Form CMS-P-0015A Facility Screener

2018 MCBS Facility Screener

Variable Name

FSINTRO

MR Screen Name Question Type

FSI01

no entry

Question Text/Description

Code List

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

Routing

FS01 -SPRESIDENOW

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

FS01

yes/no

IF RESPONDENT DOES NOT KNOW, ASK TO SPEAK TO SOMEONE WHO WOULD KNOW ADMISSION
INFORMATION.
Since (LAST INTERVIEW DATE), has (SP) lived [here/there]?

SPRESIDE

FS02

yes/no

BOX INSTR1

routing

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

BOX INSTR2

routing

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

FSVERIFY

FS03

verbatim text

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

FACNAME

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

FSTADDR1

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

FSTADDR2

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

FCITY

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

FSTATE

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

FZIPCODE

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

FPHONE

FS03a

verbatim text

CORRECT THE PORTIONS OF THE PHONE LISTED BELOW

FFAX

FSO3a

verbatim text

CORRECT THE PORTIONS OF THE FAX NUMBER LISTED BELOW

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

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

(01) BOX INSTR2
(02) FS02 - SPRESIDE

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

(01) BOX INSTR1
(02) FS08-FSWHERE

(01) ADDRESS CORRECT
(02) ADDRESS INCORRECT

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

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

FS03a- FSTADDR1

FS03a-FSTADDR2

FS03a-FCITY

FS03a-FSTATE

FS03a-FZIPCODE

FS03a-FPHONE

FS03a-FFAX

FS04- FSFACILITY

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2018 MCBS Facility Screener

Variable Name

MR Screen Name Question Type

Question Text/Description

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

Code List

Routing

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

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

FSFACILITY

FS04

code one

FSFACILITYOTH

FS04a

verbatim text

What type of facility is (FACILITY NAME)?

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

FS07-FSADMIN

FSNAME

FS05

verbatim text

(01) continuous answer
What is the name of the specific place within (FACILITY NAME) where (SP) was residing on or around since [LAST
(-8) Don't Know
INTERVIEW DATE]?
(-9) Refused

FS07-FSADMIN

FSRES

FS06

FSSPCARENAME FS06a

USE CATEGORIES AS PROBES IF NECESSARY

yes/no

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

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

verbatim text

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

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

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

FS06a- FSTADDR1

FPADDR1

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

FS06a-FSTADDR2

FPADDR2

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS06a -FCITY

FPCITY

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS06a-FSTATE

FPSTATE

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS06a-FZIPCODE

FS06a-FPHONE

FPZIPCODE

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FPPHONE

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS06a-FFAX

FPFAX

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS07 - FSADMIN

FSADMIN

FS07

verbatim text

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

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

BOX INSTR3

BOX INSTR3

routing

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

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2018 MCBS Facility Screener

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

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

FSWHERE

FS08

code one

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

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

FACNNAME

FS08a

verbatim text

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

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

FS08a- FSTADDR1

FNADDR1

FS08a

verbatim text

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

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

FS08a -FSTADDR2

FNADDR2

FS08a

verbatim text

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

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

FS08a-FCITY

FNCITY

FS08a

verbatim text

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

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

FS08a-FSTATE

FNSTATE

FS08a

verbatim text

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

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

FS08a-FZIPCODE

FNZIPCODE

FS08a

verbatim text

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

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

FS08a-FPHONE

FNPHONE

FS08a

verbatim text

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

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

FS08a-FFAX

FNFAX

FS08a

verbatim text

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

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

FSDODMM

FS09

date

What was the date of death?

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

FSDODDD

FS09

date

What was the date of death?

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

FS08a-FSDODYY

FSDODYY

FS09

date

What was the date of death?

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

CLOSING2

BOX INSTR4

routing

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

CLOSING1

no entry

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

CLOSING2

no entry

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

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