CMS-P-0015A Comm2017R79HAQ

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HAQ-Housing Characteristics

Question Text/Description

Code List

Routing

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

BOX HA1

(01) ONE-FAMILY, DETACHED
(02) TWO-FAMILY OR DUPLEX
(03) APARTMENT OR CONDOMINIUM BUILDING
(04) MOBILE HOME, TRAILER
(05) ROWHOUSE, TOWNHOUSE
(06) "MOTHER-IN-LAW" APARTMENT
(91) SOMETHING ELSE
(96) SP IS HOMELESS/TRANSIENT/IN JAIL OR PRISON
(-8) Don't Know

(01) HA2 - HLEVELS
(02) HA2 - HLEVELS
(03) HA2 - HLEVELS
(04) HAINTRO2 - HAINT1
(05) HA2 - HLEVELS
(06) HA2 - HLEVELS
(91) HA1 - DWELLOS
(96) BOX HA4
(-8) HA2 - HLEVELS

(01) continuous answer

HA2 - HLEVELS

HOUSING CHARACTERISTICS QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C003, C004, C005, C006
SPALIVE=1
SEASON=FALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after ENS.

BOX HA

routing

IF ( SP IS IN THE SUPPLEMENTAL SAMPLE), GO BOX HA1.
ELSE GO TO HA1A-SPMOVED.
IF ANSWER IS KNOWN, CODE WITHOUT ASKING:

SPMOVED

HA1A

yes/no
[Have you/Has (SP)] moved since [LAST FALL ROUND DATE]?

HAINT

BOX HA1

routing

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP DID NOT RECEIVE THE HA SECTION IN THE PREVIOUS
YEAR) OR (SP MOVED IN THE PREVIOUS YEAR [SPMOVED=1/YES]) OR (THE TYPE OF DWELLING
REPORTED IN THE PREVIOUS YEAR WAS UNKNOWN) OR (MOST RECENT TYPE OF DWELLING
COLLECTED IN A PREVIOUS ROUND = 96/HomelessJail), GO TO HAINTRO - HAINT.
ELSE IF (SP DID NOT PREVIOUSLY REPORT THAT THIS RESIDENCE HAD RAMPS AT ENTRANCES) OR (SP
DID NOT PREVIOUSLY REPORT THAT THIS RESIDENCE HAD MODIFICATIONS TO ANY BATHROOM) OR (SP
DID NOT PREVIOUSLY REPORT THAT THIS RESIDENCE HAS SPECIAL RAILINGS), GO TO HAINTRO2A HAINT2.
ELSE GO TO BOX HA1B.

HAINTRO

no entry

IF THE SP IS HOMELESS, IS TRANSIENT WITH NO PERMANENT HOME, OR IS IN JAIL OR PRISON, SELECT
NEXT PAGE WITHOUT READING THIS INTRODUCTION.
I would like to ask a few questions about [your/(SP’s)] housing situation or living arrangements.

SHOW CARD HA1
DWELLING

HA1

code one

IF TYPE OF HOUSING IS OBVIOUS, CODE WITHOUT ASKING. SELECT "SP IS HOMELESS/TRANSIENT/IN
JAIL OR PRISON" WITHOUT ASKING.
[IF HOUSING TYPE IS NOT OBVIOUS, ASK:] Which of these best describes [your/(SP’s)] home?

DWELLOS

HA1

verbatim text

SOMETHING ELSE (SPECIFY)

code one

(01) ONE
How many levels are in [your/(SP’s)] (house/apartment or condominium building/place of residence)?
(02) TWO
[THE NUMBER OF LEVELS REFERS TO THE TOTAL NUMBER OF FLOORS INCLUDING BOTH FINISHED AND
(03) THREE OR MORE
UNFINISHED BASEMENTS AND FINISHED ATTICS. DO NOT INCLUDE UNFINISHED ATTICS OR ROOF
(-8) Don't Know
TERRACES.]
(-9) Refused

yes/no

Does [your/(SP’s)] (house/apartment or condominium building/place of residence) have an elevator?
[DO NOT INCLUDE ESCALATORS, WHEELCHAIR LIFTS, OR STAIR LIFTS.]

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

HA4 - HONELEVL

Is the living space in [your/(SP’s)] (house/own apartment or condominium/place of residence) all on one level?

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

(01) HAINTRO2 - HAINT1
(02) HA5 - HBTHLEVL
(-8) HA5 - HBTHLEVL
(-9) HA5 - HBTHLEVL

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

HAINTRO2 - HAINT1

HLEVELS

HELEVTR

HONELEVL

HBTHLEVL

HA2

HA3

HA4

HA5

yes/no

yes/no

Does [your/(SP’s)] (house/own apartment or condominium/place of residence) have either a full bathroom or a half
bathroom on all levels?
[PROBE: Bathroom facilities must contain at least a flush toilet, or a bathtub or shower.]

HAINT1

HAINTRO2

no entry

Next, I would like to ask about access or mobility modifications that [you/(SP)] may have in (your/his/her)
(house/apartment or condominium building/mobile home/place of residence).

(01) HAINTRO2 - HAINT1
(02) HA3 - HELEVTR
(03) HA3 - HELEVTR
(-8) HA3 - HELEVTR
(-9) HA3 - HELEVTR

BOX HA1AB

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2017 MCBS Community Questionnaire

HAQ-Housing Characteristics

Variable Name

MR Screen Name Question Type

Question Text/Description

HAINT2

HAINTRO2A

no entry

When we were here about a year ago, we asked about access or mobility modifications that may have been a part
of [your/(SP’s)] residence at that time. Now, I would like to update our information about such modifications.

routing

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP DID NOT RECEIVE THE HA SECTION IN THE PREVIOUS
YEAR) OR (SP MOVED IN THE PREVIOUS YEAR) OR (THE TYPE OF DWELLING REPORTED IN THE
PREVIOUS YEAR WAS UNKNOWN) OR (MOST RECENT TYPE OF DWELLING COLLECTED IN A PREVIOUS
ROUND = 96/HomelessJail) OR (SP DID NOT PREVIOUSLY REPORT THAT THIS RESIDENCE HAD RAMPS AT
ENTRANCES ), GO TO HA6 - HRAMPS.
ELSE GO TO BOX HA1AC.

yes/no

(01) YES
Does [your/(SP’s)] (house/mobile home/apartment or condominium building/place of residence) have ramps at (any (02) NO
of) its entrance(s)?
(-8) Don't Know
(-9) Refused

routing

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP DID NOT RECEIVE THE HA SECTION IN THE PREVIOUS
YEAR) OR (SP MOVED IN THE PREVIOUS YEAR) OR (THE TYPE OF DWELLING REPORTED IN THE
PREVIOUS YEAR WAS UNKNOWN) OR (MOST RECENT TYPE OF DWELLING COLLECTED IN A PREVIOUS
ROUND = 96/HomelessJail) OR (SP DID NOT PREVIOUSLY REPORT THAT THIS RESIDENCE HAD
MODIFICATIONS TO ANY BATHROOM ), GO TO HA7 - HBATHRM.
ELSE GO TO BOX HA1AD.

yes/no

Does [your/(SP’s)] (house/own apartment or condominium/mobile home/place of residence) have modifications to
any bathroom such as grab bars or a shower seat?

routing

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP DID NOT
RECEIVE THE HA SECTION IN THE PREVIOUS YEAR) OR (SP
MOVED IN THE PREVIOUS YEAR) OR (THE TYPE OF DWELLING
REPORTED IN THE PREVIOUS YEAR WAS UNKNOWN) OR (MOST RECENT TYPE OF DWELLING
COLLECTED IN A PREVIOUS ROUND = 96/HomelessJail) OR (SP DID NOT PREVIOUSLY REPORT THAT THIS
RESIDENCE HAS SPECIAL RAILIINGS), GO TO HA8 - HRAILING.
ELSE GO TO BOX HA1B.

yes/no

(01) YES
Other than stair railings, does [your/(SP’s)] (house/own apartment or condominium/mobile home/place of residence) (02) NO
have special railings to help (you/him/her) move around?[DO NOT INCLUDE HANDRAILS IN BATHROOMS.]
(-8) Don't Know
(-9) Refused

routing

IF (THE SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP DID NOT RECEIVE THE HA SECTION IN THE
PREVIOUS YEAR) OR (SP MOVED IN THE PREVIOUS YEAR) OR (MOST RECENT TYPE OF DWELLING
COLLECTED IN A PREVIOUS ROUND = 96/HomelessJail) OR (THE TYPE OF HOUSING REPORTED IN THE
PREVIOUS YEAR WAS UNKNOWN), GO TO HA9 - HOUSTYPE.
ELSE IF TYPE OF HOUSING WAS REPORTED LAST TIME IT WAS ASKED, GO TO HAINTRO3 - HAINT3.
ELSE GO TO BOX HA4.

yes/no

SHOW CARD HA2
Please look at this card. Is [your/(SP’s)] [house/own apartment or condominium/mobile home/place of residence] a
part of one of these communities?[IF A RESPONDENT EXPLAINS THAT THE PLACE OF RESIDENCE IS SIMILAR
TO ONE LISTED ON THE CARD BUT CALLED BY ANOTHER NAME, SELECT “YES”.]

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

(01) HA10 - HCOMUNTY
(02) BOX HA3
(-8) HA10 - HCOMUNTY
(-9) BOX HA3
(01) HA11 - HPERCARE
(02) HA11 - HPERCARE
(03) HA11 - HPERCARE
(04) HA11 - HPERCARE
(05) HA11 - HPERCARE
(06) HA11 - HPERCARE
(07) HA11 - HPERCARE
(08) HA11 - HPERCARE
(91) HA10 - HCOMUNOS
(-8) HA11 - HPERCARE
(-9) HA11 - HPERCARE
HA11 - HPERCARE

BOX HA1AB

HRAMPS

HA6

BOX HA1AC

HBATHRM

HA7

BOX HA1AD

HRAILING

HA8

BOX HA1B

HOUSTYPE

HA9

Code List

Routing
BOX HA1AB

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

HCOMUNTY

HA10

code one

SHOW CARD HA2
[IF NECESSARY, ASK:] Which category best describes [your/(SP’s)] type of housing?

(01) RETIREMENT COMMUNITY
(02) SENIOR CITIZENS HOUSING
(03) ASSISTED LIVING FACILITY
(04) CONTINUING CARE COMMUNITY
(05) STAGED LIVING COMMUNITY
(06) RETIREMENT APARTMENTS
(07) CHURCH-PROVIDED HOUSING
(08) PERSONAL OR RESIDENTIAL CARE HOME
(91) OTHER
(-8) Don't Know
(-9) Refused

HCOMUNOS

HA10

verbatim text

OTHER (SPECIFY)

(01) continuous answer

HAINT3

HAINTRO3

no entry

The type of community [you/(SP)] [live/lives] in sometimes gives its residents access to personal care services.
Next, I would like to update our records regarding [your/(SP’s)] access to such services.

BOX HA1AC

BOX HA1AD

BOX HA1B

HA11 - HPERCARE

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2017 MCBS Community Questionnaire

Variable Name

HPERCARE

MEALPROB

MAIDPROB

WASHPROB

HELPPROB

TRANPROB

RECPROB

SERVINCL

HAQ-Housing Characteristics

MR Screen Name Question Type

Question Text/Description

Code List

Routing

HA11

yes/no

SHOW CARD HA3
Does [your/(SP’s)] place of residence give (you/him/her) access to personal care services like any of those listed on
this card?
[THE RESPONDENT ONLY HAS TO HAVE ONE PERSONAL CARE SERVICE AVAILABLE TO HIM/HER TO
QUALIFY AS A “YES” FOR THIS QUESTION.]

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

(01) HA12 - MEALPROB
(02) BOX HA3
(-8) HA12 - MEALPROB
(-9) BOX HA3

list

We are interested in personal services that might be available here in addition to housing. In [your/(SP’s)] place of
residence], [do you/does (SP)] have access to…
prepared meals?

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

HA12 - MAIDPROB

list

We are interested in personal services that might be available here in addition to housing. In [your/(SP’s)] place of
residence], [do you/does (SP)] have access to…
housekeeping, maid, or cleaning services?

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

HA12 - WASHPROB

list

We are interested in personal services that might be available here in addition to housing. In [your/(SP’s)] place of
residence], [do you/does (SP)] have access to…
laundry services?

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

HA12 - HELPPROB

list

We are interested in personal services that might be available here in addition to housing. In [your/(SP’s)] place of
residence], [do you/does (SP)] have access to…
help with medications?

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

HA12 - TRANPROB

list

We are interested in personal services that might be available here in addition to housing. In [your/(SP’s)] place of
residence], [do you/does (SP)] have access to…
transportation?

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

HA12 - RECPROB

HA12

list

We are interested in personal services that might be available here in addition to housing. In [your/(SP’s)] place of
residence], [do you/does (SP)] have access to…
recreational services, such as exercise facilities, movies, activities programs, library, card rooms, pool tables, etc.?

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

BOX HA2

BOX HA2

routing

IF SP HAD ACCESS TO AT LEAST ONE PERSONAL SERVICE LISTED AT HA12, GO TO HA13 - SERVINCL.
ELSE GO TO BOX HA2A.
(01) ALL INCLUDED
(02) SOME INCLUDED/SOME SEPARATE
(03) ALL SEPARATE
(-8) Don't Know
(-9) Refused

BOX HA2A

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

(01) HA16 - REQAGE
(02) HA15 - CAREPART
(-8) HA16 - REQAGE
(-9) HA16 - REQAGE

HA12

HA12

HA12

HA12

HA12

HA13

BOX HA2A

code one

Are these services included as part of the cost of [your/(SP’s)] housing or is there a separate charge for them?

routing

IF (THE SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP DID NOT RECEIVE THE HA SECTION IN THE
PREVIOUS YEAR) OR (SP MOVED IN THE PREVIOUS YEAR) OR (MOST RECENT TYPE OF DWELLING
COLLECTED IN A PREVIOUS ROUND = 96/HomelessJail) OR (WHETHER OR NOT SP IS ALLOWED TO
CONTINUE LIVING IN HOME IF SUBSTANTIAL CARE IS NEEDED IS UNKNOWN), GO TO HA14 - STAYPUT.
ELSE GO TO BOX HA4.
Would the (place where [you/(SP)] currently (live/lives) allow (you/him/her) to continue living in (your/his/her)
(house/apartment or condominium/mobile home/place of residence) if (you/he/she) needed substantial care?

STAYPUT

HA14

yes/no
[PROBE: Could [you/(SP)] stay where (you/he/she) (live/lives) now if (you/he/she) needed a much greater level of
care?]

CAREPART

REQAGE

yes/no

(01) YES
(02) NO
If (you/he/she) needed substantial care, would that care be provided in another part of this same place of residence?
(-8) Don't Know
(-9) Refused

HA16

yes/no

Does the place where [you/(SP)] (live/lives) now require residents to be a certain age to live there or receive
services?

BOX HA3

routing

IF HA5 - HBTHLEVL = 1/Yes OR HA7 - HBATHRM = 1/Yes, GO TO HA18 - NBRROOMS.
ELSE GO TO HA17 - PERSBATH.

HA15

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

HA16 - REQAGE

BOX HA3

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2017 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HAQ-Housing Characteristics

Question Text/Description

Code List

Routing

Now I have a few questions about the rooms in [your/(SP’s)] place of residence.
PERSBATH

HA17

yes/no

NBRROOMS

HA18

numeric

(01) YES
[Do you/Does (SP)] have (your/his/her) own bathroom facilities?
(02) NO
(-8) Don't Know
[EXPLAIN IF NECESSARY: Own bathroom facilities may be defined as the sink, flush toilet, and bathtub or shower (-9) Refused
used primarily by [you/(SP)] and is not used on a regular basis by someone not living in the household.]
How many rooms are there in [your/(SP’s)] (house/own apartment or condominium/mobile home/place of
residence), not counting bathrooms, hallways, or unfinished basements?
[Do you/Does (SP)] have (your/his/her) own kitchen?

PERKITCH

HA19

yes/no

[EXPLAIN IF NECESSARY: Own kitchen is defined as an area with a sink, non-portable cooking equipment and a
refrigerator used primarily by [you/(SP)] and not on a regular basis by someone not living in the household. Also
includes kitchenettes.]

BOX HA4

routing

IF INTTYPE in(C001, C002, C003, C004, C005, C006), GO TO HIQ.

HA18 - NBRROOMS

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

HA19 - PERKITCH

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

BOX HA4

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