CMS-P-0015A Comm2017R79INQ

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

INQ-INTRODUCTION

Question Text/Description

Code List

Routing

(01) RESPONDENT AGREES TO CONTINUE WITH
RECORDING
(02) RESPONDENT DOES NOT WANT TO BE
RECORDED

(01) IN1AA - ATDOOR
(02) INV2 - NOCARI

INTRODUCTION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=ALL
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
(Start of interview)
BOX IN1

routing

GO TO INV1 - CARIVER.
Some of this interview will be recorded for quality control purposes.

CARIVER

INV1

code one
I'd like to continue now, unless you have any questions.

NOCARI

ATDOOR

INV2

IN1AA

no entry

no entry

That's fine. The interview will not be recorded.

IN1AA - ATDOOR

REVIEW WITH THE RESPONDENT THE FOLLOWING IMPORTANT FACTS FROM THE "AT-THE-DOOR"
SHEET:
All survey information will be kept private to the extent permitted by law, as prescribed by the Privacy Act of
1974.

IN2 - VERIFYSP

Medicare benefits will not be affected in any way by survey responses or participation.
REFER TO THE "AT-THE-DOOR" SHEET IF THE RESPONDENT NEEDS ADDITIONAL REASSURANCE.

VERIFYSP

IN2

yes/no

VERIFY THE SP’S NAME. IS THE SP’S NAME CORRECT AND COMPLETE?
FIRST NAME: (SP'S FIRST NAME)
MIDDLE INITIAL: (SP'S MIDDLE INITIAL)
LAST NAME: (SP'S LAST NAME)

ROSTFNAM

IN3

text

MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.

IN3 - ROSTMINI

ROSTMINI

IN3

text

MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.

IN3 - ROSTLNAM

ROSTLNAM

IN3

text

MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.

BOX IN1A

(01) YES
(02) NO

(01) BOX IN1A
(02) IN3 - ROSTFNAM

PLEASE INDICATE THE SP'S CURRENT STATUS. IF THE CASE IS A PROXY INTERVIEW AND YOU
HAVEN'T TALKED ABOUT THE SP'S VITAL STATUS, PROBE AT THIS TIME ABOUT WHETHER THE SP IS
ALIVE OR DECEASED AND WHERE THE SP IS LOCATED.

SPAISTATUS

INS1

code one

WHEN WE REFER TO INSTITUTIONALIZED, WE ARE REFERRING TO THE MCBS DEFINITION OF A
FACILITY. FOR THE FULL MCBS DEFINITION OF A FACILITY, CLICK F1. PLEASE REMEMBER THAT
HOSPITALS ARE NOT FACILITIES UNDER THE MCBS DEFINITION SO SPS IN HOSPITALS SHOULD NOT
BE CONSIDERED TO BE INSTITUTIONALIZED BELOW.

(01) ALIVE AND NOT INSTITUTIONALIZED
(02) ALIVE AND INSTITUTIONALIZED
(03) DECEASED - DIED IN COMMUNITY
(04) DECEASED - DIED IN INSTITUTION

(01) BOX INS1
(02) INS2 - SPINSTMM
(03) INS3 - SPDIEMM
(04) INS2 - SPINSTMM

IS THE SP CURRENTLY:
What was the first date since [REFERENCE DATE] that [SP] entered the facility?
SPINSTMM

INS2

date

(01) continuous answer
[EXPLAIN IF NECESSARY: By "facility" we mean a place that provides long term care. By "first date" we mean
(-8) Don't Know
the earliest date that an SP enters any facility and does not enter a hospital or return home.]
(-9) Refused

IN2 - SPINSTDD

IF MORE THAN ONE DATE, ENTER THE EARLIEST.
What was the first date since [REFERENCE DATE] that [SP] entered the facility?
SPINSTDD

INS2

date

(01) continuous answer
[EXPLAIN IF NECESSARY: By "facility" we mean a place that provides long term care. By "first date" we mean
(-8) Don't Know
the earliest date that an SP enters any facility and does not enter a hospital or return home.]
(-9) Refused

SPINSTYY

IF MORE THAN ONE DATE, ENTER THE EARLIEST.
What was the first date since (REFERENCE DATE) that (SP) entered the facility?
SPINSTYY

INS2

date

[EXPLAIN IF NECESSARY: By "facility" we mean a place that provides long term care. By "first date" we mean
(01) continuous answer
the earliest date that an SP enters any facility and does not enter a hospital or return home.]

BOX INSA

IF MORE THAN ONE DATE, ENTER THE EARLIEST.

Page 1 of 5

2017 MCBS Community Questionnaire

Variable Name

INQ-INTRODUCTION

MR Screen Name

Question Type

Question Text/Description

BOX INSA

routing

IF (INS1 - SPAISTATUS = 4/DeceasedInInstitute) GO TO INS3 - SPDIEMM.
ELSE GO TO BOX INSA1.

SPDIEMM

INS3

date

SPDIEDD

INS3

SPDIEYY

INS3

BOX INSA1

Code List

Routing

On what date did (SP) die?

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

(01) INS3 - SPDIEDD
(-8) INS3 - SPDIEDD
(-9) INS3 - SPDIEDD

date

On what date did (SP) die?

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

(01) INS3 - SPDIEYY
(-8) INS3 - SPDIEYY
(-9) INS3 - SPDIEYY

date

On what date did (SP) die?

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

(01) BOX INSA1
(-8) BOX INSA1
(-9) BOX INSA1

routing

IF (SPDIEMM IN(-8,-9) OR SPDIEYY IN(-8,-9) THEN GO TO INS3B-INTHANK
ELSE IF (INS1 - SPAISTATUS = 3/Deceased) AND (INTTYPE in(3,7,10)) AND
(VU_SAMPLE_PERSON.NEWLY_ELIGIBLE=0) AND (SP'S DATE OF DEATH ENTERED AT INS3 IS BEFORE
JANUARY 1 OF THE CURRENT YEAR), GO TO INS3A - DEASDATE.
ELSE IF (INS1 - SPAISTATUS = 4/DeceasedInInstitute) AND (INTTYPE in(7,10)) AND (SP'S DATE OF
INSTITUTIONALIZATION ENTERED AT INS2 AND SP'S DATE OF DEATH ENTERED AT INS3 ARE BOTH
PRIOR TO JANUARY 1 OF CURRENT YEAR) AND (VU_SAMPLE_PERSON.NEWLY_ELIGIBLE=0), GO TO
INS3A - DEASDATE.
ELSE IF(INS1 - SPAISTATUS = 4/DeceasedInInstitute) AND (INTTYPE in(7,10)) AND (SP'S DATE OF
INSTITUTIONALIZATION ENTERED AT INS2 IS PRIOR TO JANUARY 1 OF CURRENT YEAR) AND (SP'S
DATE OF DEATH ENTERED AT INS3 IS ON OR AFTER JANUARY 1 OF CURRENT YEAR) AND
(VU_SAMPLE_PERSON.NEWLY_ELIGIBLE=0), GO TO INS3A1 - INSTDATE.
ELSE IF (INS1 - SPAISTATUS = 2/AliveAndInstitute) AND (INTTYPE in(7,10)) AND (SP'S DATE OF
INSTITUTIONALIZATION ENTERED AT INS2 IS BEFORE JANUARY 1 OF THE CURRENT YEAR) AND
(VU_SAMPLE_PERSON.NEWLY_ELIGIBLE=0), GO TO INS3A1 - INSTDATE.
ELSE IF(INS1-SPAISTATUS = 2/AliveAndInstitute) AND INTTYPE = 3, GO TO INS3B-INTHANK
ELSE IF (INS1-SPAISTATUS = 3/Deceased) AND INTTYPE = 3 AND SP'S DATE OF DEATH ENTERED AT
INS3 IS PRIOR TO JANUARY 1, GO TO INS3A-DEASDATE
ELSE IF (INS1-SPAISTATUS = 4/DeceasedInInstitute) AND INTTYPE = 3, GO TO INS3B-INTHANK
ELSE GO TO BOX INS1.
YOU HAVE ENTERED THAT THE SP, (SP), DIED BEFORE JANUARY 1ST OF [CURRENT YEAR]. IF THIS IS
NOT CORRECT, GO TO THE PREVIOUS PAGE AND ENTER THE CORRECT DATE AT INS3.

DEASDATE

INS3A

no entry

INS3B - INTHANK
IF THIS IS CORRECT, YOU WILL NOT BE CONDUCTING THE COMMUNITY INTERVIEW WITH THE
RESPONDENT. GO TO THE NEXT PAGE TO END THE INTERVIEW.
YOU HAVE ENTERED THAT THE SP, (SP), WAS INSTITUTIONALIZED BEFORE JANUARY 1ST OF
[CURRENT YEAR]. IF THIS IS NOT CORRECT, GO TO THE PREVIOUS PAGE AND ENTER THE CORRECT
DATE AT INS2.

INSTDATE

INS3A1

no entry

IF THIS IS CORRECT, YOU WILL NOT BE CONDUCTING THE COMMUNITY INTERVIEW WITH THE
RESPONDENT.

INS3B - INTHANK

AFTER CLICKING "NEXT PAGE", YOU WILL RETURN TO CM-FIELD. PLEASE FILL OUT A RECORD OF
CALL AND CODE THIS CASE AS A “NO COM PROXY- GO TO FAC” .
PLEASE COLLECT ANY KNOWN FACILITY CONTACT INFORMATION AND DISCUSS THE CASE WITH
YOUR FIELD MANAGER.

INTHANK

SPPROXY

INS3B

no entry

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

BOX INSB1

BOX INSB1

routing

GO TO END1 - INTLANG.

END1 - INTLANG.

BOX INS1

routing

IF SP IS DECEASED OR INSTITUTIONALIZED, SET RESPONDENT TO PROXY AND GO TO IN4A PERSON_PROXY.
ELSE GO TO IN4 - SPPROXY.

IN4

code one

WILL THIS INTERVIEW BE CONDUCTED WITH THE SAMPLE PERSON OR WITH A PROXY?

BOX INS2A

routing

IF SP IS IN THE EXIT SAMPLE, GO TO BOX INS4A.
ELSE GO TO BOX INS5.

roster

SELECT OR ADD THE NAME/RELATIONSHIP OF THE PROXY TO THE SP FOR THIS INTERVIEW.
SELECT OR ADD ONLY ONE PERSON.

PERSON_PROXY IN4A

(01) SAMPLE PERSON
(02) PROXY

(01) BOX INS2A
(02) IN4A - PERSON_PROXY

BOX INS2AA

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2017 MCBS Community Questionnaire

Variable Name

INQ-INTRODUCTION

MR Screen Name

Question Type

Question Text/Description

BOX INS2AA

routing

IF PERSON IS ADDED AT IN4A, GO TO BOX INS2A-1.
ELSE GO TO IN5 - VRFYPROX.

Code List

Routing

(01) YES
(02) NO

(01) BOX INS2A-1
(02) IN6 - ROSTFNAM

VRFYPROX

IN5

yes/no

I would like to verify your name and relationship to (SP). I have you listed as [READ NAME AND
RELATIONSHIP LISTED BELOW]. Is that correct?
FIRST NAME: (PROXY'S FIRST NAME)
LAST NAME: (PROXY'S LAST NAME)
RELATIONSHIP: (PROXY'S RELATIONSHIP TO SP)

ROSTFNAM

IN6

text

[What is your correct name and relationship to (SP)?]

(01) continuous answer

IN6 - ROSTLNAM

ROSTLNAM

IN6

text

[What is your correct name and relationship to (SP)?]

(01) continuous answer

IN6 - ROSTREL

ROSTREL

IN6

code one

[What is your correct name and relationship to (SP)?]

ROSTREOS

IN6

verbatim text

What is your correct name and relationship to (SP)?

routing

IF SP IS INSTITUTIONALIZED (SPALIVE = 2), SET REASON WHY RESPONDENT IS PROXY TO "SP IS
INSTITUTIONALIZED" (WHYPROXY = 07) AND GO TO BOX INS3.
ELSE IF SP IS DECEASED (SPALIVE = 3), SET REASON WHY RESPONDENT IS PROXY TO "SP IS
DECEASED" (WHYPROXY = 06) AND GO TO BOX INS3.
ELSE GO TO IN6A - WHYPROXY.

BOX INS2A-1

WHAT IS THE MAIN REASON THAT A PROXY RESPONDENT NECESSARY?

WHYPROXY

IN6A

code one

PNSPOS

IN6A

verbatim text

OTHER (SPECIFY)

BOX INS2B

routing

IF RESPONSE TO IN6a - WHYPROXY ONLY INCLUDES 9/CodeReasonWhy, GO TO IN6B - PNSPVB.
ELSE GO TO BOX INS3.

IN6B

verbatim text

BRIEFLY EXPLAIN WHY PROXY MUST ANSWER QUESTIONS.

PNSPVB

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER RELATIVE
(92) OTHER NON-RELATIVE
(-8) Don't Know
(-9) Refused

(01) DO NOT DISPLAY
(02) BOX INS2A-1
(03) BOX INS2A-1
(04) BOX INS2A-1
(05) BOX INS2A-1
(06) BOX INS2A-1
(07) BOX INS2A-1
(08) BOX INS2A-1
(09) BOX INS2A-1
(10) BOX INS2A-1
(11) BOX INS2A-1
(12) BOX INS2A-1
(13) BOX INS2A-1
(14) BOX INS2A-1
(50) DO NOT DISPLAY
(51) BOX INS2A-1
(52) BOX INS2A-1
(53) BOX INS2A-1
(54) BOX INS2A-1
(55) BOX INS2A-1
(56) BOX INS2A-1
(57) BOX INS2A-1
(91) IN6 - ROSTREOS
(92) IN6 - ROSTREOS
(-8) BOX INS2A-1
(-9) BOX INS2A-1

(01) continuous reponse

BOX INS2A-1

(01) SP NOT CAPABLE
PHYSICALLY/SICK/BLIND/CAN’T SPEAK/HEAR
(02) SP NOT CAPABLE MENTALLY/POOR
MEMORY/PSYCHIATRIC DISORDER
(03) SP UNABLE TO PROVIDE INFORMATION
REGARDING MEDICAL RECORDS
(04) SP IN HOSPITAL
(05) LANGUAGE PROBLEM
(06) SP IS DECEASED
(07) SP IS INSTITUTIONALIZED
(08) SP NOT AVAILABLE THIS ROUND
(09) AUTHORIZED PROXY MUST ANSWER
QUESTIONS FOR SP (CODE REASON WHY)
(91) OTHER

(01) BOX INS2B
(02) BOX INS2B
(03) BOX INS2B
(04) BOX INS2B
(05) BOX INS2B
(06) BOX INS2B
(07) BOX INS2B
(08) BOX INS2B
(09) BOX INS2B
(91) IN6A - PNSPOS

(01) continuous response

BOX INS3

BOX INS3

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2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

INQ-INTRODUCTION

Question Type

Question Text/Description

Code List

Routing

BOX INS3

routing

IF SP IS IN THE SUPPLEMENTAL SAMPLE AND IN6A - WHYPROXY = 6/SPIsDeceased, GO TO IN6B1 SUPPDIED.
ELSE IF SP IS IN THE SUPPLEMENTAL SAMPLE AND IN6A - WHYPROXY = 7/SPIsInstitute, GO TO IN6B2 SUPPINST.
ELSE IF SP IS IN THE EXIT SAMPLE AND SP IS NOT DECEASED, GO TO BOX INS4A.
ELSE GO TO BOX INS5.

SUPPDIED

IN6B1

no entry

YOU HAVE ENTERED THAT THE SP, (SP), IS DECEASED. IF THIS IS NOT CORRECT, GO TO THE
PREVIOUS PAGE AND CORRECT YOUR RESPONSE AT IN6A.

IN13-SPMARSTA

SUPPINST

IN6B2

no entry

YOU HAVE ENTERED THAT THE SP, (SP), IS INSTITUTIONALIZED. IF THIS IS NOT CORRECT, GO TO THE
PREVIOUS PAGE AND CORRECT YOUR RESPONSE AT IN6A.

IN13-SPMARSTA

BOXINS4A

routing

GO TO INS6 - EXITINFO.
As you know from all of the interviews that we have conducted, the Medicare Current Beneficiary Survey has
been collecting data from over 100,000 beneficiaries since 1991. Data from the study have been extremely
useful to many researchers who are looking at the availability and the cost of medical care for people such as
[you/(SP)].

EXITINFO

INS6

no entry

BOX IN8

At this time, the survey is going to start interviewing some new beneficiaries and we will stop interviewing some
of the people who have been with the survey for quite some time. [You are/(SP) is] one of the people that we will
no longer interview.
Therefore, this will be the last interview that will be conducted [with you/for (SP)].

EXITINFR

INS6A

no entry

At this time, the survey is going to start interviewing some new beneficiaries and we will stop interviewing some
of the people who have been with the survey for quite some time. [You are/(SP) is] one of the people that we will
no longer interview.

BOX INS5

Therefore, this will be the last interview that will be conducted [with you/for (SP)].

BOX INS5

routing

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW FROM FACILITY), GO TO IN8 - CHEKBRTH.
ELSE IF IT'S A FALL ROUND, GO TO BOX IN6.
ELSE GO TO BOX IN8.

CHEKBRTH

IN8

yes/no

I have [your/(SP’s)] date of birth listed as (CMS BIRTH DATE). Is that correct?

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

HHDOBMM

IN9

date

What is [your/(SP’s)] date of birth?

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

IN9 - HHDOBDD

HHDOBDD

IN9

date

What is [your/(SP’s)] date of birth?

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

IN9 - HHDOBYY

HHDOBYY

IN9

date

What is [your/(SP’s)] date of birth?

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

BOX IN3A

BOX IN3A

routing

IF SP'S DATE OF BIRTH MONTH, DAY OR YEAR COLLECTED AT IN9 = DK OR RF, GO TO IN11 - ROSTSEX.
ELSE GO TO IN10 - CHECKAGE.

CHECKAGE

IN10

yes/no

That makes [you/(SP)] (AGE) today. Is that correct?

(01) YES
(02) NO

(01) IN11 - ROSTSEX
(02) IN9 - HHDOBMM

ROSTSEX

IN11

code one

THE SP IS LISTED AS A (MALE/FEMALE). IF SEX IS OBVIOUS, CODE BELOW WITHOUT ASKING. IF SEX
(01) MALE
IS NOT OBVIOUS, ASK:
(02) FEMALE
[Are you/Is (SP)] male or female?

BOX IN4

routing

IF NOT MISSING GENDER FROM CMS FILES AND SP'S GENDER FROM CMS DOES NOT MATCH GENDER
ENTERED AT IN11 - ROSTSEX, GO TO IN12 - CHNGSEX.
ELSE GO TO BOX IN6.

IN12

yes/no

YOU JUST CHANGED SP’S SEX FROM (MALE/FEMALE) TO (FEMALE/MALE). DID YOU INTEND TO DO
THAT?

BOX IN6

routing

IF SP'S AGE IS > 16, DK OR RF, GO TO IN13 - SPMARSTA.
ELSE GO TO BOX IN8.

CHNGSEX

(01) YES
(02) NO

(01) IN10 - CHECKAGE
(02) IN9 - HHDOBMM
(-8) IN11 - ROSTSEX
(-9) IN11 - ROSTSEX

BOX IN4

(01) BOX IN6
(02) IN11 - ROSTSEX

Page 4 of 5

2017 MCBS Community Questionnaire

Variable Name

SPMARSTA

SPCHNLNM

MR Screen Name

Question Type

INQ-INTRODUCTION

Question Text/Description

Code List

Routing

(01) MARRIED
(02) WIDOWED
(03) DIVORCED
(04) SEPARATED
(05) NEVER MARRIED
(-8) Don't Know
(-9) Refused

BOX IN7

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

BOX IN8

IN13

code one

[Are you/Is (SP)/Was (SP)] married, widowed, divorced, separated, or never married?

BOX IN7

routing

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW FROM FACILITY), GO TO IN14 - SPCHNLNM.
ELSE GO TO BOX IN8.

IN14

numeric

Including natural, adopted, and stepchildren, how many living children [did (SP)/does (SP)/do you] have?

BOX IN8

routing

IF INTTYPE in(C001, C002, C003, C004, C005, C006, C007, C008, C009, C010), GO TO ENS.

Page 5 of 5