Cms-p-0015a Mcbs

Facility Screener
Variable Name
FSINTRO

SPRESIDENOW

MR Screen Name
FSI01

FS01

Question text/description
Code list
Hello, my name is (FI NAME). I am from NORC at the Unversity of
Chicago and we are conducting the Medicare Current Beneficiary
Survey for the Centers for Medicare and Medicaid Services, also
known as CMS, part of the United States Department of Health and
Human Services. We are studying a sample of people eligible for
Medicare who live in community and facility settings.
I am contacting you to confirm information that a person in our
sample lives or has lived in (FACILITY NAME).
Does (SP) currently live at (FACILITY NAME)?
IF RESPONDENT DOES NOT KNOW, ASK TO SPEAK TO
SOMEONE WHO WOULD KNOW ADMISSION INFORMATION.

SPRESIDE

FS02

Since (LAST INTERVIEW DATE), has (SP) lived [here/there]?
IF RESPONDENT DOES NOT KNOW OR , ASK TO SPEAK TO
SOMEONE WHO WOULD KNOW ADMISSION INFORMATION.

BOX INSTR1

FSVERIFY

FS03

FACNAME

FS03a

IF SUPPLEMENTAL SAMPLE, GO TO FS08 - FSWHERE.
ELSE CONTINUE to BOX INSTR2.
IF ADDRESS PRELOADED GO TO FS03 - FSVERIFY.
IF ADDRESS NOT PRELOADED GO TO FS3a - FSTADDR1.
I need to verify the name and contact information I have for
(FACILITY NAME). I have…READ INFORMATION BELOW
CORRECT OR ENTER THE INFORMATION BELOW

FS03a

CORRECT OR ENTER THE INFORMATION BELOW

FS03a

CORRECT OR ENTER THE INFORMATION BELOW

FS03a

CORRECT OR ENTER THE INFORMATION BELOW

FS03a

CORRECT OR ENTER THE INFORMATION BELOW

FS03a

CORRECT OR ENTER THE INFORMATION BELOW

FS03a

CORRECT THE PORTIONS OF THE PHONE LISTED BELOW

FSO3a

CORRECT THE PORTIONS OF THE FAX NUMBER LISTED
BELOW

BOX INSTR2

FSTADDR1

FSTADDR2

FCITY

FSTATE

FZIPCODE

FPHONE

FFAX

Text Fill Logic

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

(01) ADDRESS CORRECT
(02) ADDRESS INCORRECT
(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
(-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
(-8) Don't Know
(-9) Refused

[here] mode = in person
[there] mode = phone

FSFACILITY

FS04

What type of facility or place is (FACILITY NAME)? (Is this a…)
USE CATEGORIES AS PROBES IF NECESSARY

FSFACILITYOTH

FS04a

FSNAME

FS05

FSRES

FS06

FSSPCARENAME

FS06a

FS06a
FPADDR1

What type of facility is (FACILITY NAME)?

(01) continuous answer
(-8) Don't Know
(-9) Refused
What is the name of the specific place within (FACILITY NAME)
(01) continuous answer
where (SP) was residing on or around since [LAST INTERVIEW
(-8) Don't Know
DATE]?
(-9) Refused
Are residents placed in this facility by an agency of state, county, or (01) YES
local government?
(02) NO
(-8) Don't Know
(-9) Refused
Please give me the information of the person who is responsible for (01) continous answer
the oversight of (SP's) care.
(-8) Don't Know
(-9) Refused
ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW
(01) continuous answer
(-8) Don't Know
(-9) Refused

FS06a

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

FS06a

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

FS06a

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

FS06a

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

FS06a

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

FS06a

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

FPADDR2

FPCITY

FPSTATE

FPZIPCODE

FPPHONE

FPFAX

(01)CONTINUING CARE RETIREMENT COMMUNITY (CCRC)
(02) RETIREMENT COMMUNITY
(03) ADULT/GROUP HOME
(04) NURSING HOME/UNIT WITHIN A CCRC OR
RETIREMENT CENTER
(05)HOSPITAL-BASED SNF UNIT
(06) ASSISTED LIVING FACILITY
(07) BOARD AND CARE HOME
(08) DOMICILIARY CARE HOME
(09) PERSONAL CARE HOME
(010) REST HOME/RETIREMENT HOME
(11) MENTAL HEALTH CENTER/PSYCHIATRIC SETTING
(12) INSTITUTION FOR THE MENTALLY
RETARDED/DEVELOPMENTALLY DISABLED
(13) REHABILITATION FACILITY
(14) OTHER LONG-TERM CARE FACILITY (SPECIFY)
(15) PRIVATE RESIDENCE
(-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
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused

FSADMIN

FS07

BOX INSTR3
FSWHERE

FS08

FACNNAME

FS08a

FS08a
FNADDR1

What is the name of the facility administrator at (FACILITY NAME)? (01) continuous answer
(-8) Don't Know
(-9) Refused
IF FS01 - SPRESIDENOW = 01 GO TO CLOSING 2
ELSE GO TO CLOSING 2
Do you know where (SP) went after living at (FACILITY NAME)?
(01) YES
(02) NO
(03) DECEASED
(-8) DON'T KNOW
(-9) REFUSED
Please give me (SP)'s new address:
(01) continuous answer
ENTER THE INFORMATION BELOW
(-8) Don't Know
(-9) Refused
Please give me (SP)'s new address:
(01) continuous answer
ENTER THE INFORMATION BELOW
(-8) Don't Know
(-9) Refused

FS08a

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

FS08a

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

FS08a

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

FS08a

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

FS08a

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

FS08a
FNFAX
FSDODMM

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

FS09

What was the date of death?

FSDODDD

FS09

What was the date of death?

FSDODYY

FS09

What was the date of death?

BOX INSTR4

IF FS02 - SPRESIDE = 01 (YES) THEN GO TO CLOSING1
ELSE GO TO CLOSING2
That is all of the information I need at this time. Thank you very
much for your time. We will contact (you/SP) to arrange an
interview.

FNADDR2

FNCITY

FNSTATE

FNZIPCODE

FNPHONE

CLOSING1

CLOSING2

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

(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
(-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
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(-8) Don't Know
(-9) Refused
[you] FS04 - FSFACILITY <> 15
[SP] FS04 - FSFACILITY = 15