CMS-P-0015A Comm2017R79END

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

END-END QUESTIONNAIRE

Question Text/Description

Code List

Routing

(01) CONTINUE

EX1A - EXTHANK

END QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=ALL
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
If INTTYPE in (C001, C002, C004, C005, C006, C007) and SEASON=WINTER, administer after USQ.
If INTTYPE in (C003), administer after DIQ.
If INTTYPE in(C008), administer after IAQ
If (INTTYPE=C009) or (INTTYPE in(C001, C002, C004, C005, C006, C010) and SEASON=SUMMER), administer
after RXQ.

EXINTRO

EXTHANK

BOX EN1

IF EXIT ROUND CASE (INTTYPE IN (C008, C009)) AND R IS NOT DECEASED (SPALIVE^=3) GO TO EX1.
ELSE IF SP IS IN THE SUPPLEMENTAL SAMPLE (INTTYPE=C003), GO TO ETY2 - THANK_SUPP.
ELSE IF (SP IS THE RESPONDENT), GO TO ETY1 - THANK_SP.
ELSE GO TO ETY3 - THANK_PROXYPLANNER.

EX1

As I mentioned earlier, this is [your/(SP's)] final interview with this study. We have learned much from [your/(SP's)]
participation in the MCBS. Data from the study have already been used to inform Congress of the problems
Medicare beneficiaries might face regarding their access to health care. [Your/(SP's)] participation in this study has
given the United States government a much clearer picture of [your/(SP's)] health care needs and those of more
than 42 million Medicare participants.

I thank you sincerely for all the time and effort that you have put into this study. You have made a very important
contribution to the Medicare program and all of its beneficiaries by sharing [your/(SP's)] health care experiences with
us. Even though [you/(SP)] will no longer be a participant in our survey, [your/(SP's)] health care needs will continue
to be covered through the Medicare program. I'd like to express to [you/you and (SP)] appreciation on behalf of the
(01) CONTINUE
Centers for Medicare and Medicaid Services. Both NORC at the University of Chicago and the Centers for Medicare
and Medicaid Services wish [you/you and (SP)] the very best for the future.

EX1A

END1-INTLANG

[RESPONDENT MAY KEEP THE CALENDAR]

THANK_SP

ETY1

no entry

[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
time and cooperatoin during this interview.
(01) CONTINUE
CIRCLE TODAY'S DATE IN THE PLANNER AS A REFERENCE FOR THE RESPONDENT. EXPLAIN PLANNER
SECTIONS AS NECESSARY.

END1-INTLANG

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.
THANK_SUPP

ETY2

no entry

Here is a folder to keep any medical bills, receipts, Medicare statements, and insurance statements that would be
connected to [your/(SP)'s] health care visits 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.

(01) CONTINUE

END1-INTLANG

THANK_PROXYPL
ETY3
ANNER

no entry

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.
CIRCLE TODAY'S DATE IN PLANNER AS A REFERENCE FOR THE RESPONDENT. EXPLAIN PLANNER
SECTIONS IN DETAIL TO RESPONDENT.

(01) CONTINUE

THANK_PROXY

THANK_PROXY

ETY4

no entry

I would like to thank you for your time and cooperation during this interview. We may be contacting you in the future
(01) CONTINUE
for further information.

END1-INTLANG

INTLANG

END1

code 1

WAS THIS INTERVIEW CONDUCTED MOSTLY IN ENGLISH OR
SPANISH?

(02) ENGLISH
(03) SPANISH

(02) END2 - SAVECASE
(03) END2 - SAVECASE

(01) CONTINUE
(-7) Empty

BOX END

THE INTERVIEW IS OVER. PRESS ENTER OR CLICK [CLOSE] TO RETURN TO CM FIELD.

SAVECASE

END2

no entry

BOX END

routing

IF COMMUNITY CONTACT DATA COLLECTION (CCDC) MODULE HAS NOT BEEN COMPLETED (CCDC
INSTRUMENT STATUS IS "NO ACTION" OR "BREAKOFF") THEN DISPLAY "THE COMMUNITY CONTACT
DATA COLLECTION (CCDC) MODULE HAS NOT YET BEEN COMPLETED FOR THIS CASE. IF POSSIBLE,
PLEASE COMPLETE THAT MODULE WITH THE [RESPONDENT/PROXY] DIRECTLY FOLLOWING THE
INTERVIEW."
CASE IS COMPLETE.

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