Cms-p-0015a Mcbs

Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
OMPREYEG
OM1

Question type
yes/no

Question text/description
Next I’m going to ask you about other medical expenses that [you/(SP)] may have had [between (REFERENCE
DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy,
replace, or pay for repairs of eyeglasses or contact lenses?

EVENT_OMEYEG

OM2

roster

[INCLUDE NON-PRESCRIPTION READING GLASSES.]
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/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].

OMADD

OM2AA

code one

BOX OM1AA

routing

NAVIGATOR

OM2_IN

instance navigator

OMSATHMO

OM2A

yes/no

[INCLUDE NON-PRESCRIPTION READING GLASSES.]
HAVE ALL DATES BEEN ENTERED?

Code list
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
(01) ADD ANOTHER
(02) ALL DONE

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
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.

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]?

(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[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 plan
referred [you/(SP)] to.]

OMPRHEAR

BOX OM1AA1
BOX OM1AA2

routing
routing

OM3

yes/no

[INCLUDE NON-PRESCRIPTION READING GLASSES.]
GO TO OM2_IN - NAVIGATOR.
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM3 - OMPRHEAR.
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], 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?
[INCLUDE RELATED EXPENSES SUCH AS BATTERIES FOR A HEARING AID OR SPEAKING DEVICE. DO NOT
INCLUDE A WARRANTY FOR A HEARING AID AS AN OM EVENT.]

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
EVENT_OMHEAR OM4

Question type
roster

Question text/description
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair a hearing or speech device?
Please tell me the dates of each purchase or repair [since (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].

OMADD

OM4AA

code one

BOX OM1BB

routing

NAVIGATOR

OM4_IN

instance navigator

OMSATHMO

OM4A

yes/no

BOX OM1BB1
BOX OM1BB2

routing
routing

BOX OMA1

routing

ORTHINTRO

OMS5INTR

no entry

NAVIGATOR

OMS5_IN

instance navigator

RENTSTIL

OMS5

code one

HAVE ALL DATES BEEN ENTERED?

OM5

yes/no

MM:
DD:
YYYY:
(01) ADD ANOTHER
(02) ALL DONE

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
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.

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]?
[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.
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OMA1.
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.
The next questions are about orthopedic items [you were/(SP) was] renting as of (REFERENCE DATE).

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?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]

OMPRORTH

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

SHOW CARD OM1
(Other than what we already talked about,) [(Since/since) (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy, repair or rent (other) orthopedic
items, such as any of those listed on this card?
[Orthopedic items include crutches, canes, wheelchairs, walkers, corrective shoes or inserts, support
stockings, and braces or supports.]

(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) continuous answer
(-7) Empty
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
ORTHTYPE
OM6

Question type
code one

EVOSTEXT
RENTPROB

verbatim text
code one

OM6
OM6A

EVENT_OMORTH OM7

OMADD

roster

OM7AAA

BOX OM1CC

routing

NAVIGATOR

OM7_IN

instance navigator

OMSATHMO

OM7AA

yes/no

BOX OM2A
EVENT_OMORTHR OM7A
ENT

RENTSTIL

OM7B

routing
yes/no

yes/no

Question text/description
What was the item?

Code list
(01) BRACES/SUPPORTS
(02) CANE
(03) CORRECTIVE SHOES/INSERTS
(04) CRUTCHES
(05) WALKER
(06) WHEELCHAIR/CART
(07) STOCKINGS
(91) OTHER
OTHER (SPECIFY)
(01) continuous answer
Did [you/(SP)] buy or repair the (ORTHOPEDIC ITEM), or did [you/(SP)] rent (it/them)?
(01) BUY/REPAIR
(02) RENT
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN THE
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
SAME ROUND, SELECT "RENT."]
EQUIPMENT
(-8) Don't Know
(-9) Refused
SELECT OR ADD ALL DATES AT THIS ROSTER.
(01) continuous answer
When did [you/(SP)] buy (or repair) the (ORTHOPEDIC ITEM)? Please tell me all the dates [since (REFERENCE (-8) Don't Know
DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and
(-9) Refused
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
MM:
DD:
YYYY:
HAVE ALL DATES BEEN ENTERED?
(01) ADD ANOTHER
(02) ALL DONE
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
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) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
On (EVENT DATE), did [you/(SP)] buy (or repair) the (ORTHOPEDIC ITEM) at [READ MANAGED CARE PLAN
(01) YES
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
(02) NO
BELOW]?
(-8) Don't Know
(-9) Refused
[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.
ENTER ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) AND (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the (ORTHOPEDIC ITEM).

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

[Are you/Is (SP)/Was (SP)] still renting the (ORTHOPEDIC ITEM)?

MM:
DD:
YYYY:
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
EVENDMM
OM7C

EVENDDD

OM7C

Question type
date

Question text/description
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?

date

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]

EVENDYY

OM7C

date

What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]

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

BOX OM3A

routing

RENT2BUY

OM7CC

code one

REN2BVB

OM7CCVB

verbatim text

OMADD

OM7CC1

code one

BOX OM1EE

routing

OM7D

yes/no

OMSATHMO

BOX OM1EE1

routing

BOX OM4

routing

MOREORTH

OM8

yes/no

OMPRDIAB

OM9

yes/no

IF SP IS NOT DECEASED, GO TO OM7CC - RENT2BUY.
ELSE GO TO BOX OM1EE.
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.
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
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.
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]?
[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.]
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM4.
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS5_IN - NAVIGATOR.
ELSE GO TO OM8 - MOREORTH.
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/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].?
SHOW CARD OM2
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], 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.]
[DO NOT INCLUDE INSULIN.]

(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused
(01) continuous answer
(01) ADD ANOTHER
(02) ALL DONE

(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) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
EVENT_OMDIAB OM10

OMADD

OM10AA

Question type
roster

code one

BOX OM1FF

routing

NAVIGATOR

OM10_IN

instance navigator

OMSATHMO

OM10A

yes/no

Question text/description
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 DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].

HAVE ALL DATES BEEN ENTERED?

Code list
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
(01) ADD ANOTHER
(02) ALL DONE

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
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.

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]?

(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

[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.]

OMPRAMBL

BOX OM1FF1
BOX OM1FF2

routing
routing

OM11

yes/no

EVENT_OMAMBL OM12

roster

OMADD

OM12AA

code one

BOX OM1GG

routing

NAVIGATOR

OM12_IN

instance navigator

OMSATHMO

OM12A

yes/no

BOX OM1GG1

routing

GO TO OM10_IN - NAVIGATOR.
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM11 - OMPRAMBL.
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
(01) YES
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] use any (02) NO
ambulance or rescue squad service?
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
SELECT OR ADD ALL DATES AT THIS ROSTER.
(01) continuous answer
When did [you/(SP)] use an ambulance? Please tell me all the dates [since (REFERENCE DATE/SURVEY
(-8) Don't Know
REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
(-9) Refused
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
HAVE ALL DATES BEEN ENTERED?
(01) ADD ANOTHER
(02) ALL DONE
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
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.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
Was the ambulance on (EVENT DATE) provided by or approved by [READ MANAGED CARE PLAN NAME(S)
(01) YES
BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could mean that the ambulance was sent by the plan, or that [you/(SP)] or someone for
(-9) Refused
[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.

Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
BOX OM1GG2

Question type
routing

OMPRPROS

OM13

yes/no

EVENT_OMPROS

OM14

roster

OMADD

OM14AA

code one

BOX OM1HH

routing

NAVIGATOR

OM14_IN

instance navigator

OMSATHMO

OM14A

yes/no

BOX OM1HH1
BOX OM1HH2

routing
routing

BOX OMA4

routing

OXGNINTRO

OMS19INTR

no entry

NAVIGATOR

OMS19_IN

instance navigator

RENTSTIL

OMS19

code one

OMPROXGN

OM19

yes/no

Question text/description
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM13 - OMPRPROS.
SHOW CARD OM3
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy or
pay for repairs of any prostheses, such as those on the card?
[Prostheses include artificial leg or arm, mastectomy prosthesis, and artificial or glass eye.]
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 DATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].

HAVE ALL DATES BEEN ENTERED?

Code list

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
(01) ADD ANOTHER
(02) ALL DONE

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
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.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
On (EVENT DATE), did [you/(SP)] buy or repair the prosthesis at [READ MANAGED CARE PLAN NAME(S)
(01) YES
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could include buying or repairing the prosthesis at a plan center; at a place or store that honors (-9) Refused
[your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
GO TO OM14_IN - NAVIGATOR.
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OMA4.
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).
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
At the time of the last interview, [you were/(SP) was] renting oxygen-related equipment. As of [today/(DATE (01) YES
OF DEATH)/(DATE OF INSTITUTIONALIZATION)/(ENDUTILD)] (is/was) the oxygen-related equipment being
(02) NO
rented?
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
(-9) Refused
(Other than what we already talked about,) [(Since/since) (REFERENCE DATE/SURVEY REFERENCE
(01) YES
DATE/UTILDATE)/(Between/between) (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
(02) NO
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any (other) expenses for oxygen or (03) INDICATED YES BY DATAPREP
supplies or oxygen-related equipment?
(-8) Don't Know
(-9) Refused

Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
OXGNTYPE
OM19A

Question type
code one

RENTPROB

code one

OM19B

EVENT_OMOXGN OM20

roster

OMADD

OM20AAA

code one

BOX OM1II

routing

NAVIGATOR

OM20_IN

instance navigator

OMSATHMO

OM20AA

yes/no

BOX OM1II1
BOX OM7

routing
routing

Question text/description
What was that?

Code list
(01) OXYGEN/SUPPLIES
(02) OXYGEN-RELATED EQUIPMENT
Did [you/(SP)] buy or repair the oxygen-related equipment, or did [you/(SP)] rent it?
(01) BUY/REPAIR
(02) RENT
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN THE
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
SAME ROUND, SELECT "RENT."]
EQUIPMENT
(-8) Don't Know
(-9) Refused
SELECT OR ADD ALL DATES AT THIS ROSTER.
(01) continuous answer
When did (you/(SP)] purchase the [(oxygen or supplies)/(oxygen-related equipment)]? Please tell me the
(-8) Don't Know
dates of each purchase [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE (-9) Refused
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
MM:
DD:
YYYY:
HAVE ALL DATES BEEN ENTERED?
(01) ADD ANOTHER
(02) ALL DONE
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
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
On (EVENT DATE), did [you/(SP)] buy or repair the (OXYGEN ITEM) at [READ MANAGED CARE PLAN NAME(S) (01) YES
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could include buying or repairing the (OXYGEN ITEM) at a plan center; at a place or store that
(-9) Refused
honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]

EVENT_OMOXGN OM20A
RENT

roster

RENTSTIL

OM20B

yes/no

GO TO OM20_IN - NAVIGATOR.
IF OM19B - RENTPROB = 3/BoughtAndRented, GO TO OM20A - EVENT_OMOXGNRENT.
ELSE GO TO BOX OM1KK1.
SELECT OR ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the oxygen-related equipment.
[Are you/Is (SP)/Was (SP)] still renting the oxygen-related equipment?

EVENDMM

OM20C

date

What was the last date the equipment was rented?
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]

(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) continuous answer
(02) Don't Know
(03) Refused
MM:
DD:
YYYY:

Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
EVENDDD
OM20C

EVENDYY

OM20C

Question type
date

Question text/description
What was the last date the equipment was rented?

date

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]
What was the last date the equipment was rented?

BOX OM8A

routing

RENT2BUY

OM20CC

code one

REN2BVB

OM20CCVB

verbatim text

OMADD

OM20CC1

code one

BOX OM1KK

routing

OM20D1

yes/no

OMSATHMO

BOX OM1KK1

routing

BOX OM9

routing

BOX OM10

routing

OM20D

yes/no

BOX OM11

routing

BOXOMA11

routing

KDNYINTRO

OMS21INTR

no entry

NAVIGATOR

OMS21_IN

instance navigator

MOREOXGN

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]
IF SP IS NOT DECEASED, GO TO OM20CC - RENT2BUY.
ELSE GO TO BOX OM1KK.
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?

BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE OXYGEN-RELATED EQUIPMENT.
RECORD VERBATIM.
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
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.
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]?
[PROBE: This could include renting the oxygen equipment 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.]
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM9.
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS19_IN - NAVIGATOR.
ELSE GO TO BOX OM10.
IF OM20D HAS NOT BEEN ASKED, GO TO OM20D - MOREOXGN.
ELSE GO TO BOX OMA11.
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)]?

Code list
(01) continuous answer
(02) Don't Know
(03) Refused
(01) continuous answer
(02) Don't Know
(03) Refused

(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused
(01) continuous answer
(01) ADD ANOTHER
(02) ALL DONE

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

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.
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).
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED

Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
RENTSTIL
OMS21

Question type
code one

OMPRKDNY

OM21

yes/no

KDNYTYPE

OM21A

code one

RENTPROB

OM21B

code one

EVENT_OMKDNY

OM22

roster

OMADD

OM22AAA

code one

BOX OM1LL

routing

NAVIGATOR

OM22_IN

instance navigator

OMSATHMO

OM22AA

yes/no

BOX OM14
EVENT_OMKDNYR OM22A
ENT

routing
roster

RENTSTIL

yes/no

OM22B

Question text/description
At the time of the last interview, [you were/(SP) was] renting equipment for kidney dialysis. As of
(today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD)], (is/was) the equipment being
rented?

Code list
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
(-9) Refused
(Other than what we already talked about), [(Since/since) (REFERENCE DATE/SURVEY REFERENCE
(01) YES
DATE/UTILDATE)/(Between/between) (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
(02) NO
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy any (other) kidney dialysis supplies (03) INDICATED YES BY DATAPREP
or buy, rent, or repair any related equipment?
(-8) Don't Know
(-9) Refused
What was that?
(01) KIDNEY DIALYSIS SUPPLIES
(02) KIDNEY DIALYSIS EQUIPMENT
Did [you/(SP)] buy or repair the dialysis equipment, or did [you/(SP)] rent it?
(01) BUY/REPAIR
(02) RENT
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN THE
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
SAME ROUND, SELECT "RENT."]
EQUIPMENT
(-8) Don't Know
(-9) Refused
SELECT OR ADD ALL DATES AT THIS ROSTER.
(01) continuous answer
When did [you/(SP)] (purchase the kidney dialysis supplies)/(buy or repair kidney dialysis equipment)? Please (-8) Don't Know
tell me all the dates [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
(-9) Refused
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
MM:
DD:
YYYY:
HAVE ALL DATES BEEN ENTERED?
(01) ADD ANOTHER
(02) ALL DONE
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
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
On (EVENT DATE), did [you/(SP)] buy (or repair) the (KIDNEY ITEM) at [READ MANAGED CARE PLAN NAME(S) (01) YES
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could include buying (or repairing) the (KIDNEY ITEM) at a plan center; at a place or store that (-9) Refused
honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]
GO TO OM22_IN - NAVIGATOR.
SELECT OR ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] 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

Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
EVENDMM
OM22C

Question type
date

Question text/description
What was the last date the equipment was rented?
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]

EVENDDD

EVENDYY

OM22C

OM22C

date

What was the last date the equipment was rented?

date

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]
What was the last date the equipment was rented?

BOX OM15A

routing

RENT2BUY

OM22CC

code one

REN2BVB

OM22CCVB

verbatim text

OMADD

OM22CC1

code one

OMSATHMO

MOREKDNY

BOX OM1NN

routing

OM22D1

yes/no

BOX OM1NN1

routing

BOX OM16

routing

BOX OM17

routing

OM22D

yes/no

BOX OM18

routing

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]
IF SP IS NOT DECEASED, GO TO OM22CC - RENT2BUY.
ELSE GO TO BOX OM1NN.
You said [you/(SP)] stopped renting the dialysis 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?

BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE DIALYSIS EQUIPMENT.
RECORD VERBATIM.
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
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.
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]?
[PROBE: This could include renting the kidney dialysis equipment 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.]
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM16.
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS21_IN - NAVIGATOR.
ELSE GO TO BOX OM17.
IF OM22D HAS NOT BEEN ASKED, GO TO OM22D - MOREKDNY.
ELSE GO TO BOX OMA18.
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)]?

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.

Code list
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused

(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused
(01) continuous answer
(01) ADD ANOTHER
(02) ALL DONE

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
BOX OMA18

Question type
routing

OTHRINTRO

OMS23INTR

no entry

NAVIGATOR

OMS23_IN

instance navigator

RENTSTIL

OMS23

code one

OMPROTHR

OM23

yes/no

Question text/description
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).

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)/(ENDUTILD), (is/was) the (OTHER MEDICAL
EXPENSE ITEM) being rented?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
SHOW CARD OM4
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy,
rent, or repair any other medical equipment or buy any other medical supplies besides what we have talked
about?

Code list

(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

[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.]
OTHRTYPE

OM24

code one

What kind of equipment was the item?

(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

EVOSTEXT
RENTPROB

OM24
OM24A

verbatim text
code one

OTHER (SPECIFY)
Did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE ITEM), or did [you/(SP)] rent it?

(01) continuous answer
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
EQUIPMENT
(-8) Don't Know
(-9) Refused

[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN THE
SAME ROUND, SELECT "RENT."]

GETNUM

BOX OM18B

routing

OM25

numeric

IF NOT ADMINISTERING ST AND NOT ADMINISTERING NS, GO TO OM25 - GETNUM.
ELSE GO TO BOX OM1QQ1.
THIS ITEM AND NUMBER OF PURCHASES HAS BEEN ENTERED ALREADY FOR THIS ROUND. PLEASE CORRECT (01) continuous answer
THE NUMBER OF TIMES TO BE THE TOTAL NUMBER OF TIMES PURCHASED SINCE (REFERENCE
(-8) Don't Know
DATE/UTILDATE).
(-9) Refused
How many times [since (REFERENCE DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)] [[have you/has (SP)] bought or obtained/did (SP) buy or
obtain] (OTHER MEDICAL EXPENSE ITEM)?

Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
EVENT_OMOTHR OM26

OMADD

OM26AAA

Question type
roster

code one

BOX OM1OO

routing

NAVIGATOR

OM26_IN

instance navigator

OMSATHMO

OM26AA

yes/no

Question text/description
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/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]

HAVE ALL DATES BEEN ENTERED?

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]?

NAVIGATOR
BOX OM21
EVENT_OMOTHRR OM26A
ENT

instance navigator
roster

RENTSTIL

OM26A1

yes/no

EVENDMM

OM26B

date

What was the last date [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM)?
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]

OM26B

date

What was the last date [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM)?
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]

EVENDYY

OM26B

date

MM:
DD:
YYYY:
(01) ADD ANOTHER
(02) ALL DONE

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
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.

[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.]
GO TO OM26_IN - NAVIGATOR.
ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM).
[Are you/Is (SP)] still renting the (OTHER MEDICAL EXPENSE ITEM)?

EVENDDD

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

What was the last date [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM)?
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]

(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(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
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
(01) continuous answer
(-8) Don't Know
(-9) Refused
DD:
(01) continuous answer
(-8) Don't Know
(-9) Refused
YYYY:

BOX OM22A

routing

IF SP IS NOT DECEASED, GO TO OM26BB - RENT2BUY.
ELSE GO TO BOX OM1QQ.

Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
RENT2BUY
OM26BB

Question type
code one

Question text/description
You said [you/(SP)] stopped renting the (OTHER MEDICAL EXPENSE ITEM). Is this because (you/he/she) no
longer (have/has) the item or because (you/he/she) (have/has) purchased it through a rent-to-buy option?

REN2BVB

OM26BBVB

verbatim text

OMADD

OM26BB1

code one

BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE (OTHER MEDICAL EXPENSE ITEM).
RECORD VERBATIM.
HAVE ALL DATES BEEN ENTERED?

OMSATHMO

BOX OM1QQ

routing

OM26C

yes/no

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
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]?
[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.]

BOX OM1QQ1

routing

BOX OM23

routing

OM27

yes/no

BOX OM24

routing

ALTRINTRO
NAVIGATOR

OMS28INTR
OMS28_IN

no entry
instance navigator

EVBEGMM

OMS28

date

MOREOTHR

EVBEGDD

OMS28

date

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM23.
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS23_IN - NAVIGATOR.
ELSE GO TO OM27 - MOREOTHR.
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/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]?

Code list
(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused
(01) continuous answer
(01) ADD ANOTHER
(02) ALL DONE

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

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).

Last time [you/(SP)] had started to make an alteration (ALTERATION) that was not completed as of
(REFERENCE DATE/SURVEY REFERENCE DATE).
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD)] was this alteration
completed?
Last time [you/(SP)] had started to make an alteration (ALTERATION) that was not completed as of
(REFERENCE DATE/SURVEY REFERENCE DATE).
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD)] was this alteration
completed?

(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
EVBEGYY
OMS28

Question type
date

Question text/description
Last time [you/(SP)] had started to make an alteration (ALTERATION) that was not completed as of
(REFERENCE DATE/SURVEY REFERENCE DATE).
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD)] was this alteration
completed?

OMNOTDONE

OMS28

code one

OMPRALTR

BOX OM25
OM28

routing
yes/no

Code list
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

(01) ALTERATION NOT YET COMPLETED
(-7) Empty
GO TO OMS28_IN - NAVIGATOR.
SHOW CARD OM5
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], 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 examples.
[Alterations include ramps, handrails, elevator or incline chair, tub seats, tub handrails, and any car
alterations.]
What was the alteration?

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

ALTRTYPE

OM29

code one

EVOSTEXT
EVBEGMM

OM29
OM30

verbatim text
date

OTHER (SPECIFY)
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)] was
this alteration completed?

EVBEGDD

OM30

date

On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)] was
this alteration completed?

MM:
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

EVBEGYY

OM30

date

On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)] was
this alteration completed?

DD:
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

OMNOTDONE

OM30

OMADD

OM30B

BOX OM25A

code one
HAVE ALL DATES BEEN ENTERED?

routing

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM31 - MOREALTR.

(01) ELEVATOR OR INCLINE CHAIR
(02) HANDRAILS (OTHER THAN TUB)
(03) RAMPS
(04) TUB HANDRAILS
(05) TUB SEAT
(06) ANY CAR ALTERATION
(91) OTHER
(01) continuous answer
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

YYYY:
(01) ALTERATION NOT YET COMPLETED
(-7) Empty
(01) ADD ANOTHER
(02) ALL DONE

Other Medical Expenses (OMQ)
Variable Name
MR Screen Name
MOREALTR
OM31

BOX OM26

Question type
yes/no

Question text/description
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/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]?

routing

GO TO NEXT SECTION

Code list
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused