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pdf2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
HHQ - HOME HEALTH UTILIZATION
Question Type
Question Text/Description
Code List
Routing
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP. DO NOT
DISPLAY. DATA EDITING ONLY.
(-8) DON'T KNOW
(-9) REFUSED
(01) HH2 - PROVIDER_HHP
(02) HH18 - HHPRFRND
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) HH18 - HHPRFRND
(-9) HH18 - HHPRFRND
HOME HEALTH UTILIZATION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
If INTTYPE in(C001, C004), administer after HHS.
If INTTYPE in(C002, C005, C006, C007, C010) administer after IUQ.
SHOW CARD HH1
HHPRPROF
HH1
yes/no
(Besides what you have already mentioned,) [(Since/since) (REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], [have you been/has (SP) been/was (SP)] helped at home by any (other)
health or medical professionals, such as those listed on this card?
[Health professionals include nurse (visiting nurse, private duty nurse, etc.), doctor, social worker, therapist, and
hospice worker.]
(01) [Continuous answer.]
What is the name of the health professional who helped [you/(SP)] at home [since (REFERENCE
DATE/UTILDATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)]?
ENTER NAME OF PERSON WHO HELPED. DO NOT ENTER THE NAME OF PLACE OR ORGANIZATION.
PROVIDER_HHP
HH2
roster
[ADD OR SELECT ONLY ONE PROVIDER IF DIFFERENT PEOPLE COME FROM THE SAME
ORGANIZATION, PROBE FOR THE PERSON WHO USUALLY COMES OR WHO COMES MOST OFTEN.]
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY
ENTERING AN EVENT WITH THAT PROVIDER
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
N+1. ADD ANOTHER
N+2. NEED TO EDIT SPELLING OF EXISTING
PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02.
BOX
(01-N) BOX HH1AAA
(N+1) PROVNAME
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX
HH1AAA.
ELSE IF "ADD ANOTHER" SELECTED, GO TO
PROVNAME
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPLCHNGSPL.
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
HH2
verbatim text
HH2 - 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
HH2
verbatim text
GROUP:
WHICH PROVIDER IS MISSPELLED?
CHNGSPL
CHNGSPL
roster
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."
BOX HH1AAA
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
CRCTSPL-CRCTSPL
ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER. IF
YOU ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
SELECT OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02.
CRCTSPL
CRCTSPL
verbatim
WHAT IS THE CORRECT SPELLING OF THIS PROVIDER'S NAME?
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]
(01) [Continuous Answer]
BOX HH1AAA
Page 1 of 6
2019 MCBS Community Questionnaire
Variable Name
HHQ - HOME HEALTH UTILIZATION
MR Screen Name
Question Type
Question Text/Description
BOX HH1AAA
routing
IF (HOME HEALTH PROVIDER WAS ADDED AT HH2) OR (AN EXISTING PROVIDER WAS SELECTED AT
HH2 THAT WAS NOT ASSOCIATED WITH A HOME HEALTH EVENT), GO TO HH3 - PROVSPEC.
ELSE GO TO BOX HH1BBB.
PROVSPEC
HH3
code one
PROVSPOS
HH3
text
WORKSFOR
HH4
code one
PROVIDER_HHPORG
HH5
roster
BOX HH1AA
routing
Code List
(01) DENTIST/DENTAL PROVIDER
(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
What kind of health professional is (PROVIDER NAME)?
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
[SELECT THE RESPONSE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT
(16) OPTOMETRIST (OD)
SPECIFICALLY NAMES THE LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN
(17) OSTEOPATH (DO)
PARENTHESES FOLLOWING THAT PROVIDER SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL
(18) PARAMEDIC
SPECIALTY NOT LISTED BELOW, BUT LISTED ON SHOWCARD AC1, SUCH AS ‘CARDIOLOGY,’ SELECT
(19) PHYSICAL THERAPIST (PT)
'MEDICAL DOCTOR.']
(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
OTHER MEDICAL PROVIDER (SPECIFY)
(01) NAME OF ORGANIZATION GIVEN
Who does (PROVIDER NAME) work for, that is, for what place or organization?
(02) WORKS FOR SELF
(-8) DON'T KNOW
[PROBE: Or does (PROVIDER NAME) work for himself/herself?]
(-9) REFUSED
[Who does (PROVIDER NAME) work for, that is, what place or organization?]
[PROBE: Who would (you/SP) call if (PROVIDER NAME) did not show up?]
ADD OR SELECT ONLY ONE PROVIDER.
[DO NOT ADD A NEW ROSTER ENTRY IF A DIFFERENT PERSON CAME FROM AN ORGANIZATION
ALREADY LISTED ON THE ROSTER.]
IF HH4 - WORKSFOR = 1/OrganizationGiven, SET HOME HEALTH PROVIDER FOR THIS VISIT TO THE
HOME HEALTH ORGANIZATION SELECTED AT HH5, AND GO TO HH6 - HHPLACE.
ELSE SET HOME HEALTH PROVIDER FOR THIS VISIT TO THE PROVIDER SELECTED AT HH2, HH19,
ST27 OR NS27, AND GO TO BOX HH1BB.
Routing
(01)-(34), (-8), (-9) HH4 - WORKSFOR
(91) HH3 - PROVSPOS
HH4 - WORKSFOR
(01) HH5 - PROVIDER_HHPORG
(02) BOX HH1AA
(-8) BOX HH1AA
(-9) BOX HH1AA
(01) CONTINUOUS ANSWER
BOX HH1AA
(01) BOX HH1BB
(02) BOX HH1BBB
(03) BOX HH1BB
(04) BOX HH1BB
(05) BOX HH1BB
(06) BOX HH1BB
(07) BOX HH1BB
(08) BOX HH1BB
(09) BOX HH1BB
(10) BOX HH1BB
(11) BOX HH1BB
(91) HH6 - HHPLACOS
(-8) BOX HH1BB
(-9) BOX HH1BB
HHPLACE
HH6
code one
PROVIDER NAME: (PROVIDER NAME)
What kind of place or organization is (PROVIDER NAME)?
(01) MANAGED CARE PLAN (SUCH AS HMO)
(02) MEAL PROGRAM (SUCH AS MEALS ON
WHEELS)
(03) VISITING NURSE ASSOCIATION
(04) HOME HEALTH AGENCY
(05) HOSPITAL
(06) PRIVATE PHYSICIAN/GROUP PRACTICE
(07) HOSPICE
(08) REHABILITATION OR SPORTS MEDICINE
THERAPY
(09) LOCAL GOVERNMENT ORGANIZATION
(10) CHURCH OR COMMUNITY ORGANIZATION
(11) ASSISTED LIVING/RETIREMENT HOME
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
HHPLACOS
HH6
text
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
BOX HH1BBB
routing
SET HOME HEALTH PROVIDER FOR THIS VISIT TO THE PROVIDER SELECTED AT HH2 OR HH19.
IF TYPE OF HOME HEALTH PROVIDER ORGANIZATION IS A MEAL PROGRAM, GO TO HH7 - OTHMEALS.
ELSE GO TO BOX HH1BB.
Page 2 of 6
2019 MCBS Community Questionnaire
Variable Name
OTHMEALS
MR Screen Name
HH7
BOX HH1BB
BOX HH1
VAPLACE
HH8
BOX HH1A
HMOASSOC
HMOREFER
HELPUNIT
HH10A
HH10B
HH11
HHQ - HOME HEALTH UTILIZATION
Question Type
Question Text/Description
Code List
Routing
yes/no
[Between (REFERENCE DATE/UTILDATE) and (today/DATE OF DEATH/ DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did (PROVIDER NAME) provide any services to [you/(SP)] other than
delivering meals?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX HH1BB
routing
IF TYPE OF HOME HEALTH PROVIDER IS A MEAL PROGRAM THAT DID NOT PROVIDE ANY OTHER
SERVICES BESIDES MEALS, GO TO BOX HH3.
ELSE IF (HOME HEALTH PROVIDER IS A FRIEND OR RELATIVE) OR (TYPE OF HOME HEALTH
PROVIDER IS A LOCAL GOVERNMENT, CHURCH OR COMMUNITY ORGANIZATION), GO TO HH11 HELPUNIT.
ELSE GO TO BOX HH1.
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
HH8 - VAPLACE.
ELSE GO TO BOX HH1A.
yes/no
(01) YES
(02) NO
Is [(PROVIDER NAME) associated with/(PROVIDER NAME)] a Department of Veterans Affairs, or V.A., facility?
(-8) DON'T KNOW
(-9) REFUSED
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 HH10A 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 HH10B - HMOREFER.
ELSE GO TO HH11 - HELPUNIT.
yes/no
yes/no
quantity unit
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
(01) HH11 - HELPUNIT
(02) HH10B - HMOREFER
(-8) HH10B - HMOREFER
(-9) HH10B - HMOREFER
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
HH11 - HELPUNIT
(01) TOTAL NUMBER OF TIMES
(02) NUMBER OF TIMES PER DAY
(03) NUMBER OF TIMES PER WEEK
(04) NUMBER OF TIMES PER MONTH
(-8) DON'T KNOW
(-9) REFUSED
(01) HH11 - HELPNUM
(02) HH11 - HELPNUM
(03) HH11 - HELPNUM
(04) HH11 - HELPNUM
(-8) HH12 - STAYUNIT
(-9) HH12 - STAYUNIT
(01) CONTINUOUS ANSWER
HH12 - STAYUNIT
(01) HOURS ONLY
(02) MINUTES ONLY
(03) HOURS AND MINUTES
(-8) DON'T KNOW
(-9) REFUSED
(01) HH12 - STAYHOUR
(02) HH12 - STAYMIN
(03) HH12 - STAYHOUR
(-8) HH13 - NEEDNURS
(-9) HH13 - NEEDNURS
[Between (REFERENCE DATE/UTILDATE) and (today/DATE OF DEATH/ DATE OF
INSTITUTIONALIZATION/ENDUTILD)], how many times (has/did) [(PROVIDER NAME)/someone from
(PROVIDER NAME)] come to the home to help [you/(SP)]? [Remember to include all home health providers
from (PROVIDER NAME).]
[ENTER "TOTAL NUMBER OF TIMES" WHENEVER POSSIBLE.]
[DO NOT ENTER VISITS SEPARATELY FOR PEOPLE WHO WORK FOR THE SAME ORGANIZATION.]
HELPNUM
STAYUNIT
HH11
HH12
numeric
quantity unit
BOX HH1A
(Generally speaking, how long did/Generally speaking, how long does/How long did)[PROVIDER
NAME)/someone from (PROVIDER NAME)] stay with [you/(SP)]? [INCLUDE TIME SPENT SHOPPING OR
RUNNING ERRANDS.]
[PROBE: We just need to know in general.]
STAYHOUR
HH12
numeric
(01) CONTINUOUS ANSWER
If HH12 - STAYUNIT = 1/HoursOnly, go to HH13 NEEDNURS.
Else go to HH12 - STAYMIN.
STAYMIN
HH12
numeric
(01) CONTINUOUS ANSWER
HH13 - NEEDNURS
Page 3 of 6
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
HHQ - HOME HEALTH UTILIZATION
Question Type
Question Text/Description
Code List
Routing
(01) YES, AT LEAST ONE
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
HH14 - NEEDMEAL
(01) YES, AT LEAST ONE
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
HH15 - NEEDCARE
(01) YES, AT LEAST ONE
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX HH3
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) HH2 - PROVIDER_HHP
(02) HH18 - HHPRFRND
(-8) HH18 - HHPRFRND
(-9) HH18 - HHPRFRND
(01) HH2 - PROVIDER_HHP
(02) HH18 - HHPRFRND
(-8) HH18 - HHPRFRND
(-9) HH18 - HHPRFRND
SHOW CARD HH2
NEEDNURS
HH13
yes/no
(Generally speaking, did/Generally speaking, does/Did) [(PROVIDER NAME)/someone from (PROVIDER
NAME)] help [you/(SP)] by giving any medical or nursing treatment, such as the things shown on this card?
["MEDICAL OR NURSING TREATMENT" MEANS SUCH THINGS AS APPLYING STERILE BANDAGES OR
DRESSINGS, GIVING MEDICATIONS, TAKING BLOOD PRESSURE, GIVING SHOTS OR INJECTIONS.]
[PROBE: We just need to know in general.]
SHOW CARD HH3
NEEDMEAL
HH14
yes/no
(Generally speaking, did/Generally speaking, does/Did) [(PROVIDER NAME)/someone from (PROVIDER
NAME)] help with [your/(SP’s)] daily needs by doing things, such as the ones shown on this card? [HELP WITH
DAILY NEEDS MEANS HELP IN USING THE TELEPHONE, DOING HOUSEWORK, PREPARING MEALS.]
[PROBE: We just need to know in general.]
SHOW CARD HH4
NEEDCARE
HH15
yes/no
(Generally speaking, did/Generally speaking, does/Did) [(PROVIDER NAME)/someone from (PROVIDER
NAME)] help with [your/(SP’s)] personal care by doing things such as those shown on this card? [HELP WITH
PERSONAL CARE MEANS HELP WITH BATHING, SHOWERING, DRESSING, EATING, WALKING, USING
THE TOILET.]
[PROBE: We just need to know in general.]
BOX HH3
HHPMORE
HHPOMORE
HH16
HH17
routing
IF CURRENTLY ADMINISTERING ST, GO TO BOX ST31B.
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS31B.
ELSE IF CURRENTLY ADMINISTERING HHS, GO TO BOX HHS5.
ELSE IF CURRENTLY ASKING ABOUT HOME HEALTH FRIENDS OR FAMILY, GO TO BOX HH6.
ELSE IF HOME HEALTH PROVIDER WORKED FOR SELF, GO TO HH16 - HHPMORE.
ELSE GO TO HH17 - HHPOMORE.
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], [have you been/has (SP) been/was (SP)] helped at home by any other
health professionals?
yes/no
Other than the persons who (have) visited [you/(SP)] from (PROVIDER NAME) [or from the other(s) we’ve talked
about], [have you been/has (SP) been/was (SP)] helped at home by any other health professionals [since
(01) YES
(REFERENCE DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)]?
(-8) DON'T KNOW
(-9) REFUSED
[DON’T INCLUDE ANY OTHER PERSONS COMING FROM THE SAME ORG/ AGENCY LISTED BELOW]
SHOW CARD HH5
HHPRFRND
HH18
yes/no
(Besides what you have already talked about, [(Since/since) (REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], because of health problems [have you/has (SP)/did (SP)]
(received/receive) any personal care or help at home with daily needs from (any other) persons who (do/did) not
live with (you/him/her), including home health aides, homemakers, friends, neighbors, or relatives?
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP DO NOT
DISPLAY. DATA EDITING ONLY.
(-8) DON'T KNOW
(-9) REFUSED
(01) HH19 - PROVIDER_HHF
(02) BOX HH7
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX HH7
(-9) BOX HH7
(01) [Continuous answer.]
Who helped [you/(SP)]? What is the name of the person who helped (you/him/her)?
ENTER NAME OF PERSON WHO HELPED. DO NOT ENTER THE NAME OF THE PLACE OR
ORGANIZATION.
PROVIDER_HHF
HH19
roster
[SELECT OR ADD ONLY ONE PERSON. DO NOT ENTER A PERSON WHO LIVES WITH THE SP. IF
DIFFERENT PEOPLE COME FROM THE SAME ORGANIZATION, PROBE FOR THE PERSON WHO
USUALLY COMES OR WHO COMES MOST OFTEN.]
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY
ENTERING AN EVENT WITH THAT PROVIDER
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
N+1. ADD ANOTHER
N+2. NEED TO EDIT SPELLING OF EXISTING
PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02.
(01-N) BOX HH3AA
(N+1) HH19-PROVNAME
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX
HH3AA.
ELSE IF "ADD ANOTHER" SELECTED, GO TO
PROVNAME
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPLCHNGSPL.
Page 4 of 6
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
HHQ - HOME HEALTH UTILIZATION
Question Type
Question Text/Description
Code List
Routing
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
HH19
verbatim text
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
HH19
verbatim text
GROUP:
WHICH PROVIDER IS MISSPELLED?
CHNGSPL
CHNGSPL
roster
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."
BOX HH3AA
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
CRCTSPL-CRCTSPL
ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER. IF
YOU ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
SELECT OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02.
CRCTSPL
HHFTYPE
HHFRELAT
CRCTSPL
verbatim
WHAT IS THE CORRECT SPELLING OF THIS PROVIDER'S NAME?
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]
BOX HH3AA
routing
IF (HOME HEALTH PROVIDER WAS ADDED AT HH19) OR (AN EXISTING PROVIDER WAS SELECTED AT
HH19 THAT WAS NOT ASSOCIATED WITH A HOME HEALTH EVENT), GO TO HH20 - HHFTYPE.
ELSE GO TO BOX HH1BBB.
HH20
HH21
code one
code one
Is (PROVIDER NAME) a friend or neighbor, a relative, or some other type of home health provider?
How is (PROVIDER NAME) related to [you/(SP)]?
[CLASSIFY ANY “STEP” RELATIONSHIP WITH THE RELATED “NON-STEP” RELATIONSHIP (E.G., STEPDAUGHTER = DAUGHTER).]
(01) [Continuous Answer]
BOX HH3AA
(01) FRIEND OR NEIGHBOR
(02) RELATIVE
(03) OTHER TYPE OF HOME HEALTH PROVIDER
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX HH3A
(02) HH21 - HHFRELAT
(03) BOX HH3A
(-8) BOX HH3A
(-9) BOX HH3A
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(02) BOX HH3A
(03) BOX HH3A
(04) BOX HH3A
(05) BOX HH3A
(06) BOX HH3A
(07) BOX HH3A
(08) BOX HH3A
(09) BOX HH3A
(10) BOX HH3A
(11) BOX HH3A
(12) BOX HH3A
(13) BOX HH3A
(14) BOX HH3A
(51) BOX HH3A
(52) BOX HH3A
(53) BOX HH3A
(54) BOX HH3A
(55) BOX HH3A
(56) BOX HH3A
(57) BOX HH3A
(91) HH21 - HHFRELOS
(-8) BOX HH3A
(-9) BOX HH3A
Page 5 of 6
2019 MCBS Community Questionnaire
HHQ - HOME HEALTH UTILIZATION
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
HHFRELOS
HH21
text
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
BOX HH3A
BOX HH3A
routing
IF HH20 - HHFTYPE = 3/Other, DK, OR RF, GO TO HH3 - PROVSPEC.
ELSE GO TO BOX HH1AA.
BOX HH6
routing
IF (HOME HEALTH PROVIDER IS A FRIEND OR RELATIVE) OR (HOME HEALTH PROVIDER WORKS FOR
SELF), GO TO HH28 - HHFMORE.
ELSE GO TO HH29 - HHFOMORE.
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], [have you/has (SP)/did (SP)] (received/receive) personal care or help at
home with daily needs from any other persons who (do/did) not live with (you/him/her)?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) HH19 - PROVIDER_HHF
(02) BOX HH7
(-8) BOX HH7
(-9) BOX HH7
HH29
yes/no
Other than the persons who have visited [you/(SP)] from (PROVIDER NAME) [since (REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], [have you/has (SP)/did (SP)] (received/receive) personal care or help at
home with daily needs from any other persons who (do/did) not live with (you/him/her)? [DON’T INCLUDE ANY
OTHER PERSONS COMING FROM THE SAME ORG/AGENCY LISTED BELOW.]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) HH19 - PROVIDER_HHF
(02) BOX HH7
(-8) BOX HH7
(-9) BOX HH7
BOX HH7
routing
GO TO MPQ.
HHFMORE
HHFOMORE
HH28
Page 6 of 6
| File Type | application/pdf |
| Author | Shena Patel |
| File Modified | 2019-03-21 |
| File Created | 2019-03-21 |