CMS-P-0015A Introduction

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

INQ - INTRODUCTION

Question Type

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

CARIVER

INV1

code one

NOCARI

INV2

no entry

ATDOOR

IN1AA

no entry

GO TO INV1 - CARIVER.

Some of this interview will be recorded for quality control purposes.
I'd like to continue now, unless you have any questions.

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

(01) ALIVE AND NOT INSTITUTIONALIZED
WHEN WE REFER TO INSTITUTIONALIZED, WE ARE REFERRING TO THE MCBS DEFINITION OF A
(02) ALIVE AND INSTITUTIONALIZED
FACILITY. FOR THE FULL MCBS DEFINITION OF A FACILITY, CLICK F1. PLEASE REMEMBER THAT
(03) DECEASED - DIED IN COMMUNITY
HOSPITALS ARE NOT FACILITIES UNDER THE MCBS DEFINITION SO SPS IN HOSPITALS SHOULD NOT
(04) DECEASED - DIED IN INSTITUTION
BE CONSIDERED TO BE INSTITUTIONALIZED BELOW.

(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]] [the [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 the beneficiary 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 [since [REFERENCE DATE] that [SP]] [the [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 the beneficiary enters any facility and does not enter a hospital or return home.]
(-9) Refused

SPINSTYY

IF MORE THAN ONE DATE, ENTER THE EARLIEST.

Page 1 of 5

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

INQ - INTRODUCTION

Question Type

Question Text/Description

Code List

Routing

What was the first date since [since [REFERENCE DATE] that [SP]] [the [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 the beneficiary enters any facility and does not enter a hospital or return home.]

BOX INSA

IF MORE THAN ONE DATE, ENTER THE EARLIEST.

BOX INSA

routing

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

SPDIEMM

INS3

date

On what date did (SP) die?

SPDIEDD

INS3

date

On what date did (SP) die?

SPDIEYY

INS3

date

On what date did (SP) die?

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
(VIEW_MCBSCOMM_PRELOAD.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 (VIEW_MCBSCOMM_PRELOAD.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
(VIEW_MCBSCOMM_PRELOAD.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
(VIEW_MCBSCOMM_PRELOAD.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.

BOX INSA1

DEASDATE

INS3A

no entry

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

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.

(01) INS3 - SPDIEDD
(-8) INS3 - SPDIEDD
(-9) INS3 - SPDIEDD
(01) INS3 - SPDIEYY
(-8) INS3 - SPDIEYY
(-9) INS3 - SPDIEYY
(01) BOX INSA1
(-8) BOX INSA1
(-9) BOX INSA1

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

BOX INS1

routing

IN4

code one

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.
IF SP IS DECEASED OR INSTITUTIONALIZED, SET RESPONDENT TO PROXY AND GO TO IN4A PERSON_PROXY.
ELSE GO TO IN4 - SPPROXY.
WILL THIS INTERVIEW BE CONDUCTED WITH THE SAMPLE PERSON OR WITH A PROXY?

BOX INSB1

(01) SAMPLE PERSON
(02) PROXY

(01) BOX INS5
(02) IN4A - PERSON_PROXY

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2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

INQ - INTRODUCTION

Question Type

Question Text/Description

Code List

Routing

DISPLAY PERSON ROSTER AS RESPONSE
OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
(01-N) BOX INS2AA
…
(N+1) IN4A-ROSTFNAM
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
IF EXISTING PERSON SELECTED, GO TO BOX
INS2AA.
DISPLAY:
ELSE IF "ADD ANOTHER" SELECTED, GO TO IN4A1 First Name Display ROST.ROSTFNAM.
ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/OtherRelative or 92/OtherNonRelative, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

PERSON_PROXY

IN4A

roster

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

ROSTFNAM

IN4A

text

[What is the name of the person and relationship to (SP)?]

(01) continuous answer

IN4A-ROSTLNAM

ROSTLNAM

IN4A

text

[What is the name of the person and relationship to (SP)?]

(01) continuous answer

IN4A-ROSTREL

ROSTREL

ROSTREOS

IN4A

code one

[What is the name of the person and relationship to (SP)?]

IN4AROSTREOS

verbatim text

[What is the name of the person and relationship to (SP)?]

BOX INS2AA

routing

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

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

(01) DO NOT DISPLAY
(02) BOX INS2AA
(03) BOX INS2AA
(04) BOX INS2AA
(05) BOX INS2AA
(06) BOX INS2AA
(07) BOX INS2AA
(08) BOX INS2AA
(09) BOX INS2AA
(10) BOX INS2AA
(11) BOX INS2AA
(12) BOX INS2AA
(13) BOX INS2AA
(14) BOX INS2AA
(50) DO NOT DISPLAY
(51) BOX INS2AA
(52) BOX INS2AA
(53) BOX INS2AA
(54) BOX INS2AA
(55) BOX INS2AA
(56) BOX INS2AA
(57) BOX INS2AA
(91) IN4AROSTREOS - ROSTREOS
(-8) BOX INS2AA
(-9) BOX INS2AA
BOX INS2AA

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?
IF RELATIONSHIP IS MISSING, SELECT "NO" AND PROBE FOR RELATIONSHIP ON THE NEXT SCREEN. (01) YES
(02) NO
FIRST NAME: (PROXY'S FIRST NAME)
LAST NAME: (PROXY'S LAST NAME)
RELATIONSHIP: (PROXY'S RELATIONSHIP TO SP)

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

text

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

(01) continuous answer

IN6 - ROSTLNAM

text

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

(01) continuous answer

IN6 - ROSTREL

VRFYPROX

IN5

yes/no

ROSTFNAM

IN6

ROSTLNAM

IN6

Page 3 of 5

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

INQ - INTRODUCTION

Question Type

Question Text/Description

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

WHYPROXY

IN6A

code one

PNSPOS

IN6A

verbatim text

BOX INS2B

routing

IN6B

verbatim text

BOX INS3

routing

SUPPDIED

IN6B1

no entry

SUPPINST

IN6B2

no entry

PNSPVB

BOX INS5

routing

WHAT IS THE MAIN REASON THAT A PROXY RESPONDENT NECESSARY?

OTHER (SPECIFY)
IF RESPONSE TO IN6a - WHYPROXY ONLY INCLUDES 9/CodeReasonWhy, GO TO IN6B - PNSPVB.
ELSE GO TO BOX INS3.
BRIEFLY EXPLAIN WHY PROXY MUST ANSWER QUESTIONS.
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 GO TO BOX INS5.
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.
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.

Code List

Routing

(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
(-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
(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
(-8) BOX INS2A-1
(-9) BOX INS2A-1

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

(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) continuous response

BOX INS2A-1

(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
BOX INS3
BOX INS3

BOX IN6
BOX IN6

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?

HHDOBMM

IN9

date

What is [your/(SP’s)] date of birth?

HHDOBDD

IN9

date

What is [your/(SP’s)] date of birth?

HHDOBYY

IN9

date

What is [your/(SP’s)] date of birth?

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.

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused

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

BOX IN3A

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2019 MCBS Community Questionnaire

INQ - INTRODUCTION

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

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

SPMARSTA

SPCHNLNM

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, C010), GO TO ENS.

BOX INSB1

routing

GO TO END1 - INTLANG.

BOX IN4

(01) YES
(02) NO

(01) BOX IN6
(02) IN11 - ROSTSEX

(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

END1 - INTLANG.

Page 5 of 5