Form CMS-P-0015A Attachment 5 - Facility Screener

May 2012
Please Print the Following Information:

Facility Name ________________________________________
Admission Date ____________
Region ___________
SP ID# ____________________
Round ____________________ Target Interviewer ___________ Target PSU ________________

MEDICARE
CURRENT BENEFICIARY SURVEY
FACILITY SCREENER
Good (morning/afternoon). My name is
. I am from Westat, a survey research company in Rockville,
MD. We are conducting the Medicare Current Beneficiary Survey for the Centers for Medicare and Medicaid Services
(CMS), part of the United States Department of Health and Human Services. We are studying a sample of people eligible
for Medicare who live in community and facility settings.
I am contacting you to confirm information that a person in our sample has moved to (FACILITY NAME).

Q1.

Does (SP) currently live at (FACILITY NAME)?
YES .........................................................

1 (Q3)

NO ...........................................................

2 (Q2)

DK ...........................................................
3
(Ask to speak to
................................................................ someone who
................................................................
would know
................................................................
admission
................................................................
information)
Q2.

Since (LAST INTERVIEW DATE/JANUARY 1, (CURRENT YEAR), has (SP) lived (here/there)?

INSTR1.

YES ........................................................

1

(INSTR1)

NO ..........................................................

2

(CLOSING 3)

DK ..........................................................

3

(Ask to speak to
someone who
would know
admission
information)

IF SUPPLEMENTAL SAMPLE, GO TO Q4.
OTHERWISE, CONTINUE.

Q3.

I need to verify the address I have for (FACILITY NAME) (in order to send an information packet
describing the survey).
VERIFY ADDRESS, RECORD ANY CHANGES IN CHANGE COLUMN, AND GO TO Q6.
ADDRESS

CHANGES

NAME: _____________________________
ADDRESS: __________________________
___________________________________
PHONE: ____________________________
FAX: _______________________________

Q4.

Q4a.

Do you know where (SP) went after living at (FACILITY NAME)?

YES ........................................................

1

(Q5)

NO ..........................................................

2

(CLOSING 3)

DECEASED ...........................................

3

(Q4a)

What was the date of death?

DOD

Q5.

_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

______ / _____ / _____
MM
DD
YY

Please give me (SP's) new address.
RECORD NEW ADDRESS UNDER CHANGES IN Q3 AND GO TO CLOSING 3.

(CLOSING 3)

Q6.

What type of facility/place is this?
USE CATEGORIES AS PROBES IF NECESSARY.
(Is this a ........)
CONTINUING CARE RETIREMENT COMMUNITY (CCRC)

1

(Q7)

RETIREMENT COMMUNITY

2

(Q7)

ADULT/GROUP HOME

3

(Q8)

4

(Q9)

HOSPITAL-BASED SNF UNIT

5

(Q9)

ASSISTED LIVING FACILITY

6

(Q9)

BOARD AND CARE HOME

7

(Q9)

DOMICILIARY CARE HOME

8

(Q9)

PERSONAL CARE HOME

9

(Q9)

REST HOME/RETIREMENT HOME

10

(Q9)

MENTAL HEALTH CENTER/PSYCHIATRIC SETTING

11

(Q9)

INSTITUTION FOR THE MENTALLY RETARDED/DEVELOPMENTALLY DISABLED

12

(Q9)

REHABILITATION FACILITY

13

(Q9)

OTHER LONG-TERM CARE FACILITY (SPECIFY)
_______________________________

14

(Q9)

NURSING HOME/UNIT WITHIN A CCRC OR RETIREMENT CENTER

PRIVATE RESIDENCE........................... 15 (CLOSING 2)
Q7.

What is the name of the specific place within (FACILITY NAME) where (SP) was residing on or
around [ADMISSION DATE/JANUARY 1, (CURRENT YEAR)]?
________________________________
SPECIFIC PLACE NAME

Q8.

Q9.

(Q9)

Are residents placed in this facility by an agency of state, county, or local government?
YES ........................................................

1

(Q10)

NO ..........................................................

2

(Q9)

What is the name of the facility administrator?
________________________________ (CLOSING 1)
FACILITY ADMINISTRATOR'S NAME

Q10.

Please give me the name, address, and telephone number of the person who is responsible for the
oversight of (SP's) care.
ADDRESS
NAME: __________________________________________
PLACE: __________________________________________
ADDRESS: _______________________________________
________________________________________________
PHONE: _________________________________________
FAX: ____________________________________________

(CLOSING 1)

CLOSING 1
Thank you very much for your time. I will mail some information to (you/your facility administrator/NAME IN Q9)
explaining the study in detail.

CLOSING 2
TELEPHONE SCREENER:
Thank you very much for your time. A professional interviewer will contact (you/SP) within the next few weeks to
arrange for an interview.
IN PERSON SCREENER:
Thank you very much for your time. We will contact (you/SP) to arrange an interview. CONTACT YOUR
SUPERVISOR FOR PROCEDURES.

CLOSING 3
Thank you very much for your time.
We will contact you if there are additional questions.