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pdf2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
DENTAL, VISION, & HEARING CARE UTILIZATION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after HIQ.
The next questions are about any medical care [you/(SP)] may have had between (REFERENCE
DATE/UTILDATE) and (today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD).
DUINT
DUINTRO
no entry
(Now would be a good time to get out the planner that [you/(SP)] may have used to record health care visits or
other medical expenses. We will also refer to any statements you may have received since the last interview.)
DU1 - DUPROBE
First we’ll talk about dental care.
DUPROBE
PROVIDER_DU
DU1
DU2
yes/no
roster
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to a dentist or any other person for dental care?
[Dental providers include dentists, dental surgeons, endodontists, periodontists, and dental hygienists.]
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
Who did [you/(SP)] see?
SELECT OR ADD ONLY ONE PROVIDER.
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
(01-N) LIST ALL PROVIDERS AS RESPONSE
OPTIONS
(N+1) ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.
(01) DU2 - PROVIDER_DU
(02) BOX DU5
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX DU6
(-9) BOX DU6
(01-N) BOX DU1
(N+1) DU2B-PROVNAME
IF EXISTING PROVIDER SELECTED, GO TO BOX
DU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO DU2PROVNAME
ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME BELOW.
YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT
YOU DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE
GROUP OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.
PROVNAME
DU2B
verbatim text
DU2B - GRPNAME
YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
NAME:
GRPNAME
PROVSPEC
DU2B
DU2C
verbatim text
code one
GROUP:
What kind of dental provider is [PROVNAME]?
PROVSPEC
(01) GENERAL DENTIST
(35) DENTAL HYGIENIST
(36) DENTAL TECHNICIAN
(37) DENTAL/ORAL SURGEON
(38) ORTHODONTIST
(39) ENDODONTIST
(40) PERIODONTIST
(41) PROSTHODONTIST
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX DU2
(02) BOX DU2
(03) BOX DU2
(04) BOX DU2
(05) BOX DU2
(06) BOX DU2
(07) BOX DU2
(08) BOX DU2
(91) DU2C - PROVSPECOTH
(-8) BOX DU2
(-9) BOX DU2
Page 1 of 24
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
(01) DENTIST/DENTAL PROVIDER (DO NOT
DISPLAY)
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused
(01) DO NOT DISPLAY
(02) BOX DU2
(03) BOX DU2
(04) BOX DU2
(05) BOX DU2
(06) BOX DU2
(07) BOX DU2
(08) BOX DU2
(09) BOX DU2
(10) BOX DU2
(11) BOX DU2
(12) BOX DU2
(13) BOX DU2
(14) BOX DU2
(15) BOX DU2
(16) BOX DU2
(17) BOX DU2
(18) BOX DU2
(19) BOX DU2
(20) BOX DU2
(21) BOX DU2
(22) BOX DU2
(23) BOX DU2
(24) BOX DU2
(25) BOX DU2
(26) BOX DU2
(27) BOX DU2
(28) BOX DU2
(29) BOX DU2
(30) BOX DU2
(31) BOX DU2
(32) BOX DU2
(33) BOX DU2
(34) BOX DU2
(91) DU2D - PROVSPOS
(-8) BOX DU2
(-9) BOX DU2
PROVSPEC
DU2C1
code one
What kind of dental provider is [PROVNAME]?
PROVSPOS
DU2D
verbatim text
BOX DU1
routing
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO DU3 VAPLACE.
ELSE GO TO BOX DU2.
VAPLACE
DU3
BOX DU2
HMOASSOC
DU4
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?
routing
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO DU4 - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND
(THIS PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO DU5 - HMOREFER.
ELSE GO TO DU6 - EVENT_DU.
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
BOX DU2
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX DU2
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) DU6 - EVENT_DU
(02) DU5 - HMOREFER
(-8) DU5 - HMOREFER
(-9) DU5 - HMOREFER
Page 2 of 24
2020 MCBS Community Questionnaire
Variable Name
HMOREFER
MR Screen Name
DU5
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
yes/no
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
DU6 - EVENT_DU
EVENT_DU
DU6
roster
DUADD
DU6B
chose one
When did [you/(SP)] see (PROVIDER NAME)? Please tell me all the dates [since (REFERENCE
DATE/(UTILDATE))/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY
ONCE.]
MM:
DD:
YYYY:
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT "REPEAT REPEAT VISIT: YES/NO
VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.
# OF VISITS
HAVE ALL DATES BEEN ENTERED?
(01) DU6 -EVENT_DU
(02) DU7-DVPROCDR
(01) GENERAL EXAM, CHECKUP OR
CONSULTATION
(02) CLEANING, PROPHYLAXIS, OR POLISHING
(03) X-RAYS, RADIOGRAPHS, OR BITEWINGS
(04) FLUORIDE TREATMENT
(05) SEALANT (PLASTIC COATINGS ON BACK
TEETH)
(06) FILLINGS
(07) INLAYS
(08) CROWNS OR CAPS
(09) ROOT CANAL
(10) PERIODONTAL SCALING, ROOT PLANING, OR
GUM SURGERY
(11) PERIODONTAL RECALL VISIT (PERIODIC OR
REGULAR)
(12) EXTRACTION, TOOTH PULLED
(13) IMPLANTS
(14) ABSCESS OR INFECTION TREATMENT
(15) OTHER ORAL SURGERY
(16) FIXED BRIDGES
(17) DENTURES OR REMOVABLE PARTIAL
DENTURES
(18) RELINING OR REPAIR OF BRIDGES OR
DENTURES
(19) ORTHODONTIA, BRACES, OR RETAINERS
(20) BOND, WHITEN, OR BLEACH
(21) TREATMENT FOR TMD OR TMJ
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
(01) DU9-PRESMDCN
(02) DU9-PRESMDCN
(03) DU9-PRESMDCN
(04) DU9-PRESMDCN
(05) DU9-PRESMDCN
(06) DU9-PRESMDCN
(07) DU9-PRESMDCN
(08) DU9-PRESMDCN
(09) DU9-PRESMDCN
(10) DU9-PRESMDCN
(11) DU9-PRESMDCN
(12) DU9-PRESMDCN
(13) DU9-PRESMDCN
(14) DU9-PRESMDCN
(15) DU9-PRESMDCN
(16) DU9-PRESMDCN
(17) DU9-PRESMDCN
(18) DU9-PRESMDCN
(19) DU9-PRESMDCN
(20) DU9-PRESMDCN
(21) DU9-PRESMDCN
(91) DU7A-EVOSTEXT
(-8) DU9-PRESMDCN
(-9) DU9-PRESMDCN
OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)
(01) [CONTINUOUS ANSWER]
DU9 - PRESMDCN
yes/no
Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) DU10 - PRESFILL
(02) BOX DU4
(-8) BOX DU4
(-9) BOX DU4
DU10
yes/no
Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE RESPONDENT
ACTUALLY TOOK THE MEDICINE.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX DU3B
(02) BOX DU4
(-8) BOX DU4
(-9) BOX DU4
BOX DU3B
routing
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO DU10A - DUPMMEDS.
ELSE GO TO BOX PM2.
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
DU7
code all
For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.
EVOSTEXT
PRESMDCN
PRESFILL
DU6B-DUADD
(01) ADD ANOTHER
(02) ALL DONE
SHOW CARD DVH1
DVPROCDR
(01) continuous answer
(-8) Don't Know
(-9) Refused
DU7A
DU9
verbatim text
Page 3 of 24
2020 MCBS Community Questionnaire
Variable Name
DUPMMEDS
MR Screen Name
DU10A
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
no entry
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can
spell the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)]
(MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same
information on them.]
(01) INSTRUCTION WAS READ
BOX PM2
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since (REFERENCE DATE/UTILDATE), if you’d like to get those bottles, too.
BOX PM2
MEDICINE_PM1
routing
IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE,
GO TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.
MEDICINE_PM1
code one
What is the name of the medicine?
BOX PM3
routing
IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME AND STRENGTH FOR
EACH.
BOX PM3
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
SAMEFSAM
SAMEFSAM
yes/no
The strength was [MEDICINE STRENGTH].
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM4
(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.
BOX PM4
PMBOTTLE
PMBOTTLE
routing
IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.
code one
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS
ABOUT THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
Page 4 of 24
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED MEDICINE
LOOKUP BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME
MED
lookup
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT,
[MEDICINE NAME SELECTED FROM LOOKUP OR
USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
MANUALLY TYPED]
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
MED
lookup
[PM BRAND NAME]
PMGNNAME
MED
lookup
[PM GENERIC NAME]
PMFORMFD
MED
lookup
Medicine Form [FDB LIST FORM NAME]
PMFORMMC
MED
code one
PMFORMOS
MED
verbatim
PMFORMFN
MED
verbatim
[FINAL CONCATENATED MEDICINE FORM]
PMSTRNFD
MED
verbatim
Medicine Strength
(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
STRNNUMBB
MED
numeric
Medicine strength number
(01) CONTINUOUS ANSWER
STRNUNIT
MED
code one
PMSTRNOS
MED
verbatim
PMSTRUNI
MED
ookup
Medicine Form [MCBS FORM]
(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
[MEDICINE FORM OTHER SPECIFY]
Medicine strength unit
(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(-8) MED-PMSTRNFD
(-9) MED-PMSTRNFD
(01) CONTINUOUS ANSWER
(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(-8) Don't Know
(-9) Refused
(01)-(08) MED-PMEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE STRENGTH]
Page 5 of 24
2020 MCBS Community Questionnaire
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Variable Name
MR Screen Name
Question Type
Question Text/Description
PMEDID
MED
numeric
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH
THE LOOKUP. IT IS HIDDEN ON SCREEN.]
FAMILYID
MED
numeric
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
PMKNWNM
PMKNWNM
code one
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?
PMCOND
PMCOND
code one
PMCONDOS
PMCOND
verbatim
What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
OTHER (SPECIFY)
How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
GETNUM
TABNUM
GETNUM
numeric
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND,
CHECK “ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF
REFILLS.]
Code List
Routing
(01) YES
(02) NO
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND
(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01)-(19) GETNUM-GETNUM
(20) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
BOX PM5
BOX PM5
routing
IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS
("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTUNIT.
TABNUM
numeric
HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX PM6
HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]
(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW
(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
PM16 - AMTNUM
BOX PM6
AMTUNIT
PM16
quantity unit
AMTUNOS
AMTNUM
PM16
PM16
text
numeric
OTHER (SPECIFY)
Page 6 of 24
2020 MCBS Community Questionnaire
Variable Name
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
MR Screen Name
Question Type
Question Text/Description
BOX PM6
routing
IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.
Code List
Routing
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?
TABSADAY
PM12
numeric
TABSADAY95
PM12
code one
IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX:
HALF A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN (01) CONTINUOUS ANSWER
A DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT
"OTHER DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".
How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty
PM12 - TABSADAY95
PM13-TABTAKE
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]
TABTAKE
TABTAKE96
PM13
PM13
PMSATHMO
PMMORE
DUMORE
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A
PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
code one
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.
PMSATVA
yes/no
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
Veterans Affairs or V.A.?
BOX PM8
routing
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.
yes/no
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
(01) YES
NAME(S) BELOW]?
(02) NO
(-8) DON'T KNOW
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
(-9) REFUSED
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]
BOX PM7
PMSATVA
numeric
PMSATHMO
([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE
NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.])
PM17
yes/no
BOX DU4
routing
IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO DU7-DVPROCDR.
ELSE GO TO DU14-DUMORE.
DU14
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other dental care visits to this or any other
provider?
BOX DU5
routing
IF SPALIVE=1 (ALIVE) GO TO DU15-DVNEED. ELSE GO TO BOX DU6.
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R
ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't
talked about?]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PM13 - TABTAKE96
BOX PM7
BOX PM8
PMMORE-PMMORE
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX PM2
(02) BOX DU4
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) DU2 - PROVIDER_DU
(02) BOX DU5
(-8) BOX DU5
(-9) BOX DU5
Page 7 of 24
2020 MCBS Community Questionnaire
Variable Name
DVNEED
MR Screen Name
DU15
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
yes/no
Since (REFERENCE DATE), was there a time when {you/SP} needed dental care but could not get it at that
time?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) DU16 - DVNDRS
(02) BOX DU6
(-8) BOX DU6
(-9) BOX DU6
(01) BOX DU6
(02) BOX DU6
(03) BOX DU6
(04) BOX DU6
(05) BOX DU6
(06) BOX DU6
(07) BOX DU6
(08) BOX DU6
(09) BOX DU6
(10) BOX DU6
(91) DU16A - DVNDRSOS
(-8) BOX DU6
(-9) BOX DU6
DVNDRS
DU16
code all
What were the reasons that {you/SP} could not get the dental care {you/she/he} needed?
(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DENTAL OFFICE IS TOO FAR AWAY
(05) DENTAL OFFICE IS NOT OPEN AT CONVENIENT
TIMES
(06) ANOTHER DENTIST RECOMMENDED NOT
DOING IT
(07) AFRAID OR DO NOT LIKE DENTISTS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED DENTAL PROBLEMS TO GO
AWAY
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
DVNDRSOS
DU16A
verbatim text
WHAT OTHER REASON (SPECIFY)
(01) continuous answer
BOX DU6
BOX DU6
routing
GO TO VU1-VUPROBE.
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to an eye doctor or any other person for eye care?
[Eye care providers include ophthalmologists, optometrists, and opticians.]
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) VU2 - PROVIDER_VU
(02) OM1-OMPREYEG
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) OM1-OMPREYEG
(-9) OM1-OMPREYEG
Who did [you/(SP)] see?
SELECT OR ADD ONLY ONE PROVIDER.
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
(01-N) LIST ALL PROVIDERS AS RESPONSE
OPTIONS
(N+1) ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.
VUPROBE
PROVIDER_VU
VU1
VU2
roster
(01-N) BOX VU1
(N+1) VU2B-PROVNAME
IF EXISTING PROVIDER SELECTED, GO TO BOX
VU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO VU2PROVNAME
ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME BELOW.
YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT
YOU DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE
GROUP OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.
VPRVNAME
VU2B
verbatim text
YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
VU2B - GRPNAME
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
NAME:
VGRPNAME
PROVSPEC
VU2B
VU2C
verbatim text
code one
GROUP:
What kind of eye care provider is [PROVNAME]?
PROVSPEC
(02) MEDICAL DOCTOR, INCLUDING
OPHTHALMOLOGIST
(16) OPTOMETRIST (OD)
(43) OPTICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED
(02) BOX VU1
(16) BOX VU1
(43) BOX VU1
(91) VU2C - PROVSPECOTH
(-8) BOX VU1
(-9) BOX VU1
Page 8 of 24
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
(01) BOX VU1
(02) DO NOT DISPLAY
(03) BOX VU1
(04) BOX VU1
(05) BOX VU1
(06) BOX VU1
(07) BOX VU1
(08) BOX VU1
(09) BOX VU1
(10) BOX VU1
(11) BOX VU1
(12) BOX VU1
(13) BOX VU1
(14) BOX VU1
(15) BOX VU1
(16) DO NOT DISPLAY
(17) BOX VU1
(18) BOX VU1
(19) BOX VU1
(20) BOX VU1
(21) BOX VU1
(22) BOX VU1
(23) BOX VU1
(24) BOX VU1
(25) BOX VU1
(26) BOX VU1
(27) BOX VU1
(28) BOX VU1
(29) BOX VU1
(30) BOX VU1
(31) BOX VU1
(32) BOX VU1
(33) BOX VU1
(34) BOX VU1
(91) VU2D - PROVSPOS
(-8) BOX VU1
(-9) BOX VU1
PROVSPEC
VU2C1
code one
What kind of eye care provider is [PROVNAME]?
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD) (DO NOT DISPLAY)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused
PROVSPOS
VU2D
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
BOX VU1
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO VU3 VAPLACE.
ELSE GO TO BOX VU2.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX VU2
BOX VU1
VAPLACE
VU3
BOX VU2
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?
routing
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO VU4 - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND
(THIS PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO VU5 - HMOREFER.
ELSE GO TO VU6 - EVENT_VU.
HMOASSC
VU4
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
HMOREFR
VU5
yes/no
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) VU6 - EVENT_VU
(02) VU5 - HMOREFER
(-8) VU5 - HMOREFER
(-9) VU5 - HMOREFER
VU6 - EVENT_VU
Page 9 of 24
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
EVENT_VU
VU6
roster
VUADD
VU6B
chose one
Question Text/Description
Code List
When did [you/(SP)] see (PROVIDER NAME)? Please tell me all the dates [since (REFERENCE
DATE/(UTILDATE))/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY
ONCE.]
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT "REPEAT REPEAT VISIT: YES/NO
VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.
# OF VISITS
HAVE ALL DATES BEEN ENTERED?
(01) VU6 -EVENT_VU
(02) VU7-VUPROCDR
(01) EYE OR VISION EXAM
(02) CONTACT LENS FITTING
(03) CONTACT LENS PURCHASE
(04) EYE GLASS FRAME FITTING OR ADJUSTMENT
(05) EYE GLASS PURCHASE
(06) REFRACTIVE SURGERY (CORRECTIVE VISION
SURGERY)
(07) CATARACT SURGERY
(08) GLAUCOMA SURGERY
(09) CORNEAL SURGERY
(10) VITREO-RETINAL SURGERY
(11) OCULOPLASTIC SURGERY
(12) EYE MUSCLE SURGERY
(13) EYE REMOVAL
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) VU9-PRESMDCN
(02) VU9-PRESMDCN
(03) VU9-PRESMDCN
(04) VU9-PRESMDCN
(05) VU9-PRESMDCN
(06) VU9-PRESMDCN
(07) VU9-PRESMDCN
(08) VU9-PRESMDCN
(09) VU9-PRESMDCN
(10) VU9-PRESMDCN
(11) VU9-PRESMDCN
(12) VU9-PRESMDCN
(13) VU9-PRESMDCN
(91) VU7A-EVOSTEXT
(-8) VU9-PRESMDCN
(-9) VU9-PRESMDCN
OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)
(01) [CONTINUOUS ANSWER]
VU9 - PRESMDCN
yes/no
Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) VU10 - PRESFILL
(02) BOX VU4
(-8) BOX VU4
(-9) BOX VU4
VU10
yes/no
Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE RESPONDENT
ACTUALLY TOOK THE MEDICINE.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX VU3B
(02) BOX VU4
(-8) BOX VU4
(-9) BOX VU4
BOX VU3B
routing
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO VU10A - VUPMMEDS.
ELSE GO TO BOX PM2.
(01) INSTRUCTION WAS READ
BOX PM2
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
VU7
code all
For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.
EVOSTEXT
PRESMDCN
PRESFILL
VUPMMEDS
VU6B-VUADD
(01) ADD ANOTHER
(02) ALL DONE
SHOW CARD DVH2
VUPROCDR
Routing
VU7A
VU9
VU10A
verbatim text
no entry
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can
spell the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)]
(MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same
information on them.]
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since (REFERENCE DATE/UTILDATE), if you’d like to get those bottles, too.
BOX PM2
routing
IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE,
GO TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.
Page 10 of 24
2020 MCBS Community Questionnaire
Variable Name
MEDICINE_PM1
MR Screen Name
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
MEDICINE_PM1
code one
What is the name of the medicine?
BOX PM3
routing
IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
Code List
[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME AND STRENGTH FOR
EACH.
Routing
BOX PM3
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
SAMEFSAM
SAMEFSAM
yes/no
The strength was [MEDICINE STRENGTH].
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM4
(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.
BOX PM4
PMBOTTLE
PMBOTTLE
routing
IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.
code one
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS
ABOUT THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED MEDICINE
LOOKUP BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME
MED
lookup
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT,
[MEDICINE NAME SELECTED FROM LOOKUP OR
USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
MANUALLY TYPED]
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
PMFORMFD
PMFMCODE
MED
MED
MED
MED
lookup
lookup
lookup
lookup
[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]
Medicine Form [FDB LIST FORM CODE]
Page 11 of 24
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
PMFORMMC
MED
code one
PMFORMOS
MED
verbatim
PMFORMFN
MED
verbatim
Question Text/Description
Code List
Routing
Medicine Form [MCBS FORM]
(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]
PMSTRNFD
MED
verbatim
Medicine Strength
STRNNUMBB
MED
numeric
Medicine strength number
STRNUNIT
MED
code one
PMSTRNOS
MED
verbatim
PMSTRUNI
MED
ookup
PMEDID
MED
numeric
FAMILYID
MED
numeric
PMKNWNM
PMKNWNM
code one
(01) CONTINUOUS ANSWER
Medicine strength unit
(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(-8) Don't Know
(-9) Refused
(01)-(08) MED-PMEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE STRENGTH]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH
THE LOOKUP. IT IS HIDDEN ON SCREEN.]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?
(01) YES
(02) NO
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND
Page 12 of 24
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
PMCOND
PMCOND
code one
PMCONDOS
PMCOND
verbatim
Question Text/Description
What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
OTHER (SPECIFY)
How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
GETNUM
TABNUM
GETNUM
numeric
BOX PM5
routing
TABNUM
numeric
Code List
Routing
(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01)-(19) GETNUM-GETNUM
(20) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
BOX PM5
HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX PM6
(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND,
CHECK “ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF
REFILLS.]
IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS
("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTNUM.
AMTUNIT
PM16
quantity unit
HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]
(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW
AMTUNOS
PM16
text
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
PM16 - AMTNUM
AMTNUM
PM16
numeric
(01) CONTINUOUS ANSWER
BOX PM6
BOX PM6
routing
IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?
TABSADAY
PM12
numeric
IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX:
HALF A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN (01) CONTINUOUS ANSWER
A DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT
"OTHER DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".
PM12 - TABSADAY95
Page 13 of 24
2020 MCBS Community Questionnaire
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Variable Name
MR Screen Name
Question Type
TABSADAY95
PM12
code one
Question Text/Description
How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
Code List
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty
Routing
PM13-TABTAKE
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]
TABTAKE
TABTAKE96
PMSATVA
PMSATHMO
PMMORE
VUMORE
PM13
numeric
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A
PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
PM13
code one
BOX PM7
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.
PMSATVA
yes/no
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
Veterans Affairs or V.A.?
BOX PM8
routing
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.
yes/no
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
(01) YES
NAME(S) BELOW]?
(02) NO
(-8) DON'T KNOW
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
(-9) REFUSED
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]
PMSATHMO
PM17
yes/no
BOX VU4
routing
VU14
yes/no
([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE
NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.])
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R
ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't
talked about?]
IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO VU7-VUPROCDR.
ELSE GO TO VU14-VUMORE.
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other eye care visits to this or any other
provider?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PM13 - TABTAKE96
BOX PM7
BOX PM8
PMMORE-PMMORE
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX PM2
(02) BOX VU4
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) VU2 - PROVIDER_VU
(02) OM1-OMPREYEG
(-8) OM1-OMPREYEG
(-9) OM1-OMPREYEG
Next I’m going to ask you about other medical expenses related to vision care that [you/(SP)] may have had
[between (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF DEATH/DATE
OF INSTITUTIONALIZATION/ENDUTILD)].
OMPREYEG
OM1
yes/no
(01) YES
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
(02) NO
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)]
(03) INDICATED YES BY DATAPREP
buy, replace, or pay for repairs of eyeglasses or contact lenses?
(-8) Don't Know
(-9) Refused
[Please include the purchases you made during the visit(s) to eye care providers on (EVENT DATES) that you
just told me about.]
(01) OM1B-VUTYPE
(02) BOX VU5
(03) DO NOT DISPLAY.
(-8) BOX VU5
(-9) BOX VU5
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
Page 14 of 24
2020 MCBS Community Questionnaire
Variable Name
VUTYPE
MR Screen Name
OM1B
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
code all
Question Text/Description
What did [you/(SP)] buy or repair?
FOR EACH DATE, CHECK ALL THAT APPLY. THE DATE WILL BE ENTERED ON THE NEXT SCREEN.
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair glasses or contact lenses?
EVENT_OMEYEG
OM2
roster
Please tell me all the dates [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
OMADD
OM2AA
code one
In addition to the medical expenses related to vision care you just told me about, did [you/(SP)] buy, replace, or
pay for repairs for any other eyeglasses or contact lenses [since (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE
OF INSTITUTIONALIZATION/ENDUTILD)]?
Code List
Routing
(01) BUY EYEGLASS LENSES
(02) BUY EYEGLASS FRAMES
(03) BUY CONTACT LENSES
(04) REPAIR EYEGLASSES
(-8) DON'T KNOW
(-9) REFUSED
OM2-EVENT_OMEYEG
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
(01) ADD ANOTHER
(02) ALL DONE
BOX OM1AA
(01) OM1B - VUTYPE
(02) BOX OM1AA
[DISPLAY ALL EVENTS ENTERED]
BOX OM1AA
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM2A-OMSATHMO.
ELSE GO TO BOX OM1AA2.
On (EVENT DATE), did [you/(SP)] buy or repair the glasses or contact lenses at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?
OMSATHMO
OM2A
yes/no
(01) YES
(02) NO
[PROBE: This could include buying or repairing the glasses or lenses at a plan center; at an optician,
(-8) Don't Know
optometrist or other place that honors [your/(SP’s)] plan card; or through a place or service that the plan referred
(-9) Refused
[you/(SP)] to.]
BOX OM1AA2
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
VUNEED
VUVNDRS
BOX OM1AA2
routing
BOX VU5
routing
VU15
VU16
yes/no
code all
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX VU5.
IF SPALIVE=1 (ALIVE) GO TO VU15-VUNEED.
ELSE GO TO BOX VU6.
Since (REFERENCE DATE), was there a time when {you/SP} needed vision care but could not get it at that
time?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) VU16 - VUVNDRS
(02) BOX VU6
(-8) BOX VU6
(-9) BOX VU6
What were the reasons that {you/SP} could not get the vision care {you/she/he} needed?
(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DOCTOR'S OFFICE IS TOO FAR AWAY
(05) DOCTOR'S OFFICE IS NOT OPEN AT
CONVENIENT TIMES
(06) ANOTHER DOCTOR RECOMMENDED NOT
DOING IT
(07) AFRAID OR DO NOT LIKE DOCTORS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED PROBLEMS TO GO AWAY
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX VU6
(02) BOX VU6
(03) BOX VU6
(04) BOX VU6
(05) BOX VU6
(06) BOX VU6
(07) BOX VU6
(08) BOX VU6
(09) BOX VU6
(10) BOX VU6
(91) VU16A - VUVNDRSOS
(-8) BOX VU6
(-9) BOX VU6
Page 15 of 24
2020 MCBS Community Questionnaire
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
VUVNDRSOS
VU16A
verbatim text
WHAT OTHER REASON (SPECIFY)
(01) continuous answer
BOX VU6
BOX VU6
routing
GO TO HU1-HUPROBE
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to a doctor or any other person for hearing care?
[Hearing care providers include otorhinolaryngologists (ear nose and throat doctors), otologists, neurotologists,
audiologists, audiometrists, and hearing instrument specialists.]
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) HU2 - PROVIDER_HU
(02) HU15--OMHEARAD
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) OM3-OMPRHEAR
(-9) OM3-OMPRHEAR
Who did [you/(SP)] see?
SELECT OR ADD ONLY ONE PROVIDER.
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
(01-N) LIST ALL PROVIDERS AS RESPONSE
OPTIONS
(N+1) ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.
HUPROBE
PROVIDER_HU
HU1
HU2
roster
(01-N) BOX HU1
(N+1) HU2B-PROVNAME
IF EXISTING PROVIDER SELECTED, GO TO BOX
HU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO HU2PROVNAME
ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME BELOW.
YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT
YOU DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE
GROUP OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.
HPRVNAME
HU2B
verbatim text
HU2B - GRPNAME
YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
NAME:
HGRPNAM
PROVSPEC
HU2B
HU2C
verbatim text
code one
GROUP:
What kind of hearing care provider is [PROVNAME]?
PROVSPEC
(02) MEDICAL DOCTOR, INCLUDING
OTOLARYNGOLOGIST (ENT), OTOLOGIST,
NEUROTOLOGIST
(03) AUDIOLOGIST
(44) AUDIOMETRIST
(45) HEARING INSTRUMENT SPECIALIST
(91) OTHER
(-8) Don't Know
(-9) Refused
(02) BOX HU1
(03) BOX HU1
(44) BOX HU1
(45) BOX HU1
(91) HU2C - PROVSPECOTH
(-8) BOX HU1
(-9) BOX HU1
Page 16 of 24
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
PROVSPEC
PROVSPOS
VAPLACE
HU2C1
HMOREFR
Question Type
code one
HU2D
verbatim text
BOX HU1
routing
HU3
yes/no
BOX HU2
HMOASSC
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
HU4
HU5
routing
Question Text/Description
Code List
Routing
What kind of hearing care provider is [PROVNAME]?
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST (DO NOT DISPLAY)
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused
(01) BOX HU1
(02) DO NOT DISPLAY
(03) DO NOT DISPLAY
(04) BOX HU1
(05) BOX HU1
(06) BOX HU1
(07) BOX HU1
(08) BOX HU1
(09) BOX HU1
(10) BOX HU1
(11) BOX HU1
(12) BOX HU1
(13) BOX HU1
(14) BOX HU1
(15) BOX HU1
(16) BOX HU1
(17) BOX HU1
(18) BOX HU1
(19) BOX HU1
(20) BOX HU1
(21) BOX HU1
(22) BOX HU1
(23) BOX HU1
(24) BOX HU1
(25) BOX HU1
(26) BOX HU1
(27) BOX HU1
(28) BOX HU1
(29) BOX HU1
(30) BOX HU1
(31) BOX HU1
(32) BOX HU1
(33) BOX HU1
(34) BOX HU1
(91) HU2D - PROVSPOS
(-8) BOX HU1
(-9) BOX HU1
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO HU3 VAPLACE.
ELSE GO TO BOX HU2.
(01) YES
(02) NO
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?
(-8) Don't Know
(-9) Refused
BOX HU1
BOX HU2
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO HU4 - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND
(THIS PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO HU5 - HMOREFER.
ELSE GO TO HU6 - EVENT_HU.
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
yes/no
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HU6 - EVENT_HU
(02) HU5 - HMOREFER
(-8) HU5 - HMOREFER
(-9) HU5 - HMOREFER
HU6 - EVENT_HU
Page 17 of 24
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
EVENT_HU
HU6
roster
HUADD
HU6B
chose one
Question Text/Description
Code List
When did [you/(SP)] see (PROVIDER NAME)? Please tell me all the dates [since (REFERENCE
DATE/(UTILDATE))/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY
ONCE.]
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT "REPEAT REPEAT VISIT: YES/NO
VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.
# OF VISITS
HAVE ALL DATES BEEN ENTERED?
(01) HU6 -EVENT_HU
(02) HU7 - DVPROCDR
(01) HEARING AID FITTING/EVALUATION
(02) HEARING AID PURCHASE/REPAIR
(03) HEARING EXAM
(04) EAR WAX REMOVAL
(05) EAR VENTILATION TUBES
(06) TYMPANOPLASTY (RECONSTRUCTION OF EAR
DRUM)
(07) COCHLEAR IMPLANT SURGERY
(08) HEARING REHABILITATIVE SERVICES
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) HU9-PRESMDCN
(02) HU9-PRESMDCN
(03) HU9-PRESMDCN
(04) HU9-PRESMDCN
(05) HU9-PRESMDCN
(06) HU9-PRESMDCN
(07) HU9-PRESMDCN
(91) HU7A-EVOSTEXT
(-8) HU9-PRESMDCN
(-9) HU9-PRESMDCN
OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)
(01) [CONTINUOUS ANSWER]
HU9 - PRESMDCN
yes/no
Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HU10 - PRESFILL
(02) BOX HU4
(-8) BOX HU4
(-9) BOX HU4
HU10
yes/no
Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE RESPONDENT
ACTUALLY TOOK THE MEDICINE.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HU3B
(02) BOX HU4
(-8) BOX HU4
(-9) BOX HU4
BOX HU3B
routing
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO HU10A - HUPMMEDS.
ELSE GO TO BOX PM2.
(01) INSTRUCTION WAS READ
BOX PM2
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
HU7
code all
For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.
EVOSTEXT
PRESMDCN
PRESFILL
HUPMMEDS
HU6B-HUADD
(01) ADD ANOTHER
(02) ALL DONE
SHOW CARD DVH3
HUPROCDR
Routing
HU7A
HU9
HU10A
verbatim text
no entry
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can
spell the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)]
(MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same
information on them.]
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since (REFERENCE DATE/UTILDATE), if you’d like to get those bottles, too.
BOX PM2
routing
IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE,
GO TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.
Page 18 of 24
2020 MCBS Community Questionnaire
Variable Name
MEDICINE_PM1
MR Screen Name
MEDICINE_PM1
BOX PM3
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
code one
What is the name of the medicine?
routing
IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
Code List
[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME AND STRENGTH FOR
EACH.
Routing
BOX PM3
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
SAMEFSAM
SAMEFSAM
yes/no
The strength was [MEDICINE STRENGTH].
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM4
(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.
BOX PM4
PMBOTTLE
PMBOTTLE
routing
IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.
code one
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS
ABOUT THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED MEDICINE
LOOKUP BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME
MED
lookup
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT,
[MEDICINE NAME SELECTED FROM LOOKUP OR
USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
MANUALLY TYPED]
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
PMFORMFD
PMFMCODE
MED
MED
MED
MED
lookup
lookup
lookup
lookup
[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]
Medicine Form [FDB LIST FORM CODE]
Page 19 of 24
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
PMFORMMC
MED
code one
PMFORMOS
MED
verbatim
PMFORMFN
MED
verbatim
Question Text/Description
Code List
Routing
Medicine Form [MCBS FORM]
(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]
PMSTRNFD
MED
verbatim
Medicine Strength
STRNNUMBB
MED
numeric
Medicine strength number
STRNUNIT
MED
code one
PMSTRNOS
MED
verbatim
PMSTRUNI
MED
lookup
PMEDID
MED
numeric
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH
THE LOOKUP. IT IS HIDDEN ON SCREEN.]
FAMILYID
MED
numeric
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
PMKNWNM
PMKNWNM
code one
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?
Medicine strength unit
(01) CONTINUOUS ANSWER
(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(-8) Don't Know
(-9) Refused
(01)-(08) MED-PMEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE STRENGTH]
(01) YES
(02) NO
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND
Page 20 of 24
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
PMCOND
PMCOND
code one
PMCONDOS
PMCOND
verbatim
Question Text/Description
What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
OTHER (SPECIFY)
How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
GETNUM
TABNUM
GETNUM
numeric
BOX PM5
routing
TABNUM
numeric
AMTUNIT
PM16
quantity unit
AMTUNOS
AMTNUM
PM16
PM16
text
numeric
BOX PM6
routing
Code List
Routing
(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01)-(19) GETNUM-GETNUM
(20) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
BOX PM5
HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX PM6
HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]
(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW
(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
PM16 - AMTNUM
BOX PM6
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND,
CHECK “ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF
REFILLS.]
IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS
("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTNUM.
OTHER (SPECIFY)
IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?
TABSADAY
PM12
numeric
TABSADAY95
PM12
code one
IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX:
HALF A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN (01) CONTINUOUS ANSWER
A DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT
"OTHER DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty
PM12 - TABSADAY95
PM13-TABTAKE
Page 21 of 24
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
PM13 - TABTAKE96
How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]
TABTAKE
TABTAKE96
PM13
numeric
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A
PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
PM13
code one
BOX PM7
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.
PMSATVA
yes/no
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
Veterans Affairs or V.A.?
BOX PM8
routing
PMSATHMO
PMSATHMO
yes/no
PMMORE
PM17
yes/no
BOX HU4
routing
PMSATVA
HUMORE
HU14
yes/no
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED CARE
(01) YES
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
(02) NO
NAME(S) BELOW]?
(-8) DON'T KNOW
(-9) REFUSED
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]
([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE
NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.])
(01) ADD ANOTHER
(02) ALL DONE
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R
ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't
talked about?]
IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO HU7-HUPROCDR.
ELSE GO TO HU14-HUMORE.
(01) YES
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other hearing care visits to this or any other
(-8) Don't Know
provider?
(-9) Refused
BOX PM7
BOX PM8
PMMORE-PMMORE
(01) BOX PM2
(02) BOX HU4
(01) HU2 - PROVIDER_HU
(02) HU15-OMHEARAD
(-8) HU15-OMHEARAD
(-9) HU15-OMHEARAD
Next I’m going to ask you about other medical expenses related to hearing care that [you/(SP)] may have had
[between (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF DEATH/DATE
OF INSTITUTIONALIZATION/ENDUTILD)].
OMHEARAD
HU15
yes/no
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY (01) YES
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)]
(02) NO
buy, replace, or pay for repairs of a hearing aid?
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
[Please include the purchases you made during the visit(s) to hearing care provider on (EVENT DATES) that you (-9) Refused
just told me about.]
(01) HU16-INTHECANL
(02) BOX HU9
(03) DO NOT DISPLAY.
(-8) BOX HU9
(-9) BOX HU9
[DO NOT INCLUDE HEARING AID BATTERIES AT THIS QUESTION. ENTER HEARING AID BATTERIES IN
THE OMQ AS A HEARING/SPEECH DEVICE.]
Page 22 of 24
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
SHOW CARD DVH4
What type of hearing aid(s) did [you/(SP)] buy or repair?
[IF NEEDED: Were they for [your/(SP’s)] left ear, right ear, or both?]
INTHCANL
HU16
list
(01) LEFT EAR
PLEASE USE THE DVH JOB AID 1 TO HELP PROBE THE RESPONDENT FOR THE PROPER HEARING AID (02) RIGHT EAR
TYPE.
HU16-INTHEEAR
FOR EACH DATE, CHECK ALL THAT APPLY. THE DATE WILL BE ENTERED ON THE NEXT SCREEN.
In the canal hearing aid
INTHEEAR
HU16
list
In the ear hearing aid
BHNDEAR
HU16
list
Behind the ear hearing aid
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair the (HEARING AID ITEM)?
EVENT_OMHRAD
OMADD
HU17
HU18
roster
code one
Please tell me the dates of each purchase or repair [since (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE
OF INSTITUTIONALIZATION/ENDUTILD)].
(01) LEFT EAR
(02) RIGHT EAR
(01) LEFT EAR
(02) RIGHT EAR
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
In addition to the medical expenses related to hearing care you just told me about, did [you/(SP)] buy, replace, or
pay for repairs for any other hearing aids? [since (REFERENCE DATE/SURVEY REFERENCE
(01) ADD ANOTHER
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE
(02) ALL DONE
OF INSTITUTIONALIZATION/ENDUTILD)]?
HU16-BHNDEAR
HU17-EVENT_OMHRAD
HU18-OMADD
(01) HU16- INTHCANL
(02) BOX HU6
[DISPLAY ALL EVENTS ENTERED]
BOX HU6
OMSATHMO
HVNEED
routing
HU19
yes/no
BOX HU8
routing
BOX HU9
routing
HU20
yes/no
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO HU19-OMSATHMO.
ELSE GO TO BOX HU8.
On (EVENT DATE), did [you/(SP)] buy or repair the hearing aid at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HU8
Since (REFERENCE DATE), was there a time when {you/SP} needed hearing care but could not get it at that
time?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HU21- HVNDRS
(02) BOX HU10
(-8) BOX HU10
(-9) BOX HU10
(01) BOX HU10
(02) BOX HU10
(03) BOX HU10
(04) BOX HU10
(05) BOX HU10
(06) BOX HU10
(07) BOX HU10
(08) BOX HU10
(09) BOX HU10
(10) BOX HU10
(91) HU16A - HVNDRSOS
(-8) BOX HU10
(-9) BOX HU10
BOX HU10
[PROBE: This could include buying or repairing the hearing aid at a plan center; from an audiologist, or other
provider that honors [your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX HU9.
IF SPALIVE=1 (ALIVE) HU20-HVNEED. ELSE GO TO BOX HU10.
HVNDRS
HU21
code all
What were the reasons that {you/SP} could not get the hearing care {you/she/he} needed?
(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DOCTOR'S OFFICE IS TOO FAR AWAY
(05) DOCTOR'S OFFICE IS NOT OPEN AT
CONVENIENT TIMES
(06) ANOTHER DOCTOR RECOMMENDED NOT
DOING IT
(07) AFRAID OR DO NOT LIKE DOCTORS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED PROBLEMS TO GO AWAY
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
HVNDRSOS
HU21A
verbatim text
WHAT OTHER REASON (SPECIFY)
(01) continuous answer
Page 23 of 24
2020 MCBS Community Questionnaire
Variable Name
DVH - DENTAL, VISION, HEARING CARE UTILIZATION
MR Screen Name
Question Type
Question Text/Description
BOX HU10
routing
GO TO EMERGENCY ROOM UTILIZATION (ERQ).
Code List
Routing
Page 24 of 24
| File Type | application/pdf |
| Author | Shena Patel |
| File Modified | 2018-11-29 |
| File Created | 2018-11-29 |