CMS-P-0015A interviewer Remarks

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

IRQ-Interviewer Remarks

Question Type

Question Text/Description

Code List

Routing

INTERVIEWER REMARKS QUESTIONNAIRE SPECIFICATIONS
CRITERIA
(N/A)
PLACEMENT
(N/A)
IRCASEOK

IR1

no entry

THE COMMUNITY INTERVIEW FOR (SP) WAS CONDUCTED [WITH (PROXY NAME)] ON (INTERVIEW
COMPLETION DATE).

RRECHELP

IR3

yes/no

DID [(SP)/(PROXY NAME)] RECEIVE ANY HELP IN ANSWERING THE QUESTIONS?

IR3-RRECHELP
(01) YES
(02) NO

(01) IR4 - IRHELPER
(02) IR5 - RINFOSAT

(01-N) IR5 - RINFOSAT
(N+1) IR4-ROSTFNAM

IRHELPER

IR4

roster

WHO HELPED [(SP)/(PROXY NAME)] ANSWER THE QUESTIONS?
SELECT OR ADD ONLY ONE PERSON.

ROSTFNAM

IR4

text

[What is the name of the person and relationship to (SP)?]

(01) continuous answer

IR4-ROSTLNAM

ROSTLNAM

IR4

text

[What is the name of the person and relationship to (SP)?]

(01) continuous answer

IR4-ROSTREL

IF EXISTING PERSON SELECTED, GO TO IR5 RINFOSAT
ELSE IF "ADD ANOTHER" SELECTED, GO TO IR4ROSTFNAM

(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) IR5-RINFOSAT
(03) IR5-RINFOSAT
(04) IR5-RINFOSAT
(05) IR5-RINFOSAT
(06) IR5-RINFOSAT
(07) IR5-RINFOSAT
(08) IR5-RINFOSAT
(09) IR5-RINFOSAT
(10) IR5-RINFOSAT
(11) IR5-RINFOSAT
(12) IR5-RINFOSAT
(13) IR5-RINFOSAT
(14) IR5-RINFOSAT
(50) DO NOT DISPLAY
(51) IR5-RINFOSAT
(52) IR5-RINFOSAT
(53) IR5-RINFOSAT
(54) IR5-RINFOSAT
(55) IR5-RINFOSAT
(56) IR5-RINFOSAT
(57) IR5-RINFOSAT
(91) IR4 - ROSTREOS
(-8) IR5-RINFOSAT
(-9) IR5-RINFOSAT

ROSTREL

IR4

text

[What is the name of the person and relationship to (SP)?]

ROSTREOS

IR4

text

[What is the name of the person and relationship to (SP)?]

(01) continuous answer

IR5-RINFOSAT

RINFOSAT

IR5

yes/no

DO YOU FEEL THAT THE INFORMATION PROVIDED BY [(SP)/(PROXY NAME)] WAS SATISFACTORY?

(01) YES
(02) NO

(01) BOX IR3
(02) IR5OV - RINFOVB

verbatim text

WHICH OF THE FOLLOWING REASONS BELOW BEST DESCRIBES WHY YOU THINK THAT THE
INFORMATION PROVIDED WAS UNSATISFACTORY? SELECT ALL THAT APPLY.

(01) DON'T THINK RESPONDENT GAVE ACCURATE
INFORMATION
(02) DON'T THINK RESPONDENT GAVE
INFORMATION (OMITTED EVENT(S) OR
BOX IR3
STATEMENTS(S) ETC.)
(03) INFORMATION GIVEN BY THE RESPONDENT
APPEARED TO BE CONTRADICTORY (ANSWERS
DIDN'T ALIGN WITH STATEMENTS)

routing

IF SP'S PREVIOUS ROUND INTERVIEW WAS IN A FACILITY, GO TO BOX IR3A.
IF SP IS IN THE SUPPLEMENTAL SAMPLE, BOX IR3A2
IF THIS IS AN EXIT CASE AND THE PREVIOUS ROUND INTERVIEW WAS NOT SKIPPED, GO TO IR5C INTVTIME.
ELSE GO TO IR5A - REFERCAL.

RINFOVB

IR5OV

BOX IR3

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2019 MCBS Community Questionnaire

Variable Name

REFERCAL

STATEMENTTYPE

MR Screen Name

IRQ-Interviewer Remarks

Question Type

Question Text/Description

Code List

Routing

(01) YES- PLANNER PROVIDED BY MCBS
(02) YES- A PERSONAL CALENDAR OR PLANNER
(INCLUDING PAPER OR DIGITAL CALENDAR OR
BOX IR3A
PLANNER)
(03)
NO- DID NOT REFERENCE A CALENDAR OR
PLANNER

IR5A

verbatim text

DURING THE INTERVIEW, DID THE RESPONDENT/PROXY REFER TO ENTRIES MADE BY THE
RESPONDENT OR THE PROXY IN A CALENDAR OR PLANNER?

BOX IR3A

routing

IF INTTYPE IN(3) THEN GOTO BOX IR3A2.
ELSE GO TO IR5B-STATEMENTTYPE

code all

(01) FROM PAPER STATEMENT(S)
(02) FROM ELECTRONIC STATEMENT(S) PRINTED
BY RESPONDENT
(03) FROM ELECTRONIC STATEMENT(S) VIEWED
BOX IR3A1
HOW DID YOU OBTAIN STATEMENT INFORMATION FOR THIS INTERVIEW? SELECT ALL THAT APPLY. ON A COMPUTER OR OTHER ELECTRONIC
DEVICE
(04) FROM SOME OTHER WAY
(05) NO STATEMENTS COLLECTED DURING THIS
INTERVIEW

IR5B

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2019 MCBS Community Questionnaire

Variable Name

IRQ-Interviewer Remarks

MR Screen Name

Question Type

Question Text/Description

BOX IR3A1

routing

IF IR5B-STATEMENTTYPE INCLUDES (04) SOME OTHER WAY GOTO IR5B1-STATEMENTTYPEOTH,
IF IR5B-STATEMENTTYPE INCLUDES (01), (02), OR (03), GO TO IR5B2-STATEMENTBAG.
ELSE GOTO IR5C-INTVTIME.

Code List

Routing

(01) continuous answer

IR5C-INTVTIME

STATEMENTTYPEOT
IR5B1
H

verbatim text

STATEMENTBAG

IR5B2

select one

DID THE RESPONDENT UTILIZE THE FOLDER PROVIDED BY THE PROJECT TO STORE STATEMENTS?

BOX IR3A2

routing

IF INTTYPE=3, GO TO IRB3-REMEMLTR
ELSE GO TO IR5C-INTVTIME

REMEMLTR

IRB3

select one

AN ADVANCE LETTER ABOUT THIS STUDY WAS SENT DIRECTLY TO THE BENEFICIARY PRIOR TO
FIRST CONTACT. DID THE RESPONDENT REMEMBER SEEING THE ADVANCE LETTER?

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

IRB4-FIASKLTR

FIASKLTR

IRB4

select one

DID YOU MENTION THE ADVANCE LETTER TO THE RESPONDENT AS A GAINING COOPERATION
TOOL?

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

IR5C-INTVTIME

code one

HOW LONG WAS THIS INTERVIEW?
INCLUDE ALL THE TIME YOU SPENT INTERVIEWING IN THE RESPONDENT/PROXY’S HOME (AND/OR
ON THE PHONE WITH THE RESPONDENT/PROXY).

(01) LESS THAN 1 HOUR
(02) FROM 1-2 HOURS
(03) FROM 2-4 HOURS
(04) MORE THAN 4 HOURS

(01) BOX IR3B
(02) BOX IR3B
(03) IR5D - LT_REASON
(04) IR5D - LT_REASON

(01) BOX IR3B
(02) BOX IR3B
(03) BOX IR3B
(04) BOX IR3B
(05) BOX IR3B
(06) BOX IR3B
(07) BOX IR3B
(08)BOX IR3B
(91) IR5I - LT_OTHERWHY

BOX IR3B

INTVTIME

IR5C

IR5C-INTVTIME

LT_REASON

IR5D

code all

WHY DO YOU THINK THIS INTERVIEW TOOK AS LONG AS IT DID?
CHECK ALL THAT APPLY.

(01) HEAVY UTILIZATION
(02) MANY STATEMENTS
(03) STATEMENTS WERE DISORGANIZED
(04) STATEMENTS WERE ELECTRONIC AND HARD
TO ACCESS
(05) R HAD QUESTIONS COMPREHENSION
PROBLEMS
(06) R WAS TALKATIVE/RAMBLING
(07) MANY EXTERNAL INTERRUPTIONS
(08) ALWAYS TAKES THIS LONG
(91) OTHER

LT_OTHERWHY

IR5I

verbatim text

PLEASE PROVIDE MORE INFORMATION BELOW ABOUT THE LENGTH OF THE INTERVIEW.

(01) continuous answer

BOX IR3B

routing
IF THERE ARE ANY INSTRUCTIONS THAT WOULD ASSIST AN INTERVIEWER NEXT ROUND IN
REACHING THE RESPONDENT’S RESIDENCE (I.E. BUZZER DOES NOT WORK SO CALL, KNOCK ON
BACK DOOR, ETC.) PLEASE WRITE THEM IN THE BOX BELOW.
IF THERE ARE NONE, PLEASE SIMPLY HIT 'NEXT PAGE' BUTTON.

(01) continuous answer

IRDRIVE

IR6B

verbatim text

IR7OV - INTCVB

ARE THERE ANY (OTHER) COMMENTS YOU WOULD LIKE TO MAKE ABOUT THE RESPONDENT OR
INTERVIEWING SITUATION (THAT COULD HELP THE NEXT INTERVIEWER COMPLETE THIS CASE)?
PLEASE ADD ANY INFORMATION ABOUT EVENTS OR PLANS TO BE ADDED IN THE QUESTIONNAIRE
NEXT ROUND.
INTCVB

IR7OV

verbatim text

ADD INFORMATION ABOUT RESPONDENT'S HEALTH STATUS SUCH AS IF THEY MAY NEED A
PROXY NEXT ROUND OR IF YOU HAVE INDICATION THAT THE RESPONDENT MAY MOVE.

(01) continuous answer

IR10-SAVEIRQ

ADD ANY INFORMATION ABOUT HOW THE RESPONDENT STORES THEIR STATEMENTS. THIS
INCLUDES IF THE RESPONDENT KEEPS PRINTED STATEMENTS OR HAS ELECTRONIC VERSIONS.
CHARACTER LIMIT: 1042 [THIS SHOULD CHANGE BASED ON CHARACTERS ALREADY TYPED,
OVERALL LIMIT=1042]

SAVEIRQ

IR10

no entry

IRQ SESSION IS COMPLETE.

BOX IREND

routing

RETURN TO CM-FIELD

BOX IREND

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