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pdf2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
USQ-Usual Source of Care
Question Type
Question Text/Description
Code List
Routing
USUAL SOURCE OF CARE QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007
SPALIVE=1
SEASON= WINTER
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after KNQ.
PLACEPAR
US1
yes/no
(01) YES
Is there a particular doctor or other health professional, or a clinic [you/(SP)] usually [go/goes] to when [you are/he (02) NO
is/she is] sick or for advice about [your/his/her] health?
(-8) DON'T KNOW
(-9) REFUSED
BOX USA
routing
IF (INTTYPE=7) AND SP ever reported speaking a language other than English in the home
(SAMPLE_PERSON.WHATLANG EQUALS 1-"SPANISH", 2-"FRENCH", 3-"GERMAN", OR 91-"Other, Specify")
AND P_ENGWELL=1, GO TO LEP6-LANGPROB.
ELSE GO TO US39 – NUSNOTSK.
(01) BOX USB
(02) BOX USB
(03) US3A - CLNAME
(04) US3A - CLNAME
(05) US3A - CLNAME
(06) US3A - CLNAME
(07) US3A - CLNAME
(08) US3A - CLNAME
(09) US3A - CLNAME
(10) US5A - MDNAME
(11) US3A - CLNAME
(12) US3A - CLNAME
(13) US3A - CLNAME
(14) US3A - CLNAME
(91) US2 - PLACEOS
(-8) US3A - CLNAME
(-9) US3A - CLNAME
(01) CONTINUOUS ANSWER
US3A - CLNAME
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX USC
PLACEKND
US2
code one
(01) DOCTOR'S OFFICE OR GROUP PRACTICE
(02) MEDICAL CLINIC
(03) MANAGED CARE PLAN CENTER/HMO
(04) NEIGHBORHOOD/FAMILY HEALTH CENTER
(05) FREESTANDING SURGICAL CENTER
(06) RURAL HEALTH CLINIC
What kind of place [do you/does (SP)] usually go to when [you are/he is/she is] sick or for advice about
(07) COMPANY CLINIC
[your/his/her] health -- is that a managed care plan or HMO center, a clinic, a doctor or other health professional's
(08) OTHER CLINIC
office, a hospital, or some other place?
(09) WALK-IN URGENT CENTER
(10) DOCTOR COMES TO SP'S HOME
IF CLINIC, ASK: Is it a hospital outpatient clinic, or some other kind of clinic?
(11) HOSPITAL EMERGENCY ROOM
IF SOME OTHER PLACE, ASK: Where is this?
(12) HOSPITAL OUTPATIENT DEPARTMENT/CLINIC
(13) VA FACILITY
(14) MENTAL HEALTH CENTER
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
PLACEOS
US2
text
OTHER (SPECIFY)
BOX USB
routing
IF SP WAS COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND, GO TO
US2A - PLACEMCP.
ELSE IF US2 - PLACEKND = 1/DoctorsOffice, GO TO US5A - MDNAME.
ELSE GO TO US3A - CLNAME.
US2A
yes/no
Is this [doctor or other health professional/medical clinic] associated with [your/his/her] [READ MANAGED CARE
PLAN NAME(S) BELOW] plan?
BOX USC
routing
IF US2 - PLACEKND = 1/DoctorsOffice, GO TO US5A - MDNAME.
ELSE GO TO US3A - CLNAME.
PLACEMCP
What is the complete name of the [place/managed care plan or HMO center/(US2 RESPONSE)] that [you go
to/(SP) goes to]?
CLNAME
US3A
verbatim text
(01) US2 - PLACEKND
(02) BOX USA
(-8) BOX USA
(-9) BOX USA
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
(01) continuous answer
[ENCOURAGE THE RESPONDENT TO REFER TO A BILL, TELEPHONE DIRECTORY, APPOINTMENT CARD, (-8) Don't Know
ETC., FOR COMPLETE INFORMATION.]
(-9) Refused
US4 - USUALDOC
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02
USUALDOC
US4
yes/no
(01) YES
Is there a particular doctor or other health professional [you usually see/(SP) usually sees] at this [place/managed (02) NO
care plan or HMO center/(US2 RESPONSE)]?
(-8) DON'T KNOW
(-9) REFUSED
(01) US5A - MDNAME
(02) US7-INNOVATE
(-8) US7-INNOVATE
(-9) US7-INNOVATE
Page 1 of 13
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
USQ-Usual Source of Care
Question Type
Question Text/Description
What is the complete name of that doctor or other health professional?
MDNAME
US5A
verbatim text
Code List
Routing
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
(01) continuous answer
[ENCOURAGE THE RESPONDENT TO REFER TO A BILL, TELEPHONE DIRECTORY, APPOINTMENT CARD,
(-8) Don't Know
ETC., FOR COMPLETE INFORMATION.]
(-9) Refused
MDSEX - US5B
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02
MDSEX
US5B
code one
Is (US5A PROVIDER NAME) a male or female?
SHOW CARD US1
What is (US5A PROVIDER NAME)'s specialty?
PVSPEC
US6A
code one
[PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE CARD IF THEY MENTION A 'GENERIC'
SPECIALITY LIKE ‘HEART DOCTOR.’ IF RESPONDENT ONLY GIVES A 'GENERIC' SPECIALTY AND THE
GENERIC WORD IS SHOWN IN PARENTHESES FOLLOWING ONE OF THE RESPONSES, SELECT THE
RESPONSE CATEGORY FOR THAT SPECIALTY (E.G., 'CARDIOLOGY'). OTHERWISE SELECT 'OTHER DR
SPECIALTY'.]
(01) MALE
(02) FEMALE
(-8) DON’T KNOW
(-9) REFUSED
US6A - PVSPEC
(01) ALLERGY/IMMUNOLOGY
(02) ANESTHESIOLOGY
(03) CARDIOLOGY (HEART)
(04) DERMATOLOGY (SKIN)
(05) ENDOCRINOLOGY/METABOLISM
(DIABETES,THYROID)
(06) FAMILY PRACTICE
(07) GASTROENTEROLOGY
(08) GENERAL PRACTICE
(09) GENERAL SURGERY
(10) GERIATRICS (ELDERLY)
(11) GYNECOLOGY - OBSTETRICS
(12) HEMATOLOGY (BLOOD)
(13) HOSPITAL RESIDENCE
(14) INTERNAL MEDICINE (INTERNIST)
(15) NEPHROLOGY (KIDNEYS)
(16) NEUROLOGY
(17) NUCLEAR MEDICINE
(18) ONCOLOGY (TUMORS, CANCER)
(19) OPHTHALMOLOGY (EYES)
(20) ORTHOPEDICS
(21) OSTEOPATHY (DO)
(22) OTORHINOLARYNGOLOGY (EAR, NOSE,
THROAT)
(23) PAIN MANAGEMENT SPECIALIST
(24) PATHOLOGY
(25) PHYS MED/REHAB
(26) PHYSICIAN’S ASSISTANT
(27) PLASTIC SURGERY
(28) PODIATRIST
(29) PROCTOLOGY
(30) PSYCHIATRY/PSYCHIATRIST
(31) PULMONARY (LUNGS)
(32) RADIOLOGY
(33) RHEUMATOLOGY (ARTHRITIS)
(34) THORACIC SURGERY (CHEST)
(35) UROLOGY
(36) VASCULAR SURGEON/SPECIALIST
(37) AUDIOLOGIST
(38) CHIROPRACTOR
(39) DENTIST
(40) OPTOMETRIST
(41) PHYSICAL THERAPIST
(42) PSYCHOLOGIST
(43) NURSE PRACTITIONER
(91) OTHER DR SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED
(01)- (43) US7-INNOVATE
(91) US6A - MDSPECOS
(-8) US7-INNOVATE
(-9) US7-INNOVATE
Page 2 of 13
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
USQ-Usual Source of Care
Question Type
Question Text/Description
Code List
Routing
(01) CONTINUOUS ANSWER
US7-INNOVATE
OTHER DR SPECIALTY (SPECIFY)
MDSPECOS
US6A
text
[PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE CARD IF THEY MENTION A 'GENERIC'
SPECIALITY LIKE ‘HEART DOCTOR.’ IF RESPONDENT ONLY GIVES A 'GENERIC' SPECIALTY AND THE
GENERIC WORD IS SHOWN IN PARENTHESES FOLLOWING ONE OF THE RESPONSES, SELECT THE
RESPONSE CATEGORY FOR THAT SPECIALTY (E.G., 'CARDIOLOGY'). OTHERWISE SELECT 'OTHER DR
SPECIALTY'.]
Many health care providers are beginning to participate in innovative health care initiatives, programs, and
payment models. Is (US5A PROVIDER NAME)/(US3A PROVIDER NAME) associated with an innovative health
care initiative such as an accountable care organization or a patient centered medical home?
INNOVATE
US7
yes/no
(01) YES
(02) NO
[IF NEEDED: Innovative health care initiatives are programs that test ways to improve the delivery of health care,
(-8) DON'T KNOW
improve the quality of health care, lower health care costs, and reduce health disparities.]
(-9) REFUSED
BOX USD
IF THE RESPONDENT DOESN'T KNOW WHAT INNOVATIVE HEALTH CARE INITATIVES ARE OR HAS
NEVER HEARD OF INNOVATIVE HEALTH CARE INITIATIVES, SELECT 'DON'T KNOW'.
BOX USD
routing
IF (INTTYPE=7) AND (SAMPLE_PERSON.WHATLANG EQUALS 1-"SPANISH", 2-"FRENCH", 3-"GERMAN", OR
91-"Other, Specify"), GO TO LEP1A-LANGPREF.
ELSE GO TO BOX US1.
LANGPREF
LEP1A
select one
In general, in what language [do you/does (SP)] prefer to receive [your/his/her] medical care?
(01) English
(02) [LANGUAGE SPOKEN AT HOME], or
(03) Both English and [LANGUAGE SPOKEN AT HOME]
equally
(91) OTHER
(-8) Don't Know
(-9) Refused
LANGPFOS
LEP1B
verbatim text
In general, in what language [do you/does (SP)] prefer to receive [your/his/her] medical care?
(01) CONTINUOUS ANSWER
LEP2-LANGPRVD
LANGPRVD
LEP2
select one
[Does (US5A PROVIDER NAME)/Do the providers at (US3A PROVIDER NAME)] speak [LANGUAGE SPOKEN
AT HOME/LEP1B-LANGPFOS]?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) LEP3-LANGCOMM
(02) LEP4-LANGSYMP
(-8) LEP4-LANGSYMP
(-9) LEP4-LANGSYMP
LEP3
select one
(01) VERY WELL
(02) WELL
(03) NOT WELL
How well can [you/(SP)] and [(US5A PROVIDER NAME)/the providers at (US3A PROVIDER NAME)]
(04) NOT AT ALL
communicate in [LANGUAGE SPOKEN AT HOME/LEP1B-LANGPFOS] about [your/his/her] symptoms? Very well,
(-8) DON’T KNOW
well, not well, or not at all?
(-9) REFUSED
BOX LEP1
routing
IF P_ENGWELL=1, GO TO LEP6-LANGPROB. ELSE GO TO BOX US1.
(01) LEP4-LANGSYMP
(02) LEP2-LANGPRVD
(03) LEP2-LANGPRVD
(91) LEP1B-LANGPFOS
(-8) LEP2-LANGPRVD
(-9) LEP2-LANGPRVD
SHOW CARD US2
LANGCOMM
LEP4
select one
(01) VERY WELL
(02) WELL
(03) NOT WELL
Without the aid of a translator, language assistant, or interpreter, how well can [you/(SP)] and [(US5A PROVIDER
(04) NOT AT ALL
NAME)/the providers at (US3A PROVIDER NAME)] communicate in English about [your/his/her] symptoms? Very
(-8) DON’T KNOW
well, well, not well, or not at all?
(-9) REFUSED
BOX LEP2
routing
IF P_ENGWELL=1, GO TO LEP5-LANGASST. ELSE GO TO BOX US1.
BOX LEP1
SHOW CARD US2
LANGSYMP
(01) PROFESSIONAL INTERPRETER
(02) STAFF PERSON AT MEDICAL PROVIDER’S
OFFICE
(03) FAMILY MEMBER
Who helps [you/(SP)] communicate with [(US5A PROVIDER NAME)/the providers at (US3A PROVIDER NAME)] –
(04) FRIEND
a professional interpreter, a staff person at [your/his/her] provider's office, a family member, a friend, do [you/(SP)]
(05) SOMEONE ELSE
do the best that [you/(SP)] can in English, or does no one help [you/(SP)] becuase [you have/(SP) has] no trouble
(06) DOES BEST THAT CAN IN ENGLISH
communicating in English?
(07) NO ONE HELPS; NO TROUBLE
COMMUNICATING IN ENGLISH
PROBE: Anyone else?
(-8) DON’T KNOW
(-9) REFUSED
BOX LEP2
SHOW CARD US3
LANGASST
LEP5
select all
LEP6-LANGPROB
Page 3 of 13
2021 MCBS Community Questionnaire
USQ-Usual Source of Care
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
LANGPROB
LEP6
select one
Have [you/(SP)] ever had a problem understanding a medical situation because it was not explained in
[LANGAUGE SPOKEN AT HOME/LEP1B-LANGPFOS]?
(01) YES
(02) NO
(-8) DON’T KNOW
(-9) REFUSED
LEP7-LANGHELP
LEP7
select all
(01) PROFESSIONAL INTERPRETER
(02) STAFF PERSON AT MEDICAL PROVIDER’S
OFFICE
Now think about all of [your/(SP)'s] medical providers other than [your/his/her] usual provider.
(03) FAMILY MEMBER
(04) FRIEND
Who helps [you/(SP)] communicate with medical providers who do not speak [LANGUAGE SPOKEN AT
(05) SOMEONE ELSE
HOME/LEP1B-LANGPFOS]– a professional interpreter, a staff person at [your/his/her] provider's office, a family (06) DOES BEST THAT CAN IN ENGLISH
member, a friend, [do you/does (SP)] do the best that [you/(SP)] can in English, or does no one help [you/(SP)]
(07) DOES NOT SEE A MEDICAL PROVIDER
because [you have/(SP) has] no trouble communicating in English?
(08) NO ONE HELPS; HAS NO TROUBLE
COMMUNICATING IN ENGLISH
PROBE: Anyone else?
(-8) DON’T KNOW
(-9) REFUSED
BOX US1
routing
IF US1 - PLACEPAR = NO, DK, or RF, GO TO US39 - NUSNOTSK.
ELSE IF US2 - PLACEKND = 10/AtHome, GO TO PP1A-PROVYR.
ELSE GO TO US8 - GETUSHOW.
SHOW CARD US3
LANGHELP
How [do you/does (SP)] usually get to [(US5A PROVIDER NAME)'S office/(US3A PROVIDER NAME)]?
BOX US1
(01) WALKING
(02) DRIVING
(03) BEING DRIVEN
(04) AMBULANCE OR OTHER SPECIAL VEHICLE
(05) TAXI
(06) OTHER PUBLIC TRANSPORTATION
(07) DR. USUALLY COMES TO HOME
(91) SOME OTHER WAY
(-8) DON'T KNOW
(-9) REFUSED
(01) US9 - GETUSUNT
(02) US9 - GETUSUNT
(03) US9 - GETUSUNT
(04) US9 - GETUSUNT
(05) US9 - GETUSUNT
(06) US9 - GETUSUNT
(07) PP1A-PROVYR
(91) US8 - GETUSOS
(-8) PP1A-PROVYR
(-9) PP1A-PROVYR
GETUSHOW
US8
code one
GETUSOS
US8
verbatim text
SOME OTHER WAY (SPECIFY)
(01) continuous answer
US9 - GETUSUNT
GETUSUNT
US9
code one
About how long does it usually take for [you/(SP)] to get there?
(01) HOURS ONLY
(02) MINUTES ONLY
(03) HOURS AND MINUTES
(-8) DON'T KNOW
(-9) REFUSED
(01) US9 - GETUSHRS
(02) US9 - GETUSMIN
(03) US9 - GETUSHRS
(-8) US10 - ACCOMPUS
(-9) US10 - ACCOMPUS
GETUSHRS
US9
numeric
HOURS:
(01) CONTINUOUS ANSWER
If US9 GETUSUNT=3/HoursAndMinutes go to US9 GETUSMIN.
Else go to US10 - ACCOMPUS.
GETUSMIN
US9
numeric
MINUTES:
(01) CONTINUOUS ANSWER
US10 - ACCOMPUS
ACCOMPUS
US10
yes/no
[Do you/Does (SP)] usually have someone accompany [you/him/her] there?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) US11 - PERSON_USUALGO
(02) PP1A-PROVYR
(-8) PP1A-PROVYR
(-9) PP1A-PROVYR
[EXPLAIN IF NECESSARY: [Do you/Does (SP)] get there by walking, driving, being driven by someone else, by
ambulance or other special vehicle for disabled people, by taxi, other public transportation, or some other way?]
Who usually goes with [you/(SP)]?
PERSON_USUALGO
US11
roster
SELECT OR ADD ONLY ONE PERSON
ROSTFNAM
US11_NEW
text
[What is the name of the person and relationship to (SP)?]
DISPLAY PERSON ROSTER AS RESPONSE
OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) US11AA-ACCREAS
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS (N+1) US11_NEW-ROSTFNAM
(N+1) ADD ANOTHER
IF EXISTING PERSON SELECTED, GO TO US11AADISPLAY:
ACCREAS.
1 First Name Display ROST.ROSTFNAM.
ELSE IF "ADD ANOTHER" SELECTED, GO TO
2 Last Name Display ROST.ROSTLNAM.
US11_NEW-ROSTFNAM
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/OtherRelative or 92/OtherNonRelative, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
(01) CONTINUOUS ANSWER
US11_NEW - ROSTLNAM
Page 4 of 13
2021 MCBS Community Questionnaire
USQ-Usual Source of Care
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
ROSTLNAM
US11_NEW
text
[What is the name of the person and relationship to (SP)?]
(01) CONTINUOUS ANSWER
US11_NEW - ROSTREL
ROSTREL
US11_NEW
code one
[What is the name of the person and relationship to (SP)?]
ROSTREOS
US11_NEW
verbatim text
[What is the name of the person and relationship to (SP)?]
What are the reasons [you accompany (SP)/this person accompanies you/this person accompanies this person]
do?
ACCREAS
US11AA
code all
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.
(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 ANSWER
(-8) Don't Know
(-9) Refused
(01) DO NOT DISPLAY
(02) US11AA-ACCREAS
(03) US11AA-ACCREAS
(04) US11AA-ACCREAS
(05) US11AA-ACCREAS
(06) US11AA-ACCREAS
(07) US11AA-ACCREAS
(08) US11AA-ACCREAS
(09) US11AA-ACCREAS
(10) US11AA-ACCREAS
(11) US11AA-ACCREAS
(12) US11AA-ACCREAS
(13) US11AA-ACCREAS
(14) US11AA-ACCREAS
(50) DO NOT DISPLAY
(51) US11AA-ACCREAS
(52) US11AA-ACCREAS
(53) US11AA-ACCREAS
(54) US11AA-ACCREAS
(55) US11AA-ACCREAS
(56) US11AA-ACCREAS
(57) US11AA-ACCREAS
(91) US11_NEW - ROSTREOS
(-8) US11AA-ACCREAS
(-9) US11AA-ACCREAS
US11AA-ACCREAS
(01) WRITES DOWN WHAT DOCTOR
SAYS/RECORDS INSTRUCTIONS/TAKES
NOTES/REMEMBERS
(02) GIVES INFORMATION/EXPLAINS SP'S MEDICAL
CONDITION OR NEEDS TO THE DOCTOR
(03) EXPLAINS DOCTOR’S INSTRUCTIONS TO SP
(04) ASKS QUESTIONS
(05) TRANSLATES LANGUAGE
(06) SCHEDULES APPOINTMENTS
(07) NOTHING/KEEPS SP COMPANY/SITS WITH
SP/MORAL SUPPORT
(08) TRANSPORTATION
(09) SP NEEDS PHYSICAL ASSISTANCE
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) PP1A-PROVYR
(02) PP1A-PROVYR
(03) PP1A-PROVYR
(04) PP1A-PROVYR
(05) PP1A-PROVYR
(06) PP1A-PROVYR
(07) PP1A-PROVYR
(08)PP1A-PROVYR
(09) PP1A-PROVYR
(91) US11AA - ACCOTHOS
(-8) PP1A-PROVYR
(-9) PP1A-PROVYR
ACCOTHOS
US11AA
verbatim text
OTHER (SPECIFY)
(01) continuous answer
PP1A-PROVYR
PROVYR
PP1A
code one
[Have you/Has (SP)] seen [(US5A PROVIDER NAME)/(US3A PROVIDER NAME)] in the last 12 months?
(01) YES
(02) NO
(-8) DON’T KNOW
(-9) REFUSED
(01) PP1-REMINDAPPT
(02) US27-USCKEVRY
(-8) US27-USCKEVRY
(-9) US27-USCKEVRY
REMINDAPPT
PP1
yes/no
(01) YES
(02) NO
(996) NOT APPLICABLE / R DID NOT HAVE
Some offices remind patients about appointments. Before [your/(SP)'s] most recent visit with [(US5A PROVIDER APPOINTMENT
(-8) DON'T KNOW
NAME)/(US3A PROVIDER NAME) ], did [you/he/she] get a reminder from [(US5A PROVIDER NAME)'S office
(-9) REFUSED
/(US3A PROVIDER NAME)] about the appointment?
PREAPPT
PP2
yes/no
Before [your/(SP)'s] most recent visit with [(US5A PROVIDER NAME)'s office/(US3A PROVIDER NAME)], did
[you/he/she] get instructions telling [you/him/her] what to expect or how to prepare?
The next questions ask about the care [you/(SP)] received from [(US5A PROVIDER NAME)'S office/(US3A
PROVIDER NAME)].
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) PP2- PREAPPT
(02) PP2- PREAPPT
(996) PP4-MISSAPPT
(-8) PP2- PREAPPT
(-9) PP2- PREAPPT
PP4-MISSAPPT
Page 5 of 13
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
USQ-Usual Source of Care
Question Type
Question Text/Description
SHOW CARD US4
MISSAPPT
PP4
code one
Now I’m going to read you questions about the medical providers [you have/SP has] seen in the last twelve
months, that is since {TODAY'S MONTH AND YEAR - 12 MONTHS}.
People have busy lives and miss appointments for many reasons. Since (TODAY'S MONTH AND YEAR-12
MONTHS), how often did [you/(SP)] miss an appointment with [(US5A PROVIDER NAME)/(US3A PROVIDER
NAME)]?
SHOW CARD US4
NEWAPPT
PP5
code one
Since (TODAY'S MONTH AND YEAR-12 MONTHS), when [ you/(SP)] missed an appointment with US5A
PROVIDER NAME/US3A PROVIDER NAME), how often did someone from [(US5A PROVIDER NAME)'S
office/(US3A PROVIDER NAME)] contact [you/him/her] to make a new appointment?
SHOW CARD US4
DOCHLTH
PP8
code one
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] ask about things in [your/(SP)'s] work or life at home that affect
[your/(SP)'s] health?
SHOW CARD US4
DOCEASY
PP9
code one
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] explain things in a way that was easy [for (SP)] to understand?
SHOW CARD US4
DOCLSTN
PP10
code one
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] listen carefully to [you/(SP)]?
SHOW CARD US4
DOCRSPCT
PP11
code one
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] show respect for what [you/(SP)] had to say?
SHOW CARD US4
ENUFTIME
PP12
code one
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] spend enough time with [you/(SP)]?
SHOW CARD US4
HLTHIDEA
PP13
code one
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] ask whether [you/(SP)] had ideas about how to improve [your/his/her]
health?
SHOW CARD US5
STHLTHGL
PP15
code one
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [(US5A PROVIDER NAME)/the medical providers at
(US3A PROVIDER NAME)] talk with [you/(SP)] about setting goals for [your/his/her] health?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
Code List
Routing
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) PP8-DOCHLTH
(02) PP5- NEWAPPT
(03) PP5-NEWAPPT
(04) PP5- NEWAPPT
(-8) PP8-DOCHLTH
(-9) PP8-DOCHLTH
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
PP8-DOCHLTH
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
PP9- DOCEASY
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
PP10-DOCLSTN
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
PP11-DOCRSPCT
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
PP12- ENUFTIME
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
PP13- HLTHIDEA
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
PP15-STHLTHGL
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) PP16- MTHLTHGL
(02) PP16- MTHLTHGL
(03) US27-USCKEVRY
(-8) US27-USCKEVRY
(-9) US27-USCKEVRY
Page 6 of 13
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
USQ-Usual Source of Care
Question Type
Question Text/Description
SHOW CARD US5
MTHLTHGL
PP16
code one
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did the care [you/(SP)] received from [(US5A PROVIDER
NAME)/the medical providers at (US3A PROVIDER NAME)] help [you/(SP)] meet [your/his/her] goals?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
Code List
Routing
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
US27-USCKEVRY
SHOW CARD US6
USCKEVRY
US27
list
(01) STRONGLY AGREE
(02) AGREE
Now I am going to read some statements people have made about their health care. Think about the care [you
(03) DISAGREE
receive/(SP) receives] from (US5A PROVIDER NAME/US3A PROVIDER NAME). For each statement, please tell
(04) STRONGLY DISAGREE
me whether you strongly agree, agree, disagree, or strongly disagree.
(05) NOT APPLICABLE
(-8) Don't Know
[(US5A PROVIDER NAME) is/The doctors or other health professionals at (US3A PROVIDER NAME) are] very
(-9) Refused
careful to check everything when examining [you/him/her].
SHOW CARD US6
USUNWRNG
US27
list
BOX US4
routing
PP17
yes/no
[(US5A PROVIDER NAME) has/The doctors or other health professionals at (US3A PROVIDER NAME) have] a
complete understanding of the things that are wrong with [you/him/her].
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] get any instructions about your health from
any other staff [in (US5A PROVIDER NAME)'s office/ at (US3A PROVIDER NAME)]?
SHOW CARD US4
OSUPTODT
PP18
code one
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
BOX US4
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) PP18- OSUPTODT
(02) PP21- ORDRTEST
(-8) PP21- ORDRTEST
(-9) PP21- ORDRTEST
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
PP19- OSTLKCR
IF PP1A-PROVYR= 01/YES, GO TO PP17 OTHRSTFF.
ELSE GO TO BOX US5.
People often get instructions about their health from more than one person in the same office, such as other
medical providers, nurses, nutritionists, and social workers.
OTHRSTFF
US27-USUNWRNG
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did these other staff seem up-to-date about the
care [you were/(SP) was] receiving from [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER
NAME)]?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did these other staff talk with [you/(SP)] about care
(04) ALWAYS
[you/he/she] [were/was] receiving from [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER
(-8) Don't Know
NAME)]?
(-9) Refused
PP20- OSNOINFO
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
PP21- ORDRTEST
SHOW CARD US4
OSTLKCR
PP19
code one
SHOW CARD US4
OSNOINFO
ORDRTEST
PP20
PP21
code one
yes/no
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did these other staff seem to know the important
information about [your/(SP)'s] medical history?
The next set of questions ask about the care you received from [(US5A PROVIDER NAME)/the medical providers
at (US3A PROVIDER NAME)] or someone in [his/her/their] office.
(01) YES
(02) NO
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [(US5A PROVIDER NAME)/the medical providers at
(-8) DON'T KNOW
(US3A PROVIDER NAME)] or someone in [his/her/their] office order a blood test, x-ray, or other test for
(-9) REFUSED
[you/(SP)]?
(01) PP22- TSTFLWUP
(02) PP29-HLTHSRVC
(-8) PP29-HLTHSRVC
(-9) PP29-HLTHSRVC
Page 7 of 13
2021 MCBS Community Questionnaire
Variable Name
TSTFLWUP
MR Screen Name
PP22
USQ-Usual Source of Care
Question Type
code one
Question Text/Description
Code List
Routing
SHOW CARD US4
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
PP23-RQSTRSLT
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
PP24- RSLTEASY
PP29-HLTHSRVC
Since (TODAY'S MONTH AND YEAR-12 MONTHS), when [(US5A PROVIDER NAME)/the medical providers at
(US3A PROVIDER NAME)] or someone from [his/her/their] office ordered a blood test, x-ray, or other test for
[you/(SP)], how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or
someone from [his/her/their] office follow up to give [you/(SP)] those results?
SHOW CARD US4
RQSTRSLT
PP23
code one
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [you/(SP)] have to request [your/his/her] test
results before [you/he/she] got them?
RSLTEASY
PP24
code one
(01) NEVER
(02) SOMETIMES
(03) USUALLY
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often were [your/(SP)'s] test results presented in a way (04) ALWAYS
that was easy to understand?
(-8) Don't Know
(-9) Refused
HLTHSRVC
PP29
yes/no
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] need services at home to help [you/him/her]
take care of [your/his/her] health?
SHOW CARD US4
SHOW CARD US4
SRVCHELP
PP30
code one
GIVEINST
PP31
yes/no
ANYRX
PP35
yes/no
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office help [you/(SP)] get these services at
home to take care of [your/his/her] health?
[THIS IS DIFFERENT FROM THE PRESCRIPTION DRUG WHERE WE ASK IF THE R HAD ANY
PRESCRIPTIONS FILLED]
SHOW CARD US4
PP36
code one
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office talk with [you/(SP)] about how [you
were/he was/she was] supposed to take [your/his/her] medicine?
SHOW CARD US4
ASPRSCBD
PP37
code one
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [(US5A PROVIDER NAME)/the medical providers at
(-8) DON'T KNOW
(US3A PROVIDER NAME)] or someone in [his/her/their] office give [you/(SP)] instructions about how to take care
(-9) REFUSED
of [your/his/her] health?
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] take any prescription medicine?
TALKRX
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
There are many reasons why people may not always be able to take their medicines as prescribed.
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often [were you/was (SP)] able to take [your/his/her]
medicine as prescribed?
(01) PP30- SRVCHELP
(02) PP31- GIVEINST
(-8) PP31- GIVEINST
(-9) PP31- GIVEINST
PP31- GIVEINST
PP35-ANYRX
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) PP36- TALKRX
(02) BOX US5
(-8) BOX US5
(-9) BOX US5
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
PP37- ASPRSCBD
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
PP38-BADRCTN
PP38
code one
(01) NEVER
(02) SOMETIMES
(03) USUALLY
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
(04) ALWAYS
providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office talk with [you/(SP)] about what to do if
(-8) Don't Know
[you have/he has/she has] a bad reaction to [your/his/her] medicine?
(-9) Refused
BOX US5
routing
GO TO US37A CARESPCL.
SHOW CARD US4
BADRCTN
BOX US5
Page 8 of 13
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
USQ-Usual Source of Care
Question Type
Question Text/Description
Code List
Routing
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) US37B - DRINFRMD
(02) PP50-HOSADMIT
(-8) PP50-HOSADMIT
(-9) PP50-HOSADMIT
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
US37C - REMINDDR
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
US37D - STPMSPCL
SHOW CARD US1
CARESPCL
US37A
yes/no
Specialists are doctors or other health professionals who specialize in one area of health care. This card lists
some examples of specialists.
Since (TODAY'S MONTH AND YEAR-12 MONTHS) , did [you/(SP)] receive care from any specialists outside the
office of [(US5A PROVIDER NAME)/the doctors or other health professionals at (US3A PROVIDER NAME)]?
SHOW CARD US4
DRINFRMD
US37B
code one
In general, how often [does (US5A PROVIDER NAME)/do the doctors or other health professionals at (US3A
PROVIDER NAME)] seem informed and up-to-date about the care [you get/(SP) gets] from specialists?
SHOW CARD US4
REMINDDR
US37C
code one
STPMSPCL
US37D
yes/no
In general, how often [do you/does(SP)] have to remind [(US5A PROVIDER NAME)/the doctors or other health
professionals at (US3A PROVIDER NAME)] about care [you receive/(SP) receives] from specialists?
(01) YES
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did any specialists outside the office of [(US5A PROVIDER (02) NO
NAME)/the doctors or other health professionals at (US3A PROVIDER NAME)] prescribe medicine for [you/(SP)]? (-8) DON'T KNOW
(-9) REFUSED
SHOW CARD US4
TALKPMS
US37E
code one
In general, how often [does (US5A PROVIDER NAME)/do the doctors or other health professionals at (US3A
PROVIDER NAME)] talk with [you/(SP)] about the medicines prescribed by these specialists?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) US37E - TALKPMS
(02) US37E1 - NAMESPCL
(-8) US37E1 - NAMESPCL
(-9) US37E1 - NAMESPCL
US37E1 - NAMESPCL
[DISPLAY PROVIDER ROSTER AS RESPONSE
The next four questions ask about care [you/(SP)] received from the specialist [you/he/she] saw most often in the OPTIONS:
last 12 months outside the office of [(US5A PROVIDER NAME)/the doctors or other health professionals at (US3A 1. [PROVIDER 1]
PROVIDER NAME)].
2. [PROVIDER 2]
NAMESPCL
US37E1
verbatim text
First, what is the name of the specialist [you/(SP)] saw most often since (TODAY'S MONTH AND YEAR-12
MONTHS)?
(01) continuous answer
(-8) Don't Know
(-9) Refused
US37E2 - SEXSPCL
[ENCOURAGE THE RESPONDENT TO REFER TO A BILL, TELEPHONE DIRECTORY, APPOINTMENT CARD,
ETC., FOR COMPLETE INFORMATION.]
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02
SEXSPCL
US37E2
code one
Is [(US37E1 PROVIDER NAME)/the specialist you saw most often since (TODAY'S MONTH AND YEAR-12
MONTHS)] a male or female?
(01) MALE
(02) FEMALE
(-8) DON’T KNOW
(-9) REFUSED
US37F - KNOWSPCL
SHOW CARD US5
[IF NEEDED: This question is about the last twelve months, that is since (TODAY'S MONTH AND YEAR - 12
MONTHS).]
KNOWSPCL
US37F
code one
(01) YES, DEFINITELY
The next questions ask about care [you/(SP)] received from the specialist [you/he/she] saw most often in the last (02) YES, SOMEWHAT
twelve months outside the [office of (US5A PROVIDER NAME)/the doctors or other health professionals at (US3A (03) NO
PROVIDER NAME)].
(-8) Don't Know
(-9) Refused
When [you see/(SP) sees] [(US37E1-SPCLNAME)/this specialist], does [he/she/he or she] seem to know enough
information about [your/his/her] medical history?
US37G - RPTINFO
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
Page 9 of 13
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
USQ-Usual Source of Care
Question Type
Question Text/Description
SHOW CARD US4
RPTINFO
US37G
code one
When [you see/(SP) sees] [(US37E1-SPCLNAME)/this specialist], how often [do you/does (SP)] have to repeat
information that [you/he/she] [have/has] already given to [(US5A PROVIDER NAME)/the doctors or other health
professionals at (US3A PROVIDER NAME)]?
Code List
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
Routing
KNOWRSLT
SHOW CARD US4
KNOWRSLT
PP49
code one
The next questions ask about care [you/(SP)] received from the specialist [you/he/she] saw most often since
(TODAY'S MONTH AND YEAR-12 MONTHS) outside the [office of (US5A PROVIDER NAME)/the doctors or
other health professionals at (US3A PROVIDER NAME)].
When [you see/(SP) sees] [(US37E1-SPCLNAME)/this specialist], how often does [he/she/he or she] seem to
know [your/(SP)'s] important test results from other providers?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
PP50-HOSADMIT
HOSADMIT
PP50
yes/no
Since (TODAY'S MONTH AND YEAR-12 MONTHS), [were you/was (SP)] admitted to a hospital overnight or
longer?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) PP51- HOSFLWUP
(02) PP58- MNGCARE
(-8) PP58- MNGCARE
(-9) PP58- MNGCARE
HOSFLWUP
PP51
yes/no
After [your/(SP)'s] most recent hospital stay, did [(US5A PROVIDER NAME)/the medical providers at (US3A
PROVIDER NAME)] or someone in [his/her/their] office contact [you/him/her] to see how [you were/he was/she
was] doing?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PP52- HOSMED
HOSMED
PP52
yes/no
After [your/(SP)'S] most recent hospital stay, [were you/was (SP)] prescribed any medicines?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) PP53- HOSFOLLOWUP
(02) PP54- HOSINSTU
(-8) PP54- HOSINSTU
(-9) PP54- HOSINSTU
HOSFOLLOWUP
PP53
yes/no
After (your/(SP)'s)] most recent hospital stay, did [(US5A PROVIDER NAME)/the medical providers at (US3A
PROVIDER NAME)] or someone in [his/her/their] office contact [you/SP] to check if [you were/he was/she was ]
able to follow instructions about any medicines [you were/he was/she was] prescribed?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PP54- HOSINSTU
HOSINSTU
PP54
yes/no
After (your/(SP)'s] most recent hospital stay, (were you/was he/was she] given instructions about caring for
[yourself/himself/herself] at home?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) PP55- INSTUEASY
(02) PP56- HOSINFO
(-8) PP56- HOSINFO
(-9) PP56- HOSINFO
INSTUEASY
PP55
code one
HOSINFO
PP56
code one
SHOW CARD US5
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
After [your/(SP)'s] most recent hospital stay, were the instructions [you were/(SP) was] given easy to understand? (03) NO
(-8) DON'T KNOW
(-9) REFUSED
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
SHOW CARD US5
After (your/(SP)'s) most recent hospital stay, did [(US5A PROVIDER NAME)/the medical providers at (US3A
PROVIDER NAME)] seem to know the important information about this hospital stay?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
(00) 0 HARD TO MANAGE
(01) 1
(02) 2
People sometimes need to manage their medical care by making appointments with multiple providers, following
(03) 3
their instructions, and taking medicines as prescribed.
(04) 4
(05) 5
Using any number from 0 to 10, where 0 is hard and 10 is easy, what number would you use to rate how easy it
(06) 6
was for [you/(SP)] to manage [your/his/her] medical care since (TODAY'S MONTH AND YEAR-12 MONTHS)?
(07) 7
(08) 8
[IN SITUATIONS WHERE A PROXY OR SOMONE ELSE MANAGES THE RESPONDENT’S MECIAL CARE FOR
(09) 9
OR WITH THEM, ANSWER BASED ON THEIR EXPERIENCE.]
(10) 10 EASY TO MANAGE
PP56- HOSINFO
PP58-MNGCARE
SHOW CARD US7
MNGCARE
PP58
code one
PP58A-DOCCARE
Page 10 of 13
2021 MCBS Community Questionnaire
USQ-Usual Source of Care
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
DOCCARE
PP58A
code one
(01) YES
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] need help from [anyone in (US5A PROVIDER
(02) NO
NAME)'s office/the doctors or other health professionals at (US3A PROVIDER NAME)] to manage [your/his/her]
(-8) DON'T KNOW
care among these different providers and services?
(-9) REFUSED
GETHELP
PP58B
code one
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] get the help [you/he/she] needed from [(US5A (03) NO
PROVIDER NAME)'s office/the doctors or other health professionals at (US3A PROVIDER NAME)] to manage
(-8) DON'T KNOW
[your/his/her] care among these different providers and services?
(-9) REFUSED
Routing
(01) PP58B-GETHELP
(02) PP59-ONEDOC
(-8) PP59-ONEDOC
(-9) PP59-ONEDOC
SHOW CARD US5
SHOW CARD US5
ONEDOC
PP59
code one
Since (TODAY'S MONTH AND YEAR-12 MONTHS), was there one provider who knew about all [your/(SP)'s]
medical care needs?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
SHOW CARD US5
PRVNOMED
PP60
code one
Since (TODAY'S MONTH AND YEAR-12 MONTHS), was there one provider who knew about all the medicines
[you were/(SP) was] taking?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
NOTAVAIL
COMPUSE
PP60- PRVNOMED
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX US7
(01) YES
(02) NO
(03) NOT APPLICABLE
(04) NOT SURE
(-9) Refused
BOX EHR1
routing
GO TO US37I- NOTAVAIL
US37I
code one
Since (TODAY'S MONTH AND YEAR-12 MONTHS), when getting care for a medical problem, was there ever a
time when test results, medical records, or reasons for referrals were not available at the time of [your/(SP)’s]
scheduled doctor or other health professional appointment?
BOX EHR1
routing
IF US1-PLACEPAR=1, GO TO EHR2-COMPUSE,
ELSE GO TO BOX USEND.
yes/no
The next few questions will help us understand how [(US5A PROVIDER NAME)/the doctors or other health
professionals at (US3A PROVIDER NAME)] use(s) a computer during [your/(SP)'s] office visit. Please answer the (01) YES
following questions based on where [you go/(SP) goes] for medical care most of the time.
(02) NO
(-8) Don't Know
[Does (US5A PROVIDER NAME)/Do the providers at (US3A PROVIDER NAME)] use a computer during
(-9) Refused
[your/(SP)'s] office visit?
Many health care providers are beginning to use electronic or computer-based medical records instead of using
paper-based records. When [you visit/(SP) visits] [(US5A PROVIDER NAME)/the doctors or other health
professionals at (US3A PROVIDER NAME)] [does he or she/do they] generally enter [your/(SP)'s] health
information into a computer while [you are/(SP) is] present?
EMEDREC
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX US7
EHR2
US37K
yes/no
[IF SUPPORT STAFF (NURSES, MEDICAL ASSISTANTS) ENTER INFORMATION INTO THE ELECTRONIC
HEALTH RECORD DURING THEIR VISIT, SELECT “YES” AT THIS QUESTION.]
PP59-ONEDOC
(01) US37K - EMEDREC
(02) EHR6-COMPRD
(-8) EHR6-COMPRD
(-9) EHR6-COMPRD
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) EHR3-COMPSHW
(02) EHR6-COMPRD
(-8) EHR6-COMPRD
(-9) EHR6-COMPRD
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) EHR4-COMPINFO
(02) EHR6-COMPRD
(-8) EHR6-COMPRD
(-9) EHR6-COMPRD
[EXPLAIN IF NECESSARY: An “electronic health record” is an electronic version of a patient’s medical history
maintained by a provider over time. It automates the way in which doctors can access patient health information.
"Health Information" includes information such as symptoms, vital signs, test results, or prescribed medicines.]
COMPSHW
EHR3
yes/no
Is the examination room set up so that [(US5A PROVIDER NAME)/the doctors or other health professionals at
(US3A PROVIDER NAME)] can easily show [you/(SP)] information on the computer screen?
Page 11 of 13
2021 MCBS Community Questionnaire
USQ-Usual Source of Care
Variable Name
MR Screen Name
Question Type
Question Text/Description
COMPINFO
EHR4
yes/no
[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A PROVIDER NAME)] use (01) YES
the computer to show [you your/(SP) his/(SP) her] health information during [your/his/her] visit, such as trends in (02) NO
blood pressure reading, height, weight and body mass index, previous lab results, x-rays/images, immunizations or (-8) Don't Know
medications?
(-9) Refused
(01) EHR5-COMPREC
(02) EHR6-COMPRD
(-8) EHR6-COMPRD
(-9) EHR6-COMPRD
COMPREC
EHR5
yes/no
(01) YES
[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A PROVIDER NAME)] use (02) NO
the computer to show [you/(SP)] recommendations for preventive health screenings or other medical services?
(-8) Don't Know
(-9) Refused
EHR6-COMPRD
COMPRD
EHR6
yes/no
(01) YES
[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A PROVIDER NAME)] read
(02) NO
back to [you/(SP)] information that [you have/(SP) has] given during [your/(SP)'s] visit that is being put into
(-8) Don't Know
[your/(SP)'s] medical record?
(-9) Refused
EHR7-COMPINF
COMPINF
EHR7
yes/no
(01) YES
[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A PROVIDER NAME)] send
(02) NO
[you/(SP)] health information electronically, such as information about [your/(SP)'s] medications, exercise plans,
(-8) Don't Know
dietary advice, etc.?
(-9) Refused
EHR8-COMPACC
COMPACC
EHR8
yes/no
[Does (US5A PROVIDER NAME)'s/Do the doctors or other health professionals at (US3A PROVIDER NAME)'s]
office give [you/(SP)] access through [your/(SP)'s] own computer or smart phone to parts or all of [your/(SP)'s]
electronic medical record (such as a list of [your/(SP)'s] medications, lab results, x-ray reports, office notes)
through a “patient portal” or other electronic system?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX EHR2
BOX EHR2
routing
IF EHR2-COMPUSE=(01) YES, GO TO EHR9-COMPHLP,
ELSE GO TO BOX USEND
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
EHR9-COMPDIST
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
EHR9-COMPATT
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
EHR10-COMPTM
SHOW CARD US6
COMPHLP
EHR9
list
Now I am going to read some statements people have made about how their provider uses a computer. Think
about the care [you receive/(SP) receives] from (US5A PROVIDER NAME/US3A PROVIDER NAME). For each
statement, please tell me whether you strongly agree, agree, disagree, or strongly disagree.
(US5A PROVIDER NAME)'s/The doctors or other health professionals at (US3A PROVIDER NAME) use of the
computer during [my/(SP)'s] visit is helpful to [me/(SP)].
SHOW CARD US6
COMPDIST
EHR9
list
(US5A PROVIDER NAME)'s/The doctors or other health professionals at (US3A PROVIDER NAME) use of the
computer during [my/(SP)'s] visit distracts [him/her/them] from paying attention to [me/(SP)].
SHOW CARD US6
COMPATT
EHR9
list
[(US5A PROVIDER NAME)'s/The doctors or other health professionals at (US3A PROVIDER NAME)] use of the
computer during [my/(SP)'s] visit distracts [me/(SP)] from paying attention to the clinician.
Code List
Routing
SHOW CARD US8
COMPTM
EHR10
code one
(01) Much more than it should be
For the next statement, please tell me if it's much more than it should be, somewhat more than it should be, about (02) Somewhat more than it should be
(03) About what it should be
what it should be, somewhat less than it should be, much less than it should be, or no opinion?
(04) Somewhat less than it should be
(05) Much less than it should be
The amount of time during the visit that (US5A PROVIDER NAME)/the doctors or other health professionals at
(06) No opinion
(US3A PROVIDER NAME) spend(s) on the computer seems:
BOX USEND
Page 12 of 13
2021 MCBS Community Questionnaire
USQ-Usual Source of Care
Variable Name
MR Screen Name
Question Type
NUSNOTSK
US39
list
Question Text/Description
I am going to read some reasons that people have given for not having a usual source of health care. For each
one, please tell me whether or not it is a reason [you do/(SP) does] not have a usual place for health care.
There is no reason to have a usual source of health care because [you/(SP)] seldom or never [get/gets] sick. [Is
that a reason [you do/(SP) does] not have a usual source of health care?]
Code List
Routing
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
US39 - NUSMOVIN
NUSMOVIN
US39
list
[You/(SP)] recently moved into the area. [Is that a reason [you do/(SP) does] not have a usual source of health
care?]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
US39 - NUSAVAIL
NUSAVAIL
US39
list
[Your/(SP’s)] usual source of health care in this area is no longer available. [Is that a reason [you do/(SP) does]
not have a usual source of health care?]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) US42 - USWHYNAV
(02) US43 - NUSDIFFP
(-8) US43 - NUSDIFFP
(-9) US43 - NUSDIFFP
(01) US43 - NUSDIFFP
(02) US43 - NUSDIFFP
(03) US43 - NUSDIFFP
(04) US43 - NUSDIFFP
(05) US43 - NUSDIFFP
(91) US42 - USWHYNO1
(-8) US43 - NUSDIFFP
(-9) US43 - NUSDIFFP
USWHYNAV
US42
code one
Why is [your/(SP’s)] usual source of health care no longer available?
(01) PREVIOUS DOCTOR RETIRED
(02) PREVIOUS DOCTOR DIED
(03) PREVIOUS DOCTOR MOVED
(04) SP MOVED
(05) PREVIOUS DR/PLACE TOO FAR AWAY
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
USWHYNO1
US42
verbatim text
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
US43 - NUSDIFFP
NUSDIFFP
US43
list
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
US43 - NUSTOOFR
Thinking about other possible reasons that people have for not having a usual source of health care, please tell
me if this statement applies to [you/(SP)]:
[You like/(SP) likes] to go to different places for different health care needs. [Is that a reason [you do/(SP) does]
not have a usual source of health care?]
NUSTOOFR
US43
list
The places where [you/(SP)] can receive health care are too far away. [Is that a reason [you do/(SP) does] not
have a usual source of health care?]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
US43 - NUSTOOEX
NUSTOOEX
US43
list
The cost of health care is too expensive. [Is that a reason [you do/(SP) does] not have a usual source of health
care?]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX USEND
BOX USEND
routing
GO TO END.
Page 13 of 13
File Type | application/pdf |
File Title | USQ.xlsx |
Author | Wishart-Marisa |
File Modified | 2020-11-10 |
File Created | 2020-11-10 |