CMS-P-0015A Background_Questionnaire

2019 MCBS Facility Instrument

Variable Name

BQ-Background Questionnaire

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(01) BQ1PRE1 - BQ1PRECT
(02) BQEND - BQENDCT
(03) BQ1PRE1 - BQ1PRECT
(04) BQEND - BQENDCT

(01) BQRH22A - BEFORADM
(02) BQEND - BQENDCT
(03) BQEND - BQENDCT

BACKGROUND QUESTIONNAIRE SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= CFC, IPR
SEASON
If SAMPLE TYPE= CFC, then SEASON= ALL
If SAMPLE TYPE= IPR, then SEASON= FALL
PLACEMENT
Administered in flexible order after FQ and RH sections are completed.
BOX BQBEG

CONREFFN

BQ1PRECT

BQCONREF

BQ1PRE1

routing

IF BQDISP = 1/ConsentRequired OR BQDISP = 4/InitialRefusal, GO TO BQCONREF - CONREFFN. ELSE GO TO
BQ1PRE1 - BQ1PRECT.

code one

PLEASE INDICATE THE FINAL (CONSENT/REFUAL) STATUS FOR THIS SECTION.

(01) CONSENT OBTAINED (CONTINUE INTERVIEW)
(02) FINAL FINAL CONSENT DENIED
(03) REFUSAL CONVERTED (CONTINUE INTERVIEW)
(04) FINAL REFUSAL

no entry

The following questions are about (SP's) background including (his/her) use of long-term care, demographics, and
(his/her) immediate family. In answering some of these questions, you might find it useful to refer to various
records. Some of these questions refer to specific points in time while others are more general in
nature/background.
IF THERE ARE NO CONSENT OR REFUSAL ISSUES FOR THIS SECTION, PRESS "1" TO CONTINUE.

(01) CONTINUE
(02) CONSENT REQUIRED
(03) INITIAL REFUSAL

(01) BOX BQ3B
(02) BOX BQ3B
(03) BOX BQ3B
(04) BOX BQ3B
(05) BOX BQ3B
(07) BOX BQ3B
(91) BQRH22A - BEFORAOS
(-8) BOX BQ3B
(-9) BOX BQ3B

(01) Continuous answer

BOX BQ3B

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

(00) BQRH30A - BLIVEWITH
(01) BQ9PRE - BQ9PRECT
(-8) BQ9PRE - BQ9PRECT
(-9) BQ9PRE - BQ9PRECT

(01) SPOUSE
(02) DAUGHTER
(03) SON
(04) MOTHER
(05) FATHER
(06) SISTER
(07) BROTHER
(08) DAUGHTER-IN-LAW
(09) SON-IN-LAW
(10) GRANDDAUGHTER
(11) GRANDSON
(12) NIECE
(13) NEPHEW
(14) FRIEND/NEIGHBOR
(15) NURSE/NURSE'S AIDE
(16) BOARDER
(17) GUARDIAN
(91) OTHER FEMALE RELATIVE
(92) OTHER MALE RELATIVE
(93) OTHER NONRELATIVE
(-8) Don't Know
(-9) Refused

(01) BOX BQ3C1
(02) BOX BQ3C1
(03) BOX BQ3C1
(04) BOX BQ3C1
(05) BOX BQ3C1
(06) BOX BQ3C1
(07) BOX BQ3C1
(08) BOX BQ3C1
(09) BOX BQ3C1
(10) BOX BQ3C1
(11) BOX BQ3C1
(12) BOX BQ3C1
(13) BOX BQ3C1
(14) BOX BQ3C1
(15) BOX BQ3C1
(16) BOX BQ3C1
(17) BOX BQ3C1
(91) BQRH30A - BOFROS
(92) BQRH30A - BOMROS
(93) BQRH30A - BONROS
(-8) BQ9PRE - BQ9PRECT
(-9) BQ9PRE - BQ9PRECT

BEFORADM

BQRH22A

code one

(01) NURSING HOME/REHAB CENTER
(02) PERSONAL CARE HOME/RESIDENTIAL CARE
FACILITY
SHOW CARD RH1
(03) CCRC/RETIREMENT HOME/CENTER
Please look at this card and tell me what kind of place (SP) was in just before being admitted here on (ADMISSION
(04) HOSPITAL
DATE).
(05) PRIVATE HOME OR APARTMENT
(07) OTHER LTC FACILITY
PRESS F1 FOR DEFINITIONS.
(91) OTHER
(-8) Don't Know
(-9) Refused

BEFORAOS

BQRH22A

verbatim text

OTHER (SPECIFY)

BOX BQ3B

routing

IF BQRH22A - BEFORADM = 5/PrivateHomeOrApartment OR 91/Other, GO TO BQRH30AA - BLIVALONE.
ELSE GO TO BQ9PRE - BQ9PRECT.

BLIVALONE

BQRH30AA

yes/no

Did (SP) live there alone?

Who lived with (him/her) there?
BLIVEWITH

BQRH30A

Code all

BOFROS

BQRH30A

verbatim text

OTHER FEMALE RELATIVE (SPECIFY)

(01) Continuous answer

(01) BOX BQ3C1

BOMROS

BQRH30A

verbatim text

OTHER MALE RELATIVE (SPECIFY)

(01) Continuous answer

(01) BOX BQ3C1

BONROS

BQRH30A

verbatim text

OTHER NONRELATIVE (SPECIFY)

(01) Continuous answer

(01) BOX BQ3C1

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

Page 1 of 5

2019 MCBS Facility Instrument

Variable Name

BDAUGN

BQ-Background Questionnaire

MR Screen Name Question Type

Question Text/Description

BOX BQ3C1

routing

IF BQRH30A-BLIVEWITH INCLUDES 2/Daughter, GO TO BQRH30A1 - BDAUGN.
ELSE GO TO BOX BQ3C2.

BQRH30A1

Numeric

How many daughters lived there?

BSISN

BBROTN

BDLAWN

BSLAWN

BGDAUN

BGSONN

BNIECN

BNEPHN

BFRIEN

BOFRN

BOMRN

Routing

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

(01) BOX BQ3C2
(-8) BOX BQ3C2
(-9) BOX BQ3C2

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

(01) BOX BQ3C3
(-8) BOX BQ3C3
(-9) BOX BQ3C3

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

(01) BOX BQ3C4
(-8) BOX BQ3C4
(-9) BOX BQ3C4

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

(01) BOX BQ3C5
(-8) BOX BQ3C5
(-9) BOX BQ3C5

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

(01) BOX BQ3C6
(-8) BOX BQ3C6
(-9) BOX BQ3C6

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

(01) BOX BQ3C7
(-8) BOX BQ3C7
(-9) BOX BQ3C7

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

(01) BOX BQ3C8
(-8) BOX BQ3C8
(-9) BOX BQ3C8

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

(01) BOX BQ3C9
(-8) BOX BQ3C9
(-9) BOX BQ3C9

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

(01) BOX BQ3C10
(-8) BOX BQ3C10
(-9) BOX BQ3C10

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

(01) BOX BQ3C11
(-8) BOX BQ3C11
(-9) BOX BQ3C11

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

(01) BOX BQ3C12
(-8) BOX BQ3C12
(-9) BOX BQ3C12

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

(01) BOX BQ3C13
(-8) BOX BQ3C13
(-9) BOX BQ3C13

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

(01) BOX BQ3C14
(-8) BOX BQ3C14
(-9) BOX BQ3C14

IF BQRH30A-BLIVEWITH INCLUDES 3/Son, GO TO BQRH30A2 - BSONN.
ELSE GO TO BOX BQ3C3.

BQ3C2
BSONN

Code List

BQRH30A2

Numeric

How many sons lived there?

BOX BQ3C3

routing

IF BQRH30A-BLIVEWITH INCLUDES 6/Sister, GO TO BQRH30A3 - BSISN.
ELSE GO TO BOX BQ3C4.

BQRH30A3

Numeric

How many sisters lived there?

BOX BQ3C4

routing

IF BQRH30A-BLIVEWITH INCLUDES 7/Brother, GO TO BQRH30A4 - BBROTN.
ELSE GO TO BOX BQ3C5.

BQRH30A4

Numeric

How many brothers lived there?

BOX BQ3C5

routing

IF BQRH30A-BLIVEWITH INCLUDES 8/DaughterInLaw, GO TO BQRH30A5 - BDLAWN.
ELSE GO TO BOX BQ3C6.

BQRH30A5

Numeric

How many daughters-in-law lived there?

BOX BQ3C6

routing

IF BQRH30A-BLIVEWITH INCLUDES 9/SonInLaw, GO TO BQRH30A6 - BSLAWN. ELSE GO TO BOX BQ3C7.

BQRH30A6

Numeric

How many sons-in-law lived there?

BOX BQ3C7

routing

IF BQRH30A-BLIVEWITH INCLUDES 10/Granddaughter, GO TO BQRH30A7 - BGDAUN. ELSE GO TO BOX
BQ3C8.

BQRH30A7

Numeric

How many granddaughters lived there?

BOX BQ3C8

routing

IF BQRH30A-BLIVEWITH INCLUDES 11/Grandson, GO TO BQRH30A8 - BGSONN. ELSE GO TO BOX BQ3C9.

BQRH30A8

Numeric

How many grandsons lived there?

BOX BQ3C9

routing

IF BQRH30A-BLIVEWITH INCLUDES 12/Niece, GO TO BQRH30A9 - BNIECN. ELSE GO TO BOX BQ3C10.

BQRH30A9

Numeric

How many nieces lived there?

BOX BQ3C10

routing

IF BQRH30A-BLIVEWITH INCLUDES 13/Nephew, GO TO BQRH30A10 - BNEPHN. ELSE GO TO BOX BQ3C11.

BQRH30A10

Numeric

How many nephews lived there?

BOX BQ3C11

routing

IF BQRH30A-BLIVEWITH INCLUDES 14/Friend, GO TO BQRH30A11 - BFRIEN.
ELSE GO TO BOX BQ3C12.

BQRH30A11

Numeric

How many friends lived there?

BOX BQ3C12

routing

IF BQRH30A-BLIVEWITH INCLUDES 91/OtherFemaleRel, GO TO BQRH30A12 - BOFRN. ELSE GO TO BOX
BQ3C13.

BQRH30A12

Numeric

How many (OTHER FEMALE RELATIVE)s lived there?

BOX BQ3C13

routing

IF BQRH30A-BLIVEWITH INCLUDES 92/OtherMaleRel, GO TO BQRH30A13 - BOMRN. ELSE GO TO BOX
BQ3C14.

BQRH30A13

Numeric

How many (OTHER MALE RELATIVE)s lived there?

Page 2 of 5

2019 MCBS Facility Instrument

Variable Name

BQ-Background Questionnaire

MR Screen Name Question Type

Question Text/Description

BOX BQ3C14

IF BQRH30A-BLIVEWITH INCLUDES 93/OtherNonRel, GO TO BQRH30A14 - BONRN.
ELSE GO TO BQ9PRE - BQ9PRECT.

routing

Code List

Routing

(01) BOX BQ3C15
(-8) BOX BQ3C15
(-9) BOX BQ3C15

BONRN

BQRH30A14

Numeric

How many (OTHER NONRELATIVE)s lived there?

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

BQ9PRECT

BQ9PRE

code one

The next few questions are about (SP's) (level of education,) race, ethnicity, and military service.
PRESS "1" TO CONTINUE.

(01) CONTINUE

(01) BOX BQ4

BOX BQ4

routing

IF HA51-BACK.HEDULEV = DK, RF, EMPTY, OR NULL GO TO BQ9 - EDLEVELF.
ELSE GO TO BQ10A - BHISPORG.
(01) NO FORMAL SCHOOLING
(02) ELEMENTARY (1ST-8TH GRADES)
(03) SOME HIGH SCHOOL (9TH-12TH GRADES)
(04) COMPLETED HIGH SCHOOL, NO COLLEGE
(05) TECHNICAL OR TRADE SCHOOL
(06) SOME COLLEGE
(07) COLLEGE GRADUATE
(08) GRADUATE DEGREE
(-8) Don't Know
(-9) Refused

(01) BQ10A - BHISPORG
(02) BQ10A - BHISPORG
(03) BQ10A - BHISPORG
(04) BQ10A - BHISPORG
(05) BQ10A - BHISPORG
(06) BQ10A - BHISPORG
(07) BQ10A - BHISPORG
(08) BQ10A - BHISPORG
(-8) BQ10A - BHISPORG
(-9) BQ10A - BHISPORG
(00) BQ11A - BQRACE
(01) BQ10B - BHISPORD
(-8) BQ11A - BQRACE
(-9) BQ11A - BQRACE

EDLEVELF

BHISPORG

BQ9

BQ10A

code one

As far as you know, what (is/was) the highest level of schooling (SP) completed?
IF DK, USE CATEGORIES AS PROBES.

yes/no

(Is/Was) (SP) of Hispanic or Latino origin?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(01) MEXICAN/MEXICAN AMERICAN/CHICANO(A)
(02) PUERTO RICAN
(03) CUBAN
(91) OTHER HISPANIC, LATINO/A, OR SPANISH
ORIGIN
(-8) Don't Know
(-9) Refused

(01) BQ11A - BQRACE
(02) BQ11A - BQRACE
(03) BQ11A - BQRACE
(91) BQ10B - BHISPDOS
(-8) BQ11A - BQRACE
(-9) BQ11A - BQRACE

BHISPORD

BQ10B

code all

SHOW CARD BQ1AA.
Looking at this card, (is/was) (SP) Mexican, Mexican American, or
(Chicano/Chicana), Puerto Rican, Cuban, or of another Hispanic,
(Latino/Latina) or Spanish origin?
CHECK ALL THAT APPLY.

BHISPDOS

BQ10B

verbatim text

OTHER ORIGIN (SPECIFY)

(01) Continuous answer

(01) BQ11A - BQRACE

(01) AMERICAN INDIAN OR ALASKA NATIVE
(02) ASIAN
(03) BLACK OR AFRICAN AMERICAN
(04) NATIVE HAWAIIAN OR OTHER PACIFIC
ISLANDER
(05) WHITE
(91) ANOTHER RACE
(-8) Don't Know
(-9) Refused

(01) BOX BQ4A
(02) BOX BQ4A
(03) BOX BQ4A
(04) BOX BQ4A
(05) BOX BQ4A
(91) BQ11A - BRACEOS
(-8) BOX BQ4A
(-9) BOX BQ4A

(01) Continuous answer

(01) BOX BQ4A

(01) ASIAN INDIAN
(02) CHINESE
(03) FILIPINO
(04) JAPANESE
(05) KOREAN
(06) VIETNAMESE
(91) OTHER ASIAN GROUP
(-8) Don't Know
(-9) Refused

(01) BOX BQ4B
(02) BOX BQ4B
(03) BOX BQ4B
(04) BOX BQ4B
(05) BOX BQ4B
(06) BOX BQ4B
(91) BQ11B - BRACASOS
(-8) BOX BQ4B
(-9) BOX BQ4B

(01) Continuous answer

(01) BOX BQ4B

You can choose more than one group.
CHECK ALL THAT APPLY.

(01) NATIVE HAWAIIAN
(02) GUAMANIAN OR CHAMORRO
(03) SAMOAN
(91) OTHER PACIFIC ISLANDER GROUP
(-8) Don't Know
(-9) Refused

(01) BOX BQ5
(02) BOX BQ5
(03) BOX BQ5
(91) BQ11C - BRACPIOS
(-8) BOX BQ5
(-9) BOX BQ5

(01) Continuous answer

(01) BOX BQ5

BQRACE

BQ11A

code all

SHOW CARD BQ1A
Please look at this card and tell me what (is/was) (SP's) race.
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

BRACEOS

BQ11A

verbatim text

ANOTHER RACE (SPECIFY)

BOX BQ4A

routing

IF BQ11A-BQRACE INCLUDES 2/Asian, GO TO BQ11B - BRACEASD.
ELSE GO TO BOX BQ4B.

BRACEASD

BQ11B

code all

SHOW CARD BQ1B.
Looking at this card, (is/was) (SP) Asian Indian, Chinese, Filipino,
Japanese, Korean, Vietnamese or some other Asian group?
You can choose more than one group.
CHECK ALL THAT APPLY.

BRACASOS

BRACPIDT

BRACPIOS

BQ11B

verbatim text

BOX BQ4B

routing

BQ11C

code all

OTHER ASIAN GROUP (SPECIFY)
IF BQ11A-BQRACE INCLUDES 4/NativeHawaiianOrOtherPacificIslander, GO TO BQ11C - BRACPIDT.
ELSE GO TO BOX BQ5.
SHOW CARD BQ1C.
Looking at this card, (is/was) (SP) Native Hawaiian, Guamanian
or Chamorro, Samoan, or some other Pacific Islander group?

BQ11C

verbatim text

OTHER PACIFIC ISLANDER GROUP (SPECIFY)

BOX BQ5

routing

IF SP IS LESS THAN 15 YEARS OLD, GO TO BQ18PRE - BQ18PRCT.
ELSE GO TO BQ12 - BEVERAF.

Page 3 of 5

2019 MCBS Facility Instrument

Variable Name

BEVERAF

BARMEDF

BEVERNG

BNGDUTY

BVARATE

BMRJAN

BQ-Background Questionnaire

MR Screen Name Question Type

BQ12

BQ12A

BQ12B

yes/no

code all

yes/no

Question Text/Description

Code List

Routing

Did (SP) ever serve on active duty in the Armed Forces?

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

(00) BQ12B - BEVERNG
(01) BQ12A - BARMEDF
(-8) BQ12B - BEVERNG
(-9) BQ12B - BEVERNG

(01) IRAQ OR AFGHANISTAN CONFLICT (2001 Present)
(02) PERSIAN GULF WAR (Aug. 1990 - March 1991)
(03) VIETNAM ERA (Aug. 1964 - May 1975)
(04) KOREAN CONFLICT (June 1950 - Jan. 1955)
(05) WORLD WAR II (Sept. 1940 - July 1947)
(06) WORLD WAR 1 (1917 - 1918)
(07) PEACE TIME ONLY (ALL OTHER TIMES)
(-8) Don't Know

(01) BQ12B - BEVERNG
(02) BQ12B - BEVERNG
(03) BQ12B - BEVERNG
(04) BQ12B - BEVERNG
(05) BQ12B - BEVERNG
(06) DO NOT DISPLAY
(07) BQ12B - BEVERNG
(-8) BQ12B - BEVERNG

Was (SP) ever an active member of a National Guard or military reserve unit of the United States?

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

(00) BOX BQ5A
(01) BQ12C - BNGDUTY
(-8) BOX BQ5A
(-9) BOX BQ5A

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

(00) BOX BQ5A
(01) BOX BQ5A
(-8) BOX BQ5A
(-9) BOX BQ5A

SHOW CARD BQ1
Looking at this card, which time periods best describe when (SP) served in the Armed Forces?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

BQ12C

yes/no

Was all of (SP's) active duty related to National Guard or military reserve training?

BOX BQ5A

routing

IF BQ12 - BEVERAF = 1/Yes OR BQ12B - BEVERNG = 1/Yes, GO TO BQ12E - BVARATE.
ELSE GO TO BQ13 - BMRJAN.

BQ12E

Numeric

What (is/was) (SP's) (current/most recent) VA disability rating?
THE VA DISABILITY RATING IS A PERCENTAGE IN MULTIPLES OF 10 (I.E., 10%, 20%, ETC.). ENTER THE
NUMBER AS A WHOLE NUMBER. DO NOT ENTER THE "%" SIGN.

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

(01) BQ13 - BMRJAN
(-8) BQ13 - BMRJAN
(-9) BQ13 - BMRJAN

(Is/Was) (SP) married, widowed, divorced, separated, or never married?

(01) NEVER MARRIED
(02) MARRIED
(03) WIDOWED
(04) DIVORCED
(05) SEPARATED
(-8) Don't Know
(-9) Refused

(01) BQ18PRE - BQ18PRCT
(02) BQ15 - BHWLIVES
(03) BQ18PRE - BQ18PRCT
(04) BQ18PRE - BQ18PRCT
(05) BQ18PRE - BQ18PRCT
(-8) BQ18PRE - BQ18PRCT
(-9) BQ18PRE - BQ18PRCT
(01) BQ18PRE - BQ18PRCT
(02) BQ18PRE - BQ18PRCT
(03) BQ18PRE - BQ18PRCT
(04) BQ18PRE - BQ18PRCT
(05)BQ18PRE - BQ18PRCT
(06) BQ18PRE - BQ18PRCT
(07) BQ18PRE - BQ18PRCT
(08) BQ18PRE - BQ18PRCT
(91) BQ15 - BHWLIVOS
(-8) BQ18PRE - BQ18PRCT
(-9) BQ18PRE - BQ18PRCT

BQ13

code one

BHWLIVES

BQ15

code one

SHOW CARD BQ2
Please look at this card and tell me where (SP's) (husband/wife) lives now.

(01) IN THIS FACILITY
(02) OTHER NURSING HOME/REHAB CENTER
(03) PERSONAL CARE HOME/RESIDENTIAL CARE
FACILITY
(04) CCRC/RETIREMENT HOME/CENTER
(05) HOSPITAL
(06) PRIVATE HOME OR APARTMENT
(07) SPOUSE DECEASED
(08) OTHER LTC FACILITY
(91) OTHER
(-8) Don't Know
(-9) Refused

BHWLIVOS

BQ15

verbatim text

OTHER (SPECIFY)

(01) Continuous answer

(01) BQ18PRE - BQ18PRCT

BQ18PRCT

BQ18PRE

code one

(01) Continue

(01) BOX BQ10

BOX BQ10

routing

BQ18

Numeric

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

(01) BQ19 - BTOTLSON
(-8) BQ19 - BTOTLSON
(-9) BQ19 - BTOTLSON

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

(01) BQ24 - BINCOAMT
(-8) BQ24 - BINCOAMT
(-9) BQ24 - BINCOAMT

BTOTLDAU

BTOTLSON

BQ19

Numeric

The next few questions are about (SP's) immediate family.
PRESS "1" TO CONTINUE.
IF SP IS LESS THAN 15 YEARS OLD, GO TO BQ24 - BINCOAMT.
ELSE GO TO BQ18 - BTOTLDAU.
How many living daughters altogether (does/did) (SP) have, including any who may live far away?
PRESS F1 FOR DEFINITION OF DAUGHTER.
How many living sons altogether (does/did) (SP) have, including any who may live far away?
PRESS F1 FOR DEFINITION OF SON.
In studies like this, people are sometimes grouped together according to income.
SHOW CARD BQ3

BINCOAMT

BQ24

Dollar

(01) Continuous answer
Looking at this card, please tell me what (is/was) the total yearly income (SP) [and (his/her) spouse] received from (-8) Don't Know
jobs, businesses, interest, Social Security, Railroad Retirement, Supplemental Security Income (SSI), pensions, and (-9) Refused
any other sources of income, before taxes or any deductions.

(01) BQ28 - DIDABBQ
(-8) BQ25 - BLESS25
(-9) BQ25 - BLESS25

ENTER A WHOLE DOLLAR AMOUNT FOLLOWED BY ".00"

Page 4 of 5

2019 MCBS Facility Instrument

Variable Name

BLESS25

BHOWLESS

BHOWMORE

BQ-Background Questionnaire

MR Screen Name Question Type

BQ25

BQ26

BQ27

yes/no

code one

code one

Question Text/Description

Code List

Routing

(Is/Was) it less than $25,000?

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

(00) BQ27 - BHOWMORE
(01) BQ26 - BHOWLESS
(-8) BQ28 - DIDABBQ
(-9) BQ28 - DIDABBQ

Would you say it (is/was)…

(01) Less than $5,000,
(02) $5,000 - less than $10,000
(03) $10,000 - less than $15,000
(04) $15,000 - less than $20,000
(05) $20,000 - less than $25,000
(-8) Don't Know
(-9) Refused

(01) BQ28 - DIDABBQ
(02) BQ28 - DIDABBQ
(03) BQ28 - DIDABBQ
(04) BQ28 - DIDABBQ
(05) BQ28 - DIDABBQ
(-8) BQ28 - DIDABBQ
(-9) BQ28 - DIDABBQ

Would you say it (is/was)…

(01) $25,000 - less than $30,000
(02) $30,000 - less than $40,000
(03) $40,000 - less than $50,000
(04) $50,000 - less than $66,000
(05) $66,000 - less than $109,000
(06) $109,000 or more
(-8) Don't Know
(-9) Refused

(01) BQ28 - DIDABBQ
(02) BQ28 - DIDABBQ
(03) BQ28 - DIDABBQ
(04) BQ28 - DIDABBQ
(05) BQ28 - DIDABBQ
(06) BQ28 - DIDABBQ
(-8) BQ28 - DIDABBQ
(-9) BQ28 - DIDABBQ

(01) ALL
(02) MAJORITY
(03) HALF
(04) SOME
(05) NONE

(01) BQ29 - WHYABBQ
(02) BQ29 - WHYABBQ
(03) BQ29 - WHYABBQ
(04) BQ29 - WHYABBQ
(05) BQEND - BQENDCT

(01) BQEND - BQENDCT
(02) BQEND - BQENDCT
(03) BQEND - BQENDCT
(91) BQ29VB - WHYABBOS

DID YOU ABSTRACT?

DIDABBQ

BQ28

code one

TO ABSTRACT MEANS TO OBTAIN INFORMATION FROM THE BENEFICIARY'S RECORDS FOR ENTRY INTO
THE QUESTIONNAIRE. EXAMPLES OF RECORDS YOU MAY HAVE ABSTRACTED FROM INCLUDE THE
MINIMUM DATA SET (MDS), NURSES NOTES, PHYSICIANS ORDERS, AND/OR OTHER DOCUMENTS
PROVIDED BY THE FACILITY.
USE YOUR BEST JUDGMENT TO DETERMINE WHICH ANSWER IS THE MOST ACCURATE CHOICE FOR THE
AMOUNT YOU ABSTRACTED. IF THERE WAS NO ABSTRACTION AT ALL, PLEASE SELECT "NONE".

WHYABBQ

BQ29

code one

WHY DID YOU ABSTRACT?

(01) NO KNOWLEDGEABLE RESPONDENT AVAILABLE
(02) NO TIME/STAFF BURDEN TOO GREAT
(03) REFUSAL--UNWILLING TO COOPERATE
(91) OTHER

WHYABBOS

BQ29VB

verbatim text

WHY DID YOU ABSTRACT?
OTHER (SPECIFY)

(01) Continuous answer

(01) BQEND - BQENDCT

BQENDCT

BQEND

code one

(YOU HAVE COMPLETED THE BACKGROUND SECTION FOR THIS SP.)
PRESS "1" TO RETURN TO NAVIGATION SCREEN.

(01) Continue

(1) BOX BQEND

BOX BQEND

routing

GO TO NAVIGATOR

Page 5 of 5