Cms-p-0015a Mcbs

Introduction (INQ)
Variable Name
MR Screen Name
BOX IN1
INV1
CARIVER

Question type
routing
code one

Question text/description
GO TO INV1 - CARIVER.
Some of this interview will be recorded for quality control purposes.
I'd like to continue now, unless you have any questions.

NOCARI
ATDOOR

INV2
IN1AA

no entry
no entry

Code list
(01) RESPONDENT AGREES TO CONTINUE WITH
RECORDING
(02) RESPONDENT DOES NOT WANT TO BE RECORDED

That's fine. The interview will not be recorded.]
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.
REFER TO THE "AT-THE-DOOR" SHEET IF THE RESPONDENT NEEDS ADDITIONAL REASSURANCE.

VERIFYSP

IN2

yes/no

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)
MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.
MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.
MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.
IS THE SP CURRENTLY:

ROSTFNAM
ROSTMINI
ROSTLNAM
SPAISTATUS

IN3
IN3
IN3
INS1

text
text
text
code one

SPINSTMM

INS2

date

SPINSTDD

INS2

date

IF MORE THAN ONE DATE, ENTER THE EARLIEST.
What was the first date since [REFERENCE DATE] that [SP] entered the facility?

SPINSTYY

INS2

date

IF MORE THAN ONE DATE, ENTER THE EARLIEST.
What was the first date since (REFERENCE DATE) that (SP) entered the facility?

(01) YES
(02) NO

(01) ALIVE AND NOT INSTITUTIONALIZED
(02) ALIVE AND INSTITUTIONALIZED
(03) DECEASED - DIED IN COMMUNITY
(04) DECEASED - DIED IN INSTITUTION
What was the first date since [REFERENCE DATE] that [SP] entered the facility?
(01) continuous answer
(-8) Don't Know
[EXPLAIN IF NECESSARY: By "facility" we mean a place that provides long term care. By "first date" we mean (-9) Refused
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
[EXPLAIN IF NECESSARY: By "facility" we mean a place that provides long term care. By "first date" we mean (-9) Refused
the earliest date that an SP enters any facility and does not enter a hospital or return home.]

(01) continuous answer

[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.]

BOX INSA

routing

SPDIEMM

INS3

date

IF MORE THAN ONE DATE, ENTER THE EARLIEST.
IF (INS1 - SPAISTATUS = 4/DeceasedInInstitute) GO TO INS3 - SPDIEMM.
ELSE GO TO BOX INSA1.
On what date did (SP) die?

SPDIEDD

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

Introduction (INQ)
Variable Name
MR Screen Name
SPDIEYY
INS3

DEASDATE

INSTDATE

Question type
date

Question text/description
On what date did (SP) die?

BOX INSA1

routing

IF (SPDIEMM IN(-8,-9) OR SPDIEYY IN(-8,-9) THEN GO TO INS3B-INTHANK
ELSE IF (INS1 - SPAISTATUS = 3/Deceased) AND (INTTYPE in(3,7,10)) AND (SP'S DATE OF DEATH ENTERED AT
INS3 IS BEFORE JANUARY 1 OF THE CURRENT YEAR), GO TO INS3A - DEASDATE.
ELSE IF (INS1 - SPAISTATUS = 4/DeceasedInInstitute) AND (INTTYPE in(7,10)) AND (SP'S DATE OF
INSTITUTIONALIZATION ENTERED AT INS2 AND SP'S DATE OF DEATH ENTERED AT INS3 ARE BOTH PRIOR TO
JANUARY 1 OF CURRENT YEAR), GO TO INS3A - DEASDATE.
ELSE IF(INS1 - SPAISTATUS = 4/DeceasedInInstitute) AND (INTTYPE in(7,10)) AND (SP'S DATE OF
INSTITUTIONALIZATION ENTERED AT INS2 IS PRIOR TO JANUARY 1 OF CURRENT YEAR) AND (SP'S DATE OF
DEATH ENTERED AT INS3 IS ON OR AFTER JANUARY 1 OF CURRENT YEAR), GO TO INS3A1 - INSTDATE.
ELSE IF (INS1 - SPAISTATUS = 2/AliveAndInstitute) AND (INTTYPE in(7,10)) AND (SP'S DATE OF
INSTITUTIONALIZATION ENTERED AT INS2 IS BEFORE JANUARY 1 OF THE CURRENT YEAR), GO TO INS3A1 INSTDATE.
ELSE IF(INS1-SPAISTATUS = 2/AliveAndInstitute) AND INTTYPE = 3, GO TO INS3B-INTHANK
ELSE IF (INS1-SPAISTATUS = 3/Deceased) AND INTTYPE = 3 AND SP'S DATE OF DEATH ENTERED AT INS3 IS
PRIOR TO JANUARY 1, GO TO INS3A-DEASDATE
ELSE IF (INS1-SPAISTATUS = 4/DeceasedInInstitute) AND INTTYPE = 3, GO TO INS3B-INTHANK
ELSE GO TO BOX INS1.

INS3A

no entry

YOU HAVE ENTERED THAT THE SP, (SP), DIED BEFORE JANUARY 1ST OF THIS YEAR. IF THIS IS NOT CORRECT,
GO TO THE PREVIOUS PAGE AND ENTER THE CORRECT DATE AT INS3.

INS3A1

no entry

Code list
(01) continuous answer
(-8) Don't Know
(-9) Refused

IF THIS IS CORRECT, YOU WILL NOT BE CONDUCTING THE COMMUNITY INTERVIEW WITH THE RESPONDENT.
GO TO THE NEXT PAGE TO END THE INTERVIEW.
YOU HAVE ENTERED THAT THE SP, (SP), WAS INSTITUTIONALIZED BEFORE JANUARY 1ST OF 2015. IF THIS IS
NOT CORRECT, GO TO THE PREVIOUS PAGE AND ENTER THE CORRECT DATE AT INS2.
IF THIS IS CORRECT, YOU WILL NOT BE CONDUCTING THE COMMUNITY INTERVIEW WITH THE RESPONDENT.
AFTER CLICKING "NEXT PAGE", YOU WILL RETURN TO CM-FIELD. PLEASE FILL OUT A RECORD OF CALL AND
CODE THIS CASE AS A “NO COM PROXY- GO TO FAC” .
PLEASE COLLECT ANY KNOWN FACILITY CONTACT INFORMATION AND DISCUSS THE CASE WITH YOUR FIELD
MANAGER.

INTHANK

SPPROXY

PERSON_PROXY

INS3B

no entry

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.
IF SP IS DECEASED OR INSTITUTIONALIZED, SET RESPONDENT TO PROXY AND GO TO IN4A - PERSON_PROXY.
ELSE GO TO IN4 - SPPROXY.

BOX INSB1
BOX INS1

routing
routing

IN4

code one

WILL THIS INTERVIEW BE CONDUCTED WITH THE SAMPLE PERSON OR WITH A PROXY?

BOX INS2A

routing

IN4A

roster

IF SP IS IN THE EXIT SAMPLE, GO TO BOX INS4A.
ELSE GO TO BOX INS5.
SELECT OR ADD THE NAME/RELATIONSHIP OF THE PROXY TO THE SP FOR THIS INTERVIEW.
SELECT OR ADD ONLY ONE PERSON.

(01) SAMPLE PERSON
(02) PROXY

Introduction (INQ)
Variable Name
MR Screen Name
BOX INS2AA

Question type
routing

VRFYPROX

IN5

yes/no

ROSTFNAM
ROSTLNAM
ROSTREL

IN6
IN6
IN6

text
text
code one

Question text/description
IF PERSON IS ADDED AT IN4A, GO TO BOX INS2A-1.
ELSE GO TO IN5 - VRFYPROX.
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)
[What is your correct name and relationship to (SP)?]
[What is your correct name and relationship to (SP)?]
[What is your correct name and relationship to (SP)?]

Code list

(01) YES
(02) NO

(01) continuous answer
(01) continuous answer
(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
(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

BOX INS2A-1

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.

Introduction (INQ)
Variable Name
MR Screen Name
WHYPROXY
IN6A

Question type
code one

Question text/description
WHAT IS THE MAIN REASON THAT A PROXY RESPONDENT NECESSARY?

BOX INS2B

routing

PNSPVB

IN6B
BOX INS3

verbatim text
routing

IF RESPONSE TO IN6a - WHYPROXY ONLY INCLUDES 9/CodeReasonWhy, GO TO IN6B - PNSPVB.
ELSE GO TO BOX INS3.
BRIEFLY EXPLAIN WHY PROXY MUST ANSWER QUESTIONS.
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.

SUPPDIED

IN6B1

no entry

SUPPINST

IN6B2

no entry

EXITINFO

BOXINS4A
INS6

routing
no entry

Code list
(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

YOU HAVE ENTERED THAT THE SP, (SP), IS DECEASED. IF THIS IS NOT CORRECT, GO TO THE PREVIOUS PAGE
AND CORRECT YOUR RESPONSE AT IN6A.
YOU HAVE ENTERED THAT THE SP, (SP), IS INSTITUTIONALIZED. IF THIS IS NOT CORRECT, GO TO THE
PREVIOUS PAGE AND CORRECT YOUR RESPONSE AT IN6A.
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.

EXITINFR

CHEKBRTH

INS6A

no entry

BOX INS5

routing

IN8

yes/no

Therefore, this will be the last interview that will be conducted [with you/for (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.
Therefore, this will be the last interview that will be conducted [with you/for (SP)].
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.
I have [your/(SP’s)] date of birth listed as (CMS BIRTH DATE). Is that correct?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

Introduction (INQ)
Variable Name
MR Screen Name
HHDOBMM
IN9

Question type
date

Question text/description
What is [your/(SP’s)] date of birth?

HHDOBDD

IN9

date

What is [your/(SP’s)] date of birth?

HHDOBYY

IN9

date

What is [your/(SP’s)] date of birth?

BOX IN3A

routing

CHECKAGE

IN10

yes/no

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.
That makes [you/(SP)] (AGE) today. Is that correct?

ROSTSEX

IN11

code one

BOX IN4

routing

IN12

yes/no

BOX IN6

routing

IN13

code one

BOX IN7

routing

IN14

numeric

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW FROM FACILITY), GO TO IN14 - SPCHNLNM.
ELSE GO TO BOX IN8.
Including natural, adopted, and stepchildren, how many living children [did (SP)/does (SP)/do you] have?

BOX IN8

routing

GO TO NEXT SECTION

CHNGSEX

SPMARSTA

SPCHNLNM

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?
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.
YOU JUST CHANGED SP’S SEX FROM (MALE/FEMALE) TO (FEMALE/MALE). DID YOU INTEND TO DO THAT?
IF SP'S AGE IS > 16, DK OR RF, GO TO IN13 - SPMARSTA.
ELSE GO TO BOX IN8.
[Are you/Is (SP)/Was (SP)] married, widowed, divorced, separated, or never married?

Code list
(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
(01) MALE
(02) FEMALE

(01) YES
(02) NO

(01) MARRIED
(02) WIDOWED
(03) DIVORCED
(04) SEPARATED
(05) NEVER MARRIED
(-8) Don't Know
(-9) Refused

(01) continuous answer
(-8) Don't Know
(-9) Refused