CMS-P-0015A Dental, Vision, and Hearing Care Utilization

Medicare Current Beneficiary Survey (MCBS) (CMS-P-0015A)

2020_Dental_Vision_and_Hearing_Utilization_DVH

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

OMB: 0938-0568

Document [pdf]
Download: pdf | pdf
2020 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/(SP)] may have received since the last
interview.)

DU1 - DUPROBE

First, we’ll talk about dental care.

DUPROBE

DU1

yes/no

[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.]

Who did [you/(SP)] see?
PROVIDER_DU

DU2

roster

SELECT OR ADD ONLY ONE PROVIDER.
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY
ENTERING AN EVENT WITH THAT PROVIDER

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

(01) DU2 - PROVIDER_DU
(02) BOX DU5
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX DU6
(-9) BOX DU6

(01) [Continuous answer.]

(01-N) BOX DU1
(N+1) DU2B-PROVNAME
(N+2) CHNGSPL-CHNGSPL

[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.

IF EXISTING PROVIDER SELECTED, GO TO BOX
DU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO DU2BPROVNAME
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

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

DU2B

verbatim text

GROUP:

WHICH PROVIDER IS MISSPELLED?

CHNGSPL

CHNGSPL

roster

[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND 2. [PROVIDER 2]
SELECT "ADD ANOTHER."
…
N. [PROVIDER N]
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 NAME FOR
SELECT OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
ALL PROVIDERS WHERE PROVNUM>02.

PROVSPEC

CRCTSPL-CRCTSPL

Page 1 of 29

2020 MCBS Community Questionnaire

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Variable Name

MR Screen Name

Question Type

Question Text/Description

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
(01) [Continuous Answer]
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]

PROVSPEC

DU2C

code one

Code List

Routing

BOX DU1

What kind of dental provider is [PROVNAME]?

(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) DU2C1 - PROVSPEC
(-8) BOX DU2
(-9) BOX DU2

(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

BOX DU2

PROVSPEC

DU2C1

code one

What kind of dental provider is [PROVNAME]?

(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

PROVSPOS

DU2D

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

(01) [Continuous answer.]

BOX DU1

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 DU3 - VAPLACE.
ELSE GO TO BOX DU2.

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2020 MCBS Community Questionnaire

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

VAPLACE

DU3

yes/no

Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?

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

BOX DU2

BOX DU2

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.

HMOASSOC

DU4

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

(01) DU6 - EVENT_DU
(02) DU5 - HMOREFER
(-8) DU5 - HMOREFER
(-9) DU5 - HMOREFER

HMOREFER

DU5

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

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.]
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT
"REPEAT VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.

HAVE ALL DATES BEEN ENTERED?
DUADD

DU6B

chose one
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

SHOW CARD DVH1
DVPROCDR

DU7

code all

For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS

DU6B-DUADD

(01) ADD ANOTHER
(02) ALL DONE

(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

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2020 MCBS Community Questionnaire

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

EVOSTEXT

DU7A

verbatim text

OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)

(01) [CONTINUOUS ANSWER]

DU9 - PRESMDCN

PRESMDCN

DU9

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

PRESFILL

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.

(01) INSTRUCTION WAS READ

BOX PM2

DUPMMEDS

DU10A

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

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, STRENGTH, FORM, AND
QUANTITY 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).
The strength was [MEDICINE STRENGTH].
SAMEFSAM

SAMEFSAM

yes/no
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

Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.

BOX PM4

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.

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2020 MCBS Community Questionnaire

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

PMBOTTLE

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.

(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

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, USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.

[MEDICINE NAME SELECTED FROM LOOKUP OR 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]

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

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

[MEDICINE FORM OTHER SPECIFY]

STRNUNIT

MED

code one

PMSTRNOS

MED

verbatim

[MEDICINE STRENGTH UNIT OTHER SPECIFY]

PMSTRUNI

MED

ookup

[FINAL CONCATENATED MEDICINE STRENGTH]

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.]

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

Page 5 of 29

2020 MCBS Community Questionnaire

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

PMKNWNM

PMKNWNM

code one

DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?

(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

What condition is this medicine prescribed for or what is its primary use?
PMCOND

PMCOND

code one
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.

PMCONDOS

PMCOND

verbatim

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.]

BOX PM5

routing

IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
IF SAMEFSAM=1/YES AND PMFORMFN=pills (tablets, capsules), GO TO PM12-TABSADAY;
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
(-9) REFUSED

(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused

BOX PM5

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

BOX PM6

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2020 MCBS Community Questionnaire

Variable Name

AMTUNIT

MR Screen Name

PM16

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Question Type

Question Text/Description

Code List

Routing

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

(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

OTHER (SPECIFY)

(01) CONTINUOUS ANSWER

PM16 - AMTNUM

(01) CONTINUOUS ANSWER

BOX PM6

AMTUNOS

PM16

text

AMTNUM

PM16

numeric

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

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 (01) CONTINUOUS ANSWER
IN 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

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.]
(01) CONTINUOUS ANSWER
(-7) EMPTY
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF
(-8) DON'T KNOW
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".

TABTAKE

PM13

numeric

TABTAKE96

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

(01) YES
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of (02) NO
Veterans Affairs or V.A.?
(-8) DON'T KNOW
(-9) REFUSED

PMSATVA

(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY

PM13 - TABTAKE96

BOX PM7

BOX PM8

Page 7 of 29

2020 MCBS Community Questionnaire

Variable Name

PMSATHMO

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

MR Screen Name

Question Type

Question Text/Description

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.

PMSATHMO

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 NAME(S) BELOW]?
[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.])
PMMORE

PM17

yes/no
[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?]

DUMORE

DVNEED

Code List

Routing

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

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

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) AND SEASON=WINTER, GO TO DU15-DVNEED. ELSE GO TO BOX DU6.

DU15

yes/no

Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], 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

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

routing

GO TO VU1-VUPROBE.

Page 8 of 29

2020 MCBS Community Questionnaire

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

VUPROBE

VU1

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

(01) [Continuous answer.]

(01-N) BOX VU1
(N+1) VU2B-PROVNAME
(N+2) CHNGSPL-CHNGSPL

Who did [you/(SP)] see?
PROVIDER_VU

VU2

roster

SELECT OR ADD ONLY ONE PROVIDER.
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.

IF EXISTING PROVIDER SELECTED, GO TO BOX
VU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO VU2PROVNAME.
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPL.CHNGSPL..

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

VU2B - 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:

VGRPNAME

VU2B

verbatim text

GROUP:

PROVSPEC

WHICH PROVIDER IS MISSPELLED?

CHNGSPL

CHNGSPL

roster

[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND 2. [PROVIDER 2]
SELECT "ADD ANOTHER."
…
N. [PROVIDER N]
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 NAME FOR
SELECT OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
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
(01) [Continuous Answer]
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]

PROVSPEC

VU2C

code one

What kind of eye care provider is [PROVNAME]?

(02) MEDICAL DOCTOR, INCLUDING OPHTHALMOLOGIST
(16) OPTOMETRIST (OD)
(43) OPTICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED

CRCTSPL-CRCTSPL

BOX VU1

(02) BOX VU1
(16) BOX VU1
(43) BOX VU1
(91) VU2C1 - PROVSPEC
(-8) BOX VU1
(-9) BOX VU1

Page 9 of 29

2020 MCBS Community Questionnaire

Variable Name

PROVSPEC

PROVSPOS

VAPLACE

HMOASSC

MR Screen Name

VU2C1

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Question Type

code one

Question Text/Description

Code List

Routing

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

(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) 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

(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

(01) [Continuous answer.]

BOX VU1

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

BOX VU2

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

(01) VU6 - EVENT_VU
(02) VU5 - HMOREFER
(-8) VU5 - HMOREFER
(-9) VU5 - HMOREFER

VU2D

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

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.

VU3

yes/no

Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?

BOX VU2

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.

VU4

yes/no

Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

Page 10 of 29

2020 MCBS Community Questionnaire

Variable Name

HMOREFR

EVENT_VU

MR Screen Name

VU5

VU6

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Question Type

yes/no

roster

Question Text/Description

Code List

Routing

[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

VU6 - EVENT_VU

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.]
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT
"REPEAT VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.

HAVE ALL DATES BEEN ENTERED?
VUADD

VU6B

chose one
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

SHOW CARD DVH2
VUPROCDR

VU7

code all

For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS

VU6B-VUADD

(01) ADD ANOTHER
(02) ALL DONE

(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

EVOSTEXT

VU7A

verbatim text

OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)

(01) [CONTINUOUS ANSWER]

VU9 - PRESMDCN

PRESMDCN

VU9

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

PRESFILL

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.

Page 11 of 29

2020 MCBS Community Questionnaire

Variable Name

VUPMMEDS

MR Screen Name

VU10A

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, STRENGTH, FORM, AND
QUANTITY 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).
The strength was [MEDICINE STRENGTH].
SAMEFSAM

SAMEFSAM

yes/no
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.

PMBOTTLE

BOX PM4

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.

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 12 of 29

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, USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.

[MEDICINE NAME SELECTED FROM LOOKUP OR 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]

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

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

[MEDICINE FORM OTHER SPECIFY]

STRNUNIT

MED

code one

PMSTRNOS

MED

verbatim

[MEDICINE STRENGTH UNIT OTHER SPECIFY]

PMSTRUNI

MED

ookup

[FINAL CONCATENATED MEDICINE STRENGTH]

PMEDID

MED

numeric

[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH
THE LOOKUP. IT IS HIDDEN ON SCREEN.]

Medicine strength unit

(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS

(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

Page 13 of 29

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Question Type

Question Text/Description

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?

What condition is this medicine prescribed for or what is its primary use?
PMCOND

PMCOND

code one
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.

PMCONDOS

PMCOND

verbatim

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

IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
IF SAMEFSAM=1/YES AND PMFORMFN=pills (tablets, capsules), GO TO PM12-TABSADAY;
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?

[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

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

BOX PM6

Page 14 of 29

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Question Type

Question Text/Description

Code List

Routing

(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

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

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 (01) CONTINUOUS ANSWER
IN 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

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

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"

TABTAKE96

PMSATVA

(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW

PM13 - TABTAKE96

(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY

BOX PM7

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

(01) YES
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of (02) NO
Veterans Affairs or V.A.?
(-8) DON'T KNOW
(-9) REFUSED

BOX PM8

Page 15 of 29

2020 MCBS Community Questionnaire

Variable Name

PMSATHMO

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

MR Screen Name

Question Type

Question Text/Description

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.

PMSATHMO

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 NAME(S) BELOW]?
[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.])
PMMORE

PM17

yes/no
[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?]

VUMORE

BOX VU4

routing

IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO VU7-VUPROCDR.
ELSE GO TO VU14-VUMORE.

VU14

yes/no

[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?

Code List

Routing

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

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

[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE
(01) YES
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy, replace, or pay for repairs of eyeglasses or contact (03) INDICATED YES BY DATAPREP
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.]

What did [you/(SP)] buy or repair?
VUTYPE

OM1B

code all
FOR EACH DATE, CHECK ALL THAT APPLY. THE DATE WILL BE ENTERED ON THE NEXT SCREEN.

(01) BUY EYEGLASS LENSES
(02) BUY EYEGLASS FRAMES
(03) BUY CONTACT LENSES
(04) REPAIR EYEGLASSES
(-8) DON'T KNOW
(-9) REFUSED

OM2-EVENT_OMEYEG

Page 16 of 29

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Question Type

Question Text/Description

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

Code List

Routing

(01) continuous answer
(-8) Don't Know
(-9) Refused
BOX OM1AA
MM:
DD:
YYYY:

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
(01) ADD ANOTHER
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]?
(02) ALL DONE

(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

BOX OM1AA2

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX VU5.

BOX VU5

routing

IF SPALIVE=1 (ALIVE) AND SEASON=WINTER, GO TO VU15-VUNEED.
ELSE GO TO BOX VU6.

VU15

yes/no

Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], 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

Page 17 of 29

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 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

BOX VU6

VUVNDRS

VU16

code all

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

VUVNDRSOS

VU16A

verbatim text

WHAT OTHER REASON (SPECIFY)

(01) continuous answer

BOX VU6

routing

GO TO HU1-HUPROBE

HU1

yes/no

(01) YES
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to a doctor or any other person for hearing care?
(03) INDICATED YES BY DATAPREP
[Hearing care providers include otorhinolaryngologists (ear nose and throat doctors), otologists, neurotologists,
(-8) Don't Know
audiologists, audiometrists, and hearing instrument specialists.]
(-9) Refused

HUPROBE

(01) [Continuous answer.]
Who did [you/(SP)] see?
PROVIDER_HU

HU2

roster

SELECT OR ADD ONLY ONE PROVIDER.
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) HU2 - PROVIDER_HU
(02) HU15--OMHEARAD
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) OM3-OMPRHEAR
(-9) OM3-OMPRHEAR

(01-N) BOX HU1
(N+1) HU2B-PROVNAME
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX
HU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO HU2PROVNAME
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPL.CHNGSPL.

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:

Page 18 of 29

2020 MCBS Community Questionnaire

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Variable Name

MR Screen Name

Question Type

Question Text/Description

HGRPNAM

HU2B

verbatim text

GROUP:

Code List

Routing
PROVSPEC

WHICH PROVIDER IS MISSPELLED?

CHNGSPL

CHNGSPL

roster

[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND 2. [PROVIDER 2]
SELECT "ADD ANOTHER."
…
N. [PROVIDER N]
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 NAME FOR
SELECT OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
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
(01) [Continuous Answer]
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]

PROVSPEC

HU2C

code one

What kind of hearing care provider is [PROVNAME]?

(02) MEDICAL DOCTOR, INCLUDING OTOLARYNGOLOGIST
(ENT), OTOLOGIST, NEUROTOLOGIST
(03) AUDIOLOGIST
(44) AUDIOMETRIST
(45) HEARING INSTRUMENT SPECIALIST
(91) OTHER
(-8) Don't Know
(-9) Refused

CRCTSPL-CRCTSPL

BOX HU1

(02) BOX HU1
(03) BOX HU1
(44) BOX HU1
(45) BOX HU1
(91) HU2C1 - PROVSPEC
(-8) BOX HU1
(-9) BOX HU1

Page 19 of 29

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 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

PROVSPEC

HU2C1

code one

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

PROVSPOS

HU2D

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

(01) [Continuous answer.]

BOX HU1

BOX HU1

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 HU3 - VAPLACE.
ELSE GO TO BOX HU2.

HU3

yes/no

Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?

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

BOX HU2

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 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.

VAPLACE

BOX HU2

Page 20 of 29

2020 MCBS Community Questionnaire

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

HMOASSC

HU4

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

(01) HU6 - EVENT_HU
(02) HU5 - HMOREFER
(-8) HU5 - HMOREFER
(-9) HU5 - HMOREFER

HMOREFR

HU5

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

HU6 - EVENT_HU

EVENT_HU

HU6

roster

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.]
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT
"REPEAT VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.

HAVE ALL DATES BEEN ENTERED?
HUADD

HU6B

chose one
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

SHOW CARD DVH3
HUPROCDR

HU7

code all

For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.

EVOSTEXT

HU7A

verbatim text

OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS

HU6B-HUADD

(01) ADD ANOTHER
(02) ALL DONE

(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

(01) [CONTINUOUS ANSWER]

HU9 - PRESMDCN

Page 21 of 29

2020 MCBS Community Questionnaire

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

PRESMDCN

HU9

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

PRESFILL

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 MEDICINE ROSTER AS RESPONSE OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.

BOX PM3

HUPMMEDS

HU10A

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

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.

Page 22 of 29

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Question Type

Question Text/Description

Code List

Routing

(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

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).
The strength was [MEDICINE STRENGTH].
SAMEFSAM

SAMEFSAM

yes/no
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.

PMBOTTLE

BOX PM4

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.

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, USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.

[MEDICINE NAME SELECTED FROM LOOKUP OR 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]

Page 23 of 29

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Question Type

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

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

[MEDICINE FORM OTHER SPECIFY]

STRNUNIT

MED

code one

PMSTRNOS

MED

verbatim

[MEDICINE STRENGTH UNIT OTHER SPECIFY]

PMSTRUNI

MED

lookup

[FINAL CONCATENATED MEDICINE STRENGTH]

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) 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

(01) YES
(02) NO
(-9) REFUSED

(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND

Page 24 of 29

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Question Type

Question Text/Description

What condition is this medicine prescribed for or what is its primary use?
PMCOND

PMCOND

code one
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.

PMCONDOS

PMCOND

verbatim

GETNUM

GETNUM

numeric

OTHER (SPECIFY)

How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE
OF INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?

TABNUM

[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.]

BOX PM5

routing

IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
IF SAMEFSAM=1/YES AND PMFORMFN=pills (tablets, capsules), GO TO PM12-TABSADAY;
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?

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

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

BOX PM6

Page 25 of 29

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Question Type

Question Text/Description

Code List

Routing

(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

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

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 (01) CONTINUOUS ANSWER
IN 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

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

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".

TABTAKE96

PM13

code one

(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW

PM13 - TABTAKE96

(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY

BOX PM7

Page 26 of 29

2020 MCBS Community Questionnaire

Variable Name

PMSATVA

PMSATHMO

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

MR Screen Name

Question Type

Question Text/Description

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

(01) YES
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of (02) NO
Veterans Affairs or V.A.?
(-8) DON'T KNOW
(-9) REFUSED

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.

PMSATHMO

yes/no

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.

([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.])
PMMORE

PM17

yes/no
[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?]

HUMORE

BOX HU4

routing

IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO HU7-HUPROCDR.
ELSE GO TO HU14-HUMORE.

HU14

yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other hearing care visits to this or any other
provider?

Code List

Routing

BOX PM8

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

PMMORE-PMMORE

(01) ADD ANOTHER
(02) ALL DONE

(01) BOX PM2
(02) BOX HU4

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

(01) HU2 - PROVIDER_HU
(02) HU15-OMHEARAD
(-8) HU15-OMHEARAD
(-9) HU15-OMHEARAD

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

(01) HU16-INTHECANL
(02) BOX HU9
(03) DO NOT DISPLAY.
(-8) BOX HU9
(-9) BOX HU9

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 REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy, replace, or pay for repairs of a hearing aid?
[Please include the purchases you made during the visit(s) to hearing care provider on (EVENT DATES) that
you just told me about.]
[DO NOT INCLUDE HEARING AID BATTERIES AT THIS QUESTION. ENTER HEARING AID BATTERIES IN
THE OMQ AS A HEARING/SPEECH DEVICE.]

Page 27 of 29

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

Question Type

Question Text/Description

Code List

Routing

(01) LEFT EAR
(02) RIGHT EAR
(-8) Don't Know
(-9) Refued

HU16-INTHEEAR

SHOW CARD DVH4
What type of hearing aid(s) did [you/(SP)] buy or repair?
INTHCANL

HU16B

list

[IF NEEDED: Were they for [your/(SP’s)] left ear, right ear, or both?]
FOR EACH DATE, CHECK ALL THAT APPLY. THE DATE WILL BE ENTERED ON THE NEXT SCREEN.
In the canal hearing aid

INTHEEAR

HU16B

list

In the ear hearing aid

(01) LEFT EAR
(02) RIGHT EAR
(-8) Don't Know
(-9) Refued

HU16-BHNDEAR

BHNDEAR

HU16B

list

Behind the ear hearing aid

(01) LEFT EAR
(02) RIGHT EAR
(-8) Don't Know
(-9) Refued

HU17-EVENT_OMHRAD

SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair the (HEARING AID ITEM)?

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

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)].

MM:
DD:
YYYY:

In addition to the medical expenses related to hearing care you just told me about, did [you/(SP)] buy, replace,
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
(02) ALL DONE
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]?

HU18-OMADD

(01) HU16- INTHCANL
(02) BOX HU6

[DISPLAY ALL EVENTS ENTERED]

OMSATHMO

BOX HU6

routing

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.

HU19

yes/no

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)
(01) YES
BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could include buying or repairing the hearing aid at a plan center; from an audiologist, or other (-9) Refused
provider that honors [your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]

BOX HU8

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX HU9.

BOX HU8

Page 28 of 29

2020 MCBS Community Questionnaire

Variable Name

HVNEED

DVH- DENTAL, VISION, HEARING CARE UTILIZATION

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

BOX HU9

routing

IF SPALIVE=1 (ALIVE) AND SEASON=WINTER, GO TO HU20-HVNEED.
ELSE GO TO BOX HU10.

HU20

yes/no

Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], 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

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

BOX HU10

routing

GO TO EMERGENCY ROOM UTILIZATION (ERQ).

Page 29 of 29


File Typeapplication/pdf
File TitleDVH.xlsx
AuthorWishart-Marisa
File Modified2019-12-12
File Created2019-12-12

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