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pdf2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
INQ- INTRODUCTION
Question Type
Question Text/Description
Code List
Routing
(01) RESPONDENT AGREES TO CONTINUE WITH
RECORDING
(02) RESPONDENT DOES NOT WANT TO BE
RECORDED
(01) IN1AA - ATDOOR
(02) INV2 - NOCARI
INTRODUCTION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=ALL
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
(Start of interview)
BOX IN1
routing
INV1
code one
GO TO INV1 - CARIVER.
Some of this interview will be recorded for quality control purposes.
CARIVER
I'd like to continue now, unless you have any questions.
NOCARI
ATDOOR
INV2
IN1AA
no entry
no entry
That's fine. The interview will not be recorded.
IN1AA - ATDOOR
REVIEW WITH THE RESPONDENT THE FOLLOWING IMPORTANT FACTS FROM THE "AT-THE-DOOR"
SHEET:
All survey information will be kept private to the extent permitted by law, as prescribed by the Privacy Act of
1974.
IN2 - VERIFYSP
Medicare benefits will not be affected in any way by survey responses or participation.
REFER TO THE "AT-THE-DOOR" SHEET IF THE RESPONDENT NEEDS ADDITIONAL REASSURANCE.
VERIFYSP
IN2
yes/no
VERIFY THE SP’S NAME. IS THE SP’S NAME CORRECT AND COMPLETE?
FIRST NAME: (SP'S FIRST NAME)
MIDDLE INITIAL: (SP'S MIDDLE INITIAL)
LAST NAME: (SP'S LAST NAME)
ROSTFNAM
IN3
text
MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.
IN3 - ROSTMINI
ROSTMINI
IN3
text
MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.
IN3 - ROSTLNAM
ROSTLNAM
IN3
text
MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.
NS1- SPAISTATUS
(01) YES
(02) NO
(01) INS1- SPAISTATUS
(02) IN3 - ROSTFNAM
PLEASE INDICATE THE SP'S CURRENT STATUS. IF THE CASE IS A PROXY INTERVIEW AND YOU
HAVEN'T TALKED ABOUT THE SP'S VITAL STATUS, PROBE AT THIS TIME ABOUT WHETHER THE SP
IS ALIVE OR DECEASED AND WHERE THE SP IS LOCATED.
SPAISTATUS
INS1
code one
(01) ALIVE AND NOT INSTITUTIONALIZED
WHEN WE REFER TO INSTITUTIONALIZED, WE ARE REFERRING TO THE MCBS DEFINITION OF A
(02) ALIVE AND INSTITUTIONALIZED
FACILITY. FOR THE FULL MCBS DEFINITION OF A FACILITY, CLICK F1. PLEASE REMEMBER THAT
(03) DECEASED - DIED IN COMMUNITY
HOSPITALS ARE NOT FACILITIES UNDER THE MCBS DEFINITION SO SPS IN HOSPITALS SHOULD NOT
(04) DECEASED - DIED IN INSTITUTION
BE CONSIDERED TO BE INSTITUTIONALIZED BELOW.
(01) BOX INS1
(02) INS2 - SPINSTMM
(03) INS3 - SPDIEMM
(04) INS2 - SPINSTMM
IS THE SP CURRENTLY:
Page 1 of 8
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
INQ- INTRODUCTION
Question Type
Question Text/Description
Code List
Routing
(01) continuous answer
(-8) Don't Know
(-9) Refused
IN2 - SPINSTDD
(01) continuous answer
(-8) Don't Know
(-9) Refused
SPINSTYY
(01) continuous answer
BOX INSA
What was the first date [(since [REFERENCE DATE] that [SP])/([that SP])] entered the facility?
SPINSTMM
INS2
date
[EXPLAIN IF NECESSARY: By "facility" we mean a place that provides long term care. By "first date" we
mean the earliest date that the beneficiary enters any facility and does not enter a hospital or return home.]
IF MORE THAN ONE DATE, ENTER THE EARLIEST.
What was the first date [(since [REFERENCE DATE] that [SP])/([that SP])]entered the facility?
SPINSTDD
INS2
date
[EXPLAIN IF NECESSARY: By "facility" we mean a place that provides long term care. By "first date" we
mean the earliest date that the beneficiary enters any facility and does not enter a hospital or return home.]
IF MORE THAN ONE DATE, ENTER THE EARLIEST.
What was the first date [(since [REFERENCE DATE] that [SP])/([that SP])] entered the facility?
SPINSTYY
INS2
date
[EXPLAIN IF NECESSARY: By "facility" we mean a place that provides long term care. By "first date" we
mean the earliest date that the beneficiary enters any facility and does not enter a hospital or return home.]
IF MORE THAN ONE DATE, ENTER THE EARLIEST.
BOX INSA
routing
IF (INS1 - SPAISTATUS = 4/DeceasedInInstitute) GO TO INS3 - SPDIEMM.
ELSE GO TO BOX INSA1.
SPDIEMM
INS3
date
On what date did (SP) die?
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) INS3 - SPDIEDD
(-8) INS3 - SPDIEDD
(-9) INS3 - SPDIEDD
SPDIEDD
INS3
date
On what date did (SP) die?
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) INS3 - SPDIEYY
(-8) INS3 - SPDIEYY
(-9) INS3 - SPDIEYY
SPDIEYY
INS3
date
On what date did (SP) die?
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) BOX INSA1
(-8) BOX INSA1
(-9) BOX INSA1
Page 2 of 8
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name
INQ- INTRODUCTION
Question Type
Question Text/Description
BOX INSA1
routing
IF (SPDIEMM or SPINSTMM IN(-8,-9) OR SPDIEYY or SPINSTYY IN(-8,-9) THEN GO TO INS3B-INTHANK.
ELSE IF (INS1 - SPAISTATUS = 3/Deceased) AND (INTTYPE in(3,7,10)) AND
(VIEW_MCBSCOMM_PRELOAD.NEWLY_ELIGIBLE=0) AND (SP'S DATE OF DEATH ENTERED AT INS3 IS
BEFORE JANUARY 1 OF THE CURRENT YEAR), GO TO INS3A - DEASDATE.
ELSE IF (INS1 - SPAISTATUS = 4/DeceasedInInstitute) AND (INTTYPE in(7,10)) AND (SP'S DATE OF
INSTITUTIONALIZATION ENTERED AT INS2 AND SP'S DATE OF DEATH ENTERED AT INS3 ARE BOTH
PRIOR TO JANUARY 1 OF CURRENT YEAR) AND (VIEW_MCBSCOMM_PRELOAD.NEWLY_ELIGIBLE=0),
GO TO INS3A - DEASDATE.
ELSE IF(INS1 - SPAISTATUS = 4/DeceasedInInstitute) AND (INTTYPE in(7,10)) AND (SP'S DATE OF
INSTITUTIONALIZATION ENTERED AT INS2 IS PRIOR TO JANUARY 1 OF CURRENT YEAR) AND (SP'S
DATE OF DEATH ENTERED AT INS3 IS ON OR AFTER JANUARY 1 OF CURRENT YEAR) AND
(VIEW_MCBSCOMM_PRELOAD.NEWLY_ELIGIBLE=0), GO TO INS3A1 - INSTDATE.
ELSE IF (INS1 - SPAISTATUS = 2/AliveAndInstitute) AND (INTTYPE in(7,10)) AND (SP'S DATE OF
INSTITUTIONALIZATION ENTERED AT INS2 IS BEFORE JANUARY 1 OF THE CURRENT YEAR) AND
(VIEW_MCBSCOMM_PRELOAD.NEWLY_ELIGIBLE=0), GO TO INS3A1 - INSTDATE.
ELSE IF(INS1-SPAISTATUS = 2/AliveAndInstitute) AND INTTYPE = 3, GO TO INS3B-INTHANK
ELSE IF (INS1-SPAISTATUS = 3/Deceased) AND INTTYPE = 3 AND SP'S DATE OF DEATH ENTERED AT
INS3 IS PRIOR TO JANUARY 1, GO TO INS3A-DEASDATE
ELSE IF (INS1-SPAISTATUS = 4/DeceasedInInstitute) AND INTTYPE = 3, GO TO INS3B-INTHANK
ELSE GO TO BOX INS1.
INS3A
no entry
Code List
Routing
YOU HAVE ENTERED THAT THE SP, (SP), DIED BEFORE JANUARY 1ST OF [CURRENT YEAR]. IF THIS
IS NOT CORRECT, GO TO THE PREVIOUS PAGE AND ENTER THE CORRECT DATE AT INS3.
DEASDATE
BOX INS1A
IF THIS IS CORRECT, YOU WILL NOT BE CONDUCTING THE COMMUNITY INTERVIEW WITH THE
RESPONDENT. GO TO THE NEXT PAGE TO END THE INTERVIEW.
BOX INS1A
routing
IF SP IS DECEASED, SET RESPONDENT TO PROXY AND GO TO INS3B - INTHANK
YOU HAVE ENTERED THAT THE SP, (SP), WAS INSTITUTIONALIZED BEFORE JANUARY 1ST OF
[CURRENT YEAR]. IF THIS IS NOT CORRECT, GO TO THE PREVIOUS PAGE AND ENTER THE
CORRECT DATE AT INS2.
IF THIS IS CORRECT, YOU WILL NOT BE CONDUCTING THE COMMUNITY INTERVIEW WITH THE
RESPONDENT.
INSTDATE
INS3A1
no entry
INS3B - INTHANK
AFTER CLICKING "NEXT PAGE", YOU WILL RETURN TO CM-FIELD. PLEASE FILL OUT A RECORD OF
CALL AND CODE THIS CASE AS A “NO COM PROXY- GO TO FAC” .
PLEASE COLLECT ANY KNOWN FACILITY CONTACT INFORMATION AND DISCUSS THE CASE WITH
YOUR FIELD MANAGER.
INTHANK
INS3B
no entry
I would like to thank you for your time and cooperation during this interview. We may be contacting you in the
future for further information.
BOX INS1
routing
IF SP IS DECEASED OR INSTITUTIONALIZED, SET RESPONDENT TO PROXY AND GO TO IN4A PERSON_PROXY.
ELSE GO TO IN4 - SPPROXY.
BOX INSB1
Page 3 of 8
2020 MCBS Community Questionnaire
INQ- INTRODUCTION
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
SPPROXY
IN4
code one
WILL THIS INTERVIEW BE CONDUCTED WITH THE SAMPLE PERSON OR WITH A PROXY?
(01) SAMPLE PERSON
(02) PROXY
(01) BOX INS5
(02) IN4A - PERSON_PROXY
PERSON_PROXY
IN4A
roster
SELECT OR ADD THE NAME/RELATIONSHIP OF THE PROXY TO THE SP FOR THIS INTERVIEW.
SELECT OR ADD ONLY ONE PERSON.
DISPLAY PERSON ROSTER AS RESPONSE
OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE
OPTIONS
(N+1) ADD ANOTHER
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/OtherRelative or 92/OtherNonRelative, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
(01-N) BOX INS2AA
(N+1) IN4A-ROSTFNAM
IF EXISTING PERSON SELECTED, GO TO BOX
INS2AA.
ELSE IF "ADD ANOTHER" SELECTED, GO TO
IN4A-ROSTFNAM.
ROSTFNAM
IN4A
text
[What is the name of the person and relationship to (SP)?]
(01) continuous answer
IN4A-ROSTLNAM
ROSTLNAM
IN4A
text
[What is the name of the person and relationship to (SP)?]
(01) continuous answer
IN4A-ROSTREL
ROSTREL
IN4A
code one
[What is the name of the person and relationship to (SP)?]
ROSTREOS
IN4AROSTREOS
verbatim text
[What is the name of the person and relationship to (SP)?]
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) continuous reponse
(-8) Don't Know
(-9) Refused
(01) DO NOT DISPLAY
(02) BOX INS2AA
(03) BOX INS2AA
(04) BOX INS2AA
(05) BOX INS2AA
(06) BOX INS2AA
(07) BOX INS2AA
(08) BOX INS2AA
(09) BOX INS2AA
(10) BOX INS2AA
(11) BOX INS2AA
(12) BOX INS2AA
(13) BOX INS2AA
(14) BOX INS2AA
(50) DO NOT DISPLAY
(51) BOX INS2AA
(52) BOX INS2AA
(53) BOX INS2AA
(54) BOX INS2AA
(55) BOX INS2AA
(56) BOX INS2AA
(57) BOX INS2AA
(91) IN4AROSTREOS - ROSTREOS
(-8) BOX INS2AA
(-9) BOX INS2AA
BOX INS2AA
Page 4 of 8
2020 MCBS Community Questionnaire
Variable Name
INQ- INTRODUCTION
MR Screen Name
Question Type
Question Text/Description
BOX INS2AA
routing
IF PERSON IS ADDED AT IN4A, GO TO BOX INS2A-1.
ELSE GO TO IN5 - VRFYPROX.
Code List
Routing
I would like to verify your name and relationship to (SP). I have you listed as [READ NAME AND
RELATIONSHIP LISTED BELOW]. Is that correct?
IF RELATIONSHIP IS MISSING, SELECT "NO" AND PROBE FOR RELATIONSHIP ON THE NEXT SCREEN. (01) YES
(02) NO
FIRST NAME: (PROXY'S FIRST NAME)
LAST NAME: (PROXY'S LAST NAME)
RELATIONSHIP: (PROXY'S RELATIONSHIP TO SP)
(01) BOX INS2A-1
(02) IN6 - ROSTFNAM
text
[What is your correct name and relationship to (SP)?]
(01) continuous answer
IN6 - ROSTLNAM
text
[What is your correct name and relationship to (SP)?]
(01) continuous answer
IN6 - ROSTREL
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) DO NOT DISPLAY
(02) BOX INS2A-1
(03) BOX INS2A-1
(04) BOX INS2A-1
(05) BOX INS2A-1
(06) BOX INS2A-1
(07) BOX INS2A-1
(08) BOX INS2A-1
(09) BOX INS2A-1
(10) BOX INS2A-1
(11) BOX INS2A-1
(12) BOX INS2A-1
(13) BOX INS2A-1
(14) BOX INS2A-1
(51) BOX INS2A-1
(52) BOX INS2A-1
(53) BOX INS2A-1
(54) BOX INS2A-1
(55) BOX INS2A-1
(56) BOX INS2A-1
(57) BOX INS2A-1
(91) IN6 - ROSTREOS
(-8) BOX INS2A-1
(-9) BOX INS2A-1
VRFYPROX
IN5
yes/no
ROSTFNAM
IN6
ROSTLNAM
IN6
ROSTREL
IN6
code one
[What is your correct name and relationship to (SP)?]
ROSTREOS
IN6
verbatim text
What is your correct name and relationship to (SP)?
(01) continuous reponse
(-8) Don't Know
(-9) Refused
BOX INS2A-1
Page 5 of 8
2020 MCBS Community Questionnaire
Variable Name
INQ- INTRODUCTION
MR Screen Name
Question Type
Question Text/Description
BOX INS2A-1
routing
IF SP IS INSTITUTIONALIZED (SPALIVE = 2), SET REASON WHY RESPONDENT IS PROXY TO "SP IS
INSTITUTIONALIZED" (WHYPROXY = 07) AND GO TO BOX INS3.
ELSE IF SP IS DECEASED (SPALIVE = 3), SET REASON WHY RESPONDENT IS PROXY TO "SP IS
DECEASED" (WHYPROXY = 06) AND GO TO BOX INS3.
ELSE GO TO IN6A - WHYPROXY.
WHAT IS THE MAIN REASON THAT A PROXY RESPONDENT NECESSARY?
Code List
Routing
(01) SP NOT CAPABLE
PHYSICALLY/SICK/BLIND/CAN’T SPEAK/HEAR
(02) SP NOT CAPABLE MENTALLY/POOR
MEMORY/PSYCHIATRIC DISORDER
(03) SP UNABLE TO PROVIDE INFORMATION
REGARDING MEDICAL RECORDS
(04) SP IN HOSPITAL
(05) LANGUAGE PROBLEM
(06) SP IS DECEASED
(07) SP IS INSTITUTIONALIZED
(08) SP NOT AVAILABLE THIS ROUND
(09) AUTHORIZED PROXY MUST ANSWER
QUESTIONS FOR SP (CODE REASON WHY)
(91) OTHER
(01) BOX INS2B
(02) BOX INS2B
(03) BOX INS2B
(04) BOX INS2B
(05) BOX INS2B
(06) BOX INS2B
(07) BOX INS2B
(08) BOX INS2B
(09) BOX INS2B
(91) IN6A - PNSPOS
(01) continuous response
BOX INS3
WHYPROXY
IN6A
code one
PNSPOS
IN6A
verbatim text
OTHER (SPECIFY)
BOX INS2B
routing
IF RESPONSE TO IN6a - WHYPROXY ONLY INCLUDES 9/CodeReasonWhy, GO TO IN6B - PNSPVB.
ELSE GO TO BOX INS3.
IN6B
verbatim text
BRIEFLY EXPLAIN WHY PROXY MUST ANSWER QUESTIONS.
BOX INS3
routing
IF SP IS IN THE SUPPLEMENTAL SAMPLE AND IN6A - WHYPROXY = 6/SPIsDeceased, GO TO IN6B1 SUPPDIED.
ELSE IF SP IS IN THE SUPPLEMENTAL SAMPLE AND IN6A - WHYPROXY = 7/SPIsInstitute, GO TO IN6B2 SUPPINST.
ELSE GO TO BOX INS5.
SUPPDIED
IN6B1
no entry
YOU HAVE ENTERED THAT THE SP, (SP), IS DECEASED. IF THIS IS NOT CORRECT, GO TO THE
PREVIOUS PAGE AND CORRECT YOUR RESPONSE AT IN6A.
BOX IN6
SUPPINST
IN6B2
no entry
YOU HAVE ENTERED THAT THE SP, (SP), IS INSTITUTIONALIZED. IF THIS IS NOT CORRECT, GO TO
THE PREVIOUS PAGE AND CORRECT YOUR RESPONSE AT IN6A.
BOX IN6
BOX INS5
routing
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW FROM FACILITY), GO TO IN8 - CHEKBRTH.
ELSE IF IT'S A FALL ROUND, GO TO BOX IN6.
ELSE GO TO BOX IN8.
PNSPVB
BOX INS3
Page 6 of 8
2020 MCBS Community Questionnaire
INQ- INTRODUCTION
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
CHEKBRTH
IN8
yes/no
I have [your/(SP’s)] date of birth listed as (CMS BIRTH DATE). Is that correct?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) IN10 - CHECKAGE
(02) IN9 - HHDOBMM
(-8) IN11 - ROSTSEX
(-9) IN11 - ROSTSEX
HHDOBMM
IN9
date
What is [your/(SP’s)] date of birth?
(01) continuous answer
(-8) Don't Know
(-9) Refused
IN9 - HHDOBDD
HHDOBDD
IN9
date
What is [your/(SP’s)] date of birth?
(01) continuous answer
(-8) Don't Know
(-9) Refused
IN9 - HHDOBYY
HHDOBYY
IN9
date
What is [your/(SP’s)] date of birth?
(01) continuous answer
(-8) Don't Know
(-9) Refused
BOX IN3A
BOX IN3A
routing
IF SP'S DATE OF BIRTH MONTH, DAY OR YEAR COLLECTED AT IN9 = DK OR RF, GO TO IN11 ROSTSEX.
ELSE GO TO IN10 - CHECKAGE.
CHECKAGE
IN10
yes/no
That makes [you/(SP)] (AGE) today. Is that correct?
(01) YES
(02) NO
(01) IN11 - ROSTSEX
(02) IN9 - HHDOBMM
ROSTSEX
IN11
code one
THE SP IS LISTED AS A (MALE/FEMALE). IF SEX IS OBVIOUS, CODE BELOW WITHOUT ASKING. IF
SEX IS NOT OBVIOUS, ASK:
[Are you/Is (SP)] male or female?
(01) MALE
(02) FEMALE
BOX IN4
BOX IN4
routing
IF NOT MISSING GENDER FROM CMS FILES AND SP'S GENDER FROM CMS DOES NOT MATCH
GENDER ENTERED AT IN11 - ROSTSEX, GO TO IN12 - CHNGSEX.
ELSE GO TO BOX IN6.
IN12
yes/no
YOU JUST CHANGED SP’S SEX FROM (MALE/FEMALE) TO (FEMALE/MALE). DID YOU INTEND TO DO
THAT?
(01) YES
(02) NO
(01) BOX IN6
(02) IN11 - ROSTSEX
BOX IN6
routing
IF SP'S AGE IS > 16, DK OR RF, GO TO IN13 - SPMARSTA.
ELSE GO TO BOX IN8.
(01) MARRIED
(02) WIDOWED
(03) DIVORCED
(04) SEPARATED
(05) NEVER MARRIED
(-8) Don't Know
(-9) Refused
BOX IN7
CHNGSEX
SPMARSTA
IN13
code one
[Are you/Is (SP)/Was (SP)] married, widowed, divorced, separated, or never married?
Page 7 of 8
2020 MCBS Community Questionnaire
Variable Name
SPCHNLNM
INQ- INTRODUCTION
MR Screen Name
Question Type
Question Text/Description
BOX IN7
routing
IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW FROM FACILITY), GO TO IN14 SPCHNLNM.
ELSE GO TO BOX IN8.
IN14
numeric
Including natural, adopted, and stepchildren, how many living children [did (SP)/does (SP)/do you] have?
BOX IN8
routing
IF INTTYPE in(C001, C002, C003, C004, C005, C006, C007, C010), GO TO ENS.
BOX INSB1
routing
GO TO END1 - INTLANG.
Code List
Routing
(01) continuous answer
(-8) Don't Know
(-9) Refused
BOX IN8
END1 - INTLANG.
Page 8 of 8
| File Type | application/pdf |
| File Title | INQ.xlsx |
| Author | Wishart-Marisa |
| File Modified | 2019-12-16 |
| File Created | 2019-12-16 |