CMS-P-0015A Attachment 4 Facility Screener

Variable
Name

FSINTRO

MR Screen
Name

FSI01

Question type

Question text/description

no entry

Hello, my name is (FI NAME). I am from NORC at the Unversity of Chicago and we are conducting
the Medicare Current Beneficiary Survey for the Centers for Medicare and Medicaid Services, also
known as CMS, part of the United States Department of Health and Human Services. We are
studying a sample of people eligible for Medicare who live in community and facility settings.

Code List

Routing

FS01 -SPRESIDENOW

I am contacting you to confirm information that a person in our sample lives or has lived in
(FACILITY NAME).
Does (SP) currently live at (FACILITY NAME)?
SPRESIDENO
FS01
W

yes/no

(01) YES
(02) NO
IF RESPONDENT DOES NOT KNOW, ASK TO SPEAK TO SOMEONE WHO WOULD KNOW ADMISSION (-8) Don't Know
(-9) Refused
INFORMATION.
Since (LAST INTERVIEW DATE), has (SP) lived [here/there]?

SPRESIDE

(01) BOX INSTR2
(02) FS02 - SPRESIDE

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

(01) BOX INSTR1
(02) FS08-FSWHERE

FS02

yes/no

BOX INSTR1

routing

IF SUPPLEMENTAL SAMPLE, GO TO FS08 - FSWHERE.
ELSE CONTINUE to BOX INSTR2.

BOX INSTR2

routing

IF ADDRESS PRELOADED GO TO FS03 - FSVERIFY.
IF ADDRESS NOT PRELOADED GO TO FS3a - FSTADDR1.

FSVERIFY

FS03

verbatim text

I need to verify the name and contact information I have for (FACILITY NAME). I have…READ
INFORMATION BELOW

(01) ADDRESS CORRECT
(02) ADDRESS INCORRECT

(01) FS04-FSFACILITY
(02) FS03a-FACNAME

FACNAME

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

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

FS03a- FSTADDR1

CORRECT OR ENTER THE INFORMATION BELOW

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

FS03a-FSTADDR2

FS03a-FCITY

FSTADDR1

FS03a

verbatim text

IF RESPONDENT DOES NOT KNOW OR , ASK TO SPEAK TO SOMEONE WHO WOULD KNOW
ADMISSION INFORMATION.

FSTADDR2

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

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

FCITY

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

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

FS03a-FSTATE

CORRECT OR ENTER THE INFORMATION BELOW

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

FS03a-FZIPCODE

FS03a-FPHONE

FS03a-FFAX

FSTATE

FS03a

verbatim text

FZIPCODE

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

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

FPHONE

FS03a

verbatim text

CORRECT THE PORTIONS OF THE PHONE LISTED BELOW

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

Variable
Name

MR Screen
Name

Question type

Question text/description

Code List

Routing

FFAX

FSO3a

verbatim text

CORRECT THE PORTIONS OF THE FAX NUMBER LISTED BELOW

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

FS04- FSFACILITY

(01)CONTINUING CARE RETIREMENT
COMMUNITY (CCRC)
(02) RETIREMENT COMMUNITY
(03) ADULT/GROUP HOME
(04) NURSING HOME/UNIT WITHIN
A CCRC OR RETIREMENT CENTER
(05)HOSPITAL-BASED SNF UNIT
(06) ASSISTED LIVING FACILITY
(07) BOARD AND CARE HOME
(08) DOMICILIARY CARE HOME
(09) PERSONAL CARE HOME
(010) REST HOME/RETIREMENT
HOME
(11) MENTAL HEALTH
CENTER/PSYCHIATRIC SETTING
(12) INSTITUTION FOR THE
MENTALLY RETARDED
INTELLECTUALLY
DISABLED/DEVELOPMENTALLY
DISABLED
(13) REHABILITATION FACILITY
(14) OTHER LONG-TERM CARE
FACILITY (SPECIFY)
(15) PRIVATE RESIDENCE
(-8) Don't Know
(-9) Refused

(01) FS05-FSNAME
(02) FS05 -FSNAME
(03) FS06-FSRES
(04) FS07-FSADMIN
(05) FS07-FSADMIN
(06) FS07-FSADMIN
(07) FS07 -FSADMIN
(08) FS07 -FSADMIN
(09)FS07-FSADMIN
(10) FS07 -FSADMIN
(11) FS07-FSADMIN
(12) FS07-FSADMIN
(13) FS07-FSADMIN
(14) FS04a- FSFACILITYOTH
(15) CLOSING1

FS07-FSADMIN

FS07-FSADMIN

What type of facility or place is (FACILITY NAME)? (Is this a…)
FSFACILITY

FS04

code one
USE CATEGORIES AS PROBES IF NECESSARY

FSFACILITYOT
FS04a
H
FSNAME

FSRES

FS05

FS06

FSSPCARENA
FS06a
ME
FPADDR1

FS06a

verbatim text

What type of facility is (FACILITY NAME)?

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

verbatim text

What is the name of the specific place within (FACILITY NAME) where (SP) was residing on or
around since [LAST INTERVIEW DATE]?

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

Are residents placed in this facility by an agency of state, county, or local government?

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

Please give me the information of the person who is responsible for the oversight of (SP's) care.

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

FS06a- FSTADDR1

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS06a-FSTADDR2

yes/no

verbatim text

verbatim text

(01) FS06a-FSSPCARENAME
(02) FS07- FSADMIN

Variable
Name

MR Screen
Name

Question type

Question text/description

Code List

Routing

FPADDR2

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS06a -FCITY

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS06a-FSTATE

FS06a-FZIPCODE

FPCITY

FS06a

verbatim text

FPSTATE

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FPZIPCODE

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS06a-FPHONE

FPPHONE

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS06a-FFAX

FPFAX

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS07 - FSADMIN

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

BOX INSTR3

(01) FS08a-FACNAME
(02) BOX INSTR4
(03) FS09 - FSDODMM
(04) BOX INSTR4
(05) BOX INSTR4

FSADMIN

FSWHERE

FACNNAME

FS07

verbatim text

What is the name of the facility administrator at (FACILITY NAME)?

BOX INSTR3

routing

IF FS01 - SPRESIDENOW = 01 GO TO CLOSING 2
ELSE GO TO CLOSING 2

FS08

FS08a

code one

Do you know where (SP) went after living at (FACILITY NAME)?

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

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

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

FS08a- FSTADDR1

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

FS08a -FSTADDR2

FNADDR1

FS08a

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

FNADDR2

FS08a

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

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

FS08a-FCITY

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

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

FS08a-FSTATE

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

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

FS08a-FZIPCODE

FNCITY

FNSTATE

FS08a

FS08a

Variable
Name

MR Screen
Name

Question type

Question text/description

Code List

Routing

FNZIPCODE

FS08a

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

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

FS08a-FPHONE

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

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

FS08a-FFAX

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

(01) continuous answer
(-8) Don't Know
(-9) Refused
FS08a-FSDODDD

FNPHONE

FNFAX

FS08a

FS08a

FSDODMM

FS09

date

What was the date of death?

(01) continuous answer
(-8) DON'T KNOW
(-9) REFUSED

FSDODDD

FS09

date

What was the date of death?

(01) continuous answer
(-8) DON'T KNOW
(-9) REFUSED

FS08a-FSDODYY

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

CLOSING2

FSDODYY

FS09

date

What was the date of death?

BOX INSTR4

routing

IF FS02 - SPRESIDE = 01 (YES) THEN GO TO CLOSING1
ELSE GO TO CLOSING2

CLOSING1

no entry

That is all of the information I need at this time. Thank you very much for your time. We will contact
(you/SP) to arrange an interview.

CLOSING2

no entry

Thank you very much for your time.
We will contact you if there are additional questions.