Attachment 63 Attachment 63 HC Respondent Forms Section

SpecWriter Data

Form Version:

10/13/2017 2:24:18 PM

Report Type:

Full Detail

Project Database:
Language:

English

WESSQL6.MEPS_V2

Spec Label:

This is the cover page. Additional contents currently project specific.

RF - Page 1 of 73

MEPS_V2

Respondent Forms (RF) Section
(Rout

Full Detail Spec
BOX_00

Route Details:

BOX_10

Route Details:

(RF1000)

Item Type: Route

Type Class: If Then

01 Box = BOX_00, BOX_10, BOX_20, BOX_30, BOX_40, BOX_50, BOX_60, BOX_
70, BOX_80, BOX_90, BOX_100
02 Loop = LOOP_10, LOOP_20
03 End Loop = END_LP10, END_LP20
04 Single Select = RF50_01, RF50_05, RF60, RF100, RF120_01, RF120_05, RF130_01,
RF130_03
13 Address - Preloaded = RF70_01, RF70_02, RF70_03, RF70_04, RF70_05, RF70_06,
RF70_07
14 Regular Date Entry = RF50_04, RF90_01, RF90_02, RF90_03, RF120_04
20 OS Text Field = RF50_02, RF50_06, RF120_02, RF120_06, RF130_02, RF130_04
23 Text Field = RF50_03, RF120_03
24 Information Screen = RFIntro, RF10, RF20, RF30, RF40_01, RF110_01
26 Regular Date Entry - Preloaded = RF80_01, RF80_02, RF80_03

(RF1005)

Item Type: Route

Type Class: If Then

Placeholder for Context header display instructions:
Authorization Form Colors:
Panel
P21
P22
P23
P24
P25
P26

MPC
Green
White
Blue
Green
White
Blue

Pharmacy
Gray
Orchid
Pink
Gray
Orchid
Pink

RF - Page 2 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RFIntro
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1006)
Question
Enumerated
TContinue

)

BLAISE NAME: RFIntro
Field kind: Datafield

ArrayMin:

Min value:

Field Size:
Answers allowed: 1

ArrayMax:

Max value:

Show Card (

)

Look Up File (

)

Question Text:
CAPI WILL NOW DETERMINE WHICH, IF ANY, AUTHORIZATION FORMS AND HARD COPY DOCUMENTS ARE
REQUIRED FOR THIS HOUSEHOLD. THIS PROCESS MAY TAKE A FEW MOMENTS.
ANY EVENTS ADDED AFTER THIS POINT WILL NOT GENERATE NEW AUTHORIZATION FORMS UNTIL THE NEXT
ROUND.
PRESS 1 AND ENTER TO CONTINUE.

Responses:

CONTINUE

BOX_20

Programmer
Instructions:

After ‘1’ is entered, CAPI will use the AF Rules to populate the AF array.

(RF1010)

The rules for creating records that meet the authorization form (AF) definition are included
here:
https://mepspm.westat.com/Final%20Design%20Docs%20by%20Group/Respondent%
20Form%20(RF)%20Section%20Supporting%20Documents/AF%20Rules.xlsx
The specifications for the AF array are included here:
(https://mepspm.westat.com/Final%20Design%20Docs%20by%20Group/Respondent%
20Form%20(RF)%20Section%20Supporting%20Documents/AF%20array.xlsx)

Display
Instructions:

Testing/Editing
Notes:

Variable collected at MEPSSpring2018.RF_Main
Variable stored at MEPSSpring2018_PersSect.RF_Main

RF - Page 3 of 73

MEPS_V2

Respondent Forms (RF) Section
(Rout

Full Detail Spec
BOX_20

Route Details:

(RF1010)

Item Type: Route

Type Class: If Then

If:
⦁ Round 1 and at least one person-provider-pair eligible for MPC authorization form
collection for the current round [at least one record where (AF.AFType=MPC) and
(AF.RequestRd1=Yes)]
OR
⦁ Rounds 2 – 5 and at least one person-provider-pair eligible for MPC or Pharmacy
authorization form collection for the current round [at least one record where
(AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)]
OR
⦁ Rounds 2-5 and at least one person that is part of this RU (MostRecentRU=RUUnit)
rejoined the community this round from previously being institutionalized in a health
care setting [at least one record where (AF.AFType=MPC-HCI (original)) and
(AF.AFInstStatus=1 or 2)]
OR
⦁ At least one Person eligible for SAQ status collection [(Person.SAQFlag=Yes or
Person.SAQFlwUpFlag=YES) and (QS20_04 = 1 or 2)]
OR
⦁ At least one Person eligible for PSAQ status collection [(Person.PSAQFlag=Yes or
Person.PSAQFlwUpFlag=YES) and (QS20_04 = 1 or 2)]
OR
⦁ At least one Person eligible for DCS status collection (Person.DCSFlag=YES),
Continue with RF10.
Otherwise, go to BOX_100.

RF - Page 4 of 73

MEPS_V2

Respondent Forms (RF) Section
(Instr

Full Detail Spec
RF10
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1015)
Instruction
Enumerated

BLAISE NAME: AFSumm

TContinue

Answers allowed: 1

Field kind: Datafield

)

Show Card (

)

Look Up File (

Question Text:
FORM COLLECTION SUMMARY.
RU Member

Age

SAQ

{PERSON
FIRST
NAME}
{PERSON
FIRST
NAME}
{PERSON
FIRST
NAME}
{PERSON
FIRST
NAME}
{PERSON
FIRST
NAME}
Total

{Age}

{Text}

{Text}

{SS} ({TT})

{WW}

({XX})

{Age}

{Text}

{Text}

{SS} ({TT})

{WW}

({XX})

{Age}

{Text}

{Text}

{SS} ({TT})

{WW}

({XX})

{Age}

{Text}

{Text}

{SS} ({TT})

{WW}

({XX})

{Age}

{Text}

{Text}

{SS} ({TT})

{WW}

({XX})

{YY}

{(ZZ)}

{QQ
(Pending)}

DCS

{RR
(Pending)

Medical AFs
(Preprinted)
{MPCColor}

{UU}

{(VV)}

Pharmacy AFs
(Preprinted)
{PharColor}

PRESS 1 AND ENTER TO CONTINUE.

Responses:

CONTINUE

BOX_30

RF - Page 5 of 73

(RF1020)

)

MEPS_V2
Full Detail Spec

Programmer
Instructions:

Display
Instructions:

Respondent Forms (RF) Section
(Instr

Roster behavior:
1. Add, edit, select disallowed.

Roster 1 - Report Roster Definition:
This item displays the RU members roster for display only in the info pane.
Roster Filter
Display only RU members who are key (CtrlPersKey=Yes) or who were deceased in a
previous round or institutionalized in a previous round and still institutionalized and have an
outstanding authorization form [(AF.AFPersonStatus=5 or 6) and [at least one record where
(AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)]].
Display the following columns formatted in the info pane:
Column Header #1: RU Member
Display the first name (Pers. FName) of each RU member meeting the roster filter definition.
Column Header #2: Age
Display the age of the person. If age is missing, display the range for the age category.
Column Header #3: SAQ
This cell is active for this row if [(Person.SAQFlag=Yes or Person.SAQFlwUpFlag=YES) and
(QS20_04 = 1 or 2)] or if [(Person.PSAQFlag=Yes or Person.PSAQFlwUpFlag=YES) and (QS20_
04 = 1 or 2)]. Otherwise, leave cell empty. Cell display uses the value from QS20_04
(FormCmpl) or QS20_05 (FormCollect) for this person during the current round. Display
“Completed” if QS20_05 was coded ‘1’ (COMPLETED AND GIVEN TO INTERVIEWER). Display
“Refused” if QS20_05 was coded ‘5’ (REFUSED TO COMPLETE). Display “Pending” if QS20_
04 was coded ‘2’ (NEEDS REPLACEMENT) or QS20_05 was coded ‘6’ (NOT COMPLETED,
COLLECT UPDATED STATUS AT RESPONDENT FORM SECTION).
For “QQ”, display the count of the number of persons where the SAQ/PSAQ status is
“pending”. Display ‘0’ if none. The word ‘(Pending)’ will display next to this count.
(Note: The SAQ and PSAQ are never collected in the same round, thus they can share a
column.)
Column Header #4: DCS
Display “Pending” if Person.DCSFlag=YES. Otherwise, leave cell empty.
For “RR”, display the count of the number of persons where Person.DCSFlag=YES. Display ‘0’
if none. The word ‘(Pending)’ will display next to this count.
(Note: The DCS is only being distributed in the QS section and never statused. The RF section
is the first time we will get a status for the DCS.)
Column Header #5: Medical AFs (Preprinted) {MPCColor}
For “MPCColor”, display the color of the MPC form for that panel. See BOX_10 for
specifications on color.
For “SS”, display the count of the total number of MPC AFs for this RU Member. This count is
the number of records for this RU member where [(Round 1) and (AF.AFType=MPC) and
(AF.RequestRd1=Yes)] or [(Rounds 2-5) and (AF.AFType=MPC) and
RF - Page 6 of 73

MEPS_V2

Respondent Forms (RF) Section
(Instr

Full Detail Spec

(AF.AFSuperceded=Empty)]. Display ‘0’ if none.
For “TT”, display the count of the number of MPC preprinted AFs that are available for this
RU member. This count is the number of records for this RU member where [(Rounds 2-5)
and (AF.AFType=MPC) and (AF.AFSuperceded=Empty) and (AF.AFPreprinted=1 or 2)].
Display ‘0’ if none. Note: This count will always be ‘0’ in Round 1.
For “UU”, sum all the counts in “SS”. For “VV”, sum all the counts in “TT”.
Column Header #6: Pharmacy AFs (Preprinted) {PharColor}
For “PharColor”, display the color of the Pharmacy form for that panel. See BOX_10 for
specifications on color.
For “WW”, display the count of the total number of Pharmacy AFs for this RU Member. This
count is the number of records for this RU member where [(Rounds 2-5) and
(AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty)]. Display ‘0’ if none. Note: This count
will always be ‘0’ in Round 1.
For “XX”, display the count of the number of Pharmacy preprinted AFs that are available for
this RU member. This count is the number of records for this RU member where [(Rounds
2-5) and (AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty) and (AF.AFPreprinted=1 or
2)]. Display ‘0’ if none. This count will always be ‘0’ in Round 1.
For “YY”, sum all the counts in “WW”.
For “ZZ”, sum all the counts in “XX”.
Display the grid in the info pane in nonproportional text.

Testing/Editing
Notes:

BOX_30

Route Details:

Variable collected at MEPSSpring2018.RF_Main
Variable stored at MEPSSpring2018_PersSect.RF_Main

(RF1020)

Item Type: Route

Type Class: If Then

If Rounds 2-5 and at least one person that is part of this RU (MostRecentRU=RUUnit)
rejoined the community this round from previously being institutionalized in a health care
setting [at least one record where (AF.AFType=MPC-HCI (original)) and (AF.AFInstStatus=1
or 2)], continue with RF20.
Otherwise, go to BOX_40.

RF - Page 7 of 73

MEPS_V2

Respondent Forms (RF) Section
(Instr

Full Detail Spec
RF20
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1025)
Instruction
Enumerated

BLAISE NAME: AFSumm2

TContinue

Answers allowed: 1

Field kind: Datafield

)

Show Card (

)

Look Up File (

Question Text:
FORM COLLECTION SUMMARY, CONTINUED.
{PERSON 1}, {PERSON 2}, {PERSON 3}, {PERSON 4}, {PERSON N} {HAVE/HAS} {REJOINED THE HOUSEHOLD} {OR}
{DIED} AFTER BEING IN A HEALTH CARE FACILITY.
CAPI WILL ALSO PROMPT YOU TO COMPLETE AUTHORIZATION FORMS FOR INSTITUTIONAL STAYS THAT
OCCURRED DURING THE TIME {HE/SHE/THEY} {WERE/WAS} AWAY AT A HEALTH CARE FACILITY.
PRESS 1 AND ENTER TO CONTINUE.

Responses:

CONTINUE

BOX_40

RF - Page 8 of 73

(RF1030)

)

MEPS_V2

Respondent Forms (RF) Section
(Instr

Full Detail Spec

Programmer
Instructions:
Display
Instructions:

Roster 1- Report
Roster definition:
This item uses the authorization form array to display RU-members. (AF.FName, AF.MName,
AF.LName)
Roster filter:
Display only those RU members who have returned from being institutionalized in a
previous round [persons where (AF.AFType=MPC-HCI (original)) and (AF.AFInstStatus=1 or
2)].
Display RU members’ first, middle, and last names (AF.FName, AF.MName, AF.LName) in
question text. If exactly two names displayed, separate names with the word “and” and no
comma. If more than two names listed, separate names using commas, except for between
the last two names displayed. Between the last two names displayed, separate names using
the word “and”.
Display “HAVE” and “WERE” if more than one name displayed. Otherwise, display “HAS” and
“WAS”.
Display “REJOINED THE HOUSEHOLD” if there is at least one RU member listed who is living
with the family after leaving the institution (AF.AFInstStatus=2). Otherwise, use a null
display.
Display “DIED” if there is at least one RU member listed who died after leaving the
institution (AF.AFInstStatus=1). Otherwise, use a null display.
Display “OR” if there is at least one RU member listed who is living with household and at
least one RU member who is listed died after leaving institution. Otherwise, use a null
display.
Display “HE” if only one RU member meets the roster filter conditions and that RU member
is male. Display “SHE” if only one RU member meets the roster filter conditions and that RU
member is female. Otherwise, display “THEY”.

Testing/Editing
Notes:

Variable collected at MEPSSpring2018.RF_Main
Variable stored at MEPSSpring2018_PersSect.RF_Main

RF - Page 9 of 73

MEPS_V2

Respondent Forms (RF) Section
(Rout

Full Detail Spec
BOX_40

Route Details:

(RF1030)

Item Type: Route

Type Class: If Then

If:
⦁ Round 1 and at least one person-provider-pair eligible for MPC authorization form
collection for the current round [at least one record where (AF.AFType=MPC) and
(AF.RequestRd1=Yes)]
OR
⦁ Rounds 2 – 5 and at least one person-provider-pair eligible for MPC or Pharmacy
authorization form collection for the current round [at least one record where
(AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)]
OR
⦁ Rounds 2-5 and at least one person that is part of this RU (MostRecentRU=RUUnit)
rejoined the community this round from previously being institutionalized in a health
care setting [at least one record where (AF.AFType=MPC-HCI (original)) and
(AF.AFInstStatus=1 or 2)],
Continue with RF30.
Otherwise, go to LOOP_10.

RF - Page 10 of 73

MEPS_V2

Respondent Forms (RF) Section
(Instr

Full Detail Spec
RF30
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1035)
Instruction
Enumerated
TContinue

)

BLAISE NAME: AFRequest
Field kind: Datafield
Answers allowed: 1

Show Card (

)

Look Up File (

)

Question Text:
{[As I mentioned during the last interview], we/We} request written authorization to contact {medical providers}
{and} {pharmacies} to obtain complete and accurate information about health care use and expenditures.
{I would like to get authorization from {MPC_PERSON 1, MPC_PERSON 2, MPC_PERSON 3, MPC_PERSON 4,
MPC_PERSON N….} to contact medical providers for more information about the services they provide.}
{I would {also} like to get authorization from {PHAR_PERSON 1, PHAR_PERSON 2, PHAR_PERSON 3,
PHAR_PERSON 4, PHAR_PERSON N….} to contact pharmacies to obtain a printed summary.}
[HAND RESPONDENT THE AUTHORIZATION FORM BOOKLET.]
[These materials explain more about why we contact {medical providers} {and} {pharmacies} and answer
questions people sometimes ask about this part of the study. Please take a minute to review this information
while I prepare the forms.]
PRESS 1 AND ENTER TO CONTINUE.

Responses:

CONTINUE

LOOP_10

RF - Page 11 of 73

(RF1040)

MEPS_V2
Full Detail Spec

Display
Instructions:

Respondent Forms (RF) Section
(Instr

DISPLAY “[As I mentioned during the last interview], we” if not round 1. Otherwise, display
“We”.
Display “medical providers” if at least one person in the RU has at least one active MPC AF
in the current round [at least one record where [(Round 1) and (AF.AFType=MPC) and
(AF.RequestRd1=Yes)]] or [at least one record where [(Rounds 2-5) and
(AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty)]]. Otherwise, use a null display.
Display “and” if there is at least at least one active MPC and one active Phamacy AF in the
current round. Otherwise, use a null display.
Display “pharmacies” if at least one person in the RU has at least one active Pharmacy AF in
the current round [at least one record where (Rounds 2-5) and (AF.AFType=Pharmacy) and
(AF.AFSuperceded=Empty)]. Otherwise, use a null display.
Display “I would like to get authorization from {MPC_PERSON 1, MPC_PERSON 2,
MPC_PERSON 3, MPC_PERSON 4, MPC_PERSON N….} to contact medical providers for more
information about the services they provide.” if at least one person in the RU has at least
one active MPC AF in the current round. Otherwise, use a null display.
For “{MPC_PERSON 1, MPC_PERSON 2, MPC_PERSON 3, MPC_PERSON 4, MPC_PERSON
N….},” display the first names (AF.FName) of all RU members where that person has at least
one active MPC AF in the current round. Substitute “you” for the person’s first name if the
respondent is included in this list. If exactly two names displayed, separate names with the
word “and” and no comma. If more than two names listed, separate names using commas,
except for between the last two names displayed. Between the last two names displayed,
separate names using the word “and”.
Display “I would {also} like to get authorization from {PHAR_PERSON 1, PHAR_PERSON 2,
PHAR_PERSON 3, PHAR_PERSON 4, PHAR_PERSON N….} to contact pharmacies to obtain a
printed summary.” if at least one person in the RU has at least one active Pharmacy AF in
the current round. Otherwise, use a null display.
Display “also” if there is at least at least one active MPC and one active Phamacy AF in the
current round. Otherwise, use a null display.
For “{PHAR_PERSON 1, PHAR_PERSON 2, PHAR_PERSON 3, PHAR_PERSON 4, PHAR_PERSON
N….},” display the first names (AF.FName) of all RU members where that person has at least
one active Pharmacy AF in the current round. Substitute “you” for the person’s first name if
the respondent is included in this list. If exactly two names displayed, separate names with
the word “and” and no comma. If more than two names listed, separate names using
commas, except for between the last two names displayed. Between the last two names
displayed, separate names using the word “and”.

Testing/Editing
Notes:

Variable collected at MEPSSpring2018.RF_Main
Variable stored at MEPSSpring2018_PersSect.RF_Main

RF - Page 12 of 73

MEPS_V2

Respondent Forms (RF) Section
(Rout

Full Detail Spec
LOOP_10

Route Details:

(RF1040)

Type Class: Begin Loop

Item Type: Route

For each RU member, ask BOX_50 – END_LP10.
Loop definition: LOOP_10 collects the status of all eligible MPC and Pharmacy
Authorization Forms and any outstanding hard-copy forms. This loop also cycles on RU
members who have returned from the institution. This loop cycles on RU members that
meet one of the following conditions:
⦁ Round 1 and person eligible for MPC authorization form collection for the current
round [person has at least one record where (AF.AFType=MPC) and (AF.RequestRd1
=Yes)]
OR
⦁ Rounds 2 – 5 and person eligible for MPC or Pharmacy authorization form collection
for the current round [person has at least one record where (AF.AFType=MPC or
Pharmacy) and (AF.AFSuperceded=Empty)]
OR
⦁ Rounds 2-5 and person that is part of this RU (MostRecentRU=RUUnit) rejoined the
community this round from previously being institutionalized in a health care setting
[person has record where (AF.AFType=MPC-HCI (original)) and (AF.AFInstStatus=1 or
2)]
OR
⦁ Person is eligible for SAQ status collection [(Person.SAQFlag=Yes or
Person.SAQFlwUpFlag=YES) and (QS20_04 = 1 or 2)]
OR
⦁ Person is eligible for PSAQ status collection [(Person.PSAQFlag=Yes or
Person.PSAQFlwUpFlag=YES) and (QS20_04 = 1 or 2)]
OR
⦁ Person is eligible for DCS status collection (Person.DCSFlag=YES)

BOX_50

Route Details:

(RF1045)

Item Type: Route

Type Class: If Then

If:
⦁ Round 1 and person (being looped on) eligible for MPC authorization form
collection for the current round [person has at least one record where
(AF.AFType=MPC) and (AF.RequestRd1=Yes)]
OR
⦁ Rounds 2 – 5 and person (being looped on) eligible for MPC or Pharmacy
authorization form collection for the current round [person has at least one record
where (AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)],
Continue with RF40_01.
Otherwise, go to BOX_60.

RF - Page 13 of 73

MEPS_V2

Respondent Forms (RF) Section
(Rout

Full Detail Spec

RF40_01
Item Type:

(RF1050)
Question

Type Class:

Enumerated

Answer Type:

TAFFORMPREP

BLAISE NAME: AFInfo
Field kind: Datafield
ArrayMin:

Min value:

Field Size:
Answers allowed: 1

Help Available (AFInfoHelp)

ArrayMax:

Show Card (

)

Max value:

Look Up File (

)

Question Text:
INTERVIEWER: {COMPLETE A NEW AF FOR THIS PAIR./TAKE OUT PREPRINTED AF FOR THIS PAIR. IF NOT
AVAILABLE, FILL OUT A BLANK AF.}
{AF STATUS FROM PREVIOUS ROUND: {DISPLAY RECEIPT CONTROL STATUS}}
PROVIDER NAME: {Provider/Pharmacy Full Name}
ADDRESS: {Combined Street Address}
{City}, {ST} {Zip Code} {Telephone}
PATIENT: {First,[Middle],Last Name}
DOB: {MM/DD/YYYY} AGE: {XXX} {ACTION: {Status Action}}
RU ID: {RUID} REGION: {Reg ID} PROVIDER ID: {ProvID} PID: {PID}
SIGNATURE DATE ON AF MUST BE ON OR AFTER: {MM/DD/YYYY}
{IF NECESSARY, SAY: Since {LINKED PROV NAMES} (is/are) associated with a larger practice, we will ask for
authorization for just {PROVIDER FULL NAME}.}
PRESS 1 AND ENTER WHEN FORM IS PREPARED.
CTRL-S: SWITCH TO A DIFFERENT RU MEMBER.
HELP: F1

Responses:

AF FORM PREPARED

1

RF - Page 14 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Programmer
Instructions:

Preloaded grid type – flexible navigation including RF40_01, RF40_02, RF40_03, RF40_04,
RF40_N, as well as RF50_01, RF50_02, RF50_03, RF50_04, RF50_05, and RF50_06.
At grid completion, continue with RF50_01.

Display
Instructions:

Roster 1 – Report
Col #1 Header: Provider
Instructions: Display the name of the medical or pharmacy provider for this row. This
column is protected and uneditable. (use AF.ProvName from the AF array. Variable may
need to be truncated for display in grid.)
Roster Filter:
Display only MPC and Pharmacy authorization forms that are active for this person for this
round [records where [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1=Yes)] or
[(Rounds 2-5) and (AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)]]. This
column is protected and uneditable.
Col #2 Header: Type
Instructions: Display the Authorization form type – either “MPC” or “Pharmacy”. This
column is protected and uneditable. (use AF.AFType)
Col #3 Header: Color
Instructions: Display the color linked to this authorization form. (see BOX_10 rules)
Col #4 Header: Prep
Instructions: RF40_01, RF40_02, RF40_03, RF40_04, RF40_N entry field.
Display “COMPLETE A NEW AF FOR THIS PAIR.” If no preprinted AF exists for this record
(AF.AFPreprinted=Empty). Otherwise display, “TAKE OUT PREPRINTED AF FOR THIS PAIR. IF
NOT AVAILABLE, FILL OUT A BLANK AF.”
Display “AF STATUS FROM PREVIOUS ROUND: {DISPLAY RECEIPT CONTROL STATUS}” if this
AF record was outstanding from the previous round and not replaced by a new personprovider pair record [(AF.AFSuperceded=Empty) and (AF.OrigRnd< > current round) and
(AF.PL_AFRecCtrlStatus<>Empty)]. Otherwise, use a null display.
For “{DISPLAY RECEIPT CONTROL STATUS}”, display the label associated with the receipt
control status. If the receipt control status is “Other, specify”, display the other specify
status text entry field. (Use AF.PL_AFRecCtrlStatus and AF.PL_AFRecCtrlStatusOS)
The labels PROVIDER NAME:, ADDRESS:, PATIENT:, DOB:, AGE:, RU ID:, REGION:, PROVIDER
ID:, PID, AND SIGNATURE DATE…: should be displayed in the traditional blue font and size of
interviewer instructions. However, display the contents after that label (i.e., the
provider/pharmacy name, person name, etc.) in bold black. This will make the screen easier
to read.
The label ACTION: should be displayed in the traditional interviewer instruction font size –
but in red. However, display the contents after that label (i.e., status action) in bold black.
For “{Provider/Pharmacy Full Name}” display the full name of the provider or pharmacy for
this AF record. (Use AF.ProvName with no truncation).
RF - Page 15 of 73

MEPS_V2
Full Detail Spec

Respondent Forms (RF) Section
(Que

For “{Combined Street Address}” display the street address of the provider or pharmacy for
this AF record. (Concatenate AF.StrtAddr1 and AF.StrtAddr2 into one line separated with a
space)
For “{City}, {ST} {Zip Code} {Telephone}” display the rest of the
address of the provider or pharmacy for this AF record. (Use AF.City,
AF.State, AF.Zip and AF.Phone)
For “{First,[Middle],Last Name}” display the name of the RU member
for this AF record. (Use AF.FName, AF.MName, and AF.LName)
For (DOB) “{MM/DD/YYYY}” display the DOB of the RU member for this
AF record. (Use AF.DOBM, AF.DOBD, AF.DOBY). If complete DOB is
RF/DK/empty, leave the display empty. If part of the DOB is RF/DK/empty,
display "RF" or "DK" or leave empty as appropriate for that field.

For “{XXX}” display the age or age range of the RU member for this AF
record. (Use AF.Age. If Age=RF/DK/empty, use AF.AgeCat. If
AF.AgeCat= RF/DK/empty, use AF.AgeGuess.)
Display “ACTION: {Status Action}” if (AF.AFPersonStatus=3, 4, 5, or 6)
or if [(AF.AFPersonStatus=1 or 2) and [(AF.Age <=17) or (AF.AgeCat or
AF.AgeGuess=1-4)]]. Otherwise, use a null display.
For “{Status Action}” display the following:
“{Verify} Child <=13. {If so,} Need Parent/Guardian Signature” if
[(AF.AFPersonStatus=1 or 2) and [(AF.Age <=13) or (AF.AgeCat or
AF.AgeGuess=1-3)]].
Display “Verify” and “If so,” AF.Age is RF/DK/empty and AF.AgeCat or
AF.AgeGuess=1-3. Otherwise, use a null display.
“{Verify} Child 14-17. {If so,} Need Patient and Parent/Guardian
Signature” if [(AF.AFPersonStatus=1 or 2) and [(AF.Age 14-17) or
(AF.AgeCat or AF.AgeGuess=4)]].
Display “Verify” and “If so,” AF.Age is RF/DK/empty and AF.AgeCat or
AF.AgeGuess=4. Otherwise, use a null display.
“Patient Deceased {In Prior Round}. Need Proxy Signature” if
AF.AFPersonStatus=3 or 5.
Display “In Prior Round” if AF.AFPersonStatus=5.
“Patient {Still} Institutionalized. Need Proxy Signature” if
AF.AFPersonStatus=4 or 6.
Display “Still” if AF.AFPersonStatus=6.

For “{RUID}”, display the CaseID.
For “{Reg ID}”, display the region of this CaseID. (May need to get
from BFOS?)
For “{ProvID}”, display the provider ID of the provider or pharmacy for
this AF record (ProvID).
For “{PID}”, display the AF.PersID of the RU member for this AF
RF - Page 16 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

record.
For (SIGNATURE DATE) “{MM/DD/YYYY}”, display the required
signature date for this AF record (Use AF.ReqSignDt).
Display “IF NECESSARY, SAY: Since {LINKED PROV NAMES} (is/are)
associated with a larger practice, we will ask for authorization for just
{PROV NAME}.” if there are linked provider names for this AF record
(AF.LinkedAF.ProvNames < > Empty). Otherwise, use a null display.
For “{LINKED PROV NAMES}” display the text entry associated with
this field for this AF record. This will be a string of provider first and
last names. (Use AF.LinkedAF.ProvNames).
For “{PROVIDER FULL NAME}” display the full name of the provider for this AF record. (Use
AF.ProvName, truncation is okay).

Testing/Editing
Notes:

Variable collected at MEPSSpring2018.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]

RF50_01
Item Type:

(RF1055)
Question

Type Class:

Enumerated

Answer Type:

TFORMSTAT2

BLAISE NAME: AFStat
Field kind: Datafield

ArrayMin:

Min value:

ArrayMax:

Max value:

Field Size:
Answers allowed: 1

Help Available (AFStatHelp)

Show Card (

)

Look Up File (

)

Question Text:
PROVIDER NAME: {Provider/Pharmacy Full Name}
PATIENT: {First,[Middle],Last Name}
REQUEST SIGNATURE AND THEN ENTER THE AUTHORIZATION FORM STATUS.
{IF NECESSARY, SAY: Since {LINKED PROV NAMES} (is/are) associated with a larger practice, we will ask for
authorization for just {PROVIDER FULL NAME}.}
HELP: F1

Responses:

SIGNED
LEFT WITH RESPONDENT
MAILED TO RESPONDENT
REFUSED (NO FORM LEFT)
OTHER (NOT SIGNED)

1
2
3
4
91
RF - Page 17 of 73

RF50_03

(RF1065)

RF50_05
RF50_02

(RF1075)
(RF1060)

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Programmer
Instructions:

Preloaded Grid type 2 – flexible navigation, including items RF50_01, RF50_02, RF50_03,
RF50_04, RF50_05, and RF50_06, as well as RF40_01, RF40_02, RF40_03, RF40_04, RF40_N.
Refused and Don’t Know disallowed.
If RF50_01 is coded ‘2’ (LEFT WITH RESPONDENT) or ‘3’ (MAILED TO RESPONDENT), return
to RF50_01 for next authorization form on grid. At grid completion, go to BOX_60.
Set AF.AFCAPIStatus=RF50_01.

Display
Instructions:

Roster 1 – Report
Col #1 Header: Provider
Instructions: Display the name of the medical or pharmacy provider for this row. This
column is protected and uneditable. (use AF.ProvName from the AF array. Variable may
need to be truncated for display in grid.)
Roster Filter:
Display only MPC and Pharmacy authorization forms that are active for this person for this
round [records where [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1=Yes)] or
[(Rounds 2-5) and (AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)]]. This
column is protected and uneditable.
Col #2 Header: Type
Instructions: Display the Authorization form type – either “MPC” or “Pharmacy”. This
column is protected and uneditable. (use AF.AFType)
Col #3 Header: Color
Instructions: Display the color linked to this authorization form. (see BOX_10 rules)
Col #4 Header: Prep
Instructions: Display the entered responses from RF40_01-RF40_N for each authorization
form in a protected, uneditable field.
Col #5 Header: Status
Instructions: Item RF50_01. Always an active cell for every row.
Col #6 Header: Specify Status
Instructions: Item RF50_02. Display as an active cell if RF50_01 is coded ‘91’ (OTHER).
Col #7 Header: AF Number
Instructions: Item RF50_03. Display as an active cell if RF50_01 is coded ‘1’ (SIGNED).
Col #8 Header: Signature Date
Instructions: Item RF50_04. Display as an active cell if RF50_01 is coded ‘1’ (SIGNED).
Col #9 Header: Refusal Reason
Instructions: Item RF50_05. Display as an active cell if RF50_01 is coded ‘4’ (REFUSED)
Col #10 Header: Specify Refusal
Instructions: Item RF50_06. Display as an active cell if RF50_05 is coded ‘91’ (OTHER
SPECIFY).
RF - Page 18 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider/Pharmacy Full Name}” display the full name of the
provider or pharmacy for this AF record as grayed out text. (Use
AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member
for this AF record as grayed out text. (Use AF.FName, AF.MName, and
AF.LName)
Display “IF NECESSARY, SAY: Since {LINKED PROV NAMES} (is/are)
associated with a larger practice, we will ask for authorization for just
{PROV NAME}.” if there are linked provider names for this AF record
(AF.LinkedAF.ProvNames < > Empty). Otherwise, use a null display.
For “{LINKED PROV NAMES}” display the text entry associated with
this field for this AF record. This will be a string of provider first and
last names. (Use AF.LinkedAF.ProvNames).
For “{PROVIDER FULL NAME}” display the full name of the provider for this AF record. (Use
AF.ProvName, truncation is okay).

Testing/Editing
Notes:

Variable collected at MEPSSpring2018.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]

BLAISE NAME: AFStatOS
Field kind: Datafield
ArrayMin:

RF50_02
Item Type:

(RF1060)
Question

Type Class:

String

Answer Type:

{Continuous Answer.} Answers allowed: 1

Help Available (

Min value:

Field Size: 45

)

Show Card (

ArrayMax:

)

Question Text:
PROVIDER NAME: {Provider/Pharmacy Full Name}
PATIENT: {First,[Middle],Last Name}
SPECIFY OTHER AUTHORIZATION FORM STATUS:

Responses:

RF - Page 19 of 73

Max value:

Look Up File (

)

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Programmer
Instructions:

Return to RF50_01 for next authorization form on grid.
Refused and Don’t Know disallowed.
Set AF.AFCAPIStatusOS=RF50_02.

Display
Instructions:

Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider/Pharmacy Full Name}” display the full name of the provider or pharmacy for
this AF record as grayed out text. (Use AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as
grayed out text. (Use AF.FName, AF.MName, and AF.LName)

Testing/Editing
Notes:

Variable collected at MEPSSpring2018.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]

BLAISE NAME: AFNum

RF50_03
Item Type:

(RF1065)
Question

Type Class:

String

Answer Type:

{Continuous Answer.} Answers allowed: 1

Help Available (

Field kind: Datafield

ArrayMin:

Min value:

ArrayMax:

Max value:

Field Size: 8

)

Show Card (

)

Look Up File (

Question Text:
PROVIDER NAME: {Provider/Pharmacy Full Name}
PATIENT: {First,[Middle],Last Name}
ENTER AUTHORIZATION FORM NUMBER:

RF50_04

Responses:

RF - Page 20 of 73

(RF1070)

)

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Programmer
Instructions:

Refused and Don’t Know disallowed.
Set AF.AFFormID=RF50_03.
Note: Each authorization form has a pre-assigned authorization form number. This number
is linked to the authorization form type, panel and round.
Hard check: Exactly 8 digit alpha-numeric entry required. If less than 8 characters entered,
display the following message: "AUTHORIZATION FORM NUMBER REQUIRES EXACTLY 8
LETTERS/NUMBERS. VERIFY FORM NUMBER AND FORM TYPE AND RE-ENTER."
Hard Check – MPC/Pharmacy Authorization Forms: The Authorization form number entered
must follow the conventions noted below for the panel and AF type. If an authorization
form number is entered that does not meet the conventions, display the following message:
“INVALID AUTHORIZATION FORM NUMBER ENTERED. VERIFY FORM NUMBER AND FORM
TYPE AND RE-ENTER.”
MPC Authorization Form Number Conventions
Letter
5-Number
Check Digit
Round Identifier
Sequence
P21
P22
P23
Pre-Generated A-M 00001-29499 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L
Field Generated A-M 29500-44999 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L
Home Office
T
45000-49999 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L
Training/QC
Y
96000-96399 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L
Origin

Pharmacy Authorization Form Number Conventions
Letter
5-Number Check Digit
Round Identifier
Sequence
P21
P22
P23
Pre-Generated Q, R, S 70000-79999 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L
Field Generated Q, R, S 80000-89999 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L
Home Office
Z
90000-95999 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L
Training/QC
Y
96600-96799 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L
Origin

Note:
P24 will use round identifiers: M, N, P, Q, R.
P25 will use round identifiers: S, T, U, V, W.
P26 will use round identifiers: 1, 2, 3, 4, 5.

Display
Instructions:

Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider/Pharmacy Full Name}” display the full name of the provider or pharmacy for
this AF record as grayed out text. (Use AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as
grayed out text. (Use AF.FName, AF.MName, and AF.LName)

Testing/Editing
Notes:

Variable collected at MEPSSpring2018.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
RF - Page 21 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]

BLAISE NAME: AFDate

RF50_04
Item Type:

(RF1070)
Question

Type Class:

Date

Answer Type:

{Continuous Answer.} Answers allowed: 1

Help Available (

Field kind: Datafield

ArrayMin:

Min value:

ArrayMax:

Max value:

Field Size:

)

Show Card (

)

Look Up File (

Question Text:
PROVIDER NAME: {Provider/Pharmacy Full Name}
PATIENT: {First,[Middle],Last Name}
SIGNATURE DATE ON AF MUST BE ON OR AFTER: {MM/DD/YYYY}
ENTER AUTHORIZATION FORM SIGNATURE DATE:
PRESS THE ALT AND DOWN ARROW KEY TO SELECT THE DATE FROM THE CALENDAR. PRESS ENTER TO
CONTINUE.

Responses:

RF - Page 22 of 73

)

MEPS_V2
Full Detail Spec

Programmer
Instructions:

Respondent Forms (RF) Section
(Que

Return to RF50_01 for next authorization form on grid.
Refused and Don’t Know disallowed.
Hard check: Date entered must be on or after the interview date of the most recent round’s
interview for which the pair is/was eligible for authorization form collection (use
AF.ReqSignDt), but cannot be after ‘Today’s’ Date’ (the current date set on the laptop,
which may be different from RU reference period end date). If date is before correct date,
display the following message: “AUTHORIZATION FORM MUST BE SIGNED ON OR AFTER
ABOVE DATE. VERIFY AND RE-ENTER DATE OR COMPLETE NEW AF.”

Display
Instructions:

Display the date field for the signature date here. The FI should be able to either type in the
full date or use the pop-up calendar. Pressing the alt and down arrow key, will bring up the
popup calendar defaulted to today’s date (the computer date). Once the FI selects the date
on the pop-up calendar, CAPI will fill in the date in this format: / / , pressing enter to
continue will take the FI to the next screen.
Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider/Pharmacy Full Name}” display the full name of the provider or pharmacy for
this AF record as grayed out text. (Use AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as
grayed out text. (Use AF.FName, AF.MName, and AF.LName)
For (SIGNATURE DATE) “{MM/DD/YYYY}”, display the required signature date for this AF
record (Use AF.ReqSignDt). This date should be displayed in bold black.

Testing/Editing
Notes:

Variable collected at MEPSSpring2018.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]

RF - Page 23 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF50_05
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1075)
Question
Enumerated
TREFUSAL

BLAISE NAME: AFRfResn
Field kind: Datafield

ArrayMin:

Min value:

Field Size:
Answers allowed: 1

ArrayMax:

Max value:

)

Show Card (

)

Look Up File (

)

Question Text:
PROVIDER NAME: {Provider/Pharmacy Full Name}
PATIENT: {First,[Middle],Last Name}
SELECT MAIN REASON FOR REFUSAL:

Responses:

Programmer
Instructions:

DOESN'T WANT TO BOTHER PROVIDER
CONFIDENTIALITY/SENSITIVE INFO
PAYMENT PROBLEM WITH PROVIDER
HAS ALREADY GIVEN ENOUGH
INFORMATION
WANTS MORE INFO BEFORE SIGNING
NOT INTERESTED IN STUDY
NO REASON GIVEN
OTHER SPECIFY

1
2
3
4
5
6
7
91

RF50_06

(RF1080)

If coded ‘1’, ‘2’, ‘3’, ‘4’, ‘5’, ‘6’, or ‘7’, return to RF50_01 for next authorization form on grid.
Refused and Don’t Know disallowed.

Display
Instructions:

Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider/Pharmacy Full Name}” display the full name of the provider or pharmacy for
this AF record as grayed out text. (Use AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as
grayed out text. (Use AF.FName, AF.MName, and AF.LName)

Testing/Editing
Notes:

Variable collected at MEPSSpring2018.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]

RF - Page 24 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF50_06
Item Type:

(RF1080)
Question
String

Type Class:
Answer Type:

BLAISE NAME: AFRfOS
Field kind: Datafield
Field Size: 45

{Continuous Answer.} Answers allowed: 1

Help Available (

)

Show Card (

ArrayMin:

Min value:

ArrayMax:

Max value:

)

Look Up File (

)

Question Text:
PROVIDER NAME: {Provider/Pharmacy Full Name}
PATIENT: {First,[Middle],Last Name}
SPECIFY OTHER REASON FOR REFUSAL:

Responses:

Programmer
Instructions:

Return to RF50_01 for next authorization form on grid.
Refused and Don’t Know disallowed.

Display
Instructions:

Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider/Pharmacy Full Name}” display the full name of the provider or pharmacy for
this AF record as grayed out text. (Use AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as
grayed out text. (Use AF.FName, AF.MName, and AF.LName)

Testing/Editing
Notes:

BOX_60

Route Details:

Variable collected at MEPSSpring2018.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]

(RF1085)

Item Type: Route

Type Class: If Then

If Rounds 2-5 and person (being looped on) that is part of this RU
(MostRecentRU=RUUnit) rejoined the community this round from previously being
institutionalized in a health care setting [person has record where (AF.AFType=MPC-HCI
(original)) and (AF.AFInstStatus=1 or 2)], continue with RF60.
Otherwise, go to BOX_90.

RF - Page 25 of 73

MEPS_V2

Respondent Forms (RF) Section
(Rout

Full Detail Spec

LOOP_20

Route Details:

(RF1090)

Type Class: Begin Loop

Item Type: Route

For each of the following:
Institution 1
Institution 2
Institution 3
Institution 4
Institution 5
Ask BOX_70-END_LP20.
Loop definition: LOOP_20 collects/verifies the name, address, admit and discharge dates
of every health care institution a person who has rejoined the community resided in
during the time they were not part of the MEPS interview. The response to RF100
determines if the loop cycles again. If RF100 is coded ‘1’ (YES), the loop cycles to collect
the next health care institution. If RF100 is coded ‘2’ (NO), ‘RF’ (REFUSED), or ‘DK’ (DON’T
KNOW), the loop ends. However, there can only be a maximum of 5 health care
institutions, so RF100 will not be asked once there are 5 institutions.

BOX_70

Route Details:

(RF1095)

Item Type: Route

Type Class: If Then

If first cycle of LOOP_20, continue with RF60.
Otherwise, go to RF70_01.

RF - Page 26 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF60
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1100)
Question
Enumerated
TYESNO

)

BLAISE NAME: HCIConf
Field kind: Datafield

ArrayMin:

Min value:

Field Size:
Answers allowed: 1

ArrayMax:

Max value:

Show Card (

)

Look Up File (

Question Text:
I have recorded that {you/{PERSON}} {rejoined the household/passed away} after being in a health care facility.
I would like to collect the name, address, and telephone number for each nursing home or other long-term care
institution that provided 24 hour skilled nursing care where {you/{PERSON}} resided between {DATE ORIG
INSTITUTIONALIZED} and {DATE REJOINED COMMUNITY}.
In an earlier interview, I recorded that {you/{PERSON}} entered {ORIG INSTITUTION NAME}. Is that correct?

Responses:

YES
NO
REFUSED
DON'T KNOW

1
2
RF
DK

RF - Page 27 of 73

RF70_01
RF70_01
RF70_01
RF70_01

(RF1105)
(RF1105)
(RF1105)
(RF1105)

)

MEPS_V2
Full Detail Spec

Programmer
Instructions:

Respondent Forms (RF) Section
(Que

If coded ‘2’ (NO), ‘RF’ (REFUSED), or ‘DK’ (DON’T KNOW), set AF.AFSuperceded=Yes for the
record where AF.AFType=MPC-HCI (original). Create a new record where: AF.AFType=MPCHCI (additional). Set AF.OrigRnd and AF.AFYear. From the MPC-HCI (original) record, copy
over all the “info about person” variables to the new record.
Set AF.ReqSignDt to RU reference period end date regardless of response to RF60.
Set AFYear to 1 if current round =1 or 2. Set AFYear to 2 if current round =3, 4 or 5
regardless of response to RF60.

Display
Instructions:

For “{PERSON}” display the full name of the person being looped on (Person.FullName).
Display “rejoined the household” if person has returned to live in this RU [(AF.AFInstStatus=
2) for the record where AF.AFType=MPC-HCI (original)]. Display “passed away” if person
died after leaving the institution [(AF.AFInstStatus=1) for the record where AF.AFType=MPCHCI (original)].
For “{DATE ORIG INSTITUTIONALIZED}”, display the date the person was first
institutionalized [(AF.OrigInstMM, DD, YYYY) for the record where AF.AFType=MPC-HCI
(original)]. Display as full month, xx, YYYY - e.g., "January 1, 2016". Display “DK” or “RF” for
missing values.
For “{DATE REJOINED COMMUNITY}”, display the date the person left the health care facility
[(AF.DtRejoinedMM, DD, YYYY) for the record where AF.AFType=MPC-HCI (original)]. (This is
the date collected at RE200/RE220/RE240). Display as full month, xx, YYYY - e.g., "January 1,
2016". Display “DK” or “RF” for missing values.
For “{ORIG INSTITUTION NAME}”, display the name of the health care facility the person
reported when he/she was first institutionalized [Use AF.ProvName for the AF record where
AF.AFType=MPC-HCI (orginal)].

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]

RF - Page 28 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF70_01
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1105)
Question
String

BLAISE NAME: HCIName
Field kind: Datafield
Field Size: 40

{Continuous Answer.} Answers allowed: 1

)

Show Card (

ArrayMin:

Min value:

ArrayMax:

Max value:

)

Look Up File (

Question Text:
{VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON}
WAS LIVING./Please give me the name, address and telephone number of the nursing home or long term care
institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living.}
{Is the name:/What is the name?}
{INSTITUTION NAME}
{STREET ADDRESS1}
{STREET ADDRESS2}
{CITY}, {STATE} {ZIP CODE}
{TELEPHONE NUMBER}

RF70_02

Responses:

RF - Page 29 of 73

(RF1110)

)

MEPS_V2
Full Detail Spec

Programmer
Instructions:

Respondent Forms (RF) Section
(Que

Refused and Don’t Know disallowed.
General programming instructions for RF70_01 to RF70_06: If first cycle through LOOP_20
and RF60 is coded ‘1’ (YES), prefill each available address field in the response pane entry
fields with health care institution information from the round the person was first
institutionalized (RE450_01-RE450_06). Use AF.ProvName, AF.StrtAddr1, AF.StrtAddr2,
AF.City, AF.State, and AF.Zip for the AF record where AF.AFType=MPC-HCI (orginal).
General programming instructions for RF70_01 to RF70_06: If first cycle through LOOP_20
and RF60 is coded ‘2’ (YES), ‘RF’ (REFUSED) or ‘DK’ (DON’T KNOW) or if not first cycle
through LOOP_20, leave the response pane entry fields empty for completion. As name,
address, and phone are collected, these values must be added to both the provider fields in
the AF array as well as the provider array so that a ProvID can be created.
General programming instructions for RF70_07: Leave the response pane entry field empty
for completion for all cycles of LOOP_20.
Set Provider.ProvID and AF.ProvID to MaxProvID +1. Set Provider.MPTP to 1 (Facility). Set
Provider.CreateQ to RF70. Set Provider.OrigRnd to current round. Set Provider.OrigRU to
current RU. Set Provider.MPLName and AF.ProvName = RF70_01.

Display
Instructions:

Display RF70_01 through RF70_07 vertically on the same form pane.
Display “VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE
FACILITY WHERE {PERSON} WAS LIVING.” and “Is the name:” if first cycle through LOOP_20
and RF60 is coded ‘1’ (YES). Otherwise, display “Please give me the name, address and
telephone number of the nursing home or long term care institution (that provided 24 hour
skilled nursing care) where {you were/{PERSON} was} living.” and “What is the name?”
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
Display address fields in the info pane with most recent health care institution address
information. Use a null display if response entry fields are empty. As entries are updated in
the current round, the display in the info pane should also be updated.
Display {INSTITUTION NAME} in the info pane in bold, black, but all other address display
fields in lighter “grayed-out” text.

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]

RF - Page 30 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF70_02
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1110)
Question
String

BLAISE NAME: HCIStrt
Field kind: Datafield
Field Size: 40

{Continuous Answer.} Answers allowed: 1

)

Show Card (

ArrayMin:

Min value:

ArrayMax:

Max value:

)

Look Up File (

Question Text:
{VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON}
WAS LIVING./Please give me the name, address and telephone number of the nursing home or long term care
institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living.}
{Is the street address:/What is the street address?}
{INSTITUTION NAME}
{STREET ADDRESS1}
{STREET ADDRESS2}
{CITY}, {STATE} {ZIP CODE}
{TELEPHONE NUMBER}

Responses:
REFUSED
DON'T KNOW

RF
DK

RF - Page 31 of 73

RF70_03

(RF1115)

RF70_03
RF70_03

(RF1115)
(RF1115)

)

MEPS_V2
Full Detail Spec

Programmer
Instructions:

Respondent Forms (RF) Section
(Que

See general programming instructions at RF70_01.
Set Provider.MPStrt and AF.StrtAddr1 = RF70_02.

Display
Instructions:

Display RF70_01 through RF70_07 vertically on the same form pane.
Display “VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE
FACILITY WHERE {PERSON} WAS LIVING.” and “Is the street address:” if first cycle through
LOOP_20 and RF60 is coded ‘1’ (YES). Otherwise, display “Please give me the name, address
and telephone number of the nursing home or long term care institution (that provided 24
hour skilled nursing care) where {you were/{PERSON} was} living.” and “What is the street
address?”
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
Display “VERIFY THE NAME…” or “Please give me…” in brackets and lighter “grayed-out” text
when on RF70_02 through RF70_07.
Display address fields in the info pane with most recent health care institution address
information. Use a null display if response entry fields are empty. As entries are updated in
the current round, the display in the info pane should also be updated.
Display {STREET ADDRESS1} in the info pane in bold, black, but all other address display
fields in lighter “grayed-out” text.

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]

RF - Page 32 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF70_03
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1115)
Question
String

BLAISE NAME: HCIStrt2
Field kind: Datafield
Field Size: 40

{Continuous Answer.} Answers allowed: 1

)

Show Card (

ArrayMin:

Min value:

ArrayMax:

Max value:

)

Look Up File (

Question Text:
{VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON}
WAS LIVING./Please give me the name, address and telephone number of the nursing home or long term care
institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living.}
{VERIFY/ENTER} BUILDING OR ADDITIONAL ADDRESS INFORMATION, AS NECESSARY. IF NONE, PRESS ENTER TO
CONTINUE.
{INSTITUTION NAME}
{STREET ADDRESS1}
{STREET ADDRESS2}
{CITY}, {STATE} {ZIP CODE}
{TELEPHONE NUMBER}

Responses:
EMPTY
REFUSED
DON'T KNOW

Empty
RF
DK

RF - Page 33 of 73

RF70_04

(RF1120)

RF70_04
RF70_04
RF70_04

(RF1120)
(RF1120)
(RF1120)

)

MEPS_V2
Full Detail Spec

Programmer
Instructions:

Respondent Forms (RF) Section
(Que

See general programming instructions at RF70_01.
Set AF.StrtAddr2 = RF70_03.
(There is no street address 2 in the provider array.)

Display
Instructions:

Display RF70_01 through RF70_07 vertically on the same form pane.
Display “VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE
FACILITY WHERE {PERSON} WAS LIVING.” and “VERIFY:” if first cycle through LOOP_20 and
RF60 is coded ‘1’ (YES). Otherwise, display “Please give me the name, address and
telephone number of the nursing home or long term care institution (that provided 24 hour
skilled nursing care) where {you were/{PERSON} was} living.” and “ENTER”.
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
Display “VERIFY THE NAME…” or “Please give me…” in brackets and lighter “grayed-out” text
when on RF70_02 through RF70_07.
Display address fields in the info pane with most recent health care institution address
information. Use a null display if response entry fields are empty. As entries are updated in
the current round, the display in the info pane should also be updated.
Display {STREET ADDRESS2} in the info pane in bold, black, but all other address display
fields in lighter “grayed-out” text.

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]

RF - Page 34 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF70_04
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1120)
Question
String

BLAISE NAME: HCICity
Field kind: Datafield
Field Size: 35

{Continuous Answer.} Answers allowed: 1

)

Show Card (

ArrayMin:

Min value:

ArrayMax:

Max value:

)

Look Up File (

Question Text:
{VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON}
WAS LIVING./Please give me the name, address and telephone number of the nursing home or long term care
institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living.}
{Is the city:/What is the city?}
{INSTITUTION NAME}
{STREET ADDRESS1}
{STREET ADDRESS2}
{CITY}, {STATE} {ZIP CODE}
{TELEPHONE NUMBER}

Responses:
REFUSED
DON'T KNOW

RF
DK

RF - Page 35 of 73

RF70_05

(RF1125)

RF70_05
RF70_05

(RF1125)
(RF1125)

)

MEPS_V2
Full Detail Spec

Programmer
Instructions:

Respondent Forms (RF) Section
(Que

See general programming instructions at RF70_01.
Set Provider. ProvCity and AF.City = RF70_04.

Display
Instructions:

Display RF70_01 through RF70_07 vertically on the same form pane.
Display “VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE
FACILITY WHERE {PERSON} WAS LIVING.” and “Is the city:” if first cycle through LOOP_20
and RF60 is coded ‘1’ (YES). Otherwise, display “Please give me the name, address and
telephone number of the nursing home or long term care institution (that provided 24 hour
skilled nursing care) where {you were/{PERSON} was} living.” and “What is the city?”
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
Display “VERIFY THE NAME…” or “Please give me…” in brackets and lighter “grayed-out” text
when on RF70_02 through RF70_07.
Display address fields in the info pane with most recent health care institution address
information. Use a null display if response entry fields are empty. As entries are updated in
the current round, the display in the info pane should also be updated.
Display {CITY} in the info pane in bold, black, but all other address display fields in lighter
“grayed-out” text.

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]

RF - Page 36 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF70_05
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1125)
Question
String

BLAISE NAME: HCIState
Field kind: Datafield
Field Size: 2

{Continuous Answer.} Answers allowed: 1

)

Show Card (

ArrayMin:

Min value:

ArrayMax:

Max value:

)

Look Up File (

Question Text:
{VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON}
WAS LIVING./Please give me the name, address and telephone number of the nursing home or long term care
institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living.}}
{Is the state:/What is the state?}
TYPE THE FIRST LETTER OF THE STATE, THEN USE ARROW KEYS IF NEEDED TO LOCATE STATE, AND PRESS ENTER
TO SELECT.
{INSTITUTION NAME}
{STREET ADDRESS1}
{STREET ADDRESS2}
{CITY}, {STATE} {ZIP CODE}
{TELEPHONE NUMBER}

Responses:
REFUSED
DON'T KNOW

RF
DK

RF - Page 37 of 73

RF70_06

(RF1130)

RF70_06
RF70_06

(RF1130)
(RF1130)

)

MEPS_V2
Full Detail Spec

Programmer
Instructions:

Respondent Forms (RF) Section
(Que

See general programming instructions at RF70_01.
Use the state lookup file.
Set Provider.MPST and AF.State = RF70_05.
Note: The entry Foreign country (FC) is allowed.

Display
Instructions:

Display RF70_01 through RF70_07 vertically on the same form pane.
Display “VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE
FACILITY WHERE {PERSON} WAS LIVING.” and “Is the state:” if first cycle through LOOP_20
and RF60 is coded ‘1’ (YES). Otherwise, display “Please give me the name, address and
telephone number of the nursing home or long term care institution (that provided 24 hour
skilled nursing care) where {you were/{PERSON} was} living.” and “What is the state?”
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
Display “VERIFY THE NAME…” or “Please give me…” in brackets and lighter “grayed-out” text
when on RF70_02 through RF70_07.
Display address fields in the info pane with most recent health care institution address
information. Use a null display if response entry fields are empty. As entries are updated in
the current round, the display in the info pane should also be updated.
Display {STATE} in the info pane in bold, black, but all other address display fields in lighter
“grayed-out” text.

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]

RF - Page 38 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF70_06
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1130)
Question
String

BLAISE NAME: HCIZip
Field kind: Datafield
Field Size: 5

{Continuous Answer.} Answers allowed: 1

)

Show Card (

ArrayMin:

Min value:

ArrayMax:

Max value:

)

Look Up File (

Question Text:
{VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON}
WAS LIVING./Please give me the name, address and telephone number of the nursing home or long term care
institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living.}
{Is the zip code:/What is the zip code?}
{INSTITUTION NAME}
{STREET ADDRESS1}
{STREET ADDRESS2}
{CITY}, {STATE} {ZIP CODE}
{TELEPHONE NUMBER}

Responses:
REFUSED
DON'T KNOW

RF
DK

RF - Page 39 of 73

RF70_07

(RF1135)

RF70_07
RF70_07

(RF1135)
(RF1135)

)

MEPS_V2
Full Detail Spec

Programmer
Instructions:

Respondent Forms (RF) Section
(Que

See general programming instructions at RF70_01.
Hard check: Exactly 5 digit numeric entry required. If less than 5 numeric digits entered or
any characters entered that are not numeric, display the following message: "ZIP CODE
ENTRY REQUIRES EXACTLY 5 NUMBERS. PROBE AND RE-ENTER OR ENTER F5 (DON'T KNOW)
IF FULL ZIP CODE IS NOT KNOWN."
Set Provider.ProvZip and AF.Zip = RF70_06.

Display
Instructions:

Display RF70_01 through RF70_07 vertically on the same form pane.
Display “VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE
FACILITY WHERE {PERSON} WAS LIVING.” and “Is the zip code:” if first cycle through LOOP_
20 and RF60 is coded ‘1’ (YES). Otherwise, display “Please give me the name, address and
telephone number of the nursing home or long term care institution (that provided 24 hour
skilled nursing care) where {you were/{PERSON} was} living.” and “What is the zip code?”
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
Display “VERIFY THE NAME…” or “Please give me…” in brackets and lighter “grayed-out” text
when on RF70_02 through RF70_07.
Display address fields in the info pane with most recent health care institution address
information. Use a null display if response entry fields are empty. As entries are updated in
the current round, the display in the info pane should also be updated.
Display {ZIP CODE} in the info pane in bold, black, but all other address display fields in
lighter “grayed-out” text.

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]

RF - Page 40 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF70_07
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1135)
Question
String

BLAISE NAME: HCIPhone
Field kind: Datafield
Field Size: 10

{Continuous Answer.} Answers allowed: 1

)

Show Card (

ArrayMin:

Min value:

ArrayMax:

Max value:

)

Look Up File (

Question Text:
{VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON}
WAS LIVING./Please give me the name, address and telephone number of the nursing home or long term care
institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living.}
What is the telephone number?
IF NO TELEPHONE, ENTER DON’T KNOW.
{INSTITUTION NAME}
{STREET ADDRESS1}
{STREET ADDRESS2}
{CITY}, {STATE} {ZIP CODE}
{TELEPHONE NUMBER}

Responses:
REFUSED
DON'T KNOW

RF
DK

RF - Page 41 of 73

RF80_01

(RF1140)

RF80_01
RF80_01

(RF1140)
(RF1140)

)

MEPS_V2
Full Detail Spec

Programmer
Instructions:

Respondent Forms (RF) Section
(Que

See general programming instructions at RF70_01.
10-digit entry required; use number input mask (xxx-xxx-xxxx) in response field.
Hard check: Exactly 10 digit numeric entry required. If less than 10 numeric digits entered
or any characters entered that are not numeric, display the following message: "PHONE
ENTRY REQUIRES EXACTLY 10 NUMBERS. PROBE AND RE-ENTER OR ENTER F5 (DON'T
KNOW) IF FULL PHONE NUMBER IS NOT KNOWN."
Set Provider.ProvPhone and AF.Phone = RF70_07.

Display
Instructions:

Display RF70_01 through RF70_07 vertically on the same form pane.
Display “VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE
FACILITY WHERE {PERSON} WAS LIVING.” if first cycle through LOOP_20 and RF60 is coded
‘1’ (YES). Otherwise, display “Please give me the name, address and telephone number of
the nursing home or long term care institution (that provided 24 hour skilled nursing care)
where {you were/{PERSON} was} living.”
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
Display “VERIFY THE NAME…” or “Please give me…” in brackets and lighter “grayed-out” text
when on RF70_02 through RF70_07.
Display address fields in the info pane with most recent health care institution address
information. Use a null display if response entry fields are empty. As entries are updated in
the current round, the display in the info pane should also be updated.
Display {TELEPHONE NUMBER} in the info pane in bold, black, but all other address display
fields in lighter “grayed-out” text.

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]

RF - Page 42 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF80_01
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1140)
Question
Integer

BLAISE NAME: HCIAdmitMM
Field kind: Datafield
Field Size: 2

{Continuous Answer.} Answers allowed: 1

)

Show Card (

ArrayMin:

Min value: 1

ArrayMax:

Max value: 12

)

Look Up File (

Question Text:
{I recorded that {you/{PERSON}} entered {ORIG INSTITUTION NAME} on {DATE ORIG INSTITUTIONALIZED}. Is
that correct?/What date {were you/was {PERSON}} admitted to {INSTITUTION NAME}?}
{VERIFY/ENTER} MONTH.

RF80_02

Responses:

RF - Page 43 of 73

(RF1145)

)

MEPS_V2
Full Detail Spec

Programmer
Instructions:

Respondent Forms (RF) Section
(Que

DK AND RF disallowed for month.
If first cycle through LOOP_20 and RF60 is coded ‘1’ (YES), prefill RF80_01 with
AF.OrigInstMM.

Display
Instructions:

Display “I recorded that {you/{PERSON}} entered {ORIG INSTITUTION NAME} on {DATE ORIG
INSTITUTIONALIZED}. Is that correct?” and “VERIFY” if first cycle through LOOP_20 and RF60
is coded ‘1’ (YES). Otherwise, display “What date {were you/was {PERSON}} admitted to
{INSTITUTION NAME}?” and “ENTER”.
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
For “{DATE ORIG INSTITUTIONALIZED}”, display the date the person was first
institutionalized [(AF.OrigInstMM, DD, YYYY) for the record where AF.AFType=MPC-HCI
(original)]. Display as full month, xx, YYYY - e.g., "January 1, 2016". Display “DK” or “RF” for
missing values.
For “{ORIG INSTITUTION NAME}”, display the name of the health care facility the person
reported when he/she was first institutionalized [Use AF.ProvName for the AF record where
AF.AFType=MPC-HCI (orginal)].
For “{INSTITUTION NAME}”, display the name of the institution verified/entered at RF70_01
during this loop (also AF.ProvName for this record).
Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]

RF - Page 44 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF80_02
Item Type:
Type Class:
Answer Type:

(RF1145)
Question
Integer

BLAISE NAME: HCIAdmitDD
Field kind: Datafield
Field Size: 2

{Continuous Answer.} Answers allowed: 1

Help Available (

)

Show Card (

ArrayMin:

Min value: 1

ArrayMax:

Max value: 31

)

Look Up File (

Question Text:
{I recorded that {you/{PERSON}} entered {ORIG INSTITUTION NAME} on {DATE ORIG INSTITUTIONALIZED}. Is
that correct?/What date {were you/was {PERSON}} admitted to {INSTITUTION NAME}?}
{VERIFY/ENTER} DAY.

Responses:
REFUSED
DON'T KNOW
Programmer
Instructions:

Display
Instructions:

RF
DK

RF80_03

(RF1150)

RF80_03
RF80_03

(RF1150)
(RF1150)

If first cycle through LOOP_20 and RF60 is coded ‘1’ (YES), prefill RF80_02 with
AF.OrigInstDD.

See display instructions at RF80_01.
Display the first paragraph in grayed-out text.
Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]

RF - Page 45 of 73

)

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF80_03
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1150)
Question
Integer

BLAISE NAME: HCIAdmitYYYY
Field kind: Datafield
Field Size: 4

{Continuous Answer.} Answers allowed: 1

)

Show Card (

ArrayMin:

Min value: 1900

ArrayMax:

Max value: 2100

)

Look Up File (

Question Text:
{I recorded that {you/{PERSON}} entered {ORIG INSTITUTION NAME} on {DATE ORIG INSTITUTIONALIZED}. Is
that correct?/What date {were you/was {PERSON}} admitted to {INSTITUTION NAME}?}
{VERIFY/ENTER} 4-DIGIT YEAR.

RF90_01

Responses:

RF - Page 46 of 73

(RF1155)

)

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Programmer
Instructions:

DK and RF disallowed for year.
If first cycle through LOOP_20 and RF60 is coded ‘1’ (YES), prefill RF80_03 with
AF.OrigInstYYYY.
Hard check: Month and Year entered at RF80_01 and RF80_03 must be on or after month
and year originally institutionalized (AF.OrigInstMM, YYYY) and on or before month and year
rejoined community (AF.DtRejoinedMM, YYYY). If the month and year entered fall outside of
this range, display the following message: “DATE ADMITTED TO HEALTH CARE FACILITY
MUST BE BETWEEN THE DATE FIRST INSTITUTIONALIZED ({AF.OrigInstMM, DD, YYYY}) AND
DATE {REJOINED COMMUNITY/DIED} ({AF.DtRejoinedMM, DD, YYYY}). VERIFY AND REENTER DATE.” Note: If any part of the dates are DK, RF, or empty, do not invoke the hard
check. Only using month and year since those fields are required at these three items,
whereas day is not.

Display
Instructions:

See display instructions at RF80_01.
Display the first paragraph in grayed-out text.
Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.
In the hard check message, display “REJOINED COMMUNITY” IF [(AF.AFInstStatus=2) for the
record where AF.AFType=MPC-HCI (original)]. Display “DIED” if person died after leaving the
institution [(AF.AFInstStatus=1) for the record where AF.AFType=MPC-HCI (original)].

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]

BLAISE NAME: HCIDischMM
Field kind: Datafield
ArrayMin:

RF90_01
Item Type:

(RF1155)
Question

Type Class:

Integer

Answer Type:

{Continuous Answer.} Answers allowed: 1

Help Available (

)

Min value: 1

Field Size: 2

Show Card (

ArrayMax:

Max value: 12

)

Look Up File (

Question Text:
What date {were you/was {PERSON}} discharged from {INSTITUTION NAME}?
ENTER MONTH.

RF90_02

Responses:
RF - Page 47 of 73

(RF1160)

)

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Programmer
Instructions:
Display
Instructions:

DK AND RF disallowed for month.

For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
For “{INSTITUTION NAME}”, display the name of the institution verified/entered at RF70_01
during this loop (also AF.ProvName for this record).
Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]

BLAISE NAME: HCIDischDD
Field kind: Datafield
ArrayMin:

RF90_02
Item Type:

(RF1160)
Question

Type Class:

Integer

Answer Type:

{Continuous Answer.} Answers allowed: 1

Help Available (

)

Min value: 1

Field Size: 2

Show Card (

ArrayMax:

Max value: 31

)

Look Up File (

Question Text:
What date {were you/was {PERSON}} discharged from {INSTITUTION NAME}?
ENTER DAY.

Responses:
REFUSED
DON'T KNOW

RF
DK

RF - Page 48 of 73

RF90_03

(RF1165)

RF90_03
RF90_03

(RF1165)
(RF1165)

)

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Display
Instructions:

See display instructions at RF90_01.
Display the first paragraph in grayed-out text.
Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]

Testing/Editing
Notes:

BLAISE NAME: HCIDischYYYY

RF90_03
Item Type:

(RF1165)
Question

Type Class:

Integer
Field Size: 4
{Continuous Answer.} Answers allowed: 1

Answer Type:

Help Available (

)

Field kind: Datafield

Show Card (

ArrayMin:

Min value: 1900

ArrayMax:

Max value: 2100

)

Look Up File (

Question Text:
What date {were you/was {PERSON}} discharged from {INSTITUTION NAME}?
ENTER 4-DIGIT YEAR.

BOX_80

Responses:

RF - Page 49 of 73

(RF1170)

)

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Programmer
Instructions:

DK AND RF disallowed for year.
Hard check: Month and Year entered at RF90_01 and RF90_03 must be on or after month
and year originally institutionalized (AF.OrigInstMM, YYYY) and on or before month and year
rejoined community (AF.DtRejoinedMM, YYYY). If the month and year entered fall outside of
this range, display the following message: “DATE DISCHARGED FROM HEALTH CARE FACILITY
MUST BE BETWEEN THE DATE FIRST INSTITUTIONALIZED ({AF.OrigInstMM, DD, YYYY}) AND
DATE {REJOINED COMMUNITY/DIED} ({AF.DtRejoinedMM, DD, YYYY}). VERIFY AND REENTER DATE.” Note: If any part of the dates are DK, RF, or empty, do not invoke the hard
check. Only using month and year since those fields are required at these three items,
whereas day is not.

Display
Instructions:

See display instructions at RF90_01.
Display the first paragraph in grayed-out text.
Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.
In the hard check message, display “REJOINED COMMUNITY” IF [(AF.AFInstStatus=2) for the
record where AF.AFType=MPC-HCI (original)]. Display “DIED” if person died after leaving the
institution [(AF.AFInstStatus=1) for the record where AF.AFType=MPC-HCI (original)].

Testing/Editing
Notes:

BOX_80

Route Details:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]

(RF1170)

Item Type: Route

Type Class: If Then

If [(first cycle of LOOP_20) and (RF60 is coded ‘1’ (YES)) and (month and year at RF90_01
And RF90_03=AF.DtRejoinedMM, YYYY)], go to END_LP20 (Loop 20 will cycle only once).
Else, continue with RF100 if there are less than 5 health care institutions already

RF - Page 50 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF100
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1175)
Question
Enumerated
TYESNO

)

BLAISE NAME: HCIOth
Field kind: Datafield

ArrayMin:

Min value:

Field Size:
Answers allowed: 1

ArrayMax:

Max value:

Show Card (

)

Look Up File (

Question Text:
Between {DATE ORIG INSTITUTIONALIZED} and {DATE REJOINED COMMUNITY}, did {you/{PERSON}} stay in
another nursing home or other long-term care institution that provided 24 hour skilled nursing care [other than
{INSTITUTION NAME}]?

Responses:

YES
NO
REFUSED
DON'T KNOW

1
2
RF
DK

RF - Page 51 of 73

END_LP20
END_LP20
END_LP20
END_LP20

(RF1180)
(RF1180)
(RF1180)
(RF1180)

)

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Programmer
Instructions:

If coded ‘1’ (YES), create a new record where: AF.AFType=MPC-HCI (additional). Set
AF.OrigRnd and AF.AFYear. Set AF.ReqSignDt to RU reference period end date. From the
MPC-HCI (original) record, copy over all the “info about person” variables to the new record.
The next cycle of LOOP_20 will cycle to set the info about provider information for this
newly created record.

Display
Instructions:

For “{DATE ORIG INSTITUTIONALIZED}”, display the date the person was first
institutionalized [(AF.OrigInstMM, DD, YYYY) for the record where AF.AFType=MPC-HCI
(original)]. Display as full month, xx, YYYY - e.g., "January 1, 2016". Display “DK” or “RF” for
missing values.
For “{DATE REJOINED COMMUNITY}”, display the date the person left the health care facility
[(AF.DtRejoinedMM, DD, YYYY) for the record where AF.AFType=MPC-HCI (original)]. (This is
the date collected at RE200/RE220/RE240). Display as full month, xx, YYYY - e.g., "January 1,
2016". Display “DK” or “RF” for missing values.
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
For “{INSTITUION NAME}”, display the name of the institution at RF70_01 verified/entered
during this cycle of LOOP_20 (also AF.ProvName for this record).

Testing/Editing
Notes:

END_LP20

Route Details:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]

(RF1180)

Item Type: Route

Type Class: End Loop

If RF100 is coded ‘1’ (YES), cycle to collect next institution if there are less than 5 health
care institutions already recorded.
Otherwise, end loop 20 and continue with RF110_01.

RF - Page 52 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF110_01
Item Type:
Type Class:
Answer Type:

(RF1185)
Question
Enumerated

BLAISE NAME: HCIInfo

TAFFORMPREP

Field kind: Datafield

ArrayMin:

Min value:

Field Size:
Answers allowed: 1

ArrayMax:

Max value:

Help Available (AFInfoHelp)

Show Card (

)

Look Up File (

)

Question Text:
INTERVIEWER: COMPLETE A NEW MPC AF FOR THIS PAIR. ON TOP LEFT CORNER OF FORM, PRINT “HCI”.
PROVIDER NAME: {Provider}
ADDRESS: {Combined Street Address}
{City}, {ST} {Zip Code} {Telephone}
PATIENT: {First,[Middle],Last Name}
DOB: {MM/DD/YYYY}
AGE: {XXX}
RU ID: {RUID}

REGION: {Reg ID}

ACTION: {Status Action}
PROVIDER ID: {ProvID}

PID: {PID}

SIGNATURE DATE ON AF MUST BE ON OR AFTER: {MM/DD/YYYY}
PRESS 1 AND ENTER WHEN FORM IS PREPARED.
HELP: F1

Responses:

AF FORM PREPARED

1

RF - Page 53 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Programmer
Instructions:

Preloaded grid type – flexible navigation including RF110_01, RF110_02, RF110_03, RF110_
04, RF110_N, as well as RF120_01, RF120_02, RF120_03, RF120_04, RF120_05, and RF120_
06.
At grid completion, continue with RF120_01.

Display
Instructions:

Roster 1 – Report
Col #1 Header: Provider
Instructions: Display the name of the institutional provider for this row. This column is
protected and uneditable. (AF.ProvName) Variable may need to be truncated for display in
grid.)
Roster Filter:
Display only MPC authorization forms for health care institutions that are active for this
person for this round [records where [(AF.AFType=MPC-HCI (original)) and
(AF.Superceded=Empty)] or [AF.AFType=MPC-HCI (additional)]. This column is protected and
uneditable.
Col #2 Header: Type
Instructions: Display the Authorization form type – “MPC-HCI”. This column is protected and
uneditable.
Col #3 Header: Color
Instructions: Display the color linked to this authorization form. (see BOX_10 rules for
regular MPC forms)
Col #4 Header: Prep
Instructions: RF110_01, RF110_02, RF110_03, RF110_04, RF110_N entry field.
The labels PROVIDER NAME:, ADDRESS:, PATIENT:, DOB:, AGE:, RU ID:, REGION:,
AGE:, PROVIDER ID:, PID, AND SIGNATURE DATE…: should be displayed in the traditional
blue font and size of interviewer instructions. However, display the contents after that label
(i.e., the provider/pharmacy name, person name, etc.) in bold black. This will make the
screen easier to read.
The label ACTION: should be displayed in the traditional interviewer instruction font size –
but in red. However, display the contents after that label (i.e., status action) in bold black.
For “{Provider}” display the full name of the provider for this AF record. (Use AF.ProvName
with no truncation).
For “{Combined Street Address}” display the street address of the provider for this AF
record. (Concatenate AF.StrtAddr1 and AF.StrtAddr2 into one line separated with a space)
For “{City}, {ST} {Zip Code} {Telephone}” display the rest of the address of the provider for
this AF record. (Use AF.City, AF.State, AF.Zip and AF.Phone)
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record. (Use
AF.FName, AF.MName, and AF.LName)
For (DOB) “{MM/DD/YYYY}” display the DOB of the RU member for this AF record. (Use
AF.DOBM, AF.DOBD, AF.DOBY). If complete DOB is RF/DK/empty, leave the display empty. If
RF - Page 54 of 73

MEPS_V2
Full Detail Spec

Respondent Forms (RF) Section
(Que

part of the DOB is RF/DK/empty, display "RF" or "DK" or leave empty as appropriate for that
field.
For “{XXX}” display the age or age range of the RU member for this AF record. (Use AF.Age.
If Age=RF/DK/empty, use AF.AgeCat. If AF.AgeCat= RF/DK/empty, use
AF.AgeGuess.)
Display “ACTION: {Status Action}” if (AF.AFPersonStatus=3) or if
[(AF.AFPersonStatus=1 or 2) and [(AF.Age <=17) or (AF.AgeCat or
AF.AgeGuess=1-4)]]. Otherwise, use a null display.
For “{Status Action}” display the following:
“{Verify} Child <=13. {If so,} Need Parent/Guardian Signature” if
[(AF.AFPersonStatus=1 or 2) and [(AF.Age <=13) or (AF.AgeCat or
AF.AgeGuess=1-3)]].
Display “Verify” and “If so,” AF.Age is RF/DK/empty and AF.AgeCat or
AF.AgeGuess=1-3. Otherwise, use a null display.
“{Verify} Child 14-17. {If so,} Need Patient and Parent/Guardian
Signature” if [(AF.AFPersonStatus=1 or 2) and [(AF.Age 14-17) or
(AF.AgeCat or AF.AgeGuess=4)]].
Display “Verify” and “If so,” AF.Age is RF/DK/empty and AF.AgeCat or
AF.AgeGuess=4. Otherwise, use a null display.
“Patient Deceased. Need Proxy Signature” if AF.AFPersonStatus=3.
For “{RUID}”, display the CaseID.
For “{Reg ID}”, display the region of this CaseID. (May need to get
from BFOS?)
For “{ProvID}”, display the provider ID of the provider or pharmacy for
this AF record (ProvID).
For “{PID}”, display the AF.PersID of the RU member for this AF
record.
For (SIGNATURE DATE) “{MM/DD/YYYY}”, display the required signature date for this AF
record (Use AF.ReqSignDt).

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF110Table.RF110Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF110Table.RF110Grid[1..100]

RF - Page 55 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF120_01
Item Type:
Type Class:
Answer Type:

(RF1190)
Question
Enumerated
TFORMSTAT2

BLAISE NAME: HCIStat
Field kind: Datafield

ArrayMin:

Min value:

Field Size:
Answers allowed: 1

ArrayMax:

Max value:

Help Available (AFStatHelp)

Show Card (

)

Look Up File (

)

Question Text:
PROVIDER NAME: {Provider Full Name}
PATIENT: {First,[Middle],Last Name}
REQUEST SIGNATURE AND THEN ENTER THE AUTHORIZATION FORM STATUS.
HELP: F1

Responses:

SIGNED
LEFT WITH RESPONDENT
MAILED TO RESPONDENT
REFUSED (NO FORM LEFT)
OTHER (NOT SIGNED)

1
2
3
4
91

RF - Page 56 of 73

RF120_03

(RF1200)

RF120_05
RF120_02

(RF1210)
(RF1195)

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Programmer
Instructions:

Preloaded Grid type 2 – flexible navigation, including items RF120_01, RF120_02, RF120_03,
RF120_04, RF120_05, and RF120_06 as well as RF110_01, RF110_02, RF110_03, RF110_ 04,
RF110_N.
Refused and Don’t Know disallowed.
If RF120_01 is coded ‘2’ (LEFT WITH RESPONDENT) or ‘3’ (MAILED TO RESPONDENT), return
to RF120_01 for next authorization form on grid. At grid completion, go to BOX_90.
Set AF.AFCAPIStatus=RF120_01.

Display
Instructions:

Roster 1 – Report
Col #1 Header: Provider
Instructions: Display the name of the institutional provider for this row. This column is
protected and uneditable. (AF.ProvName) Variable may need to be truncated for display in
grid.)
Roster Filter:
Display only MPC authorization forms for health care institutions that are active for this
person for this round [records where [(AF.AFType=MPC-HCI (original)) and
(AF.Superceded=Empty)] or [AF.AFType=MPC-HCI (additional)]. This column is protected and
uneditable.
Col #2 Header: Type
Instructions: Display the Authorization form type – “MPC-HCI”. This column is protected and
uneditable.
Col #3 Header: Color
Instructions: Display the color linked to this authorization form. (see BOX_10 rules for
regular MPC forms)
Col #4 Header: Prep
Instructions: Display the entered responses from RF110_01-RF110_N for each authorization
form in a protected, uneditable field.
Col #5 Header: Status
Instructions: Item RF120_01. Always an active cell for every row.
Col #6 Header: Specify Status
Instructions: Item RF120_02. Display as an active cell if RF120_01 is coded ‘91’ (OTHER).
Col #7 Header: AF Number
Instructions: Item RF120_03. Display as an active cell if RF120_01 is coded ‘1’ (SIGNED).
Col #8 Header: Signature Date
Instructions: Item RF120_04. Display as an active cell if RF120_01 is coded ‘1’ (SIGNED).
Col #9 Header: Refusal Reason
Instructions: Item RF120_05. Display as an active cell if RF120_01 is coded ‘4’ (REFUSED)
Col #10 Header: Specify Refusal
RF - Page 57 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Instructions: Item RF50_06. Display as an active cell if RF120_05 is
coded ‘91’ (OTHER SPECIFY).
Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider Full Name}” display the full name of the provider for
this AF record as grayed out text. (Use AF.ProvName with no
truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as
grayed out text. (Use AF.FName, AF.MName, and AF.LName)

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF110Table.RF110Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF110Table.RF110Grid[1..100]

BLAISE NAME: HCIStatOS

RF120_02
Item Type:
Type Class:

(RF1195)
Question
String

Answer Type:

{Continuous Answer.} Answers allowed: 1

Help Available (

Field kind: Datafield
Field Size: 45

)

Show Card (

ArrayMin:

Min value:

ArrayMax:

Max value:

)

Question Text:
PROVIDER NAME: {Provider Full Name}
PATIENT: {First,[Middle],Last Name}
SPECIFY OTHER AUTHORIZATION FORM STATUS:

Responses:

RF - Page 58 of 73

Look Up File (

)

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Programmer
Instructions:

Return to RF120_01 for next authorization form on grid.
Refused and Don’t Know disallowed.
Set AF.AFCAPIStatusOS=RF120_02.

Display
Instructions:

Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider Full Name}” display the full name of the provider for this AF record as grayed
out text. (Use AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as
grayed out text. (Use AF.FName, AF.MName, and AF.LName)

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF110Table.RF110Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF110Table.RF110Grid[1..100]

BLAISE NAME: HCINum

RF120_03
Item Type:

(RF1200)
Question

Type Class:

String
Field Size: 8
{Continuous Answer.} Answers allowed: 1

Answer Type:

Help Available (

)

Field kind: Datafield

Show Card (

ArrayMin:

Min value:

ArrayMax:

Max value:

)

Look Up File (

Question Text:
PROVIDER NAME: {Provider Full Name}
PATIENT: {First,[Middle],Last Name}
ENTER AUTHORIZATION FORM NUMBER:

RF120_04

Responses:

RF - Page 59 of 73

(RF1205)

)

MEPS_V2
Full Detail Spec

Programmer
Instructions:

Respondent Forms (RF) Section
(Que

Refused and Don’t Know disallowed.
Set AF.AFFormID=RF120_03.
Note: Each authorization form has a pre-assigned authorization form number. This number
is linked to the authorization form type, panel and round.
Hard check: Exactly 8 digit alpha-numeric entry required. If less than 8 characters entered,
display the following message: "AUTHORIZATION FORM NUMBER REQUIRES EXACTLY 8
LETTERS/NUMBERS. VERIFY FORM NUMBER AND FORM TYPE AND RE-ENTER."
Hard Check – MPC-HCI: The Authorization form number entered must follow the
conventions noted at RF50_03 (see earlier) for regular MPC forms. If an authorization form
number is entered that does not meet the conventions, display the following message:
“INVALID AUTHORIZATION FORM NUMBER ENTERED. VERIFY FORM NUMBER AND FORM
TYPE AND RE-ENTER.”

Display
Instructions:

Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider Full Name}” display the full name of the provider for this AF record as grayed
out text. (Use AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as
grayed out text. (Use AF.FName, AF.MName, and AF.LName)

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF110Table.RF110Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF110Table.RF110Grid[1..100]

RF - Page 60 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF120_04
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1205)
Question
Date

BLAISE NAME: HCIDate
Field kind: Datafield

Field Size:
{Continuous Answer.} Answers allowed: 1

)

Show Card (

ArrayMin:

Min value:

ArrayMax:

Max value:

)

Look Up File (

Question Text:
PROVIDER NAME: {Provider Full Name}
PATIENT: {First,[Middle],Last Name}
SIGNATURE DATE ON AF MUST BE ON OR AFTER: {MM/DD/YYYY}
ENTER AUTHORIZATION FORM SIGNATURE DATE:
PRESS THE ALT AND DOWN ARROW KEY TO SELECT THE DATE FROM THE CALENDAR. PRESS ENTER TO
CONTINUE.

Responses:

RF - Page 61 of 73

)

MEPS_V2
Full Detail Spec

Programmer
Instructions:

Respondent Forms (RF) Section
(Que

Return to RF120_01 for next authorization form on grid.
Refused and Don’t Know disallowed.
Hard check: Date entered must be on or after the interview date of the most recent round’s
interview for which the pair is/was eligible for authorization form collection (use
AF.ReqSignDt), but cannot be after ‘Today’s’ Date’ (the current date set on the laptop,
which may be different from RU reference period end date). If date is before correct date,
display the following message: “AUTHORIZATION FORM MUST BE SIGNED ON OR AFTER
ABOVE DATE. VERIFY AND RE-ENTER DATE OR COMPLETE NEW AF.”

Display
Instructions:

Display the date field for the signature date here. The FI should be able to either type in the
full date or use the pop-up calendar. Pressing the alt and down arrow key, will bring up the
popup calendar defaulted to today’s date (the computer date). Once the FI selects the date
on the pop-up calendar, CAPI will fill in the date in this format: / / , pressing enter to
continue will take the FI to the next screen.
Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider Full Name}” display the full name of the provider for this AF record as grayed
out text. (Use AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as
grayed out text. (Use AF.FName, AF.MName, and AF.LName)
For (SIGNATURE DATE) “{MM/DD/YYYY}”, display the required signature date for this AF
record (Use AF.ReqSignDt). This date should be displayed in bold black.

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF110Table.RF110Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF110Table.RF110Grid[1..100]

RF - Page 62 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF120_05
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1210)
Question
Enumerated
TREFUSAL

)

BLAISE NAME: HCIRfResn
Field kind: Datafield

ArrayMin:

Min value:

Field Size:
Answers allowed: 1

ArrayMax:

Max value:

Show Card (

)

Look Up File (

Question Text:
PROVIDER NAME: {Provider Full Name}
PATIENT: {First,[Middle],Last Name}
SELECT MAIN REASON FOR REFUSAL:

Responses:

DOESN'T WANT TO BOTHER PROVIDER
CONFIDENTIALITY/SENSITIVE INFO
PAYMENT PROBLEM WITH PROVIDER
HAS ALREADY GIVEN ENOUGH
INFORMATION
WANTS MORE INFO BEFORE SIGNING
NOT INTERESTED IN STUDY
NO REASON GIVEN
OTHER SPECIFY

1
2
3
4
5
6
7
91

RF - Page 63 of 73

RF120_06

(RF1215)

)

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Programmer
Instructions:

Refused and Don’t Know disallowed.
If coded ‘1’, ‘2’, ‘3’, ‘4’, ‘5’, ‘6’, or ‘7’, return to RF120_01 for next authorization form on
grid.

Display
Instructions:

Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider Full Name}” display the full name of the provider for this AF record as grayed
out text. (Use AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as
grayed out text. (Use AF.FName, AF.MName, and AF.LName)

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF110Table.RF110Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF110Table.RF110Grid[1..100]

BLAISE NAME: HCIRfOS
Field kind: Datafield
ArrayMin:

RF120_06
Item Type:
Type Class:

(RF1215)
Question

Answer Type:

{Continuous Answer.} Answers allowed: 1

Help Available (

String

)

Min value:

Field Size: 45

Show Card (

ArrayMax:

)

Question Text:
PROVIDER NAME: {Provider Full Name}
PATIENT: {First,[Middle],Last Name}
SPECIFY OTHER REASON FOR REFUSAL:

Responses:

RF - Page 64 of 73

Max value:

Look Up File (

)

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Programmer
Instructions:

Return to RF120_01 for next authorization form on grid.
Refused and Don’t Know disallowed.

Display
Instructions:

Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider Full Name}” display the full name of the provider for this AF record as grayed
out text. (Use AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as
grayed out text. (Use AF.FName, AF.MName, and AF.LName)

Testing/Editing
Notes:

BOX_90

Route Details:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF110Table.RF110Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF110Table.RF110Grid[1..100]

(RF1220)

Item Type: Route

Type Class: If Then

If:
⦁ At least one Person eligible for SAQ status collection [(Person.SAQFlag=Yes or
Person.SAQFlwUpFlag=YES) and (QS20_04 = 1 or 2)]
OR
⦁ At least one Person eligible for PSAQ status collection [(Person.PSAQFlag=Yes or
Person.PSAQFlwUpFlag=YES) and (QS20_04 = 1 or 2)]
OR
⦁ At least one Person eligible for DCS status collection (Person.DCSFlag=YES)
Continue with RF130_01.
Otherwise go to BOX_100.

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Respondent Forms (RF) Section
(Que

Full Detail Spec
RF130_01
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1225)
Question
Enumerated
TSAQCOMP2

BLAISE NAME: FormCollectFinal
Field kind: Datafield

ArrayMin:

Min value:

Field Size:
Answers allowed: 1

ArrayMax:

Max value:

)

Show Card (

)

Look Up File (

)

Question Text:
PERSON: {First Middle Last Name}

PID: {PID}

FORM: {SAQ/PSAQ ({BLUE/PURPLE})/DCS}

{Earlier we asked {you/{PERSON}} to complete a brief survey about health and health opinions./Earlier we asked
{you/{PERSON}} to complete a few questions about the care received for diabetes./Earlier we asked that
someone knowledgeable about {your/{PERSON}’s} diabetes to complete a few questions about the care
received.} I would like to collect that form now.
COLLECT COMPLETED {MALE (BLUE)/FEMALE (PURPLE)} {SAQ/PSAQ/DCS}.
{{SAQ/PSAQ} WAS CODED AS {COMPLETED/REFUSED} EARLIER IN THE INTERVIEW. ENTER THROUGH THE FIELDS
IF NO UPDATE TO STATUS IS NECESSARY.}
SELECT THE STATUS OF THE {SAQ/PSAQ/DCS}:

Responses:

COMPLETED AND GIVEN TO
INTERVIEWER
NOT COMPLETED, WILL PICK UP AT A
LATER DATE
NOT COMPLETED, WILL MAIL TO
OFFICE
MAILED TO RESPONDENT
REFUSED TO COMPLETE (NO FORM
LEFT)
{NOT COMPLETED, COLLECT UPDATED
STATUS AT RESPONDENT FORM
SECTION}
OTHER

1
2
3
4
5

RF130_03

(RF1235)

RF130_02

(RF1230)

6

91

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MEPS_V2

Respondent Forms (RF) Section
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Full Detail Spec

Programmer
Instructions:

The grid should be Preloaded Grid Type 1: forced navigation, including RF130_01, RF130_02,
RF130_03, and RF130_04.
If coded ‘1’, ‘2’, ‘3’, or ‘4’, return to RF130_01 for next hard copy form on grid.
At grid completion, continue with BOX_100.
Refused and Don’t Know disallowed.
The number of rows in the grid will correspond to the hard copy flags set for this RU
member (Person.DCSFlag= YES, [(Person.SAQFlag=Yes or Person.SAQFlwUpFlag=YES) and
(QS20_04 = 1 or 2)], [(Person.PSAQFlag=Yes or Person.PSAQFlwUpFlag=YES) and (QS20_04 =
1 or 2)]
NOTE TO PROGRAMMERS: An RU member will never have BOTH the SAQ and PSAQ active
in the same round. The maximum number of rows in the grid will be two. This grid needs to
be configurable to accommodate the addition of other required hardcopy materials as
requested by the client in future panels.

Display
Instructions:

Do not display response category 6. It is reserved for the Quality Supplement (QS) Section.
Roster Report 1
Roster Definition: Display the hardcopy materials required for this RU member as described
below.
Row #1 (DCS) should display as active if Person.DCSFlag-YES.
Row #2 (SAQ) should display as active if [(Person.SAQFlag=Yes or Person.SAQFlwUpFlag=YES)
and (QS20_04 = 1 or 2)].
Row #3 (PSAQ) should display as active if [(Person.PSAQFlag=Yes or
Person.PSAQFlwUpFlag=YES) and (QS20_04 = 1 or 2)].
NOTE: If QS20_04 was coded ‘3’ (NOT COMPLETED-NO REPLACEMENT NECESSARY) for the
SAQ/PSAQ for this person, this row is not eligible for display in the RF section. We will not
update the status at all from the QS section for forms with this code.
Format the form pane column headers as follows:
Col #1 Header: Form Type
Instructions:
-Display “DCS” on Col #1, Row #1 as an uneditable, protected cell
-Display “SAQ” on Col#1, Row #2 as an uneditable, protected cell
-Display “PSAQ” on Col#1, Row #3 as an uneditable, protected cell
Col #2 Header: QS Status
Instructions: Display the status from the QS section as an uneditable, protected field.
Display “Completed/Given to FI” if QS 20_05 was coded ‘1’ for this form. Display “Refused”
if QS20_05 was coded ‘5’ for this form. Display “Pending” [if form type is DCS] or [if QS20_
05 was coded ‘6’ for this form] or [if QS20_04 was coded ‘2’ for this form].
Col#3 Header: Final Status
Instructions: Item RF130_01. If QS Status (Col #2)=Pending, display this cell as empty and
RF - Page 67 of 73

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Respondent Forms (RF) Section
(Que

ready for completion. If QS Status (Col #2)=Completed/Given to FI or Refused, prefill this
cell with the numeric value from QS20_05 (FormCollect) for this form. This cell is still
editable and can be updated by the FI.
Col#4 Header: Specify Status
Instructions: Item RF130_02. Display as an active cell if RF130_01 is coded ‘91’ (OTHER).
Col#5 Header: Refusal Reason
Instructions: Item RF130_03. Display as an active cell if RF130_01 is coded ‘5’ (REFUSED TO
COMPLETE). If QS Status (Col #2)=Pending, display this cell as empty and ready for
completion (if RF130_01=5). If QS Status (Col #2)=Refused, prefill this cell with the numeric
value from QS20_06 (FormRfResn) for this form. This cell is still editable and can be updated
by the FI.
Col#6 Header: Specify Refusal
Instructions: Item RF130_04. Display as an active cell if RF130_03 is coded ‘91’ (OTHER). If
QS Status (Col #2)=Pending, display this cell as empty and ready for completion (if RF130_03
=91). If QS Status (Col #2)=Refused, prefill this cell with the text entry from QS20_07
(FormRfOS) for this form. This cell is still editable and can be updated by the FI.
For “{First Middle Last Name}”, display the first, middle and last names of the person being
looped on. Use Person.FName, Person.MName, and Person.LName.
For “{PID}”, display the Person ID for the person being looped on. Use PersID.
Display “SAQ” if on row for SAQ.
Display “PSAQ ({BLUE/PURPLE})” if on row for PSAQ. Display “(BLUE)” if person being
looped on is male. Otherwise, display “(PURPLE)”.
Display “DCS” if on row for DCS.
Display the first line of interviewer instructions, PERSON, PID, FORM, in grayed out text.
Display “Earlier we asked {you/{PERSON}} to complete a brief survey about health and
health opinions.” if on row for SAQ or PSAQ.
Display “Earlier we asked {you/{PERSON}} to complete a few questions about the care
received for diabetes.” if on row for DCS and QS20_01 was coded ‘1’ (SELF) for the person
being looped on.
Display “Earlier we asked that someone knowledgeable about {your/{PERSON}’s} diabetes to
complete a few questions about the care received.” if on row for DCS and QS20_01 was
coded ‘2’ (PROXY) for the person being looped on.
Display “{MALE (BLUE)/FEMALE (PURPLE)}” if on row for PSAQ. Otherwise, use a null
display. Display “MALE (BLUE)” if person being looped on is male. Otherwise, display
“FEMALE (PURPLE)”.
Display “{SAQ/PSAQ} WAS CODED AS {COMPLETED/REFUSED} EARLIER IN THE INTERVIEW.
ENTER THROUGH THE FIELDS IF NO UPDATE TO STATUS IS NECESSARY.” if QS Status (Col #
2)=Completed/Given to FI or Refused. Otherwise, use a null display.
Display “COMPLETED” if QS Status (Col #2)=Completed/Given to FI. Display “REFUSED” if QS
Status (Col #2)= Refused.

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Full Detail Spec

If QS Status (Col #2)=Completed/Given to FI or Refused, display the first paragraph “Earlier …
collect that form now.”, the interviewer instructions “COLLECT…/DCS}”, and the interviewer
instruction “SELECT … /DCS}” in grayed out text. Otherwise, first paragraph and interviewer
instructions should be formatted as specified in UI documentation.

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF130Table.RF130Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF130Table.RF130Grid[1..100]

BLAISE NAME: FormCollectOSFinal
Field kind: Datafield
ArrayMin:

RF130_02
Item Type:
Type Class:

(RF1230)
Question

Answer Type:

{Continuous Answer.} Answers allowed: 1

Help Available (

String

Min value:

Field Size: 45

)

Show Card (

ArrayMax:

Max value:

)

Question Text:
PERSON: {First Middle Last Name}

PID: {PID}

FORM: {SAQ/PSAQ ({BLUE/PURPLE})/DCS}

SPECIFY OTHER STATUS:

Responses:

RF - Page 69 of 73

Look Up File (

)

MEPS_V2
Full Detail Spec

Programmer
Instructions:

Respondent Forms (RF) Section
(Que

Return to RF130_01 for next hardcopy form on grid.
Refused and Don’t Know disallowed.

Display
Instructions:

For “{First Middle Last Name}”, display the first, middle and last names of the person being
looped on. Use Person.FName, Person.MName, and Person.LName.
For “{PID}”, display the Person ID for the person being looped on. Use PersID. Display “SAQ”
if on row for SAQ.
Display “PSAQ ({BLUE/PURPLE})” if on row for PSAQ. Display “(BLUE)” if person being looped
on is male. Otherwise, display “(PURPLE)”.
Display “DCS” if on row for DCS.
Display the first line of interviewer instructions, PERSON, PID, FORM, in grayed out text.

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF130Table.RF130Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF130Table.RF130Grid[1..100]

RF - Page 70 of 73

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec
RF130_03
Item Type:
Type Class:
Answer Type:

Help Available (

(RF1235)
Question
Enumerated
TSAQREF

BLAISE NAME: FormRFResnFinal
Field kind: Datafield

ArrayMin:

Min value:

Field Size:
Answers allowed: 1

ArrayMax:

Max value:

)

Show Card (

)

Look Up File (

Question Text:
PERSON: {First Middle Last Name}

PID: {PID}

FORM: {SAQ/PSAQ ({BLUE/PURPLE})/DCS}

SELECT MAIN REASON FOR {SAQ/PSAQ/DCS} REFUSAL:

Responses:

TOO BUSY/NOT INTERESTED
TOO PERSONAL/SENSITIVE
INFORMATION
TOO MUCH OF A PHYSICAL/MENTAL
HARDSHIP
HAS ALREADY GIVEN ENOUGH
INFORMATION
WANTS MORE INFORMATION
NOT INTERESTED
NO REASON GIVEN
OTHER

1
2
3
4
5
6
7
91

RF - Page 71 of 73

RF130_04

(RF1240)

)

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Programmer
Instructions:

If coded ‘1’, ‘2’, ‘3’, ‘4’, ‘5’, ‘6’, or ‘7’, return to RF130_01 for next hard copy form on grid.
Refused and Don’t Know disallowed.

Display
Instructions:

For “{First Middle Last Name}”, display the first, middle and last names of the person being
looped on. Use Person.FName, Person.MName, and Person.LName.
For “{PID}”, display the Person ID for the person being looped on. Use PersID. Display “SAQ”
if on row for SAQ.
Display “PSAQ ({BLUE/PURPLE})” if on row for PSAQ. Display “(BLUE)” if person being looped
on is male. Otherwise, display “(PURPLE)”.
Display “DCS” if on row for DCS.
Display the first line of interviewer instructions, PERSON, PID, FORM, in grayed out text.

Testing/Editing
Notes:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF130Table.RF130Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF130Table.RF130Grid[1..100]

BLAISE NAME: FormRFOSFinal

RF130_04
Item Type:
Type Class:

(RF1240)
Question
String

Answer Type:

{Continuous Answer.} Answers allowed: 1

Help Available (

Field kind: Datafield
Field Size: 45

)

Show Card (

ArrayMin:

Min value:

ArrayMax:

Max value:

)

Question Text:
PERSON: {First Middle Last Name}

PID: {PID}

FORM: {SAQ/PSAQ ({BLUE/PURPLE})/DCS}

SPECIFY OTHER REASON FOR REFUSAL:

Responses:

RF - Page 72 of 73

Look Up File (

)

MEPS_V2

Respondent Forms (RF) Section
(Que

Full Detail Spec

Programmer
Instructions:

Return to RF130_01 for next hardcopy form on grid.
Refused and Don’t Know disallowed.

Display
Instructions:

For “{First Middle Last Name}”, display the first, middle and last names of the person being
looped on. Use Person.FName, Person.MName, and Person.LName.
For “{PID}”, display the Person ID for the person being looped on. Use PersID. Display “SAQ”
if on row for SAQ.
Display “PSAQ ({BLUE/PURPLE})” if on row for PSAQ. Display “(BLUE)” if person being looped
on is male. Otherwise, display “(PURPLE)”.
Display “DCS” if on row for DCS.
Display the first line of interviewer instructions, PERSON, PID, FORM, in grayed out text.

Testing/Editing
Notes:

END_LP10

Route Details:

Variable collected at
MEPSSpring2018.RF_Main.RF_Loop10.RF130Table.RF130Grid[1..100]
Variable stored at MEPSSpring2018
_PersSect.RF_Main.RF_Loop10.RF130Table.RF130Grid[1..100]

(RF1245)

Item Type: Route

Type Class: End Loop

Cycle on next person who meets the conditions state in the loop definition.
If no other persons meet the stated conditions, end LOOP_10 and continue with BOX_
100.

BOX_100

Route Details:

(RF1250)

Item Type: Route

Type Class: If Then

Go to next questionnaire section.

[End of RF]
RF - Page 73 of 73