CMS-P-0015A Residence History

2019 MCBS Facility Instrument

Variable Name

MR Screen Name

RH-Residence History

Question Type

Question Text/Description

Code List

Routing

(01) Continue

(01) BOX RH1

(01) Continue

(01) BOX RH1

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

(01) RH2 - ADMITDD1
(-8) RH3 - RH3CT
(-9) RH3 - RH3CT

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

(01) RH2 - ADMITYY1
(-8) RH3 - RH3CT
(-9) RH3 - RH3CT

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

(01) BOX RH2
(-8) RH3 - RH3CT
(-9) RH3 - RH3CT

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

(01) RH2 - ADMITDD2
(-8) RH3 - RH3CT
(-9) RH3 - RH3CT

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

(01) RH2 - ADMITYY2
(-8) RH3 - RH3CT
(-9) RH3 - RH3CT

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

(01) BOX RH2A1
(-8) RH3 - RH3CT
(-9) RH3 - RH3CT

(01) [Continuous answer.]

(01) BOX RH2

RESIDENCE HISTORY SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= ALL
SEASON=ALL
PLACEMENT
Administered after FQ section is completed.

BOX RHBEG

routing

IF SP IS A CFR, GO TO RH2PRE - RH2PRECT.
ELSE GO TO RH1PRE - RH1PRECT.

Now, I would like to ask you about the places where (SP) stayed for one night or more between [January 1,
(CURRENT YEAR)/(his/her) admission to this (facility/home)/(his/her) readmission to this (facility/home)] and
today including staying in [other parts of (LARGER FACILITY),] hospitals or other places.
RH1PRECT

RH1PRE

code one
In answering these questions, it might be helpful for you to review records that show discharges or transfers
from (FACILITY) to [other parts of (LARGER FACILITY),] hospitals or other places.
PRESS "1" TO CONTINUE.
On my last visit on (REF DATE), (SP) was alive and a resident of (FACILITY).

RH2PRECT

RH2PRE

code one

BOX RH1

routing

RH2

date

Now, I would like to ask you about all the places (SP) has stayed since my last visit, including staying in [other
parts of (LARGER FACILITY)], hospitals or other places.
PRESS "1" TO CONTINUE.
If CFR, GO TO RH7 - RHALIVE.
ELSE IF SP IS EXPECTED IPR1, GO TO RH2 - ADMITMM1.
ELSE GO TO RH2A - ADMITMM2.
On what date was (SP) most recently admitted to (FACILITY)?

ADMITMM1

MONTH
On what date was (SP) most recently admitted to (FACILITY)?
ADMITDD1

RH2

date
DAY
On what date was (SP) most recently admitted to (FACILITY)?

ADMITYY1

RH2

date
YEAR

ADMITMM2

RH2A

date

On what date [on or around (ADMISSION DATE REPORTED BY A PREVIOUS SOURCE),] do your records
show (SP) was admitted to (FACILITY)?
IF SP NEVER ADMITTED, ENTER "DK" IN MONTH FIELD.
MONTH

ADMITDD2

RH2A

date

On what date [on or around (ADMISSION DATE REPORTED BY A PREVIOUS SOURCE),] do your records
show (SP) was admitted to (FACILITY)?
IF SP NEVER ADMITTED, ENTER "DK" IN MONTH FIELD.
DAY

ADMITYY2

RH2A

date

On what date [on or around (ADMISSION DATE REPORTED BY A PREVIOUS SOURCE),] do your records
show (SP) was admitted to (FACILITY)?
IF SP NEVER ADMITTED, ENTER "DK" IN MONTH FIELD.
YEAR

WHYADDIS

BOX RH2A1

routing

IF SP IS IPR OR RH2A DATE IS WITHIN +/- 7 DAYS OF ADMISSION DATE REPORTED BY A PREVIOUS
SOURCE, GO TO BOX RH2.
ELSE GO TO RH2AVB - WHYADDIS.

RH2AVB

verbatim

DESCRIBE WHY THERE IS A DISCREPANCY BETWEEN THE ADMISSION DATE REPORTED BY A
PREVIOUS SOURCE AND THE ADMISSION DATE ENTERED DURING THIS INTERVIEW.

BOX RH2

routing

IF IPR, GO TO RH6 - RHSEX.
ELSE GO TO RH7 - RHALIVE.

Page 1 of 6

2019 MCBS Facility Instrument

Variable Name

RH3CT

MR Screen Name

RH3

RH-Residence History

Question Type

code one

Question Text/Description

Code List

Please tell me the name and title of someone in (FACILITY) who could give me that information.
RECORD RESPONDENT INFORMATION ON PERSON ROSTER AND SELECT ENTRY WHEN RH IS
RESTARTED.

Routing

BOX RHEND

PRESS "1" TO CONTINUE.

RHSEX

RHALIVE

RH6

RH7

code one

yes/no

ASK IF NOT OBVIOUS.
Is (SP) male or female?

(01) MALE
(02) FEMALE

(01) RH7 - RHALIVE
(02) RH7 - RHALIVE

Is (SP) alive?

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

(00) RH8 - RHDODMM
(01) BOX RH7
(-8) BOX RH7
(-9) BOX RH7

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

(01) RH8 - RHDODDD
(-8) BOX RH6
(-9) BOX RH6

On what date did (SP) die?
RHDODMM

RH8

date

RHDODDD

RH8

date

DAY

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

(01) RH8 - RHDODYY
(-8) RH8 - RHDODYY
(-9) RH8 - RHDODYY

RHDODYY

RH8

date

YEAR

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

(01) BOX RH6
(-8) BOX RH6
(-9) BOX RH6

BOX RH6

routing

IF SP IS IPR, GO TO RH3B - RHINEL.
ELSE IF MONTH OR YEAR OF DEATH IS DK OR RF, GO TO RH3 - RH3CT.
ELSE, GO TO BOX RH7.

BOX RH7

routing

IF SP IS IPR, GO TO RH9 - RHDOBMM.
ELSE GO TO BOX RH9A.

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

(01) RH9 - RHDOBDD
(-8) RH9 - RHDOBDD
(-9) RH9 - RHDOBDD

RHDOBMM

RH9

date

MONTH
[IF RESPONDENT ANSWERS "DK", PROBE: Do you know what month (SP) died?]

What (is/was) (SP's) date of birth?
ENTER A 4-DIGIT YEAR.
MONTH

RHDOBDD

RH9

date

DAY

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

(01) RH9 - RHDOBYY
(-8) RH9 - RHDOBYY
(-9) RH9 - RHDOBYY

RHDOBYY

RH9

date

YEAR

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

(01) BOX RH9A
(-8) BOX RH9A
(-9) BOX RH9A

RHAGE

RH10

numeric

Approximately how old is (SP)?

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

(01) BOX RH9A
(-8) BOX RH9A
(-9) BOX RH9A

BOX RH9A

routing

IF SP IS A CFR, GO TO RH11A - RHPROBE1.
ELSE GO TO RH11B - RHPROBE2.

RHPROBE1

RH11A

yes/no

Between (REF DATE), (the date of my last visit), and (RH END OF REFERENCE PERIOD) has (SP) been in
(FACILITY) the whole time or has (he/she) spent one or more nights [in another part of (LARGER FACILITY),]
in a hospital, or in some other place?

(00) NO, OTHER PLACE
(01) YES, WHOLE TIME
(-9) Refused

(00) BOX RH13A
(01) BOX RH10
(-9) BOX RH10

RHPROBE2

RH11B

yes/no

Between (REF DATE) and (RH END OF REFERENCE PERIOD) has (SP) been in (FACILITY) the whole time (00) NO, OTHER PLACE
or has (she/he) spent one or more nights [in another part of (LARGER FACILITY),] in a hospital, or in some
(01) YES, WHOLE TIME
other place?
(-9) Refused

(00) BOX RH13A
(01) BOX RH10
(-9) BOX RH10

yes/no

(00) NO, LEFT
(01) YES, WHOLE TIME
(-8) Don't Know
(-9) Refused

(00) BOX RH13A
(01) BOX RH10
(-8) BOX RH10
(-9) BOX RH10

RHPROBE3

RH12

Between (CURRENT START DATE) and (END OF RH REFERENCE PERIOD) was (SP) in (CURRENT
PLACE) the whole time?

Page 2 of 6

2019 MCBS Facility Instrument

Variable Name

MR Screen Name

BOX RH10

CURDIED

CURSTIL

RH12A

RH-Residence History

Question Type

Question Text/Description

routing

(IF RH11A-RHPROBE1 = 1/YesWholeTime, OR
RH11B-RHPROBE2 = 1/YesWholeTime, OR
RH12-RHPROBE3 = 1/YesWholeTime) AND SP IS ALIVE OR VITAL STATUS IS NOT KNOWN, GO TO BOX
RH24.
(IF RH11A-RHPROBE1 = RF, OR
RH11B-RHPROBE2 = RF, OR
RH12-RHPROBE3 = DK or RF) AND SP IS ALIVE OR VITAL STATUS IS NOT KNOWN, GO TO RH12B CURSTIL.
ELSE GO TO RH12A - CURDIED.

code one

Code List

Routing

Was (he/she) in (CURRENT PLACE) when (he/she) died on (DATE OF DEATH) or somewhere else?

(00) SOMEWHERE ELSE
(01) IN (FACILITY)
(-8) Don't Know
(-9) Refused

(00) BOX RH13A
(01) BOX RH24
(-8) BOX RH24
(-9) BOX RH24

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

(00) BOX RH13A
(01) BOX RH24
(-8) BOX RH24
(-9) BOX RH24

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

(01) RH13 - STAYEDD
(-8) RH13 - STAYEDD
(-9) RH13 - STAYEDD

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

(01) RH13 - STAYEYY
(-8) RH13 - STAYEYY
(-9) RH13 - STAYEYY

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

(01) BOX RH11
(-8) BOX RH11
(-9) BOX RH11

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

(01) RH21 - XSTPLACS
(-8) RH21 - XSTPLACS
(-9) RH21 - XSTPLACS

(01) [Continuous answer.]

(01) BOX RH12

(01) [Continuous answer.]

(01) BOX RH13

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

(00) RH22 - PLACKIRH
(01) RH22 - PLACKIRH
(-8) RH22 - PLACKIRH
(-9) RH22 - PLACKIRH

(01) NURSING HOME/REHAB CENTER
(02) PERSONAL CARE HOME/RESIDENTIAL CARE
FACILITY
(03) CCRC/RETIREMENT HOME/CENTER
(04) HOSPITAL
(05) PRIVATE HOME OR APARTMENT
(07) OTHER LTC FACILITY
(91) OTHER

(01) BOX RH15
(02) BOX RH15
(03) BOX RH15
(04) BOX RH15
(05) BOX RH15
(07) BOX RH15
(91) RH22 - PLKIRHOS

RH12B

yes/no

Is (he/she) still at (CURRENT PLACE)?

BOX RH13A

routing

GO TO RH13 - STAYEMM.

RH13

date

When did (SP) leave (CURRENT PLACE)?
STAYEMM

MONTH
When did (SP) leave (CURRENT PLACE)?
STAYEDD

RH13

date
DAY
When did (SP) leave (CURRENT PLACE)?

STAYEYY

RH13

date
YEAR

STAYNITE

XSTPLACS

BOX RH11

routing

IF ANY PART OF RH13 DATE IS MISSING, GO TO RH14 - STAYNITE.
ELSE GO TO RH21 - XSTPLACS.

RH14

numeric

About how many nights did (he/she) spend there?

RH21

roster

[Where did (he/she) go on (START DATE)?/Where is (he/she) living now?/Where was (he/she) staying when
(he/she) died on (DATE OF DEATH)?]
SELECT NAME FROM LIST OR SELECT "[NEED TO ADD PLACE]".

XSTPLACN

BOX RH12

routing

IF RH21-XSTPLACS = "[NEED TO ADD PLACE]", GO TO RH21A - XSTPLACN.
ELSE GO TO BOX RH13.

RH21A

Text

ENTER THE NAME OF THE PLACE.

routing

IF PLACE ADDED AT RH21A-XSTPLACN AND FACILITY IS PART OF A LARGER PLACE, GO TO RH21B LOCTEMP.
ELSE IF PLACE ADDED AT RH21A-XSTPLACN, GO TO RH22 - PLACKIRH.
ELSE IF PLACE SELECTED IS A HOSPITAL, GO TO RH25 - SNFWING.
ELSE GO TO BOX RH18.

BOX RH13

LOCTEMP

PLACKIRH

RH21B

RH22

yes/no

code one

Is (ADDED PLACE NAME) part of (LARGER FACILITY NAME)?

SHOW CARD RH1
Please look at this card and tell me what kind of place (ADDED PLACE NAME) is:
PRESS F1 FOR DEFINITIONS.

PLKIRHOS

RH22

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) BOX RH15

Page 3 of 6

2019 MCBS Facility Instrument

Variable Name

MR Screen Name

BOX RH15

SNFWING

RH25

RH-Residence History

Question Type

Question Text/Description

routing

IF RH22 - PLACKIRH = 1/NursingHomeRehabCenter, 2/PersonalCareHome, OR 7/OtherLtcFacility, GO TO
BOX RH24.
ELSE IF RH22 - PLACKIRH = 3/CcrcRetirementHomeCenter, GO TO BOX RH18.
ELSE IF RH22 - PLACKIRH = 4/Hospital, GO TO RH25 - SNFWING.
ELSE GO TO RH30A - LALONE.

yes/no

Was (SP) staying in a SNF wing or SNF unit of (CURRENT PLACE)?

Code List

Routing

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

(00) BOX RH24
(01) BOX RH24
(-8) BOX RH24
(-9) BOX RH24

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

(00) BOX RH19
(01) BOX RH19
(-8) BOX RH19
(-9) BOX RH19

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

(01) RH28 - NWINGCIT
(-8) RH28 - NWINGCIT
(-9) RH28 - NWINGCIT

IF PLACKIND OF PLACE ADDED OR SELECTED = 1/NursingHomeRehabCenter,
2/PersonalCareHomeResidentialCareFacility, OR 7/OtherLtcFacility AND RH12-RHPROBE3 = 1/Yes AND SP
IS ALIVE OR VITAL STATUS IS NOT KNOWN, GO TO BOX RH31.
BOX RH18

NURWING

NAMNWING

routing

ELSE IF PLACKIND OF PLACE ADDED OR SELECTED = 1/NursingHomeRehabCenter,
2/PersonalCareHomeResidentialCareFacility, OR 7/OtherLtcFacility AND (RH11A-RHPROBE1 = 0/No, DK, or
RF, OR RH11B-RHPROBE2 = 0/No, DK, or RF, OR RH12-RHPROBE3 = 0/No, DK, or RF) OR SP IS
DECEASED AND PLACE SELECTED IS TARGET FACILITY, GO TO BOX RH24.
IF PLACKIND = 5/PrivateHomeOrApartment OR 91/Other, GO TO RH30A - LALONE.
ELSE IF PLACKIND = 3/CcrcRetirementHomeCenter, GO TO RH27 - NURWING.

RH27

Yes/No

Was (he/she) staying in a nursing wing, nursing unit, assisted living unit, or personal care unit of (CURRENT
PLACE)?

BOX RH19

routing

IF RH27-NURWING = 1/Yes, GO TO RH28 - NAMNWING.
ELSE GO TO RH29 - PRIVHOME.

RH28

Text

[INTERVIEWER: ASK THE FOLLOWING QUESTIONS AND RECORD THE INFORMATION, AS
AVAILABLE. SELECT "DON'T KNOW" FOR ANY ITEM THAT IS NOT AVAILABLE.]
What is the name of this nursing wing, nursing unit, assisted living unit or personal care unit?

NWINGCIT

RH28

Text

In what city is this place located?

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

(01) RH28 - NWINGSTA
(-8) RH28 - NWINGSTA
(-9) RH28 - NWINGSTA

NWINGSTA

RH28

Text

In what state is this place located?

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

(01) BOX RH21
(-8) BOX RH21
(-9) BOX RH21

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

(00) BOX RH21
(01) BOX RH21
(-8) BOX RH21
(-9) BOX RH21

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

(00) RH30 - LWITH
(01) BOX RH24
(-8) BOX RH24
(-9) BOX RH24

(01) SPOUSE
(02) DAUGHTER
(03) SON
(04) MOTHER
(05) FATHER
(06) SISTER
(07) BROTHER
(08) GUARDIAN
(09) OTHER FEMALE RELATIVE
(10) OTHER MALE RELATIVE
(11) OTHER NONRELATIVE
(-8) Don't Know
(-9) Refused

(01) BOX RH24
(02) BOX RH24
(03) BOX RH24
(04) BOX RH24
(05) BOX RH24
(06) BOX RH24
(07) BOX RH24
(08) BOX RH24
(09) BOX RH24
(10) BOX RH24
(11) BOX RH24
(-8) BOX RH24
(-9) BOX RH24

PRIVHOME

LALONE

RH29

yes/no

Was (he/she) staying in a private home or apartment at (CURRENT PLACE)?

BOX RH21

routing

IF RH29-PRIVHOME = 1/Yes, GO TO RH30A - LALONE.
ELSE GO TO BOX RH24.

RH30A

yes/no

(Did/Does) (SP) live there alone?

Who (lived/lives) with (him/her) there?
LWITH

RH30

code all

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

Page 4 of 6

2019 MCBS Facility Instrument

Variable Name

MR Screen Name

RH-Residence History

Question Type

Question Text/Description

BOX RH24

routing

IF ALL DAYS IN REFERENCE PERIOD ACCOUNTED FOR AND SP'S LAST STAY IS IN A PLACE OTHER
THAN THE TARGET FACILITY, GO TO BOX RH36.
IF ALL DAYS IN REFERENCE PERIOD ACCOUNTED FOR AND SP IS STILL A RESIDENT OF THE
TARGET FACILITY, GO TO RH49A - CNSNTREQ.
ELSE GO TO RH12 - RHPROBE3.

BOX RH31

routing

IF (SP IS ALIVE OR SP'S VITAL STATUS IS NOT KNOWN ) AND NOT A RESIDENT OF TARGET FACILITY,
GO TO BOX RH36.
ELSE GO TO RH49A - CNSNTREQ.

BOX RH36

routing

GO TO RH36 - FORMDIS.

Code List

Routing

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

(00) RH49A - CNSNTREQ
(01) RH48 - CONTNAME
(-8) RH49A - CNSNTREQ
(-9) RH49A - CNSNTREQ

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

(01) RH48 - CONTADDR
(-8) RH48 - CONTADDR
(-9) RH48 - CONTADDR

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

(01) RH48 - CONTCITY
(-8) RH48 - CONTCITY
(-9) RH48 - CONTCITY

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

(01) RH48 - CONTSTAT
(-8) RH48 - CONTSTAT
(-9) RH48 - CONTSTAT

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

(01) RH48 - CONTZIP
(-8) RH48 - CONTZIP
(-9) RH48 - CONTZIP

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

(01) RH48 - CONTAREA
(-8) RH48 - CONTAREA
(-9) RH48 - CONTAREA

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

(01) RH48 - CONTEXCH
(-8) RH48 - CONTEXCH
(-9) RH48 - CONTEXCH

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

(01) RH48 - CONTLOCL
(-8) RH48 - CONTLOCL
(-9) RH48 - CONTLOCL

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

(01) RH48 - CONTREL
(-8) RH48 - CONTREL
(-9) RH48 - CONTREL

Earlier you told me (SP) had been discharged to (DISCHARGE PLACE).
Was (SP) formally discharged from (FACILITY) for the stay at (LAST PLACE NAME FROM RH21) that began
on (DISCHARGE DATE)?
FORMDIS

RH36

yes/no

IF YOU ARE AT THIS SCREEN THEN THE BENEFICIARY HAS BEEN RECORDED AS BEING
DISCHARGED FROM THE FACILITY, EITHER FORMALLY OR INFORMALLY, AND THIS CASE WILL
CROSSOVER WHEN THE INTERVIEW IS COMPLETE. IF THE BENEFICIARY HAS NOT BEEN
DISCHARGED FROM THE FACILITY, PLEASE PRESS THE "UP" ARROW ON YOUR KEYBOARD TO GO
BACK TO THE PREVIOUS SCREEN (RH12) AND MAKE SURE IT IS ANSWERED CORRECTLY.
PRESS F1 FOR DEFINITION OF FORMAL DISCHARGE.

CONTNAME

RH48

text

Please tell me the name, address, and telephone number of someone we could contact regarding (SP) at
(DISCHARGE PLACE).
NAME

CONTADDR

RH48

text

Please tell me the name, address, and telephone number of someone we could contact regarding (SP) at
(DISCHARGE PLACE).
ADDRESS

CONTCITY

RH48

text

Please tell me the name, address, and telephone number of someone we could contact regarding (SP) at
(DISCHARGE PLACE).
CITY

CONTSTAT

RH48

text

Please tell me the name, address, and telephone number of someone we could contact regarding (SP) at
(DISCHARGE PLACE).
STATE

CONTZIP

RH48

text

Please tell me the name, address, and telephone number of someone we could contact regarding (SP) at
(DISCHARGE PLACE).
ZIP CODE

CONTAREA

RH48

text

Please tell me the name, address, and telephone number of someone we could contact regarding (SP) at
(DISCHARGE PLACE).
AREACODE

CONTEXCH

RH48

text

Please tell me the name, address, and telephone number of someone we could contact regarding (SP) at
(DISCHARGE PLACE).
EXCHANGE

CONTLOCL

RH48

text

Please tell me the name, address, and telephone number of someone we could contact regarding (SP) at
(DISCHARGE PLACE).
LOCAL

Page 5 of 6

2019 MCBS Facility Instrument

Variable Name

MR Screen Name

RH-Residence History

Question Type

Question Text/Description

Code List

Routing
(01) RH49A - CNSNTREQ
(02) RH49A - CNSNTREQ
(03) RH49A - CNSNTREQ
(04) RH49A - CNSNTREQ
(05) RH49A - CNSNTREQ
(06) RH49A - CNSNTREQ
(07) RH49A - CNSNTREQ
(08) RH49A - CNSNTREQ
(09) RH49A - CNSNTREQ
(10) RH49A - CNSNTREQ
(11) RH49A - CNSNTREQ
(12) RH49A - CNSNTREQ
(13) RH49A - CNSNTREQ
(14) RH49A - CNSNTREQ
(15) RH49A - CNSNTREQ
(16) RH49A - CNSNTREQ
(17) RH49A - CNSNTREQ
(18) RH49A - CNSNTREQ
(91) RH49 - CONTRFOS
(92) RH49 - CONTRMOS
(93) RH49 - CONTNROS
(-8) RH49A - CNSNTREQ
(-9) RH49A - CNSNTREQ

CONTREL

RH49

code one

What is the relationship of (CONTACT NAME FROM RH48) to (SP)?

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

CONTRFOS

RH49

Text

OTHER FEMALE RELATIVE (SPECIFY)

(01) [Continuous answer.]

(01) RH49A - CNSNTREQ

CONTRMOS

RH49

Text

OTHER MALE RELATIVE (SPECIFY)

(01) [Continuous answer.]

(01) RH49A - CNSNTREQ

CONTNROS

RH49

Text

OTHER NON-RELATIVE (SPECIFY)

(01) [Continuous answer.]

(01) RH49A - CNSNTREQ

CNSNTREQ

RH49A

yes/no

WAS "CONSENT" REQUIRED AND OBTAINED FOR THIS SP?
PRESS F1 FOR A DEFINITION OF "CONSENT".

(00) NO
(01) YES

(00) RH50 - DIDABRH
(01) RH49B - WRITVERB

WRITVERB

RH49B

yes/no

WAS THE "CONSENT" WRITTEN OR VERBAL (BY TELEPHONE)?

(01) WRITTEN
(02) VERBAL

(01) RH50 - DIDABRH
(02) RH50 - DIDABRH

DIDABRH

RH50

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
(01) ALL
DOCUMENTS PROVIDED BY THE FACILITY.
(02) MAJORITY
(03) HALF
USE YOUR BEST JUDGMENT TO DETERMINE WHICH ANSWER IS THE MOST ACCURATE CHOICE FOR
(04) SOME
THE AMOUNT YOU ABSTRACTED. IF THERE WAS NO ABSTRACTION AT ALL, PLEASE SELECT
(05) NONE
"NONE".

(01) RH51 - WHYABRH
(02) RH51 - WHYABRH
(03) RH51 - WHYABRH
(04) RH51 - WHYABRH
(05) RHEND - RHENDCNT

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

(01) RHEND - RHENDCNT
(02) RHEND - RHENDCNT
(03) RHEND - RHENDCNT
(91) RH51 - WHYABROS

WHYABRH

RH51

code one

WHY DID YOU ABSTRACT?

WHYABROS

RH51

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) RHEND - RHENDCNT

(01) Continue

(01) BOX RHEND

(01) Continue

(01) BOX RHEND

RHINEL

RH3B

code one

Thank you. Those are all the questions I have for you at the moment. Someone from my office may call you
to verify some of the data I have collected. We appreciate your help on this important study.
PRESS "1" TO CONTINUE.

RHENDCNT

RHEND

code one

THANK THE RESPONDENT.
PRESS "1" TO RETURN TO THE NAVIGATION SCREEN.

BOX RHEND

routing

GO TO NAVIGATOR

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