CMS-P-0015A Comm2019R83OMQ

Other Medical Expenses (OMQ)
Variable Name

MR Screen Name

Question type

Question text/description
OTHER MEDICAL EXPENSES QUESTIONNAIRE SPECIFICATIONS

Code list

Routing

CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=ALL
Other: N/A
PLACEMENT
Administer after PMQ.

OMPREYEG

OM1

yes/no

Next I’m going to ask you about other medical expenses that [you/(SP)] may have had [between (REFERENCE
DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
(01) YES
(02) NO
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
(03) INDICATED YES BY DATAPREP
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy,
(-8) Don't Know
replace, or pay for repairs of eyeglasses or contact lenses?
(-9) Refused
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair glasses or contact lenses?

EVENT_OMEYEG

OM2

roster

Please tell me all the dates [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
HAVE ALL DATES BEEN ENTERED?

OMADD

NAVIGATOR

OM2AA

code one

BOX OM1AA

routing

OM2_IN

instance navigator

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM2_IN - NAVIGATOR.
ELSE GO TO BOX OM1AA2.

On (EVENT DATE), did [you/(SP)] buy or repair the glasses or contact lenses at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?
OMSATHMO

OMINTRO

OM2A

yes/no

BOX OM1AA1

routing

BOX OM1AA2

routing

OMINTRO

routing

[PROBE: This could include buying or repairing the glasses or lenses at a plan center; at an optician,
optometrist or other place that honors [your/(SP’s)] plan card; or through a place or service that the plan
referred [you/(SP)] to.]

(01) OM2 - EVENT_OMEYEG
(02) OM3 - OMPRHEAR
(03) DO NOT DISPLAY.
(-8) OM3 - OMPRHEAR
(-9) OM3 - OMPRHEAR

(01) continuous answer
(-8) Don't Know
(-9) Refused
BOX OM1AA
MM:
DD:
YYYY:
(01) ADD ANOTHER
(02) ALL DONE

(01) OM2-EVENT_OMEYEG
(02) BOX OM1AA

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

(01) OM2A - OMSATHMO
(02) BOX OM1AA2

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

BOX OM1AA1

[INCLUDE NON-PRESCRIPTION READING GLASSES.]
GO TO OM2_IN - NAVIGATOR.
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM3 - OMPRHEAR.
Next I’m going to ask you about other medical expenses that [you/(SP)] may have had [between (REFERENCE
DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF DEATH/DATE OF
(01) CONTINUE
INSTITUTIONALIZATION/ENDUTILD)].

OM3-OMHRSPCH

[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy,
replace, or pay for repairs of an hearing aid, amplifier for a telephone, or similar device to help [you/(SP)]
hear or speak?
OMPRHEAR
OMHRSPCH

OM3

yes/no
[INCLUDE RELATED EXPENSES SUCH AS BATTERIES FOR A HEARING AID OR SPEAKING DEVICE. DO NOT
INCLUDE A WARRANTY FOR A HEARING AID AS AN OM EVENT.]

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

(01) OM4 - EVENT_OMHEAR
EVENT_OMHRSP
(02) BOX OMA1
(03) DO NOT DISPLAY.
(-8) BOX OMA1
(-9) BOX OMA1

[DO NOT REPORT HEARING AID PURCHASES OR REPAIRS AT THIS QUESTION.]
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair a hearing or speech device?
EVENT_OMHEAR
EVENT_OMHRSP

OM4

roster

Please tell me the dates of each purchase or repair [since (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
HAVE ALL DATES BEEN ENTERED?

OMADD

NAVIGATOR

OM4AA

code one

BOX OM1BB

routing

OM4_IN

instance navigator

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM4_IN - NAVIGATOR.
ELSE GO TO BOX OM1BB2.

On (EVENT DATE), did [you/(SP)] buy or repair the hearing or speech device at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?
OMSATHMO

OM4A

yes/no

BOX OM1BB1

routing

BOX OM1BB2

routing

BOX OMA1

routing

ORTHINTRO

OMS5INTR

no entry

NAVIGATOR

OMS5_IN

instance navigator

[PROBE: This could include buying or repairing the hearing or speech device at a plan center; from an
audiologist, speech pathologist, or other provider that honors [your/(SP’s)] plan card; or through a place or
service that the plan referred [you/(SP)] to.]
GO TO OM4_IN - NAVIGATOR.
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OMA1
IF SP WAS STILL RENTING AT LEAST ONE ORTHOPEDIC ITEM AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO OMS5INTR - ORTHINTRO.
ELSE GO TO OM5 - OMPRORTH.
The next questions are about orthopedic items [you were/(SP) was] renting as of (REFERENCE DATE).

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:

OM4AA-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM4-EVENT_OMHEAR
EVENT_OMHRSP
(02) BOX OM1BB

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

(01) OM4A - OMSATHMO
(02) BOX OM1BB2

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

BOX OM1BB1

(01) continuous answer
(-7) Empty
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED

OMS5_IN - NAVIGATOR
(01) OMS5 - RENTSTIL
(02) OM5 - OMPRORTH

RENTSTIL

OMS5

code one

At the time of the last interview, [you were/(SP) was] renting (ORTHOPEDIC ITEM). As of (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION), (was/were/is/are) the (ORTHOPEDIC ITEM) being rented?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]

OMPRORTH

OM5

yes/no

SHOW CARD OM1
(Other than what we already talked about,) [(Since/since) (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy, repair or rent (other) orthopedic
items, such as any of those listed on this card?
[Orthopedic items include crutches, canes, wheelchairs, walkers, corrective shoes or inserts, support
stockings, and braces or supports.]

ORTHTYPE

OM6

code one

What was the item?

EVOSTEXT

OM6

verbatim text

OTHER (SPECIFY)
Did [you/(SP)] buy or repair the (ORTHOPEDIC ITEM), or did [you/(SP)] rent (it/them)?

RENTPROB

OM6A

EVENT_OMORTH OM7

OMADD

code one

roster

OM7AAA

BOX OM1CC

routing

NAVIGATOR

OM7_IN

instance navigator

OMSATHMO

OM7AA

yes/no

BOX OM2A

routing

EVENT_OMORTHR
OM7A
ENT

RENTSTIL

OM7B

yes/no

yes/no

[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN THE
SAME ROUND, SELECT "RENT."]

(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused

(01) BOX OM1EE
(02) OM7C - EVENDMM
(03) BOX OM4
(-8) BOX OM4
(-9) BOX OM4

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

(01) OM6 - ORTHTYPE
(02) OM9 - OMPRDIAB
(03) DO NOT DISPLAY.
(-8) OM9 - OMPRDIAB
(-9) OM9 - OMPRDIAB

(01) BRACES/SUPPORTS
(02) CANE
(03) CORRECTIVE SHOES/INSERTS
(04) CRUTCHES
(05) WALKER
(06) WHEELCHAIR/CART
(07) STOCKINGS
(91) OTHER
(01) continuous answer
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
EQUIPMENT
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused

(01) OM7 - EVENT_OMORTH
(02) OM7 - EVENT_OMORTH
(03) OM7 - EVENT_OMORTH
(04) OM6A - RENTPROB
(05) OM6A - RENTPROB
(06) OM6A - RENTPROB
(07) OM7 - EVENT_OMORTH
(91) OM6 - EVOSTEXT
OM6A - RENTPROB

SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy (or repair) the (ORTHOPEDIC ITEM)? Please tell me all the dates [since (REFERENCE
DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and
MM:
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
DD:
YYYY:
HAVE ALL DATES BEEN ENTERED?
(01) ADD ANOTHER
(02) ALL DONE
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM7_IN - NAVIGATOR.
ELSE GO TO BOX OM1EE1.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
On (EVENT DATE), did [you/(SP)] buy (or repair) the (ORTHOPEDIC ITEM) at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
(01) YES
BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could include buying or repairing the (ORTHOPEDIC ITEM) at a plan center; at a place or store
(-9) Refused
that honors [your/(SP's)] plan card; or through a place or store that the plan referred [you/(SP)] to.]
GO TO OM7_IN - NAVIGATOR.
(01) continuous answer
(-8) Don't Know
ENTER ONLY ONE DATE AT THIS ROSTER.
(-9) Refused
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) AND (DATE OF DEATH/DATE OF
MM:
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the (ORTHOPEDIC ITEM).
DD:
YYYY:

[Are you/Is (SP)/Was (SP)] still renting the (ORTHOPEDIC ITEM)?

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

(01) OM7 - EVENT_OMORTH
(02) OM7A - EVENT_OMORTHRENT
(03) DO NOT DISPLAY.
(-8) OM7 - EVENT_OMORTH
(-9) OM7 - EVENT_OMORTH

OM7AAA-OMADD

(01) OM7-EVENT_OMORTH
(02) BOX OM1CC

(01) OM7AA - OMSATHMO
(02) BOX OM1EE1

BOX OM2A

OM7B - RENTSTIL

(01) BOX OM1EE
(02) OM7C - EVENDMM
(03) DO NOT DISPLAY.
(-8) BOX OM1EE1
(-9) BOX OM1EE1

What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?
EVENDMM

OM7C

date

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?

EVENDDD

OM7C

date

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?

EVENDYY

OM7C

BOX OM3A

date

routing

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]

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

OM7C - EVENDYY

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

BOX OM3A

YYYY:

IF SP IS NOT DECEASED, GO TO OM7CC - RENT2BUY.
ELSE GO TO BOX OM1EE.

RENT2BUY

OM7CC

code one

You said [you/(SP)] stopped renting the (ORTHOPEDIC ITEM). Is this because (you/he/she) no longer
(have/has) that item or because (you/he/she) (have/has) purchased it through a rent-to-buy option?

(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused

REN2BVB

OM7CCVB

verbatim text

BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE (ORTHOPEDIC ITEM).
RECORD VERBATIM.

(01) continuous answer

HAVE ALL DATES BEEN ENTERED?
OMADD

OM7CC1

BOX OM1EE

OMSATHMO

MOREORTH

OMPRDIAB

OM7D

code one

routing

routing

BOX OM4

routing

OM8

OM9

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM7D - OMSATHMO.
ELSE GO TO BOX OM1EE1.
Did [you/(SP)] rent the (ORTHOPEDIC ITEM) at [READ MANAGED CARE PLAN NAME(S) BELOW] or through a
service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?

yes/no

BOX OM1EE1

yes/no

yes/no

OM7C - EVENDDD

[PROBE: This could include renting the (ORTHOPEDIC ITEM) at a plan center; at a place or store that honors
[your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP]] to.]
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM4.
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS5_IN - NAVIGATOR.
ELSE GO TO OM8 - MOREORTH.
In addition to the orthopedic item(s) you just told me about, did [you/(SP)] buy, repair, or rent any other
orthopedic items [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].?
SHOW CARD OM2
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy
diabetic equipment or supplies, such as those listed on this card?
[Diabetic equipment or supplies include syringes, test paper, test strips, and blood monitoring kits.]

(01) BOX OM1EE
(02) BOX OM1EE
(03) OM7CCVB - REN2BVB
(-8) BOX OM1EE
(-9) BOX OM1EE
BOX OM1EE
OM7CC-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM7A-EVENT_OMORTHRENT
(02) BOX OM1EE

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

BOX OM1EE1

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

(01) OM6 - ORTHTYPE
(02) OM9 - OMPRDIAB
(03) OM9 - OMPRDIAB
(04) OM9 - OMPRDIAB

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

(01) OM10 - EVENT_OMDIAB
(02) OM11 - OMPRAMBL
(03) DO NOT DISPLAY.
(-8) OM11 - OMPRAMBL
(-9) OM11 - OMPRAMBL

[DO NOT INCLUDE INSULIN.]

EVENT_OMDIAB

OM10

roster

SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy diabetic equipment or supplies? Please tell me all the dates [since (REFERENCE
DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
HAVE ALL DATES BEEN ENTERED?

OMADD

OM10AA

code one
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:

OM10AA-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM10-EVENT_OMDIAB
(02) BOX OM1FF

NAVIGATOR

OMSATHMO

OMPRAMBL

BOX OM1FF

routing

OM10_IN

instance navigator

OM10A

BOX OM1FF1

routing

BOX OM1FF2

routing

OM11

EVENT_OMAMBL OM12

OMADD

yes/no

yes/no

roster

OM12AA

code one

BOX OM1GG

routing

NAVIGATOR

OM12_IN

instance navigator

OMSATHMO

OM12A

yes/no

BOX OM1GG1

routing

BOX OM1GG2

routing

OMPRPROS

OM13

yes/no

EVENT_OMPROS

OM14

roster

OMADD

OM14AA

code one

BOX OM1HH

routing

IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM10_IN - NAVIGATOR.
ELSE GO TO BOX OM1FF2.

On (EVENT DATE), did [you/(SP)] buy the diabetic equipment or supplies at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?
[PROBE: This could include buying the diabetic equipment or supplies at a plan center; at a place or store
that honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]
GO TO OM10_IN - NAVIGATOR.
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM11 - OMPRAMBL.

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

(01) OM10A - OMSATHMO
(02) BOX OM1FF2

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

BOX OM1FF1

(01) YES
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
(02) NO
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] use any (03) INDICATED YES BY DATAPREP
ambulance or rescue squad service?
(-8) Don't Know
(-9) Refused
SELECT OR ADD ALL DATES AT THIS ROSTER.
(01) continuous answer
When did [you/(SP)] use an ambulance? Please tell me all the dates [since (REFERENCE DATE/SURVEY
(-8) Don't Know
REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
(-9) Refused
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
HAVE ALL DATES BEEN ENTERED?
(01) ADD ANOTHER
(02) ALL DONE
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM12_IN - NAVIGATOR.
ELSE GO TO BOX OM1GG2.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
Was the ambulance on (EVENT DATE) provided by or approved by [READ MANAGED CARE PLAN NAME(S)
BELOW]?
(01) YES
(02) NO
[PROBE: This could mean that the ambulance was sent by the plan, or that [you/(SP)] or someone for
(-8) Don't Know
[you/(SP)] contacted the plan for them to authorize or approve the use of the ambulance. This approval
(-9) Refused
could have come after the use of the ambulance.]
GO TO OM12_IN - NAVIGATOR.
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM13 - OMPRPROS.
SHOW CARD OM3
(01) YES
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
(02) NO
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy or
(03) INDICATED YES BY DATAPREP
pay for repairs of any prostheses, such as those on the card?
(-8) Don't Know
(-9) Refused
[Prostheses include artificial leg or arm, mastectomy prosthesis, and artificial or glass eye.]
(01) continuous answer
(-8) Don't Know
SELECT OR ADD ALL DATES AT THIS ROSTER.
(-9) Refused
When did [you/(SP)] buy or repair the prosthesis? Please tell me all the dates [since (REFERENCE
DATE/SURVEY REFERENCE DATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE) and
MM:
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
DD:
YYYY:
HAVE ALL DATES BEEN ENTERED?
(01) ADD ANOTHER
(02) ALL DONE
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM14_IN - NAVIGATOR.
ELSE GO TO BOX OM1HH2.

(01) OM12 - EVENT_OMAMBL
(02) OM13 - OMPRPROS
(03) DO NOT DISPLAY.
(-8) OM13 - OMPRPROS
(-9) OM13 - OMPRPROS

OM12AA-OMADD
(01) OM12-EVENT_OMAMBL
(02) BOX OM1GG

(01) OM12A - OMSATHMO
(02) BOX OM1GG2

BOX OM1GG1

(01) OM14 - EVENT_OMPROS
(02) BOX OMA4
(03) DO NOT DISPLAY.
(-8) BOX OMA4
(-9) BOX OMA4

OM14AA-OMADD

(01) OM14-EVENT_OMPROS
(02) BOX OM1HH

NAVIGATOR

OM14_IN

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

instance navigator

(01) OM14A - OMSATHMO
(02) BOX OM1HH2

On (EVENT DATE), did [you/(SP)] buy or repair the prosthesis at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
OMSATHMO

OM14A

yes/no

BOX OM1HH1

routing

BOX OM1HH2

routing

BOX OMA4

routing

OXGNINTRO

OMS19INTR

no entry

NAVIGATOR

OMS19_IN

instance navigator

RENTSTIL

OMS19

code one

OMPROXGN

OM19

yes/no

OXGNTYPE

OM19A

code one

RENTPROB

OM19B

EVENT_OMOXGN OM20

OMADD

NAVIGATOR

code one

roster

OM20AAA

code one

BOX OM1II

routing

OM20_IN

instance navigator

(01) YES
(02) NO
(-8) Don't Know
[PROBE: This could include buying or repairing the prosthesis at a plan center; at a place or store that honors
(-9) Refused
[your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
GO TO OM14_IN - NAVIGATOR.
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OMA4.
IF SP WAS STILL RENTING OXYGEN-RELATED EQUIPMENT AT THE TIME OF THE PREVIOUS ROUND INTERVIEW,
GO TO OMS19INTR - OXGNINTRO.
ELSE GO TO OM19 - OMPROXGN.
The next questions are about oxygen-related equipment [you were/(SP) was] renting as of (REFERENCE
DATE).

OMSATHMO

OM20AA

yes/no
[PROBE: This could include buying or repairing the (OXYGEN ITEM) at a plan center; at a place or store that
honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]

BOX OM1II1

routing

BOX OM7

routing

OMS19_IN - NAVIGATOR

(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
At the time of the last interview, [you were/(SP) was] renting oxygen-related equipment. As of [today/(DATE (01) YES
OF DEATH)/(DATE OF INSTITUTIONALIZATION)/(ENDUTILD)] (is/was) the oxygen-related equipment being
(02) NO
rented?
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
(-9) Refused
(01) YES
(Other than what we already talked about,) [(Since/since) (REFERENCE DATE/SURVEY REFERENCE
(02) NO
DATE/UTILDATE)/(Between/between) (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
(03) INDICATED YES BY DATAPREP
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any (other) expenses for oxygen or
(-8) Don't Know
supplies or oxygen-related equipment?
(-9) Refused
(01) OXYGEN/SUPPLIES
What was that?
(02) OXYGEN-RELATED EQUIPMENT
(01) BUY/REPAIR
Did [you/(SP)] buy or repair the oxygen-related equipment, or did [you/(SP)] rent it?
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN THE
EQUIPMENT
SAME ROUND, SELECT "RENT."]
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
SELECT OR ADD ALL DATES AT THIS ROSTER.
(-9) Refused
When did (you/(SP)] purchase the [(oxygen or supplies)/(oxygen-related equipment)]? Please tell me the
dates of each purchase [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
MM:
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
DD:
YYYY:
HAVE ALL DATES BEEN ENTERED?
(01) ADD ANOTHER
(02) ALL DONE
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM20_IN - NAVIGATOR.
ELSE GO TO BOX OM7.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
On (EVENT DATE), did [you/(SP)] buy or repair the (OXYGEN ITEM) at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?

GO TO OM20_IN - NAVIGATOR.
IF OM19B - RENTPROB = 3/BoughtAndRented, GO TO OM20A - EVENT_OMOXGNRENT.
ELSE GO TO BOX OM1KK1.

BOX OM1HH1

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

(01) OMS19 - RENTSTIL
(02) OM19 - OMPROXGN
(01) BOX OM1KK
(02) OM20C - EVENDMM
(03) BOX OM9
(-8) BOX OM9
(-9) BOX OM9
(01) OM19A - OXGNTYPE
(02) BOX OMA11
(03) DO NOT DISPLAY.
(-8) BOX OMA11
(-9) BOX OMA11
(01) OM20 - EVENT_OMOXGN
(02) OM19B - RENTPROB
(01) OM20 - EVENT_OMOXGN
(02) OM20A - EVENT_OMOXGNRENT
(03) OM20 - EVENT_OMOXGN
(-8) OM20 - EVENT_OMOXGN
(-9) OM20 - EVENT_OMOXGN

OM20AAA-OMADD

(01) OM20-EVENT_OMOXGN
(02) BOX OM1II

(01) OM20AA - OMSATHMO
(02) BOX OM7

BOX OM1II1

EVENT_OMOXGN
OM20A
RENT

RENTSTIL

OM20B

roster

yes/no

SELECT OR ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the oxygen-related equipment.

[Are you/Is (SP)/Was (SP)] still renting the oxygen-related equipment?

What was the last date the equipment was rented?
EVENDMM

OM20C

date

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]
What was the last date the equipment was rented?

EVENDDD

EVENDYY

OM20C

date

OM20C

date

BOX OM8A

routing

RENT2BUY

OM20CC

code one

REN2BVB

OM20CCVB

verbatim text

OMADD

OM20CC1

code one

BOX OM1KK

OMSATHMO

MOREOXGN

OM20D1

routing

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]
What was the last date the equipment was rented?
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]
IF SP IS NOT DECEASED, GO TO OM20CC - RENT2BUY.
ELSE GO TO BOX OM1KK.
You said [you/(SP)] stopped renting the oxygen-related equipment. Is this because (you/he/she) no longer
(have/has) the equipment or because (you/he/she) (have/has) purchased it through a rent-to-buy option?
BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE OXYGEN-RELATED EQUIPMENT.
RECORD VERBATIM.
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM20D1 - OMSATHMO.
ELSE GO TO BOX OM1KK1.
Did [you/(SP)] rent the oxygen equipment at [READ MANAGED CARE PLAN NAME(S) BELOW] or through a
service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?

yes/no

BOX OM1KK1

routing

BOX OM9

routing

BOX OM10

routing

OM20D

yes/no

BOX OM11

routing

BOXOMA11

routing

[PROBE: This could include renting the oxygen equipment at a plan center; at a place or store that honors
[your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM9.
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS19_IN - NAVIGATOR.
ELSE GO TO BOX OM10.
IF OM20D HAS NOT BEEN ASKED, GO TO OM20D - MOREOXGN.
ELSE GO TO BOX OMA11.
In addition to the [(oxygen or supplies)/(oxygen-related equipment)] that you just told me about, did
[you/(SP)] [(buy oxygen or supplies)/(have any expenses for oxygen-related equipment)]?
IF OM19A - OXYGTYPE = 1/Supplies, SET NEXT OXYGEN TYPE TO EQUIPMENT AND GO TO OM19B RENTPROB.
ELSE SET NEXT OXYGEN TYPE TO SUPPLIES AND GO TO OM20 - EVENT_OMOXGN.
IF SP WAS RENTING AT LEAST ONE KIDNEY DIALYSIS EQUIPMENT AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO OMS21INTR - KDNYINTRO.
ELSE GO TO OM21 - OMPRKDNY.

(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) continuous answer
(02) Don't Know
(03) Refused

OM20B - RENTSTIL
(01) BOX OM1KK
(02) OM20C - EVENDMM
(03) DO NOT DISPLAY.
(-8) BOX OM1KK1
(-9) BOX OM1KK1

OM20C - EVENDDD
MM:
DD:
YYYY:
(01) continuous answer
(02) Don't Know
(03) Refused

OM20C - EVENDYY

(01) continuous answer
(02) Don't Know
(03) Refused

BOX OM8A

(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX OM1KK
(02) BOX OM1KK
(03) OM20CCVB - REN2BVB
(04) BOX OM1KK
(05) BOX OM1KK

(01) continuous answer

OM20CC1-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM20A-EVENT_OMOXGNRENT
(02) BOX OM1KK

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

BOX OM1KK1

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

(01) BOX OM11
(02) BOX OMA11
(-8) BOX OMA11
(-9) BOX OMA11

KDNYINTRO

OMS21INTR

no entry

NAVIGATOR

OMS21_IN

instance navigator

RENTSTIL

OMS21

code one

The next questions are about kidney dialysis equipment [you were/(SP) was] renting as of (REFERENCE
DATE).

At the time of the last interview, [you were/(SP) was] renting equipment for kidney dialysis. As of
(today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD)], (is/was) the equipment being
rented?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]

OMPRKDNY

OM21

yes/no

(Other than what we already talked about), [(Since/since) (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy any (other) kidney dialysis supplies
or buy, rent, or repair any related equipment?

KDNYTYPE

OM21A

code one

What was that?
Did [you/(SP)] buy or repair the dialysis equipment, or did [you/(SP)] rent it?

RENTPROB

EVENT_OMKDNY

OMADD

NAVIGATOR

OMSATHMO

OM21B

OM22

roster

OM22AAA

code one

BOX OM1LL

routing

OM22_IN

instance navigator

OM22AA

yes/no

BOX OM14

routing

EVENT_OMKDNYR
OM22A
ENT

RENTSTIL

code one

OM22B

roster

yes/no

[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN THE
SAME ROUND, SELECT "RENT."]

OM22C

date

(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) KIDNEY DIALYSIS SUPPLIES
(02) KIDNEY DIALYSIS EQUIPMENT
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
EQUIPMENT
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused

(01) OMS21 - RENTSTIL
(02) OM21 - OMPRKDNY
(01) BOX OM1NN
(02) OM22C - EVENDMM
(03) BOX OM16
(-8) BOX OM16
(-9) BOX OM16
(01) OM21A - KDNYTYPE
(02) BOX OMA18
(03) DO NOT DISPLAY.
(-8) BOX OMA18
(-9) BOX OMA18
(01) OM22 - EVENT_OMKDNY
(02) OM21B - RENTPROB
(01) OM22 - EVENT_OMKDNY
(02) OM22A - EVENT_OMKDNYRENT
(03) DO NOT DISPLAY.
(-8) OM22 - EVENT_OMKDNY
(-9) OM22 - EVENT_OMKDNY

SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] (purchase the kidney dialysis supplies)/(buy or repair kidney dialysis equipment)? Please
tell me all the dates [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
MM:
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
DD:
YYYY:
HAVE ALL DATES BEEN ENTERED?
(01) ADD ANOTHER
(02) ALL DONE
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM22_IN - NAVIGATOR.
ELSE GO TO BOX OM1NN1.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED

(01) OM22-EVENT_OMKDNY
(02) BOX OM1LL

On (EVENT DATE), did [you/(SP)] buy (or repair) the (KIDNEY ITEM) at [READ MANAGED CARE PLAN NAME(S)
(01) YES
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could include buying (or repairing) the (KIDNEY ITEM) at a plan center; at a place or store that
(-9) Refused
honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]

BOX OM14

GO TO OM22_IN - NAVIGATOR.
SELECT OR ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the kidney dialysis equipment.

[Are you/Is (SP)/Was (SP)] still renting the kidney dialysis equipment?

What was the last date the equipment was rented?
EVENDMM

OMS21_IN - NAVIGATOR

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]

(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused

OM22AAA-OMADD

(01) OM22AA - OMSATHMO
(02) BOX OM1NN1

OM22B - RENTSTIL
(01) BOX OM1NN
(02) OM22C - EVENDYY
(03) DO NOT DISPLAY.
(-8) BOX OM1NN1
(-9) BOX OM1NN1

OM22C - EVENDDD
MM:
DD:
YYYY:

What was the last date the equipment was rented?
EVENDDD

OM22C

date

EVENDYY

OM22C

date

BOX OM15A

routing

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]
What was the last date the equipment was rented?
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]
IF SP IS NOT DECEASED, GO TO OM22CC - RENT2BUY.
ELSE GO TO BOX OM1NN.

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

OM22C - EVENDYY

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

BOX OM15A

RENT2BUY

OM22CC

code one

You said [you/(SP)] stopped renting the dialysis equipment. Is this because (you/he/she) no longer
(have/has) the equipment or because (you/he/she) (have/has) purchased it through a rent-to-buy option?

(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused

REN2BVB

OM22CCVB

verbatim text

BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE DIALYSIS EQUIPMENT.
RECORD VERBATIM.

(01) continuous answer

HAVE ALL DATES BEEN ENTERED?
OMADD

OM22CC1

BOX OM1NN

OMSATHMO

OM22D1

code one

routing

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM22D1 - OMSATHMO.
ELSE GO TO BOX OM1NN1.
Did [you/(SP)] rent the kidney dialysis equipment at [READ MANAGED CARE PLAN NAME(S) BELOW] or
through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?

yes/no

BOX OM1NN1

routing

BOX OM16

routing

BOX OM17

routing

[PROBE: This could include renting the kidney dialysis equipment at a plan center; at a place or store that
honors [your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM16.
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS21_IN - NAVIGATOR.
ELSE GO TO BOX OM17.
IF OM22D HAS NOT BEEN ASKED, GO TO OM22D - MOREKDNY.
ELSE GO TO BOX OMA18.

OM22D

yes/no

In addition to the [(kidney dialysis supplies)/(kidney dialysis equipment)] that you just told me about, did
[you/(SP)] [(obtain any kidney dialysis equipment)/(buy any kidney dialysis supplies)]?

BOX OM18

routing

IF OM21A - KDNYTYPE = 1/Supplies, SET NEXT KIDNEY TYPE TO EQUIPMENT AND GO TO OM21B - RENTPROB.
ELSE SET NEXT KIDNEY TYPE TO SUPPLIES AND GO TO OM22 - EVENT_OMKDNY.

BOX OMA18

routing

OTHRINTRO

OMS23INTR

no entry

NAVIGATOR

OMS23_IN

instance navigator

MOREKDNY

RENTSTIL

OMS23

code one

OM22CC1-OMADD
(01) ADD ANOTHER
(02) ALL DONE

(01) OM22A-EVENT_OMKDNYRENT
(02) BOX OM1NN

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

BOX OM1NN1

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

(01) BOX OM18
(02) BOX OMA18
(-8) BOX OMA18
(-9) BOX OMA18

IF SP WAS STILL RENTING AT LEAST ONE OTHER MEDICAL EQUIPMENT AT THE TIME OF THE PREVIOUS
ROUND INTERVIEW, GO TO OMS23INTR - OTHRINTRO.
ELSE GO TO OM23 - OMPROTHR.
The next questions are about other medical equipment [you were/(SP) was] renting as of (REFERENCE
DATE).

At the time of the last interview, [you were/(SP) was] renting (OTHER MEDICAL EXPENSE ITEM). As of
(today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD), (is/was) the (OTHER MEDICAL
EXPENSE ITEM) being rented?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]

(01) BOX OM1NN
(02) BOX OM1NN
(03) OM22CCVB - REN2BVB
(-8) BOX OM1NN
(-9) BOX OM1NN
BOX OM1NN

OMS23_IN - NAVIGATOR
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused

(01) OMS23 - RENTSTIL
(02) OM23 - OMPROTHR
(01) BOX OM1QQ
(02) OM26B - EVENDMM
(03) BOX OM23
(-8) BOX OM23
(-9) BOX OM23

OMPROTHR

OM23

yes/no

SHOW CARD OM4
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy,
rent, or repair any other medical equipment or buy any other medical supplies besides what we have talked
about?

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
[Other medical equipment and supplies include portable commodes or raised toilet seats, portable tub seats,
(-9) Refused
special chairs or cushions, hospital beds, ostomy supplies, incontenence supplies such as Depends, Serenity
or other brands of disposable undergarments, pads or briefs, bandages, dressings, tape supplies, pulmonary
equipment such as a Nebulizer or CPAP, and blood pressure equipment such as cuffs or monitors, etc.]

OTHRTYPE

OM24

code one

What kind of equipment was the item?

EVOSTEXT

OM24

verbatim text

OTHER (SPECIFY)
Did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE ITEM), or did [you/(SP)] rent it?

RENTPROB

GETNUM

OM24A

code one

BOX OM18B

routing

OM25

numeric

EVENT_OMOTHR OM26

OMADD

roster

OM26AAA

code one

BOX OM1OO

routing

NAVIGATOR

OM26_IN

instance navigator

OMSATHMO

OM26AA

yes/no

NAVIGATOR

BOX OM21

instance navigator

[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN THE
SAME ROUND, SELECT "RENT."]

(01) PORTABLE COMMODE OR RAISED TOILET SEAT
(02) PORTABLE TUB SEAT
(03) SPECIAL CHAIR/CUSHION/MATTRESS
(04) HOSPITAL BED/BED SIDES
(05) OSTOMY SUPPLIES
(06) INCONTINENCE SUPPLIES (I.E. DEPENDS,
SERENITY DISPOSABLE DIAPERS OR PADS)
(07) BANDAGES, DRESSINGS, TAPE SUPPLIES
(08) PULMONARY EQUIPMENT
(09) BLOOD PRESSURE EQUIPMENT
(91) OTHER
(01) continuous answer
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
EQUIPMENT
(-8) Don't Know
(-9) Refused

IF NOT ADMINISTERING ST AND NOT ADMINISTERING NS, GO TO OM25 - GETNUM.
ELSE GO TO BOX OM1QQ1.
THIS ITEM AND NUMBER OF PURCHASES HAS BEEN ENTERED ALREADY FOR THIS ROUND. PLEASE CORRECT
THE NUMBER OF TIMES TO BE THE TOTAL NUMBER OF TIMES PURCHASED SINCE (REFERENCE
(01) continuous answer
DATE/UTILDATE).
(-8) Don't Know
How many times [since (REFERENCE DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF
(-9) Refused
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)] [[have you/has (SP)] bought or obtained/did (SP) buy or
obtain] (OTHER MEDICAL EXPENSE ITEM)?
(01) continuous answer
(-8) Don't Know
SELECT OR ADD ALL DATES AT THIS ROSTER.
(-9) Refused
When did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE ITEM)? Please tell me all the dates [since
(REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE
MM:
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]
DD:
YYYY:
HAVE ALL DATES BEEN ENTERED?
(01) ADD ANOTHER
(02) ALL DONE
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM26_IN - NAVIGATOR.
ELSE GO TO BOX OM1QQ1.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
On (EVENT DATE), did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE ITEM) at [READ MANAGED
CARE PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
(01) YES
NAME(S) BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could include buying or repairing the (OTHER MEDICAL EXPENSE ITEM) at a plan center; at a
(-9) Refused
place or store that honors [your/(SP’s)] plan card; or through a place or store that the plan referred
[you/(SP)] to.]
GO TO OM26_IN - NAVIGATOR.

(01) OM24 - OTHRTYPE
(02) BOX OM24
(03) DO NOT DISPLAY.
(04) BOX OM24
(05) BOX OM24

(01) OM24A - RENTPROB
(02) OM24A - RENTPROB
(03) OM24A - RENTPROB
(04) OM24A - RENTPROB
(05) BOX OM18B
(06) BOX OM18B
(07) BOX OM18B
(08) OM24A - RENTPROB
(09) OM26 - EVENT_OMOTHR
(91) OM24 - EVOSTEXT
OM24A - RENTPROB
(01) OM26 - EVENT_OMOTHR
(02) OM26A - EVENT_OMOTHRRENT
(03) DO NOT DISPLAY.
(-8) OM26 - EVENT_OMOTHR
(-9) OM26 - EVENT_OMOTHR

BOX OM1QQ1

OM27AAA-OMADD

(01) OM26-EVENT_OMOTHR
(02) BOX OM1OO

(01) OM26AA - OMSATHMO
(02) BOX OM1QQ1

BOX OM21

EVENT_OMOTHRR
OM26A
ENT

RENTSTIL

OM26A1

roster

yes/no

ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM).

[Are you/Is (SP)] still renting the (OTHER MEDICAL EXPENSE ITEM)?

What was the last date [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM)?
EVENDMM

OM26B

date

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]
What was the last date [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM)?

EVENDDD

OM26B

date

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]
What was the last date [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM)?

EVENDYY

OM26B

BOX OM22A

date

routing

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE RENTAL
PERIOD.]

(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused

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

BOX OM22A

YYYY:

IF SP IS NOT DECEASED, GO TO OM26BB - RENT2BUY.
ELSE GO TO BOX OM1QQ.

OM26BB

code one

You said [you/(SP)] stopped renting the (OTHER MEDICAL EXPENSE ITEM). Is this because (you/he/she) no
longer (have/has) the item or because (you/he/she) (have/has) purchased it through a rent-to-buy option?

REN2BVB

OM26BBVB

verbatim text

BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE (OTHER MEDICAL EXPENSE ITEM).
RECORD VERBATIM.

(01) continuous answer

HAVE ALL DATES BEEN ENTERED?

BOX OM1QQ

code one

routing

OM26B - EVENDDD

OM26B - EVENDYY

RENT2BUY

OM26BB1

(01) BOX OM1QQ
(02) OM26B - EVENDMM
(03) DO NOT DISPLAY.
(-8) BOX OM1QQ1
(-9) BOX OM1QQ1

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

(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused

OMADD

OM26A1 - RENTSTIL

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM26C - OMSATHMO.
ELSE GO TO BOX OM1QQ1.

(01) BOX OM1QQ
(02) BOX OM1QQ
(03) OM26BBVB - REN2BVB
(-8) BOX OM1QQ
(-9) BOX OM1QQ
BOX OM1QQ
OM26BB1-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM26A-EVENT_OMOTHRRENT
(02) BOX OM1QQ

Did [you/(SP)] rent the (OTHER MEDICAL EXPENSE ITEM) at [READ MANAGED CARE PLAN NAME(S) BELOW]
or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
OMSATHMO

MOREOTHR

OM26C

yes/no

BOX OM1QQ1

routing

BOX OM23

routing

OM27

yes/no

BOX OM24

routing

ALTRINTRO

OMS28INTR

no entry

NAVIGATOR

OMS28_IN

instance navigator

(01) YES
(02) NO
(-8) Don't Know
[PROBE: This could include renting the (OTHER MEDICAL EXPENSE ITEM) at a plan center; at a place or store
(-9) Refused
that honors [your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]

BOX OM1QQ1

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM23.
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS23_IN - NAVIGATOR.
ELSE GO TO OM27 - MOREOTHR.
In addition to the medical equipment you just told me about, did [you/(SP)] buy, rent, or repair any other
medical equipment [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]?

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

(01) OM24 - OTHRTYPE
(02) BOX OM24
(-8) BOX OM24
(-9) BOX OM24

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

OMS28_IN - NAVIGATOR
(01) OMS28 - EVENDMM
(02) OM28 - OMPRALTR

IF SP HAD AT LEAST ONE ALTERATION THAT WAS NOT COMPLETE AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO OMS28INTR - ALTRINTRO.
ELSE GO TO OM28 - OMPRALTR.
The next questions are about an alteration [you were/(SP) was] making as of (REFERENCE DATE).

Last time [you/(SP)] had started to make an alteration (ALTERATION) that was not completed as of
(REFERENCE DATE/SURVEY REFERENCE DATE).
EVENDMM

EVENDDD

EVENDYY

OMNOTDONE

OMPRALTR

OMS28

OMS28

date

date

OMS28

date

OMS28

code one

BOX OM25

routing

OM28

yes/no

On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD)] was this alteration
completed?
Last time [you/(SP)] had started to make an alteration (ALTERATION) that was not completed as of
(REFERENCE DATE/SURVEY REFERENCE DATE).
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD)] was this alteration
completed?
Last time [you/(SP)] had started to make an alteration (ALTERATION) that was not completed as of
(REFERENCE DATE/SURVEY REFERENCE DATE).
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD)] was this alteration
completed?

GO TO OMS28_IN - NAVIGATOR.
SHOW CARD OM5
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] make
any alterations or modify the inside or outside of (your/his/her) home or car because of some illness or
injury? This card lists some examples.
[Alterations include ramps, handrails, elevator or incline chair, tub seats, tub handrails, and any car
alterations.]

ALTRTYPE

OM29

code one

EVOSTEXT

OM29

verbatim text

OM30

date

EVENDMM

EVENDDD

EVENDYY

OM30

OM30

date

date

(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

OMS28 - EVENDDD

(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

OMS28 -EVENDYY

(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

OMS28 - OMNOTDONE

(01) ALTERATION NOT YET COMPLETED
(-7) Empty

BOX OM25

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

(01) OM29 - ALTRTYPE
(02) BOX OM26
(03) DO NOT DISPLAY.
(-8) BOX OM26
(-9) BOX OM26

(01) ELEVATOR OR INCLINE CHAIR
(02) HANDRAILS (OTHER THAN TUB)
(03) RAMPS
(04) TUB HANDRAILS
What was the alteration?
(05) TUB SEAT
(06) ANY CAR ALTERATION
(91) OTHER
OTHER (SPECIFY)
(01) continuous answer
(01) continuous answer
(-7) Empty
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
(-8) Don't Know
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)] was this
(-9) Refused
alteration completed?
MM:
(01) continuous answer
(-7) Empty
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
(-8) Don't Know
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)] was this
(-9) Refused
alteration completed?
DD:
(01) continuous answer
(-7) Empty
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
(-8) Don't Know
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)] was this
(-9) Refused
alteration completed?

(01) OM30 - EVBEGMM
(02) OM30 - EVBEGMM
(03) OM30 - EVBEGMM
(04) OM30 - EVBEGMM
(05) OM30 - EVBEGMM
(06) OM30 - EVBEGMM
(91) OM29 - EVOSTEXT
OM30 - EVENDMM

OM30 - EVENDDD

OM30 - EVENDDD

OM30 - OMNOTDONE

YYYY:
OMNOTDONE

OM30

(01) ALTERATION NOT YET COMPLETED
(-7) Empty

code one
HAVE ALL DATES BEEN ENTERED?

OMADD

OM30B
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

(01) ADD ANOTHER
(02) ALL DONE

OM30B-OMADD
(01) OM30-EVBEGMM
(02) BOX OM25A

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM31 - MOREALTR.

OM31

yes/no

In addition to the alteration(s) you just told me about, did [you/(SP)] make any other alterations because of
some illness or injury [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]?

BOX OM26

routing

GO TO STQ.

BOX OM25A

MOREALTR

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

(01) OM29 - ALTRTYPE
(02) BOX OM26
(-8) BOX OM26
(-9) BOX OM26