Section Specifications for USF
Round 69
Created on 5/9/2014 6:14:12 PM
Box Instructions
IF USDISP = 1/ConsentRequired OR USDISP = 4/InitialRefusal, GO TO USCONREF - CONREFFN.
ELSE GO TO US1PRE - US1PRECT.
Question Text
PLEASE INDICATE THE FINAL (CONSENT/REFUAL) STATUS FOR THIS SECTION.
Field 1: CONREFFN
Field 1 Routing
Value |
Label |
Route |
1 |
CONSENT OBTAINED (CONTINUE INTERVIEW) |
US1PRE - US1PRECT |
2 |
FINAL CONSENT DENIED |
USEND - USENDCT |
3 |
REFUSAL CONVERTED (CONTINUE INTERVIEW) |
US1PRE - US1PRECT |
4 |
FINAL REFUSAL |
USEND - USENDCT |
Question Text
This
series of questions is about the health care services that (SP) may
have received between (US REFERENCE START DATE) and (US REFERENCE END
DATE) while (he/she) resided in (FACILITY).
[The
questions include any services that (he/she) received outside this
(facility/home), as well as care from any providers who saw (him/her)
here. The kinds of services I will be asking about include physician
care, dental care, mental health services, various kinds of
therapies, and care from other kinds of health care providers. I
will be asking about the type of provider and the frequency or
duration of the services. Please do not include care while (he/she)
was an overnight inpatient in an acute care hospital.]
IF THERE ARE NO CONSENT OR REFUSAL ISSUES FOR THIS SECTION, PRESS "1" TO CONTINUE.
Field 1: US1PRECT
Field 1 Routing
Value |
Label |
Route |
1 |
CONTINUE |
US1 - OUTMDVST |
2 |
CONSENT REQUIRED |
USEND - USENDCT |
3 |
INITIAL REFUSAL |
USEND - USENDCT |
Other Programming Instructions
Report Display
Display
report above question text.
Display all stays where STAY.XSTPLAC
<> 000 that were reported for this SP in
chronological
order by start date of the stay.
Report header: STAY
TIMELINE
Report layout:
Column 1, header="Place Name",
display PLAC.PLACNAME of
PLAC where PLAC.PLACNUM =
STAY.XSTPLAC.
Column 2, header="Start Date",
display
STAY.STAYSMM+STAY.STAYSDD+STAY.STAYSYY in month,
day
year format.
Column 3, header="End Date",
display
STAY.STAYEMM+STAY.STAYEDD+STAY.STAYEYY in month,
day
year format.
Column 4, header="Stay Type",
display STAY.STAYCLAS.
Background Variable Assignments
Variable Name |
Assignment Instructions |
US1PLONG |
FACR.US1PLONG = curent round |
Question Text
Between (US REFERENCE START DATE) and (US REFERENCE END DATE) while a resident in this (facility/home), did (SP) see a medical doctor of any kind, outside the (facility/home), excluding mental health therapy provided by a psychiatrist?
Field 1: OUTMDVST
Field 1 Routing
Value |
Label |
Route |
0 |
NO |
US3 - INMDVST |
1 |
YES |
US2 - OUTMDFRQ |
|
Don't Know |
US3 - INMDVST |
|
Refused |
US3 - INMDVST |
Question Text
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many times did (he/she) see doctors outside this (facility/home)?
Field 1: OUTMDFRQ
Field 1 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
US3 - INMDVST |
|
Don't Know |
US3 - INMDVST |
|
Refused |
US3 - INMDVST |
Question Text
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), did (he/she) see a medical doctor of any kind, here, in this (facility/home), excluding mental health therapy provided by a psychiatrist?
Field 1: INMDVST
Field 1 Routing
Value |
Label |
Route |
0 |
NO |
US6PRE - US6PRECT |
1 |
YES |
US5A - ANYMDFRQ |
|
Don't Know |
US3A - US3ACT |
|
Refused |
US6PRE - US6PRECT |
Question Text
Please
tell me the name and title of someone in (FACILITY) who could give me
that information.
Thank you for your time, those are all
the questions I have for you. Right now I need to continue with
[PERSON NAMED] to complete these questions.
PRESS
"CTRL/R" TO ADD A PERSON TO THE PERSON ROSTER.
PRESS
"1" TO CONTINUE.
Field 1: US3ACT
Field 1 Routing
Value |
Label |
Route |
1 |
CONTINUE |
BOX USEND |
Other Programming Instructions
Report Display
Display
report above question text.
Display all stays where STAY.XSTPLAC
<> 000 that were reported for this SP in
chronological
order by start date of the stay.
Report header: STAY
TIMELINE
Report layout:
Column 1, header="Place Name",
display PLAC.PLACNAME of
PLAC where PLAC.PLACNUM =
STAY.XSTPLAC.
Column 2, header="Start Date",
display
STAY.STAYSMM+STAY.STAYSDD+STAY.STAYSYY in month,
day
year format.
Column 3, header="End Date",
display
STAY.STAYEMM+STAY.STAYEDD+STAY.STAYEYY in month,
day
year format.
Column 4, header="Stay Type",
display STAY.STAYCLAS.
Design Notes
Terminate Use with this respondent and return to navigation screen. Set USE status, on the navigate screen to READY. Begin USE at US1PRE on re-entry.
Question Text
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many times did (he/she) see any doctor here?
Field 1: ANYMDFRQ
Field 1 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
US6PRE - US6PRECT |
|
Don't Know |
US6PRE - US6PRECT |
|
Refused |
US6PRE - US6PRECT |
Question Text
The following questions are about services used both inside and outside this (facility/home). We are only interested in services (SP) received while residing in (FACILITY).
PRESS "1" TO CONTINUE.
Field 1: US6PRECT
Field 1 Routing
Value |
Label |
Route |
1 |
CONTINUE |
US6 - DENTVST |
Other Programming Instructions
Report Display
Display
report above question text.
Display all stays where STAY.XSTPLAC
<> 000 that were reported for this SP in
chronological
order by start date of the stay.
Report header: STAY
TIMELINE
Report layout:
Column 1, header="Place Name",
display PLAC.PLACNAME of
PLAC where PLAC.PLACNUM =
STAY.XSTPLAC.
Column 2, header="Start Date",
display
STAY.STAYSMM+STAY.STAYSDD+STAY.STAYSYY in month,
day
year format.
Column 3, header="End Date",
display
STAY.STAYEMM+STAY.STAYEDD+STAY.STAYEYY in month,
day
year format.
Column 4, header="Stay Type",
display STAY.STAYCLAS.
Question Text
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), did (he/she) see a dentist, dental surgeon, dental assistant, or any other professional for dental care?
Field 1: DENTVST
Field 1 Routing
Value |
Label |
Route |
0 |
NO |
US8 - MENTLVST |
1 |
YES |
US7 - DENTFRQ |
|
Don't Know |
US8 - MENTLVST |
|
Refused |
US8 - MENTLVST |
Question Text
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many times did (he/she) see a dentist, dental surgeon, dental assistant, or any other professional for dental care?
Field 1: DENTFRQ
Field 1 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
US8 - MENTLVST |
|
Don't Know |
US8 - MENTLVST |
|
Refused |
US8 - MENTLVST |
Question Text
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), did (he/she) see a psychiatrist or any other mental health care professional either inside or outside this (facility/home)?
Field 1: MENTLVST
Field 1 Routing
Value |
Label |
Route |
0 |
NO |
US12 - PHYSTHPY |
1 |
YES |
US9 - PSYCHTYP |
|
Don't Know |
US12 - PHYSTHPY |
|
Refused |
US12 - PHYSTHPY |
Question Text
What
type of mental health specialist did (he/she) see?
[PROBE:
Any others?]
SELECT
ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
Field 1: PSYCHTYP
Field 1 Routing
Value |
Label |
Route |
1 |
LICENSED CLINICAL SOCIAL WORKER |
BOX US10A |
2 |
PSYCHIATRIC NURSE |
BOX US10A |
3 |
PSYCHIATRIC SOCIAL WORKER |
BOX US10A |
4 |
PSYCHIATRIST |
BOX US10A |
5 |
PSYCHOLOGIST |
BOX US10A |
91 |
OTHER |
US9 - PSYCHOS |
Field 2: PSYCHOS
OTHER (SPECIFY)
Field 2 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
BOX US10A |
Box Instructions
IF US9-PSYCHTYP INCLUDES 1/LicensedClinicalSocWork, GO TO US10A - LCSOWSES.
ELSE GO TO BOX US10B.
Question Text
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits did (he/she) have to a licensed clinical social worker?
Field 1: LCSOWSES
Field 1 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
US11A - LCSOWTYP |
|
Don't Know |
US11A - LCSOWTYP |
|
Refused |
US11A - LCSOWTYP |
Question Text
Were these individual sessions, group sessions, or some of both?
Field 1: LCSOWTYP
Field 1 Routing
Value |
Label |
Route |
1 |
INDIVIDUAL |
BOX US10B |
2 |
GROUP |
BOX US10B |
3 |
BOTH |
BOX US10B |
Box Instructions
IF US9-PSYCHTYP INCLUDES 2/PsychiatricNurse, GO TO US10B - PSCNUSES.
ELSE GO TO BOX US10C.
Question Text
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits did (he/she) have to a psychiatric nurse?
Field 1: PSCNUSES
Field 1 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
US11B - PSCNUTYP |
|
Don't Know |
US11B - PSCNUTYP |
|
Refused |
US11B - PSCNUTYP |
Question Text
Were these individual sessions, group sessions, or some of both?
Field 1: PSCNUTYP
Field 1 Routing
Value |
Label |
Route |
1 |
INDIVIDUAL |
BOX US10C |
2 |
GROUP |
BOX US10C |
3 |
BOTH |
BOX US10C |
Box Instructions
IF US9-PSYCHTYP INCLUDES 3/PsychiatricSocWork, GO TO US10C - PSSOWSES.
ELSE GO TO BOX US10D.
Question Text
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits did (he/she) have to a psychiatric social worker?
Field 1: PSSOWSES
Field 1 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
US11C - PSSOWTYP |
|
Don't Know |
US11C - PSSOWTYP |
|
Refused |
US11C - PSSOWTYP |
Question Text
Were these individual sessions, group sessions, or some of both?
Field 1: PSSOWTYP
Field 1 Routing
Value |
Label |
Route |
1 |
INDIVIDUAL |
BOX US10D |
2 |
GROUP |
BOX US10D |
3 |
BOTH |
BOX US10D |
Box Instructions
IF US9-PSYCHTYP INCLUDES 4/Psychiatrist, GO TO US10D - PSCIASES.
ELSE GO TO BOX US10E.
Question Text
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits did (he/she) have to a psychiatrist?
Field 1: PSCIASES
Field 1 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
US11D - PSCIATYP |
|
Don't Know |
US11D - PSCIATYP |
|
Refused |
US11D - PSCIATYP |
Question Text
Were these individual sessions, group sessions, or some of both?
Field 1: PSCIATYP
Field 1 Routing
Value |
Label |
Route |
1 |
INDIVIDUAL |
BOX US10E |
2 |
GROUP |
BOX US10E |
3 |
BOTH |
BOX US10E |
Box Instructions
IF US9-PSYCHTYP INCLUDES 5/Psychologist, GO TO US10E - PSCOLSES.
ELSE GO TO BOX US10F.
Question Text
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits did (he/she) have to a psychologist?
Field 1: PSCOLSES
Field 1 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
US11E - PSCOLTYP |
|
Don't Know |
US11E - PSCOLTYP |
|
Refused |
US11E - PSCOLTYP |
Question Text
Were these individual sessions, group sessions, or some of both?
Field 1: PSCOLTYP
Field 1 Routing
Value |
Label |
Route |
1 |
INDIVIDUAL |
BOX US10F |
2 |
GROUP |
BOX US10F |
3 |
BOTH |
BOX US10F |
Box Instructions
IF US9-PSYCHTYP INCLUDES 91/Other, GO TO US10F - PSOTRSES.
ELSE GO TO US12 - PHYSTHPY.
Question Text
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), how many sessions or visits did (he/she) have to a (OTHER MENTAL HEALTH SPECIALIST)?
Field 1: PSOTRSES
Field 1 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
US11F - PSOTRTYP |
|
Don't Know |
US11F - PSOTRTYP |
|
Refused |
US11F - PSOTRTYP |
Question Text
Were these individual sessions, group sessions, or some of both?
Field 1: PSOTRTYP
Field 1 Routing
Value |
Label |
Route |
1 |
INDIVIDUAL |
US12 - PHYSTHPY |
2 |
GROUP |
US12 - PHYSTHPY |
3 |
BOTH |
US12 - PHYSTHPY |
Question Text
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), did (he/she) see a therapist such as a physical therapist, speech therapist, I.V. therapist, occupational therapist, or respiratory therapist?
Field 1: PHYSTHPY
Field 1 Routing
Value |
Label |
Route |
0 |
NO |
US22A - PODRTHPY |
1 |
YES |
US13 - PHTPYWKL |
|
Don't Know |
US22A - PODRTHPY |
|
Refused |
US22A - PODRTHPY |
Question Text
SHOW CARD US1
Please look at this card and tell me about how often each week therapy was provided.
PRESS F1 FOR INFORMATION ON "ONE-TIME EVALUATION".
Field 1: PHTPYWKL
Field 1 Routing
Value |
Label |
Route |
1 |
LESS THAN ONCE A WEEK |
US14 - PHTPYFRQ |
2 |
ONCE OR TWICE A WEEK |
US14 - PHTPYFRQ |
3 |
3 TO 5 TIMES A WEEK |
US14 - PHTPYFRQ |
4 |
MORE THAN 5 TIMES A WEEK |
US14 - PHTPYFRQ |
5 |
ONE-TIME EVALUATION |
US22A - PODRTHPY |
|
Don't Know |
US14 - PHTPYFRQ |
|
Refused |
US22A - PODRTHPY |
Question Text
SHOW CARD US2
Now look at this card. Between (US REFERENCE START DATE) and (US REFERENCE END DATE), over how long a period was therapy provided?
Field 1: PHTPYFRQ
Field 1 Routing
Value |
Label |
Route |
1 |
LESS THAN 1 WEEK |
US22A - PODRTHPY |
2 |
1 TO 3 WEEKS |
US22A - PODRTHPY |
3 |
4 TO 8 WEEKS |
US22A - PODRTHPY |
4 |
MORE THAN 8 WEEKS BUT NOT THE WHOLE TIME |
US22A - PODRTHPY |
5 |
ABOUT THE WHOLE TIME |
US22A - PODRTHPY |
|
Don't Know |
US22A - PODRTHPY |
|
Refused |
US22A - PODRTHPY |
Question Text
Between (US REFERENCE START DATE) and (US REFERENCE END DATE) was (SP) seen by a podiatrist (either inside or outside this (facility/home))?
Field 1: PODRTHPY
Field 1 Routing
Value |
Label |
Route |
0 |
NO |
US23 - EDHBSERV |
1 |
YES |
US23 - EDHBSERV |
|
Don't Know |
US23 - EDHBSERV |
|
Refused |
US23 - EDHBSERV |
Question Text
Between
(US REFERENCE START DATE) and (US REFERENCE END DATE), did (he/she)
receive educational or habilitational services (either inside or
outside this (facility/home))?
[PROBE:
"Habilitational services" include training in daily living
skills, self care, and so on, in a structured program.]
Field 1: EDHBSERV
Field 1 Routing
Value |
Label |
Route |
0 |
NO |
US29 - OTHCPROV |
1 |
YES |
US24 - EDUORHAB |
|
Don't Know |
US29 - OTHCPROV |
|
Refused |
US29 - OTHCPROV |
Question Text
Were those services educational, habilitational, or both?
Field 1: EDUORHAB
Field 1 Routing
Value |
Label |
Route |
1 |
EDUCATIONAL |
US25 - EDHABFRQ |
2 |
HABILITATIONAL |
US25 - EDHABFRQ |
3 |
BOTH |
US25 - EDHABFRQ |
|
Don't Know |
US25 - EDHABFRQ |
|
Refused |
US29 - OTHCPROV |
Question Text
SHOW CARD US2
Please look at this card and tell me, between (US REFERENCE START DATE) and (US REFERENCE END DATE), over how long a period were these (educational/habilitational) services provided?
Field 1: EDHABFRQ
Field 1 Routing
Value |
Label |
Route |
1 |
LESS THAN 1 WEEK |
BOX US2 |
2 |
1 TO 3 WEEKS |
BOX US2 |
3 |
4 TO 8 WEEKS |
BOX US2 |
4 |
MORE THAN 8 WEEKS BUT NOT THE WHOLE TIME |
BOX US2 |
5 |
ABOUT THE WHOLE TIME |
BOX US2 |
|
Don't Know |
BOX US2 |
|
Refused |
BOX US2 |
Box Instructions
IF US24-EDUORHAB = 3/Both, THEN GO TO US27 - HABFRQ.
ELSE GO TO US29 - OTHCPROV.
Question Text
SHOW CARD US2
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), over how long a period were these habilitational services provided?
Field 1: HABFRQ
Field 1 Routing
Value |
Label |
Route |
1 |
LESS THAN 1 WEEK |
US29 - OTHCPROV |
2 |
1 TO 3 WEEKS |
US29 - OTHCPROV |
3 |
4 TO 8 WEEKS |
US29 - OTHCPROV |
4 |
MORE THAN 8 WEEKS BUT NOT THE WHOLE TIME |
US29 - OTHCPROV |
5 |
ABOUT THE WHOLE TIME |
US29 - OTHCPROV |
|
Don't Know |
US29 - OTHCPROV |
|
Refused |
US29 - OTHCPROV |
Question Text
SHOW CARD US3 FOR PROMPTING AS NEEDED.
Between (US REFERENCE START DATE) and (US REFERENCE END DATE), did (he/she) receive care from any other licensed or certified health care provider (either inside or outside this (facility/home))?
PRESS F1 FOR "ANY OTHER PROVIDER" CLARIFICATION.
Field 1: OTHCPROV
Field 1 Routing
Value |
Label |
Route |
0 |
NO |
US31PRE - US31PRCT |
1 |
YES |
US30 - TYPHCPRV |
|
Don't Know |
US31PRE - US31PRCT |
|
Refused |
US31PRE - US31PRCT |
Question Text
What kind of provider was that?
SELECT
ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
Field 1: TYPHCPRV
Field 1 Routing
Value |
Label |
Route |
1 |
AUDIOLOGIST |
US31PRE - US31PRCT |
2 |
DIETICIAN |
US31PRE - US31PRCT |
3 |
LABORATORY TECHNICIAN |
US31PRE - US31PRCT |
4 |
NURSE PRACTITIONER |
US31PRE - US31PRCT |
5 |
OPHTHALMOLOGIST |
US31PRE - US31PRCT |
6 |
OPTOMETRIST |
US31PRE - US31PRCT |
7 |
PHYSICIAN'S ASSISTANT |
US31PRE - US31PRCT |
8 |
RECREATIONAL THERAPIST |
US31PRE - US31PRCT |
9 |
REGISTERED NURSE |
US31PRE - US31PRCT |
10 |
SOCIAL WORKER |
US31PRE - US31PRCT |
11 |
X-RAY TECHNICIAN |
US31PRE - US31PRCT |
91 |
OTHER |
US30 - TYPPRVOS |
Field 2: TYPPRVOS
OTHER (SPECIFY)
Field 2 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
US31PRE - US31PRCT |
Question Text
The next few questions are about any visits (SP) may have made to a hospital emergency room from (US REFERENCE START DATE) through (US REFERENCE END DATE). Please do not include visits to the emergency room that were immediately followed by inpatient hospital stays.
PRESS "1" TO CONTINUE.
Field 1: US31PRCT
Field 1 Routing
Value |
Label |
Route |
1 |
CONTINUE |
US32 - ERVISITS |
Question Text
While (he/she) was in this (facility/home), did (he/she) make any visits to a hospital emergency room between (US REFERENCE START DATE) and (US REFERENCE END DATE)?
Field 1: ERVISITS
Field 1 Routing
Value |
Label |
Route |
0 |
NO |
US37 - RETSMDAY |
1 |
YES |
US33 - ERVSTMM |
|
Don't Know |
US37 - RETSMDAY |
|
Refused |
US37 - RETSMDAY |
Question Text
COLLECT ALL ER VISITS.
Please tell me all dates (SP) made a visit to a hospital emergency room between (US REFERENCE START DATE) and (US REFERENCE END DATE).
[PROBE:
Were there any more visits to the ER?]
IF NO MORE DATES,
PRESS ENTER TO CONTINUE.
Field 1: ERVSTMM
Field 1 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
US33 - ERVSTDD |
|
Don't Know |
US33 - ERVSTDD |
|
Refused |
US33 - ERVSTDD |
Field 2: ERVSTDD
Field 2 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
US33 - ERVSTYY |
|
Don't Know |
US33 - ERVSTYY |
|
Refused |
US33 - ERVSTYY |
Field 3: ERVSTYY
Field 3 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
BOX US33 |
|
Don't Know |
BOX US33 |
|
Refused |
BOX US33 |
Other Programming Instructions
Roster/Grid Display
Column # |
Header |
Instructions |
1 |
Month |
ERVSTMM. Input field 1. |
2 |
Day |
ERVSTDD. Input field 2. |
3 |
Year |
ERVSTYY. Input field 3. |
Background Variable Assignments
Variable Name |
Assignment Instructions |
US33NEXT |
US33NEXT = 1/Indicated |
Box Instructions
CREATE NEW EMERGENCY ROOM VISITS FOR EACH DATE ADDED AND GO TO US37 - RETSMDAY.
Other Programming Instructions
Design Notes
MAXIMUM ROSTER LENGTH = 20
Question Text
[Besides the (health care providers and emergency room/health care providers/emergency room) visits you have already told me about, did (he/she) ever go to the hospital and return on the same day/Did (he/she) ever go to the hospital and return on the same day]?
Field 1: RETSMDAY
Field 1 Routing
Value |
Label |
Route |
0 |
NO |
US40 - USEEQUIP |
1 |
YES |
US38 - RETSMFRQ |
|
Don't Know |
US40 - USEEQUIP |
|
Refused |
US40 - USEEQUIP |
Question Text
How many times did this happen between (US REFERENCE START DATE) and (US REFERENCE END DATE)?
Field 1: RETSMFRQ
Field 1 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
US40 - USEEQUIP |
|
Don't Know |
US40 - USEEQUIP |
|
Refused |
US40 - USEEQUIP |
Question Text
SHOW CARD US4
Now I'd like to ask you about any kind of supplies, equipment, or other types of medical services (SP) received other than the ones I've already mentioned. Please look at this first card and tell me what supplies or services (SP) received between (US REFERENCE START DATE) and (US REFERENCE END DATE).
SELECT
ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
Field 1: USEEQUIP
Field 1 Routing
Value |
Label |
Route |
1 |
AMBULANCE SERVICE |
BOX US3 |
2 |
CLOTH DIAPERS |
BOX US3 |
3 |
DIABETIC EQUIPMENT OR SUPPLIES |
BOX US3 |
4 |
DISPOSABLE DIAPERS |
BOX US3 |
5 |
EQUIPMENT OR SUPPLIES FOR KIDNEY DIALYSIS |
BOX US3 |
6 |
EYE GLASSES OR CONTACT LENSES |
BOX US3 |
7 |
HEARING AID OR OTHER COMMUNICATION DEVICE |
BOX US3 |
8 |
ORTHOPEDIC ITEMS |
BOX US3 |
9 |
OSTOMY SUPPLIES |
BOX US3 |
10 |
OXYGEN |
BOX US3 |
11 |
PROSTHESIS |
BOX US3 |
96 |
NONE OF THE ABOVE |
BOX US3 |
|
Don't Know |
BOX US3 |
|
Refused |
BOX US3 |
Box Instructions
IF US40-USEEQUIP INCLUDES DK OR RF, GO TO US43 - MSTURN.
ELSE GO TO US42 - USEEQUI2.
Question Text
SHOW CARD US5
Please look at this second card and tell me what medical devices or equipment (he/she) received between (US REFERENCE START DATE) and (US REFERENCE END DATE).
SELECT
ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
Field 1: USEEQUI2
Field 1 Routing
Value |
Label |
Route |
1 |
BEDSIDE COMMODE |
US43 - MSTURN |
2 |
BED PADS (CLOTH OR DISPOSABLE) |
US43 - MSTURN |
3 |
CATHETER AND CATHETER SUPPLIES |
US43 - MSTURN |
4 |
FEEDING SUPPLIES (INCLUDE PUMPS, SYRINGES, TUBES) |
US43 - MSTURN |
5 |
G TUBE AND SUPPLIES |
US43 - MSTURN |
6 |
GERI CHAIR |
US43 - MSTURN |
7 |
HOSPITAL BED |
US43 - MSTURN |
8 |
IV SUPPLIES |
US43 - MSTURN |
9 |
NEBULIZER |
US43 - MSTURN |
10 |
SPECIAL MATTRESS, CUSHIONS OR MATTRESS PADS (INCLUDING EGG CRATE, AIR) |
US43 - MSTURN |
11 |
SUCTION MACHINE AND SUPPLIES |
US43 - MSTURN |
12 |
TED HOSE AND SUPPLIES |
US43 - MSTURN |
13 |
WHEELCHAIR/WALKER |
US43 - MSTURN |
91 |
SOME OTHER TYPE OF DEVICE OR EQUIPMENT |
US42 - OTHREQOS |
96 |
NONE OF THE ABOVE |
US43 - MSTURN |
Field 2: OTHREQOS
SOME OTHER TYPE OF DEVICE OR EQUIPMENT (SPECIFY)
Field 2 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
US43 - MSTURN |
Question Text
Please tell me if (SP) received any of the following medical services. Did (he/she) receive…
Field 1: MSTURN
turning and positioning?
Field 1 Routing
Value |
Label |
Route |
0 |
NO |
US43 - MSTUBE |
1 |
YES |
US43 - MSTUBE |
|
Don't Know |
US43 - MSTUBE |
|
Refused |
US43 - MSTUBE |
Field 2: MSTUBE
tubefeeding?
Field 2 Routing
Value |
Label |
Route |
0 |
NO |
US43 - MSRESTR |
1 |
YES |
US43 - MSRESTR |
|
Don't Know |
US43 - MSRESTR |
|
Refused |
US43 - MSRESTR |
Field 3: MSRESTR
restraints?
Field 3 Routing
Value |
Label |
Route |
0 |
NO |
US43 - MSINJECT |
1 |
YES |
US43 - MSINJECT |
|
Don't Know |
US43 - MSINJECT |
|
Refused |
US43 - MSINJECT |
Field 4: MSINJECT
injections?
Field 4 Routing
Value |
Label |
Route |
0 |
NO |
US45 - OTHMEDNC |
1 |
YES |
US45 - OTHMEDNC |
|
Don't Know |
US45 - OTHMEDNC |
|
Refused |
US45 - OTHMEDNC |
Question Text
SHOW CARD US6
Now I'd like to ask about any other medically necessary items or provider services (SP) received that we haven't talked about already. Please look at this last card and tell me what other items or services (he/she) received between (US REFERENCE START DATE) and (US REFERENCE END DATE)?
SELECT
ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
Field 1: OTHMEDNC
Field 1 Routing
Value |
Label |
Route |
1 |
APPLYING/CHANGING DRESSINGS INCLUDING BAND-AIDS |
US46 - DIDABUS |
2 |
APPLYING/MONITORING HOT PACKS |
US46 - DIDABUS |
3 |
CATHETERIZATION AND IRRIGATION |
US46 - DIDABUS |
4 |
FEEDING (WITH SPOON SYRINGE PUMP OR OTHER DEVICE) |
US46 - DIDABUS |
5 |
G TUBE USE AND CARE |
US46 - DIDABUS |
6 |
INCONTINENCE |
US46 - DIDABUS |
7 |
IV USE AND CARE |
US46 - DIDABUS |
8 |
PACEMAKER CHECK |
US46 - DIDABUS |
9 |
SKIN TREATMENTS FOR PREVENTION/TREATMENT OF SKIN ULCERS |
US46 - DIDABUS |
10 |
SUCTIONING |
US46 - DIDABUS |
91 |
SOME OTHER KIND OF ITEM OR SERVICE |
US45 - OTHRSEOS |
96 |
NONE OF THE ABOVE |
US46 - DIDABUS |
|
Don't Know |
US46 - DIDABUS |
Field 2: OTHRSEOS
SOME OTHER KIND OF ITEM OR SERVICE (SPECIFY)
Field 2 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
US46 - DIDABUS |
Question Text
DID YOU ABSTRACT?
Field 1: DIDABUS
Field 1 Routing
Value |
Label |
Route |
1 |
ALL |
US47 - WHYABUS |
2 |
MAJORITY |
US47 - WHYABUS |
3 |
HALF |
US47 - WHYABUS |
4 |
SOME |
US47 - WHYABUS |
5 |
NONE |
USEND - USENDCT |
Question Text
WHY DID YOU ABSTRACT?
Field 1: WHYABUS
Field 1 Routing
Value |
Label |
Route |
1 |
NO KNOWLEDGEABLE RESPONDENT AVAILABLE |
USEND - USENDCT |
2 |
NO TIME/STAFF BURDEN TOO GREAT |
USEND - USENDCT |
3 |
REFUSAL--UNWILLING TO COOPERATE |
USEND - USENDCT |
91 |
OTHER |
US47 - WHYABUOS |
Field 2: WHYABUOS
OTHER (SPECIFY)
Field 2 Routing
Value |
Label |
Route |
1 |
[Continuous answer.] |
USEND - USENDCT |
Question Text
(YOU HAVE COMPLETED THE USE SECTION FOR THIS SP.)
PRESS "1" TO RETURN TO NAVIGATION SCREEN.
Field 1: USENDCT
Field 1 Routing
Value |
Label |
Route |
1 |
CONTINUE |
BOX USEND |
Other Programming Instructions
Background Variable Assignments
USDISP:
If
US1PRE-US1PRECT = 2/ConsentRequired, USDISP = 1/ConsentRequired.
Else
if US1PRE-US1PRECT = 3/InitialRefusal, USDISP = 4/InitialRefusal.
Else if USCONREF-CONREFFN = 2/FinalConsentDenied, USDISP =
11/FinalConsentDenied.
Else if USCONREF-CONREFFN =
4/FinalRefusal, USDISP = 12/FinalRefusal.
Else USDISP =
96/Complete.
Box Instructions
GO TO NAVIGATOR
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Ryan Hubbard |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |