?
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
[you were] respondent is SP
[(SP) was] respondent is proxy
[were you] respondent is SP
[was (SP)] respondent is proxy
DD
IP1A - EVENDYY
date
You told me [you were/(SP) was] admitted to (HOSPITAL NAME) from the
emergency room on (ADMISSION DATE). When [were you/was (SP)]
discharged from (HOSPITAL NAME) for the stay that started on (ADMISSION
DATE)?
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
[you were] respondent is SP
[(SP) was] respondent is proxy
[were you] respondent is SP
[was (SP)] respondent is proxy
YY
IP1A - STILLHOSP
BOX IP1AB
BOX IP1AA
EVENDMM
EVENDDD
EVENDYY
STILLHOSP
IPPROBE
PROVIDER_IP
IP1A
IP1A
IP1A
[you were] respondent is SP
[(SP) was] respondent is proxy
[were you] respondent is SP
[was (SP)] respondent is proxy
BOX IP1B
yes/no
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], [have you been/has (SP)
been/was (SP)] [admitted to a hospital/admitted any other time to this or any
other hospital] as an inpatient -- either for an overnight stay or for a "same day"
procedure?
IF HAD SAME DAY PROCEDURE AND IS NOT SURE IF ADMITTED OR
NOT, TREAT AS OUTPATIENT EVENT AND ENTER WHEN YOU GET TO
(01) YES
OP UTILIZATION.
(02) NO
(03) INDICATED YES BY DATAPREP
[ENTER A STAY AT A DRUG AND REHABILITATION CENTER AS AN IP
(-8) Don't Know
EVENT, NOT AN IU EVENT.]
(-9) Refused
[Since (REFERENCE DATE)] respondent is SP or proxy, SP not
deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you been] respondent is SP
[has (SP) been] respondent is proxy, SP alive
[was (SP)] respondent is proxy, SP deceased
[admitted to a hospital] first time through loop
[admitted any other time to this or any other hospital] second or
more times through loop
(01) IP2 - PROVIDER_IP
(02) BOX IP6
(03) DO NOT DISPLAY.
DATA EDITING ONLY.
(-8) BOX IP6
(-9) BOX IP6
roster
Where [were you/was (SP)] admitted -- to which hospital?
SELECT OR ADD ONLY ONE HOSPITAL.
[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE
HOSPITAL.]
[were you] respondent is SP
[was (SP)] respondent is proxy
BOX IP2
IP1A
date
BOX IP1B
routing
IP1
IP2
You told me [you were/(SP) was] admitted to (HOSPITAL NAME) from the
emergency room on (ADMISSION DATE). When [were you/was (SP)]
discharged from (HOSPITAL NAME) for the stay that started on (ADMISSION (01) SP IS STILL IN HOSPITAL
DATE)?
(-7) Empty
IF SP WAS REPORTED AS STILL IN THE HOSPITAL AT IP1A, GO TO BOX
IP5.
ELSE GO TO IP7 - ANYOPERS.
BOX IP1A
VAPLACE
HMOASSOC
BOX IP2
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A.
IN THE CURRENT ROUND OR ANY PREVIOUS ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO IP3 VAPLACE.
ELSE GO TO BOX IP2AA.
IP3
yes/no
Is (HOSPITAL NAME) a Department of Veterans Affairs, or V.A., facility?
BOX IP2AA
routing
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE
CURRENT ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH A
MANAGED CARE PLAN IS UNKNOWN), GO TO IP3A - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING
THE CURRENT ROUND) AND (THIS PROVIDER IS NOT ASSOCIATED
WITH A MANAGED CARE PLAN), GO TO IP3B - HMOREFER.
ELSE GO TO IP4 - EVBEGMM.
IP3A
yes/no
Is (HOSPITAL NAME) associated with [your/(SP’s)] [READ MANAGED CARE
PLAN NAME(S) BELOW] plan?
[Were you/Was (SP)] referred to (HOSPITAL NAME) by [READ MANAGED
CARE PLAN NAME(S) BELOW]?
HMOREFER
IP3B
yes/no
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE
PHYSICIAN (PCP).]
EVBEGMM
IP4
date
When [were you/was (SP)] admitted to and discharged from (HOSPITAL
NAME)?
EVBEGDD
IP4
date
When [were you/was (SP)] admitted to and discharged from (HOSPITAL
NAME)?
EVBEGYY
IP4
date
When [were you/was (SP)] admitted to and discharged from (HOSPITAL
NAME)?
When [were you/was (SP)] admitted to and discharged from (HOSPITAL
NAME)?
EVENDMM
IP4
date
DISCHARGE DATE:
EVENDDD
IP4
date
When [were you/was (SP)] admitted to and discharged from (HOSPITAL
NAME)?
EVENDYY
IP4
date
STILLHOSP
IP4
date
When [were you/was (SP)] admitted to and discharged from (HOSPITAL
NAME)?
When [were you/was (SP)] admitted to and discharged from (HOSPITAL
NAME)?
routing
IF INPATIENT ADMISSION AND DISCHARGE DATE OVERLAP AN
EXISTING IP STAY, GO TO IP4_ERR - IPOVERLP.
ELSE GO TO BOX IP3.
BOX IP2A
IPOVERLP
ANYOPERS
BOX IP2AA
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) IP4 - EVBEGMM
(02) IP3B - HMOREFER
(-8) IP3B - HMOREFER
(-9) IP3B - HMOREFER
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
(01) SP IS STILL IN HOSPITAL
(-7) Empty
IP4_ERR
code 1
BOX IP3
routing
INVALID DATE. THIS DATE OVERLAPS AN EXISTING IP STAY FROM
(ADMISSION DATE) TO [(DISCHARGE DATE)/SP STILL IN HOSPITAL].
IF SP WAS REPORTED AS STILL IN THE HOSPITAL AT IP4, GO TO BOX
IP5.
ELSE GO TO IP7 - ANYOPERS
yes/no
Were any operations performed on [you/(SP)] during the hospital stay that was
(ADMISSION DATE) to (DISCHARGE DATE)?
(01) YES
(02) NO
[Operations include surgery and other surgical procedures like setting bones, (-8) Don't Know
stitching or removing growths, or any cutting of the skin.]
(-9) Refused
routing
IF CURRENTLY ADMINISTERING ST, GO TO BOX ST23B.
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS23B.
ELSE IF SP IS IN THE EXIT SAMPLE AND PREVIOUS ROUND INTERVIEW
NOT SKIPPED, GO TO BOX IP6.
ELSE GO TO IP13 - PRESMDCN.
yes/no
At the time [you were /(SP) was] discharged, were any medicines prescribed
for [you/(SP)]?
IP7
BOX IP4A
PRESMDCN
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
IP13
[Were you] respondent is SP
[Was (SP)] respondent is proxy
[were you] respondent is SP
[was (SP)] respondent is proxy
MM
IP4 - EVBEGDD
[were you] respondent is SP
[was (SP)] respondent is proxy
DD
IP4 - EVBEGYY
[were you] respondent is SP
[was (SP)] respondent is proxy
YY
IP4 - EVENDMM
[were you] respondent is SP
[was (SP)] respondent is proxy
MM
IP4 - EVENDDD
[were you] respondent is SP
[was (SP)] respondent is proxy
DD
IP4 - EVENDYY
YY
IP4 - STILLHOSP
[were you] respondent is SP
[was (SP)] respondent is proxy
[were you] respondent is SP
[was (SP)] respondent is proxy
(01) CORRECT DATES
(02) CONTINUE INTERVIEW
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
IP4 - EVBEGMM
BOX IP2A
(01) IP4 - EVBEGMM
(02) BOX IP3
[you] respondent is SP
[(SP)] respondent is proxy
(01) BOX IP4A
(02) IP10 - SPECCOND
(-8) IP10 - SPECCOND
(-9) IP10 - SPECCOND
[you were] respondent is SP
[(SP) was] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
(01) IP14 - PRESFILL
(02) BOX IP5
(-8) BOX IP5
(-9) BOX IP5
Were any of the prescriptions filled?
PRESFILL
IP14
BOX IP4B
yes/no
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT
FOR THE RESPONDENT, WHEN IT WAS OBTAINED, WHETHER OR NOT
THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE
RESPONDENT ACTUALLY TOOK THE MEDICINE.]
routing
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN
ASKED IN THE CURRENT ROUND, GO TO IP14A - IPPMMEDS.
ELSE GO TO IP15 - MEDICINE_IP.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX IP4B
(02) BOX IP5
(-8) BOX IP5
(-9) BOX IP5
It would be helpful if I could look at any medicine bottle(s), container(s), or
bag(s) that you have so that I can spell the medicine name correctly and enter
the strength of the medicine. [Also, please take out [your/(SP's)] (MEDICARE
PRESCRIPTION DRUG PLAN NAME) medicine statements, which should
have that same information on them.]
IPPMMEDS
MEDICINE_IP
IP14A
IP15
BOX IP5
IPMORE
IP16
BOX IP6
no entry
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all
of the medicines [you/(SP)] obtained since the last interview, if you’d like to get
those bottles, too.
roster
Please tell me the names of these medicines.
ENTER ALL MEDICINES.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
INCLUDE STRENGTH WITH NAME.
routing
IF ASKING ABOUT ONGOING IP STAY FROM THE PREVIOUS ROUND, GO
TO BOX IP1AB.
ELSE IF ASKING ABOUT AN EMERGENCY ROOM VISIT IN THE CURRENT
ROUND THAT RESULTED IN AN IP STAY, THEN
IF SP HAS ANOTHER EMERGENCY ROOM VISIT IN THE CURRENT
ROUND THAT RESULTED IN AN IP STAY THAT HAS NOT BEEN ASKED
ABOUT, GO TO BOX IP1AA.
ELSE GO TO IP1 - IPPROBE.
ELSE GO TO IP16 - IPMORE.
yes/no
routing
IF RESPONDENT HAS ALREADY MENTIONED ANOTHER INPATIENT
STAY, ENTER “YES” WITHOUT ASKING. OTHERWISE, ASK:
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], [have you had/has (SP) had/did
(SP) have] any other admissions to this or any other hospital as an inpatient -either for an overnight stay or for a "same day" procedure?
IF HAD SAME DAY PROCEDURE AND IS NOT SURE IF ADMITTED OR
NOT, TREAT AS OUTPATIENT EVENT AND ENTER WHEN YOU GET TO
OP UTILIZATION.
(01) YES
(02) NO
[ENTER A STAY AT A DRUG AND REHABILITATION CENTER AS AN IP
(-8) Don't Know
EVENT, NOT AN IU EVENT.]
(-9) Refused
GO TO NEXT SECTION
[your] respondent is SP
[(SP's)] respondent is proxy
[you] respondent is SP
[(SP)] respondent is proxy
IP15 - MEDICINE_IP
BOX IP5
[Since (REFERENCE DATE)] respondent is SP or proxy, SP not
deceased or institutionalized
[Between (REFERENCE DATE) and (DATE OF DEATH)]
respondent is proxy, SP deceased
[Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION)] respondent is proxy, SP
institutionalized
[have you had] respondent is SP
[has (SP) had] respondent is proxy, SP alive
[did (SP) have] respondent is proxy, SP deceased
(01) IP2 - PROVIDER_IP
(02) BOX IP6
(-8) BOX IP6
(-9) BOX IP6
| File Type | application/pdf |
| Author | [email protected] |
| File Modified | 2015-07-06 |
| File Created | 2015-07-06 |