Summary of New Items

MCBS Revision to Current Clearance
Proposed Changes to Community Interview and Effect on Burden

Community Interview Change
(Addition/Deletion/Change)

Winter
2021
Section

Round 89

Summer
2021
Round 90

Fall
2021
Round 91

Effect on
Annual
Burden

Question Name

Question text

Skip instructions

Now I have some questions that ask about how Medicare beneficiaries use the Internet to
access health care related information.

Addition

KNQ

Increase of
0.7
minutes

DURING THE PAST 12 MONTHS, (has anyone/have you) used the Internet to
-

-

Increase of
0.7 minutes

KN53A KCOMINTE

Look up health information (for [you/(SP)])?

KN53A -KCOMPRES

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Now I have some questions that ask about how Medicare beneficiaries use the Internet to
access health care related information.
DURING THE PAST 12 MONTHS, (has anyone/have you) used the Internet to
KN53A KCOMPRES

Fill a prescription (for [you/(SP)])?

KN53A -KCOMAPPO

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Now I have some questions that ask about how Medicare beneficiaries use the Internet to
access health care related information.
DURING THE PAST 12 MONTHS, (has anyone/have you) used the Internet to
KN53A KCOMAPPO

Schedule an appointment with a health care provider (for [you/(SP)])?

KN53A -KCOMCOMM

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Now I have some questions that ask about how Medicare beneficiaries use the Internet to
access health care related information.
KN53A KCOMCOMM

DURING THE PAST 12 MONTHS, (has anyone/have you) used the Internet to
Communicate with a health care provider (for [you/(SP)])?

BOX KN8

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Have you/Has (SP)] lost weight in the past 6 months without trying to lose this weight?
IF RESPONDENT REPORTS A WEIGHT LOSS BUT THE WEIGHT WAS GAINED
BACK, CONSIDER IT AS NO WEIGHT LOSS.
Addition

HFQ

-

-

Increase of Increase of
1.7 minutes 1.7 minutes

LOSTWGHT LOSTWGHT

[IF NEEDED: Is [your/(SP)'s] clothing fitting more loosely?]

EATLESWK - EATLESWK

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Have you/Has (SP)] been eating less than usual for more than a week?

EATLESWK EATLESWK

IF THE RESPONDENT REPORTS THAT THEY HAVE INTENTIONALLY BEEN
EATING LESS (DIETING, FASTING, ETC.) SELECT "YES" AT THIS SCREEN
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

HFHINTRO - DIFINTRO

SHOW CARD HF8
This card lists some examples of different types of dietary supplements.

DISUPPYR DISUPPYR

Since (LAST HF MONTH YEAR), [have you/has (SP)] used or taken any vitamins,
minerals, herbals or other dietary supplements? Include prescription and non-prescription
supplements.
[IF NEEDED: Include any supplements that you have already told me about.]

If (01) YES, go to MULTVTYR MULTVTYR
If (02) NO, go to BOX MH1
If (-8) DON'T KNOW, go to BOX MH1
If (-9) REFUSED, go to BOX MH1

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Since (LAST HF MONTH YEAR), did [you/(SP)] take any multivitamins, such as One a
Day, Theragran, or Centrum type multivitamins?
[IF NEEDED: Multivitamins may be pills, liquids, or packets]
MULTVTYR MULTVTYR

[IF NEEDED: Include any multivitamins that you have already told me about.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

VITSUPYR - VITSUPYR

SHOW CARD HF9
Please look at the vitamins and dietary supplements listed on this card. Since (LAST HF
MONTH YEAR), what vitamins and dietary supplements did [you/(SP)] take at least once?
Do not include vitamins and dietary supplements that are taken as part of a multivitamin.
[IF NEEDED: Include any vitamins or dietary supplements (that are not part of a
multivitamin) that you have already told me about.]
IF RESPONDENT HAS PROVIDED YOU WITH SUPPLEMENT BOTTLES YOU MAY
USE THOSE TO ANSWER THE QUESTION IF THE SUPPLEMENT WAS TAKEN
SINCE (LAST HF MONTH YEAR).
SELECT ALL THAT APPLY

VITSUPYR VITSUPYR

(01) Calcium (with or without vitamin D)
(02) Choline
(03) Coenzyme Q
(04) Eye health supplement (such as Ocuvite PreserVision or I-Caps)
(05) Fiber supplement (such as Metamucil or Benefiber)
(06) Folate or folic acid
(07) Garlic supplement
(08) Iron
(09) Joint supplement (such as glucosamine, with or without chondroitin or other
ingredients)
(10) Magnesium
(11) Melatonin
(12) Niacin
(13) Omega-3 (ALA/DHA/EPA) or fish oil
(14) Potassium
(15) Probiotics (in pill, powder, or liquid form)
(16) Saw palmetto
(17) Vitamin A
(18) Vitamin B-12
(19) Vitamin B-complex
(20) Vitamin C
(21) Vitamin D (NOT as part of a calcium supplement)
(22) Vitamin E
(23) Zinc
(91) Other Supplement(s)
(-8) Don't Know
(-9) Refused

If (01)-(23) ANY SUPPLEMENT, go to BOX
MH1
If (91) OTHER SUPPLEMENT(S), go to
VITOTHOS
If (-8) DON'T KNOW, go to BOX MH1
If (-9) REFUSED, go to BOX MH1

What were the names of those other supplements?
ENTER UP TO 5 ADDITIONAL SUPPLEMENTS AT THIS SCREEN.
IF RESPONDENT REPORTS MORE THAN 5 OTHER SUPPLEMENTS, ENTER THE
SUPPLEMENTS THAT WERE TAKEN THE MOST OFTEN SINCE (LAST HF MONTH
YEAR).
VITOTHOS VITOTHOS

[INSERT TEXT BOX 1 FOR SUPPLEMENT 1]
[INSERT TEXT BOX 2 FOR SUPPLEMENT 2]
[INSERT TEXT BOX 3 FOR SUPPLEMENT 3]
[INSERT TEXT BOX 4 FOR SUPPLEMENT 4]
[INSERT TEXT BOX 5 FOR SUPPLEMENT 5]

BOX MH1

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
IF R IS MISSING BOTH OF THEIR HANDS, SELECT "(02) R CANNOT PARTICIPATE"
WITHOUT READING TEXT BELOW.
Addition

PXQ

-

Increase of Increase of Increase of
2.8 minutes 2.7 minutes 5.4 minutes

GRPSTART GRPSTART

Now I would like to assess the strength of your hand in a gripping action.
(01) CONTINUE
(02) R CANNOT PARTICIPATE (MISSING BOTH HANDS)

If (01) CONTINUE, go to MSNGHAND MSNGHAND
If (02) R CANNOT PARTICIPATE, go to
BOX PXEND

IF R IS OBVIOUSLY MISSING ONE HAND, SELECT WHICH HAND IS MISSING. IF R
IS NOT OBVIOUSLY MISSING A HAND, SELECT "CONTINUE"

MSNGHAND MSNGHAND (01) R IS MISSING RIGHT HAND
(02) R IS MISSING LEFT HAND
(03) CONTINUE

DOMNHAND - DOMNHAND

IF SP IS OBVIOUSLY MISSING A HAND OR ARM, SELECT THE REMAINING HAND
AND DO NOT ASK. OTHERWISE, ASK:
Which is your dominant hand?
DOMNHAND - [If Needed: Which hand do you use to hold a pencil?]
DOMNHAND
(01) Right
(02) Left
(03) Both hands equally dominant
(-8) DON'T KNOW
(-9) REFUSED

GRPINTRO - GRPINTRO

Now we will measure your grip strength
We will use this machine [SHOW DYNAMOMETER] to measure how strong your hands
are.
GRPINTRO GRPINTRO

You will squeeze the handle 2 times [per hand], one practice and one test trial, while your
arm is at your side and your elbow is bent like this [DEMONSTRATE 90 DEGREES].
The handle won’t move, but the machine will show how hard you squeezed. [PRESS RESET
AND TEST, THEN SQUEEZE TO DEMONSTRATE].
See? [SHOW RESPONDENT THE FORCE MEASUREMENT].
(01) CONTINUE

BOX PX1

SHOW CARD PX4
Let’s practice with your RIGHT hand.
Is there any reason why you feel you cannot participate with your right hand? The items on
this card list some examples of reasons why you should not participate.
IF RESPONDENT HAS ANY OF THE CONDITIONS LISTED ON SHOWCARD PX4
FOR THEIR RIGHT HAND, SELECT CONTINUE WITHOUT COMPLETING THE
PRACTICE TRIAL
RHANDPRC RHANDPRC

When I say ‘squeeze,’ I want you to squeeze the handle hard, but not as hard as you can.
[If Needed: We are starting with the right hand, even if you are not right handed.]

BOX PX2

[SUPPORT DYNAMOMETER DURING PRACTICE]
Ready? 3-2-1-squeeze. [HOLD FOR 3-4 SECONDS]
Stop.
[PRESS RESET AND TEST ON DYNAMOMETER BEFORE CONTINUING]
(01) CONTINUE

SHOW CARD PX4
Let’s practice with your LEFT hand.
Is there any reason why you feel you cannot participate with your left hand? The items on
this card list some examples of reasons why you should not participate.
IF RESPONDENT HAS ANY OF THE CONDITIONS LISTED ON SHOWCARD PX4
FOR THEIR LEFT HAND, SELECT CONTINUE WITHOUT COMPLETING THE
PRACTICE TRIAL
LHANDPRC LHANDPRC

When I say ‘squeeze,’ I want you to squeeze the handle hard, but not as hard as you can.

BOX PX3

[SUPPORT DYNAMOMETER DURING PRACTICE.]
Ready? 3-2-1-squeeze. [HOLD FOR 3-4 SECONDS]
Stop.
[PRESS RESET AND TEST ON DYNAMOMETER BEFORE CONTINUING]
(01) CONTINUE

IF RESPONDENT HAS ANY OF THE CONDITIONS LISTED ON SHOWCARD PX4
FOR THEIR RIGHT HAND, SELECT "TEST COULD NOT BE COMPLETED"
WITHOUT CONDUCTING THE TEST
Now we’re going to test your RIGHT hand. When I say ‘squeeze,’ this time I want you to
squeeze the handle as hard as you can.
RHANDTST RHANDTST

[SUPPORT DYNAMOMETER DURING TEST]
Ready? 3-2-1-squeeze! Harder, harder, harder! [HOLD FOR 3-4 SECONDS]
Stop.

If (01) CONTINUOUS ANSWER, go to BOX
PX4
If (996) TEST COULD NOT BE
COMPLETED, go to RHDREASN RHDREASN

[RECORD FORCE TO NEAREST TENTH OF A POUND]
[PRESS RESET AND TEST ON DYNAMOMETER]
(01) continuous answer
(996) TEST COULD NOT BE COMPLETED
REASON WHY CANNOT BE COMPLETED FOR RIGHT HAND

RHDREASN RHDREASN

RHDRSNOS RHDRSNOS

(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) NOT ATTEMPTED, R MET EXCLUSION CRITERIA
(07) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) [Continuous answer]

If (01)-(07) ANY REASON, go to BOX PX4
If (91) OTHER, go to RHDRSNOS RHDRSNOS
If (-8) DON'T KNOW, go to BOX PX4
If (-9) REFUSED, go to BOX PX4

BOX PX4

IF RESPONDENT HAS ANY OF THE CONDITIONS LISTED ON SHOWCARD PX4
FOR THEIR LEFT HAND, SELECT "TEST COULD NOT BE COMPLETED" WITHOUT
CONDUCTING THE TEST AND TURN OFF THE DYNAMOMETER.
Now we’re going to test your LEFT hand. When I say ‘squeeze,’ this time I want you to
squeeze the handle as hard as you can.
LHANDTST LHANDTST

[SUPPORT DYNAMOMETER DURING TEST]
Ready? 3-2-1-squeeze! Harder, harder, harder! [HOLD FOR 3-4 SECONDS]
Stop.
[RECORD FORCE TO NEAREST TENTH OF A POUND]
[TURN OFF THE DYNAMOMETER]
(01) continuous answer
(996) TEST COULD NOT BE COMPLETED

If (01) CONTINUOUS ANSWER, go to BOX
PXEND
If (996) TEST COULD NOT BE
COMPLETED, go to LHDREASN

REASON WHY CANNOT BE COMPLETED FOR LEFT HAND

LHDREASN LHDREASN

LHDRSNOS LHDRSNOS

(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) NOT ATTEMPTED, R MET EXCLUSION CRITERIA
(07) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) [Continuous answer]

If (01)-(07) ANY REASON, go to BOX
PXEND
If (91) OTHER, go to LHDRSNOS LHDRSNOS
If (-8) DON'T KNOW, go to BOX PXEND
If (-9) REFUSED, go to BOX PXEND

BOX PXEND