CMS-P-0015A Comm2017R79ERQ

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

ERQ - Emergency Room Utilization

Question Type

Question Text/Description

Code List

Routing

EMERGENCY ROOM UTILIZATION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C009, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after DUQ.

ERPROBE

ER1

yes/no

(01) YES
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], [have you gone/has (SP) gone/did (SP) go] to a hospital emergency room (03) INDICATED YES BY DATAPREP
for medical care?
(-8) Don't Know
(-9) Refused

(01) ER2 - PROVIDER_ER
(02)BOX ER6
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX ER6
(-9) BOX ER6

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
PROVIDER_ER

ER2

roster

Where did [you/(SP)] go (to which hospital)?
SELECT OR ADD ONLY ONE HOSPITAL.
[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE HOSPITAL.]

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

BOX ER1

N. [PROVIDER N]
N+1. ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.

[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
ENTER THE NAME OF THE PROVIDER AND THE BILLING/GROUP OR PRACTICE NAME BELOW.
PROVNAME

ER2

verbatim

[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE HOSPITAL]

BOX ER1

YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT
YOU DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE
GROUP OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.
NAME:

GROUPNAM

ER2

BOX ER1

VAPLACE

ER3

BOX ER1B

HMOASSOC

HMOREFER

ER3A

ER3B

verbatim

GROUP:

routing

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO ER3 VAPLACE.
ELSE GO TO BOX ER1B.

yes/no

Is (PROVIDER NAME) a Department of Veterans Affairs, or V.A., facility?

routing

IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO ER3A - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (THIS
PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO ER3B - HMOREFER.
ELSE GO TO ER4 - EVENT_ER.

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

BOX ER1B

(01) ER4 - EVENT_ER
(02) ER3B - HMOREFER
(-8) ER3B - HMOREFER
(-9) ER3B - HMOREFER

ER4 - EVENT_ER

yes/no

Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

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

yes/no

[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]

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

Page 1 of 6

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

ERQ - Emergency Room Utilization

Question Type

EVENT_ER

ER4

roster

ERADD

ER4B

choose one

NAVIGATOR

ERADMIT

PRESMDCN

PRESFILL

ER4_IN

ER6

ER7

ER8

BOX ER3A

ERPMMEDS

ER8A

Question Text/Description

Code List

When did [you/(SP)] go to the emergency room at (PROVIDER NAME)?

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

Please tell me all the dates [since REFERENCE DATE/UTILDATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
MM:
[IF THE SAMPLE PERSON SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY DD:
ONCE.]
YYYY:
HAVE ALL DATES BEEN ENTERED?

Routing

ER4_IN - NAVIGATOR

(01) ADD ANOTHER
(02) ALL DONE

(01) ER6 -EVENT_ER
(02) ER6_IN - NAVIGATOR

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

(01) ER6 - ERADMIT
(02) ER10 - ERMORE

[Were you/Was (SP)] admitted to (PROVIDER NAME) from the emergency room?

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

(01) BOX ER4
(02) ER7 - PRESMDCN
(-8) ER7 - PRESMDCN
(-9) ER7 - PRESMDCN

yes/no

During [your/(SP’s)] visit to the emergency room, were any medicines prescribed for [you/(SP)]?

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

(01) ER8 - PRESFILL
(02) BOX ER4
(-8) BOX ER4
(-9) BOX ER4

yes/no

Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE RESPONDENT
ACTUALLY TOOK THE MEDICINE.]

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

(01) BOX ER3A
(02) BOX ER4
(-8) BOX ER4
(-9) BOX ER4

routing

IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO ER8A - ERPMMEDS.
ELSE GO TO BOX PM2.

instance navigator

yes/no

no entry

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
YOU HAVE ENTERED DATES FOR THE FOLLOWING EVENTS. SELECT AN EVENT TO DISCUSS WITH SP
OR PRESS [PREVIOUS] TO GO BACK AND ADD MORE EVENTS.
[DISPLAY ALL EVENTS ADDED AT ER6]
[EVENT DATE, PROVIDER]

It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can spell
the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)]
(MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same
information on them.]

BOX PM 2

[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles, too.

BOX PM2

MEDICINE_PM1

routing

IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE,
GO TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.

MEDICINE_PM1

code one

What is the name of the medicine?

BOX PM3

routing

IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.

[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME AND STRENGTH FOR
EACH.

BOX PM3

Page 2 of 6

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

ERQ - Emergency Room Utilization

Question Type

Question Text/Description

Code List

Routing

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

BOX PM4

CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
SAMEFSAM

SAMEFSAM

yes/no

The strength was [MEDICINE STRENGTH].
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.

BOX PM4

PMBOTTLE

PMBOTTLE

routing

IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.

code one

(01) YES
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
(02) NO
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
(03) NO BUT R CAN ANSWER QUESTIONS
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS ABOUT
(-8) DON'T KNOW
THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
(-9) REFUSED

(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM

TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE BOX BELOW.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME

MED

[MEDICINE NAME SELECTED FROM LOOKUP OR
MANUALLY TYPED]

lookup
[PRESCRIBED MEDICINE LOOKUP TOOL]

PMBRNAME

MED

lookup

[PM BRAND NAME]

PMGNNAME

MED

lookup

[PM GENERIC NAME]

PMFORMFD

MED

lookup

Medicine Form [FDB LIST FORM NAME]

PMFMCODE

MED

lookup

Medicine Form [FDB LIST FORM CODE]

PMFORMMC

MED

code one

Medicine Form [MCBS FORM]

(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know

PMFORMOS

MED

verbatim

[MEDICINE FORM OTHER SPECIFY]

(01) CONTINUOUS ANSWER

PMFORMFN

MED

verbatim

[FINAL CONCATENATED MEDICINE FORM]

PMSTRNFD

MED

verbatim

Medicine Strength

(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW

STRNNUMBB

MED

numeric

Medicine strength number

(01) CONTINUOUS ANSWER

(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS

Page 3 of 6

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

ERQ - Emergency Room Utilization

Question Type

Question Text/Description

STRNUNIT

MED

code one

PMSTRNOS

MED

verbatim

[MEDICINE STRENGTH UNIT OTHER SPECIFY]

PMSTRUNI

MED

lookup

[FINAL CONCATENATED MEDICINE STRENGTH]

PMEDID

MED

numeric

[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]

FAMILYID

MED

numeric

[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]

PMKNWNM

PMKNWNM

code one

DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?

PMCOND

PMCOND

code one

PMCONDOS

PMCOND

verbatim

GETNUM

TABNUM

GETNUM

numeric

Medicine strength unit

What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.

OTHER (SPECIFY)

Code List
(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER

(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND

(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01)-(19) GETNUM-GETNUM
(20) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND, CHECK
(-9) Refused
“ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF REFILLS.]

BOX PM5

routing

TABNUM

numeric

HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?

(01)-(08) MED-MEDID
(91) MED-PMSTRNOS

(01) YES
(02) NO
(-9) REFUSED

How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?

IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS
("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTNUM.

Routing

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

BOX PM5

BOX PM6

Page 4 of 6

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

ERQ - Emergency Room Utilization

Question Type

Question Text/Description

Code List

Routing
(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6

AMTUNIT

PM16

quantity unit

HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]

(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW

AMTUNOS

PM16

text

OTHER (SPECIFY)

(01) CONTINUOUS ANSWER

PM16 - AMTNUM

AMTNUM

PM16

numeric

(01) CONTINUOUS ANSWER

BOX PM6

BOX PM6

routing

IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?

TABSADAY

PM12

numeric

TABSADAY95

PM12

code one

IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX:
HALF A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN A (01) CONTINUOUS ANSWER
DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".

(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty

PM12 - TABSADAY95

PM13-TABTAKE

How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]
TABTAKE

PM13

numeric
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A
PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".

TABTAKE96

PMSATVA

PMSATHMO

PM13

code one

BOX PM7

routing

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.

PMSATVA

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
Veterans Affairs or V.A.?

BOX PM8

routing

IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.

PMSATHMO

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?

(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW

PM13 - TABTAKE96

(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY

BOX PM7

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

BOX PM8

(01) YES
(02) NO
(-8) DON'T KNOW
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors [your/(SP’s)] (-9) REFUSED
plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]

PMMORE-PMMORE

Page 5 of 6

2017 MCBS Community Questionnaire

Variable Name

PMMORE

ERMORE

MR Screen Name

PM17

ERQ - Emergency Room Utilization

Question Type

yes/no

Question Text/Description
([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE
NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.])
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R
ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't
talked about?]

ER10

yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other visits to the emergency room at this or any
other hospital?

BOX ER5

routing

IF WINTER ROUND AND ((SP REPORTED AN EMERGENCY ROOM VISIT AT ER2) AND (SP IS ALIVE AND
NOT INSTITUTIONALIZED)), GO TO AC6A - EWAITUNT.
ELSE GO TO BOX ER6.

BOX ER6

routing

GO TO IPQ.

Code List

Routing

(01) ADD ANOTHER
(02) ALL DONE

(01) BOX PM2
(02) ER10 - ERMORE

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

(01) ER2 - PROVIDER_ER
(02) BOX ER5
(-8) BOX ER5
(-9) BOX ER5

Page 6 of 6