Cms-p-0015a Mcbs

Closing (CLQ)
Variable Name

MR Screen Name Question type Question text/description
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.
BOX CLBEG
routing
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
PHONEXCH
PHONLOCL
NOPHONE

CL2

phone

What is your phone number?

BOX CL2

routing

IF CL2 - NOPHONE = 1/NoPhone OR CL2 - PHONAREA = DK/RF, GO TO BOX CL8.
ELSE GO TO CL3 - PHONAREA.

PHONAREA
PHONEXCH
PHONLOCL
NOPHONE

Do you have a second phone number?
CL3

phone
[PROBE: What is that number?]

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
[ ] PERSON DOES NOT HAVE PHONE

(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
[ ] PERSON DOES NOT HAVE PHONE

Closing (CLQ)
Variable Name

MR Screen Name Question type Question text/description
I'd like to verify your address and phone number. I have it listed as .. [READ
ADDRESS AND PHONE LISTED BELOW].

Code list

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)

(01) YES
(02) NO

PHONE 1: (PRIMARY PHONE NUMBER)
PHONE 2: [(SECONDARY PHONE NUMBER)/NONE]
[IF ANY INFORMATION IS INCORRECT, SELECT "NO". IF ANY INFORMATION IS
MISSING (E.G., AN APARTMENT NUMBER OR SECONDARY PHONE NUMBER),
SELECT “NO” TO ENTER THE MISSING DATA.]
STADDR1

CL5

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

STADDR2

CL5

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

CITY

CL5

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

STATE

CL5

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

ZIPCODE

CL5

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

PHONAREA
PHONEXCH
PHONLOCL
NOPHONE

CL5

phone

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

PHONAREA2
PHONEXCH2
PHONLOCL2
NOPHONE2

CL5

phone

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

(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
[ ] PERSON DOES NOT HAVE PHONE
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
[ ] PERSON DOES NOT HAVE PHONE

Closing (CLQ)
Variable Name

PHONBEST

MR Screen Name Question type Question text/description
IF SP is deceased or institutionalized, go to CL62 - THANK_PROXY.
If Respondent is SP and a phone number was added at AV5 (not in .,-7,-8,-9) , then
go to CL9-PHONBEST, fill with number entered at AV5.
Else if Proxy interview and a phone number was added at CL2 (not in .,-7,-8,-9)
BOX CL8
routing
then go to CL9-PHONBEST, fill with number entered at CL2.
Else if SPHONE1 not in (.,-7,-8,-9), go to CL9-PHONBEST fill
SAMPLE_PERSON.SPPHONE1.
Else go to CL10 - PHONNINT.
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 interview.
CL9
yes/no

PHONNINT

CL10

yes/no

PHONAREA
PHONEXCH
PHONLOCL

CL11

phone

CL12

What is the best number to call to arrange for the next interview?
ENTER 10 DIGIT NUMBER (NO DASHES)

code 1
[IF THIS NUMBER BELONGS TO SOMEONE ELSE, PLEASE SELECT “OTHER.”]

PHONWHOS

CL12

verbatim text

BOX CL14

routing

(01) YES
(02) NO, ANOTHER NUMBER IS BEST
(03) NO, PHONE NUMBER NOT AVAILABLE
(-8) Don't Know
(-9) Refused

Is (PREVIOUS BEST PHONE NUMBER FOR NEXT INTERVIEW) the best phone
number to call to arrange for the next interview?
As you may know, the Medicre Current Beneficiary Survey involves another
(01) YES
interview. The next interview will be similar to the one we had today. We will be
(02) NO
calling in about 4 months to set up a convenient time for the next interview.
(-8) Don't Know
(-9) Refused
Is there a phone number to call to arrange for the next interview?

What type of phone is this?
PHONWHER

Code list

OTHER (SPECIFY)
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.

(01) [Continuous answer.]
(01) PROXY'S OR SP'S HOME (LANDLINE)
(02) PROXY'S OR SP'S WORK/OFFICE (LANDLINE)
(06) PROXY'S OR SP'S CELL
(03) NEIGHBOR'S
(04) FRIEND'S
(05) RELATIVE'S
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]

Closing (CLQ)
Variable Name

MR Screen Name Question type Question text/description
Code list
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)

CON1INFO

CL15

code 1

CITY: (CITY) STATE: (STATE) ZIPCODE: (ZIPCODE)

(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

PHONE 1: (PRIMARY PHONE NUMBER)
PHONE 2: [(SECONDARY PHONE NUMBER)/NONE]
[PROBE FOR A REPLACEMENT CONTACT THAT DOES NOT LIVE WITH RESPONDENT
IF THIS CONTACT IS NO LONGER VALID.]
[IF ANY INFORMATION IS INCORRECT, SELECT “NO”. IF ANY INFORMATION IS
MISSING (E.G., AN APARTMENT NUMBER OR SECONDARY PHONE NUMBER),
SELECT “NO” TO ENTER THE MISSING DATA.]
STADDR1

CL17

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

STADDR2

CL17

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

CITY

CL17

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

STATE

CL17

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

ZIPCODE

CL17

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

PHONAREA
PHONEXCH
PHONLOCL
NOPHONE

CL17

phone

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

(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
[ ] PERSON DOES NOT HAVE PHONE

Closing (CLQ)
Variable Name
PHONAREA2
PHONEXCH2
PHONLOCL2
NOPHONE2

MR Screen Name Question type Question text/description

CL17

phone

REPORT_CONTACT1

CL23

code 1

PERSON_CONTACT1

CL24

roster

STADDR1

CL25

address

STADDR2

CL25

address

CITY

CL25

address

STATE

CL25

address

ZIPCODE

CL25

address

PHONAREA
PHONEXCH
PHONLOCL
NOPHONE

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

Code list
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
[ ] PERSON DOES NOT HAVE PHONE

[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
(01) RESPONDENT REPORTS A CONTACT NAME
name of someone who is not living with [you/(SP)].
(02) RESPONDENT DID NOT REPORT A CONTACT NAME
(-8) Don't Know
[AVOID ENTERING PROXIES AND HOUSEHOLD MEMBERS AS CONTACTS UNLESS
(-9) Refused
THEY HAVE DIFFERENT CONTACT INFORMATION, FOR EXAMPLE A DIFFERENT
PHONE NUMBER.]
[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.]
[AVOID ENTERING PROXIES AND HOUSEHOLD MEMBERS AS CONTACTS UNLESS
THEY HAVE DIFFERENT CONTACT INFORMATION, FOR EXAMPLE A DIFFERENT
PHONE NUMBER.]
[Please give me an address for contacting (FIRST CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]
[Please give me an address for contacting (FIRST CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]
[Please give me an address for contacting (FIRST CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]
[Please give me an address for contacting (FIRST CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]
[Please give me an address for contacting (FIRST CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]

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.]

BOX CL26

routing

IF CL26 - NOPHONE = 1/NoPhone OR CL26 -PHONAREA = DK/RF, GO TO BOX CL29.
ELSE GO TO CL28-PHONAREA.

(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
[ ] PERSON DOES NOT HAVE PHONE

Closing (CLQ)
Variable Name
PHONAREA
PHONEXCH
PHONLOCL
NOPHONE

MR Screen Name Question type Question text/description
Is there a second phone number for contacting (FIRST CONTACT NAME)?
CL28

phone

BOX CL29

routing

[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]
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.

Code list
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
[ ] PERSON DOES NOT HAVE PHONE

[READ INFORMATION BELOW] Is this correct?
CONTACT 2: (SECOND CONTACT NAME FROM PREVIOUS ROUND)
STREET ADDRESS 1: (STREET ADDRESS LINE 1)
CON2INFO

CL30

code 1

STREET ADDRESS 2: (STREET ADDRESS LINE 2)
CITY: (CITY) STATE: (STATE) ZIPCODE: (ZIPCODE)

(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

PHONE 1: (PRIMARY PHONE NUMBER)
PHONE 2: [(SECONDARY PHONE NUMBER)/NONE]
[IF ANY INFORMATION IS INCORRECT, SELECT “NO”. IF ANY INFORMATION IS
MISSING (E.G., AN APARTMENT NUMBER OR SECONDARY PHONE NUMBER),
SELECT “NO” TO ENTER THE MISSING DATA.]
STADDR1

CL32

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

STADDR2

CL32

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

CITY

CL32

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

(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

Closing (CLQ)
Variable Name

MR Screen Name Question type Question text/description

STATE

CL32

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

ZIPCODE

CL32

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

PHONAREA
PHONEXCH
PHONLOCL
NOPHONE

CL32

phone

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

PHONAREA2
PHONEXCH2
PHONLOCL2
NOPHONE2

CL32

phone

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

REPORT_CONTACT2

CL38

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 D101someone who is not living with [you/(SP)].
[AVOID ENTERING PROXIES AND HOUSEHOLD MEMBERS AS CONTACTS UNLESS
THEY HAVE DIFFERENT CONTACT INFORMATION, FOR EXAMPLE A DIFFERENT
PHONE NUMBER.]

Code list
(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
[ ] PERSON DOES NOT HAVE PHONE
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
[ ] PERSON DOES NOT HAVE PHONE

(01) RESPONDENT REPORTS A CONTACT NAME
(02) RESPONDENT DID NOT REPORT A CONTACT NAME
(-8) Don't Know
(-9) Refused

[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)].]
PERSON_CONTACT2

STADDR1

CL39

CL40

roster

address

STADDR2

CL40

address

CITY

CL40

address

STATE

CL40

address

(01) [Continuous answer.]
[AVOID ENTERING PROXIES AND HOUSEHOLD MEMBERS AS CONTACTS UNLESS
THEY HAVE DIFFERENT CONTACT INFORMATION, FOR EXAMPLE A DIFFERENT
PHONE NUMBER.]
[Please give me an address for contacting (SECOND CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]
[Please give me an address for contacting (SECOND CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]
[Please give me an address for contacting (SECOND CONTACT NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]
[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
(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

Closing (CLQ)
Variable Name
ZIPCODE
PHONAREA
PHONEXCH
PHONLOCL
NOPHONE

MR Screen Name Question type Question text/description
[Please give me an address for contacting (SECOND CONTACT NAME).]
CL40
address
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]
Please give me a phone number for contacting (SECOND CONTACT NAME).
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
CL41
phone
FOR COMPLETE INFORMATION.]
ENTER 10 DIGIT NUMBER (NO DASHES)
BOX CL41

PHONAREA
PHONEXCH
PHONLOCL
NOPHONE

routing

If CL41 - NOPHONE = 1/NoPhone OR CL41 - PHONAREA = DK/RF, GO TO BOX CL44.
ELSE GO TO CL43-PHONAREA.
Is there a second phone number for contacting (SECOND CONTACT NAME)?

CL43

phone

BOX CL44

routing

ANOTHHOM

CL45

yes/no

STADDR1

CL46

address

STADDR2

CL46

address

CITY

CL46

address

STATE

CL46

address

ZIPCODE

CL46

address

PHONAREA
PHONEXCH
PHONLOCL
NOPHONE

CL47

code 1

Code list
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
[ ] PERSON DOES NOT HAVE PHONE

[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]

(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
[ ] PERSON DOES NOT HAVE PHONE

IF A VACATION HOME HAS BEEN COLLECTED FOR THE SP, GO TO CL48 - VERIFY.
ELSE GO TO CL45 - ANOTHHOM.
(01) YES
[Do you/Does (SP)] spend more than one month away, during the year, at another (02) NO
home other than your primary home?
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
[Please give me an address for this home.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-7) Empty
[Please give me an address for this home.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
[Please give me an address for this home.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
[Please give me an address for this home.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
[Please give me an address for this home.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
Please give me a phone number for this home.
(-7) Empty
(-8) Don't Know
ENTER 10 DIGIT NUMBER (NO DASHES)
(-9) Refused
[ ] PERSON DOES NOT HAVE PHONE

Closing (CLQ)
Variable Name

MR Screen Name Question type Question text/description
Code list
CODE "YES" IF ALREADY KNOWN, OTHERWISE ASK.
I would like to verify the address and phone number 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)

VERIFY

CL48

yes/no

STREET ADDRESS 2: (VACATION HOME ADDRESS LINE 2)
CITY: (VACATION HOME CITY)
(VACATION HOME ZIPCODE)

(01) YES
(02) NO
(03) SP NO LONGER HAS 2ND HOME

STATE: (VACATION HOME STATE) ZIPCODE:

PHONE NUMBER: (VACATION HOME PHONE NUMBER)
[IF ANY INFORMATION IS INCORRECT, SELECT “NO”. IF ANY INFORMATION IS
MISSING (E.G., AN APARTMENT NUMBER OR SECONDARY PHONE NUMBER),
SELECT “NO” TO ENTER THE MISSING DATA.]
STADDR1

CL49

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

STADDR2

CL49

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

CITY

CL49

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

STATE

CL49

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

ZIPCODE

CL49

address

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

PHONAREA
PHONEXCH
PHONLOCL
NOPHONE

CL49

phone

ENTER CORRECT OR MISSING ADDRESS AND PHONE NUMBER.
CLEAR ADDRESS LINE 2 IF NO LONGER APPLICABLE.

(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
[ ] PERSON DOES NOT HAVE PHONE

Closing (CLQ)
Variable Name

MR Screen Name Question type Question text/description

OTHHOMMN

CL51A

select all

FUTRPROX

CL52

code 1

PERSON_FUTRPROXY

CL53

roster

BOX CL53

routing

BOX CL53B

routing

IF THE FUTURE PROXY LIVES IN THE HOUSEHOLD WITH THE SP, GO TO BOX CL58.
ELSE GO TO CL54 - STADDR1.

CL54

address

[Please give me an address for contacting (FUTURE PROXY NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]
[Please give me an address for contacting (FUTURE PROXY NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]

STADDR1

STADDR2

CL54

address

CITY

CL54

address

STATE

CL54

address

ZIPCODE

CL54

address

Code list
(01) JANUARY
(02) FEBRUARY
(03) MARCH
(04) APRIL
(05) MAY
(06) JUNE
(07) JULY
Which calendar months [do you/does (SP) usually spend at this other home?
(08) AUGUST
(09) SEPTEMBER
(10) OCTOBER
(11) NOVEMBER
(12) DECEMBER
(91) VARIES/NO PREDICTABLE SCHEDULE
(-8) Don't Know
(-9) Refused
(01) SOMEONE NAMED
During our remaining interviews, we will continue to collect information about
(02) NO ONE NAMED
health care visits and the costs of any health care [you/(SP)] may receive. If for
(03) REFUSED TO NAME SOMEONE
some reason you could not do the interview, please give me the name of someone
(-8) Don't Know
who would be able to provide the information for [you/SP)].
(-9) Refused
[Please give me the name of someone who would be able to provide this
information for [you/(SP)].]
(01) [Continuous answer.]
ENTER ONLY ONE PERSON.
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.

[Please give me an address for contacting (FUTURE PROXY NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]
[Please give me an address for contacting (FUTURE PROXY NAME).]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]
[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
(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

Closing (CLQ)
Variable Name
PHONAREA
PHONEXCH
PHONLOCL
NOPHONE

MR Screen Name Question type Question text/description

CL55

BOX CL55
PHONAREA
PHONEXCH
PHONLOCL
NOPHONE

phone

routing

CL57

phone

BOX CL58

routing

THANK_SP

CL59

no entry

THANK_SUPP

CL60

no entry

THANK_PROXYPLANNER

CL61

no entry

THANK_PROXY

CL62

no entry

BOX CLEND

routing

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 = DK/RF, GO TO BOX
CL58.
ELSE GO TO CL57-PHONAREA.
Is there a second phone number for contacting (FUTURE PROXY NAME)?

Code list
(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
[ ] PERSON DOES NOT HAVE PHONE

(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused
[ ] PERSON DOES NOT HAVE PHONE

[PROBE: What is that number?]
[ENCOURAGE THE RESPONDENT TO REFER TO ADDRESS BOOKS, LETTERS, ETC.,
FOR COMPLETE INFORMATION.]
IF A FIRST FUTURE PROXY WAS ADDED (CL52-FUTRPROX=1), GO TO CL52 FUTURPROX TO ADD A SECOND FUTURE PROXY.
ELSE 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.
[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
(01) CONTINUE
time and cooperatoin during this interview.
CIRCLE TODAY'S DATE IN THE PLANNER AS A REFERENCE FOR THE RESPONDENT.
EXPLAIN PLANNER SECTIONS AS NECESSARY.
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.
Here is a bag to keep any medical bills, receipts, Medicare statements, and
insurance statements that would be connected to [your/(SP)'s] health care visits (01) CONTINUE
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.
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.
(01) CONTINUE
CIRCLE TODAY'S DATE IN PLANNER AS A REFERENCE FOR THE RESPONDENT.
EXPLAIN PLANNER SECTIONS IN DETAIL TO RESPONDENT.
I would like to thank you for your time and cooperation during this interview. We
(01) CONTINUE
may be contacting you in the future for further information.
GO TO NEXT SECTION