Download:
pdf |
pdf2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
DENTAL, VISION, & HEARING CARE UTILIZATION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after HIQ.
The next questions are about any medical care [you/(SP)] may have had between (REFERENCE
DATE/UTILDATE) and (today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD).
DUINT
DUINTRO
no entry
(Now would be a good time to get out the planner that [you/(SP)] may have used to record health care visits or
other medical expenses. We will also refer to any statements [you/(SP)] may have received since the last
interview.)
DU1 - DUPROBE
First, we’ll talk about dental care.
DUPROBE
DU1
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to a dentist or any other person for dental care?
[Dental providers include dentists, dental surgeons, endodontists, periodontists, and dental hygienists.]
Who did [you/(SP)] see?
PROVIDER_DU
DU2
roster
SELECT OR ADD ONLY ONE PROVIDER.
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY
ENTERING AN EVENT WITH THAT PROVIDER
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) DU2 - PROVIDER_DU
(02) BOX DU5
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX DU5
(-9) BOX DU5
(01) [Continuous answer.]
(01-N) BOX DU1
(N+1) DU2B-PROVNAME
(N+2) CHNGSPL-CHNGSPL
[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
N+1. ADD ANOTHER
N+2. NEED TO EDIT SPELLING OF EXISTING PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME FOR
ALL PROVIDERS WHERE PROVNUM>02.
IF EXISTING PROVIDER SELECTED, GO TO BOX
DU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO DU2BPROVNAME
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPLCHNGSPL.
ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME BELOW.
YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL
BUT YOU DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION,
ENTER THE GROUP OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD
BLANK.
PROVNAME
DU2B
verbatim text
DU2B - GRPNAME
YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE
THE PROVIDER NAME IS ENTERED CORRECTLY.
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
NAME:
GRPNAME
DU2B
verbatim text
GROUP:
WHICH PROVIDER IS MISSPELLED?
CHNGSPL
CHNGSPL
roster
[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND 2. [PROVIDER 2]
SELECT "ADD ANOTHER."
…
N. [PROVIDER N]
ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER.
IF YOU ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME FOR
SELECT OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
ALL PROVIDERS WHERE PROVNUM>02.
PROVSPEC
CRCTSPL-CRCTSPL
Page 1 of 30
2021 MCBS Community Questionnaire
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Variable Name
MR Screen Name
Question Type
Question Text/Description
CRCTSPL
CRCTSPL
verbatim
WHAT IS THE CORRECT SPELLING OF THIS PROVIDER'S NAME?
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
(01) [Continuous Answer]
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]
PROVSPEC
DU2C
code one
Code List
Routing
BOX DU1
What kind of dental provider is [PROVNAME]?
(01) GENERAL DENTIST
(35) DENTAL HYGIENIST
(36) DENTAL TECHNICIAN
(37) DENTAL/ORAL SURGEON
(38) ORTHODONTIST
(39) ENDODONTIST
(40) PERIODONTIST
(41) PROSTHODONTIST
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX DU2
(02) BOX DU2
(03) BOX DU2
(04) BOX DU2
(05) BOX DU2
(06) BOX DU2
(07) BOX DU2
(08) BOX DU2
(91) DU2C1 - PROVSPEC
(-8) BOX DU2
(-9) BOX DU2
(01) DO NOT DISPLAY
(02) BOX DU2
(03) BOX DU2
(04) BOX DU2
(05) BOX DU2
(06) BOX DU2
(07) BOX DU2
(08) BOX DU2
(09) BOX DU2
(10) BOX DU2
(11) BOX DU2
(12) BOX DU2
(13) BOX DU2
(14) BOX DU2
(15) BOX DU2
(16) BOX DU2
(17) BOX DU2
(18) BOX DU2
(19) BOX DU2
(20) BOX DU2
(21) BOX DU2
(22) BOX DU2
(23) BOX DU2
(24) BOX DU2
(25) BOX DU2
(26) BOX DU2
(27) BOX DU2
(28) BOX DU2
(29) BOX DU2
(30) BOX DU2
(31) BOX DU2
(32) BOX DU2
(33) BOX DU2
(34) BOX DU2
(91) DU2D - PROVSPOS
(-8) BOX DU2
(-9) BOX DU2
BOX DU2
PROVSPEC
DU2C1
code one
What kind of dental provider is [PROVNAME]?
(01) DENTIST/DENTAL PROVIDER (DO NOT DISPLAY)
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused
PROVSPOS
DU2D
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
Page 2 of 30
2021 MCBS Community Questionnaire
Variable Name
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
MR Screen Name
Question Type
Question Text/Description
BOX DU1
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND
OR ANY PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO
TO DU3 - VAPLACE.
ELSE GO TO BOX DU2.
DU3
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?
BOX DU2
routing
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF
THIS PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO DU4 HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND
(THIS PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO DU5 - HMOREFER.
ELSE GO TO DU6 - EVENT_DU.
HMOASSOC
DU4
yes/no
HMOREFER
DU5
yes/no
VAPLACE
EVENT_DU
DU6
roster
Code List
Routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX DU2
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) DU6 - EVENT_DU
(02) DU5 - HMOREFER
(-8) DU5 - HMOREFER
(-9) DU5 - HMOREFER
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S)
BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
DU6 - EVENT_DU
When did [you/(SP)] see (PROVIDER NAME)? Please tell me all the dates [since (REFERENCE
DATE/(UTILDATE))/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE
ONLY ONCE.]
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT
"REPEAT VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.
HAVE ALL DATES BEEN ENTERED?
DUADD
DU6B
chose one
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS
DU6B-DUADD
(01) ADD ANOTHER
(02) ALL DONE
(01) DU6 -EVENT_DU
(02) DU7-DVPROCDR
Page 3 of 30
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
SHOW CARD DVH1
DVPROCDR
DU7
code all
For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.
Code List
Routing
(01) GENERAL EXAM, CHECKUP OR CONSULTATION
(02) CLEANING, PROPHYLAXIS, OR POLISHING
(03) X-RAYS, RADIOGRAPHS, OR BITEWINGS
(04) FLUORIDE TREATMENT
(05) SEALANT (PLASTIC COATINGS ON BACK TEETH)
(06) FILLINGS
(07) INLAYS
(08) CROWNS OR CAPS
(09) ROOT CANAL
(10) PERIODONTAL SCALING, ROOT PLANING, OR GUM
SURGERY
(11) PERIODONTAL RECALL VISIT (PERIODIC OR REGULAR)
(12) EXTRACTION, TOOTH PULLED
(13) IMPLANTS
(14) ABSCESS OR INFECTION TREATMENT
(15) OTHER ORAL SURGERY
(16) FIXED BRIDGES
(17) DENTURES OR REMOVABLE PARTIAL DENTURES
(18) RELINING OR REPAIR OF BRIDGES OR DENTURES
(19) ORTHODONTIA, BRACES, OR RETAINERS
(20) BOND, WHITEN, OR BLEACH
(21) TREATMENT FOR TMD OR TMJ
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
(01) DU9-PRESMDCN
(02) DU9-PRESMDCN
(03) DU9-PRESMDCN
(04) DU9-PRESMDCN
(05) DU9-PRESMDCN
(06) DU9-PRESMDCN
(07) DU9-PRESMDCN
(08) DU9-PRESMDCN
(09) DU9-PRESMDCN
(10) DU9-PRESMDCN
(11) DU9-PRESMDCN
(12) DU9-PRESMDCN
(13) DU9-PRESMDCN
(14) DU9-PRESMDCN
(15) DU9-PRESMDCN
(16) DU9-PRESMDCN
(17) DU9-PRESMDCN
(18) DU9-PRESMDCN
(19) DU9-PRESMDCN
(20) DU9-PRESMDCN
(21) DU9-PRESMDCN
(91) DU7A-EVOSTEXT
(-8) DU9-PRESMDCN
(-9) DU9-PRESMDCN
EVOSTEXT
DU7A
verbatim text
OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)
(01) [CONTINUOUS ANSWER]
DU9 - PRESMDCN
PRESMDCN
DU9
yes/no
Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) DU10 - PRESFILL
(02) BOX DU4
(-8) BOX DU4
(-9) BOX DU4
PRESFILL
DU10
yes/no
Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE
RESPONDENT ACTUALLY TOOK THE MEDICINE.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX DU3B
(02) BOX DU4
(-8) BOX DU4
(-9) BOX DU4
BOX DU3B
routing
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO DU10A - DUPMMEDS.
ELSE GO TO BOX PM2.
(01) INSTRUCTION WAS READ
BOX PM2
DUPMMEDS
DU10A
no entry
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can
spell the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)]
(MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same
information on them.]
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since (REFERENCE DATE/UTILDATE), if you’d like to get those bottles, too.
BOX PM2
routing
IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS
CASE, GO TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.
Page 4 of 30
2021 MCBS Community Questionnaire
Variable Name
MEDICINE_PM1
MR Screen Name
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
MEDICINE_PM1
code one
What is the name of the medicine?
BOX PM3
routing
IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
Code List
[DISPLAY MEDICINE ROSTER AS RESPONSE OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.
Routing
BOX PM3
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
The strength was [MEDICINE STRENGTH].
SAMEFSAM
SAMEFSAM
yes/no
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM4
(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.
PMBOTTLE
BOX PM4
routing
IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.
PMBOTTLE
code one
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS
PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS
ABOUT THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED
MEDICINE LOOKUP BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME
MED
lookup
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND
CORRECT, USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
[MEDICINE NAME SELECTED FROM LOOKUP OR MANUALLY
TYPED]
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
MED
lookup
[PM BRAND NAME]
PMGNNAME
MED
lookup
[PM GENERIC NAME]
PMFORMFD
MED
lookup
Medicine Form [FDB LIST FORM NAME]
PMFORMMC
MED
code one
Medicine Form [MCBS FORM]
(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS, DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(-8) MED-PMSTRNFD
(-9) MED-PMSTRNFD
Page 5 of 30
2021 MCBS Community Questionnaire
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Variable Name
MR Screen Name
Question Type
PMFORMOS
MED
verbatim
Question Text/Description
PMFORMFN
MED
verbatim
[FINAL CONCATENATED MEDICINE FORM]
PMSTRNFD
MED
verbatim
Medicine Strength
(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
STRNNUMBB
MED
numeric
Medicine strength number
(01) CONTINUOUS ANSWER
[MEDICINE FORM OTHER SPECIFY]
STRNUNIT
MED
code one
PMSTRNOS
MED
verbatim
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
PMSTRUNI
MED
ookup
[FINAL CONCATENATED MEDICINE STRENGTH]
PMEDID
MED
numeric
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH
THE LOOKUP. IT IS HIDDEN ON SCREEN.]
FAMILYID
MED
numeric
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
PMKNWNM
PMKNWNM
code one
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?
Medicine strength unit
What condition is this medicine prescribed for or what is its primary use?
PMCOND
PMCOND
code one
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
Code List
Routing
(01) CONTINUOUS ANSWER
(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(-8) Don't Know
(-9) Refused
(01)-(08) MED-PMEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID
(01) YES
(02) NO
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND
(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01)-(19) GETNUM-GETNUM
(20) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM
Page 6 of 30
2021 MCBS Community Questionnaire
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
PMCONDOS
PMCOND
verbatim
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE
OF INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
GETNUM
TABNUM
AMTUNIT
GETNUM
numeric
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND,
CHECK “ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF
REFILLS.]
Routing
(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
BOX PM5
BOX PM5
routing
IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
IF SAMEFSAM=1/YES AND PMFORMFN=pills (tablets, capsules), GO TO PM12-TABSADAY;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD
CONTAINS ("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTUNIT.
TABNUM
numeric
HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX PM6
quantity unit
HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]
(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW
(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
PM16 - AMTNUM
(01) CONTINUOUS ANSWER
BOX PM6
PM16
AMTUNOS
PM16
text
AMTNUM
PM16
numeric
BOX PM6
routing
IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?
TABSADAY
PM12
numeric
TABSADAY95
PM12
code one
IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX:
HALF A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN (01) CONTINUOUS ANSWER
IN A DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT
"OTHER DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty
PM12 - TABSADAY95
PM13-TABTAKE
Page 7 of 30
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]
(01) CONTINUOUS ANSWER
(-7) EMPTY
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF
(-8) DON'T KNOW
A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
TABTAKE
PM13
numeric
TABTAKE96
PM13
code one
BOX PM7
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND
OR ANY PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.
PMSATVA
yes/no
(01) YES
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of (02) NO
Veterans Affairs or V.A.?
(-8) DON'T KNOW
(-9) REFUSED
BOX PM8
routing
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.
PMSATVA
PMSATHMO
PMSATHMO
yes/no
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED
CARE PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE
PLAN NAME(S) BELOW]?
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]
([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE
NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.])
PMMORE
PM17
yes/no
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF
R ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we
haven't talked about?]
DUMORE
BOX DU4
routing
IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO DU7-DVPROCDR.
ELSE GO TO DU14-DUMORE.
DU14
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other dental care visits to this or any other
provider?
BOX DU5
routing
IF SPALIVE=1 (ALIVE) AND SEASON=WINTER, GO TO DU15-DVNEED. ELSE GO TO BOX DU6.
PM13 - TABTAKE96
BOX PM7
BOX PM8
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PMMORE-PMMORE
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX PM2
(02) BOX DU4
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) DU2 - PROVIDER_DU
(02) BOX DU5
(-8) BOX DU5
(-9) BOX DU5
Page 8 of 30
2021 MCBS Community Questionnaire
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
DVNEED
DU15
yes/no
Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], was there a time when
{you/SP} needed dental care but could not get it at that time?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) DU16 - DVNDRS
(02) BOX DU6
(-8) BOX DU6
(-9) BOX DU6
(01) BOX DU6
(02) BOX DU6
(03) BOX DU6
(04) BOX DU6
(05) BOX DU6
(06) BOX DU6
(07) BOX DU6
(08) BOX DU6
(09) BOX DU6
(10) BOX DU6
(91) DU16A - DVNDRSOS
(-8) BOX DU6
(-9) BOX DU6
DVNDRS
DU16
code all
What were the reasons that {you/SP} could not get the dental care {you/she/he} needed?
(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DENTAL OFFICE IS TOO FAR AWAY
(05) DENTAL OFFICE IS NOT OPEN AT CONVENIENT TIMES
(06) ANOTHER DENTIST RECOMMENDED NOT DOING IT
(07) AFRAID OR DO NOT LIKE DENTISTS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED DENTAL PROBLEMS TO GO AWAY
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
DVNDRSOS
DU16A
verbatim text
WHAT OTHER REASON (SPECIFY)
(01) continuous answer
BOX DU6
BOX DU6
routing
GO TO VU1-VUPROBE.
VU1
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to an eye doctor or any other person for eye care?
[Eye care providers include ophthalmologists, optometrists, and opticians.]
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) VU2 - PROVIDER_VU
(02) OM1-OMPREYEG
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) OM1-OMPREYEG
(-9) OM1-OMPREYEG
(01) [Continuous answer.]
(01-N) BOX VU1
(N+1) VU2B-PROVNAME
(N+2) CHNGSPL-CHNGSPL
VUPROBE
Who did [you/(SP)] see?
PROVIDER_VU
VU2
roster
SELECT OR ADD ONLY ONE PROVIDER.
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY
ENTERING AN EVENT WITH THAT PROVIDER
[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
N+1. ADD ANOTHER
N+2. NEED TO EDIT SPELLING OF EXISTING PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME FOR
ALL PROVIDERS WHERE PROVNUM>02.
IF EXISTING PROVIDER SELECTED, GO TO BOX
VU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO VU2PROVNAME.
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPL.CHNGSPL..
Page 9 of 30
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME BELOW.
YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL
BUT YOU DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION,
ENTER THE GROUP OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD
BLANK.
VPRVNAME
VU2B
verbatim text
VU2B - GRPNAME
YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE
THE PROVIDER NAME IS ENTERED CORRECTLY.
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
NAME:
VGRPNAME
VU2B
verbatim text
GROUP:
PROVSPEC
WHICH PROVIDER IS MISSPELLED?
CHNGSPL
CHNGSPL
roster
[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND 2. [PROVIDER 2]
SELECT "ADD ANOTHER."
…
N. [PROVIDER N]
ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER.
IF YOU ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME FOR
SELECT OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
ALL PROVIDERS WHERE PROVNUM>02.
CRCTSPL
CRCTSPL
verbatim
WHAT IS THE CORRECT SPELLING OF THIS PROVIDER'S NAME?
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
(01) [Continuous Answer]
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]
PROVSPEC
VU2C
code one
What kind of eye care provider is [PROVNAME]?
(02) MEDICAL DOCTOR, INCLUDING OPHTHALMOLOGIST
(16) OPTOMETRIST (OD)
(43) OPTICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED
CRCTSPL-CRCTSPL
BOX VU1
(02) BOX VU1
(16) BOX VU1
(43) BOX VU1
(91) VU2C1 - PROVSPEC
(-8) BOX VU1
(-9) BOX VU1
Page 10 of 30
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
(01) BOX VU1
(02) DO NOT DISPLAY
(03) BOX VU1
(04) BOX VU1
(05) BOX VU1
(06) BOX VU1
(07) BOX VU1
(08) BOX VU1
(09) BOX VU1
(10) BOX VU1
(11) BOX VU1
(12) BOX VU1
(13) BOX VU1
(14) BOX VU1
(15) BOX VU1
(16) DO NOT DISPLAY
(17) BOX VU1
(18) BOX VU1
(19) BOX VU1
(20) BOX VU1
(21) BOX VU1
(22) BOX VU1
(23) BOX VU1
(24) BOX VU1
(25) BOX VU1
(26) BOX VU1
(27) BOX VU1
(28) BOX VU1
(29) BOX VU1
(30) BOX VU1
(31) BOX VU1
(32) BOX VU1
(33) BOX VU1
(34) BOX VU1
(91) VU2D - PROVSPOS
(-8) BOX VU1
(-9) BOX VU1
PROVSPEC
VU2C1
code one
What kind of eye care provider is [PROVNAME]?
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD) (DO NOT DISPLAY)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused
PROVSPOS
VU2D
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
BOX VU1
BOX VU1
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND
OR ANY PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO
TO VU3 - VAPLACE.
ELSE GO TO BOX VU2.
VU3
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX VU2
BOX VU2
routing
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF
THIS PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO VU4 HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND
(THIS PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO VU5 - HMOREFER.
ELSE GO TO VU6 - EVENT_VU.
VU4
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) VU6 - EVENT_VU
(02) VU5 - HMOREFER
(-8) VU5 - HMOREFER
(-9) VU5 - HMOREFER
VAPLACE
HMOASSC
Page 11 of 30
2021 MCBS Community Questionnaire
Variable Name
HMOREFR
EVENT_VU
MR Screen Name
VU5
VU6
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
yes/no
roster
Question Text/Description
Code List
Routing
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S)
BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
VU6 - EVENT_VU
When did [you/(SP)] see (PROVIDER NAME)? Please tell me all the dates [since (REFERENCE
DATE/(UTILDATE))/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE
ONLY ONCE.]
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT
"REPEAT VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.
HAVE ALL DATES BEEN ENTERED?
VUADD
VU6B
chose one
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
SHOW CARD DVH2
VUPROCDR
VU7
code all
For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS
VU6B-VUADD
(01) ADD ANOTHER
(02) ALL DONE
(01) VU6 -EVENT_VU
(02) VU7-VUPROCDR
(01) EYE OR VISION EXAM
(02) CONTACT LENS FITTING
(03) CONTACT LENS PURCHASE
(04) EYE GLASS FRAME FITTING OR ADJUSTMENT
(05) EYE GLASS PURCHASE
(06) REFRACTIVE SURGERY (CORRECTIVE VISION SURGERY)
(07) CATARACT SURGERY
(08) GLAUCOMA SURGERY
(09) CORNEAL SURGERY
(10) VITREO-RETINAL SURGERY
(11) OCULOPLASTIC SURGERY
(12) EYE MUSCLE SURGERY
(13) EYE REMOVAL
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) VU9-PRESMDCN
(02) VU9-PRESMDCN
(03) VU9-PRESMDCN
(04) VU9-PRESMDCN
(05) VU9-PRESMDCN
(06) VU9-PRESMDCN
(07) VU9-PRESMDCN
(08) VU9-PRESMDCN
(09) VU9-PRESMDCN
(10) VU9-PRESMDCN
(11) VU9-PRESMDCN
(12) VU9-PRESMDCN
(13) VU9-PRESMDCN
(91) VU7A-EVOSTEXT
(-8) VU9-PRESMDCN
(-9) VU9-PRESMDCN
EVOSTEXT
VU7A
verbatim text
OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)
(01) [CONTINUOUS ANSWER]
VU9 - PRESMDCN
PRESMDCN
VU9
yes/no
Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) VU10 - PRESFILL
(02) BOX VU4
(-8) BOX VU4
(-9) BOX VU4
PRESFILL
VU10
yes/no
Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE
RESPONDENT ACTUALLY TOOK THE MEDICINE.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX VU3B
(02) BOX VU4
(-8) BOX VU4
(-9) BOX VU4
BOX VU3B
routing
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO VU10A - VUPMMEDS.
ELSE GO TO BOX PM2.
Page 12 of 30
2021 MCBS Community Questionnaire
Variable Name
VUPMMEDS
MR Screen Name
VU10A
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
no entry
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can
spell the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)]
(MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same
information on them.]
(01) INSTRUCTION WAS READ
BOX PM2
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since (REFERENCE DATE/UTILDATE), if you’d like to get those bottles, too.
BOX PM2
MEDICINE_PM1
routing
IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS
CASE, GO TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.
MEDICINE_PM1
code one
What is the name of the medicine?
BOX PM3
routing
IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
[DISPLAY MEDICINE ROSTER AS RESPONSE OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.
BOX PM3
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
The strength was [MEDICINE STRENGTH].
SAMEFSAM
SAMEFSAM
yes/no
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM4
(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.
PMBOTTLE
BOX PM4
routing
IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.
PMBOTTLE
code one
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS
PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS
ABOUT THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
Page 13 of 30
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED
MEDICINE LOOKUP BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME
MED
lookup
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND
CORRECT, USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
[MEDICINE NAME SELECTED FROM LOOKUP OR MANUALLY
TYPED]
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
MED
lookup
[PM BRAND NAME]
PMGNNAME
MED
lookup
[PM GENERIC NAME]
PMFORMFD
MED
lookup
Medicine Form [FDB LIST FORM NAME]
Medicine Form [MCBS FORM]
(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS, DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
PMFORMMC
MED
code one
PMFORMOS
MED
verbatim
PMFORMFN
MED
verbatim
[FINAL CONCATENATED MEDICINE FORM]
PMSTRNFD
MED
verbatim
Medicine Strength
(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
STRNNUMBB
MED
numeric
Medicine strength number
(01) CONTINUOUS ANSWER
[MEDICINE FORM OTHER SPECIFY]
STRNUNIT
MED
code one
PMSTRNOS
MED
verbatim
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
PMSTRUNI
MED
ookup
[FINAL CONCATENATED MEDICINE STRENGTH]
Medicine strength unit
(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(01) CONTINUOUS ANSWER
(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(-8) Don't Know
(-9) Refused
(01)-(08) MED-PMEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID
Page 14 of 30
2021 MCBS Community Questionnaire
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Variable Name
MR Screen Name
Question Type
Question Text/Description
PMEDID
MED
numeric
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH
THE LOOKUP. IT IS HIDDEN ON SCREEN.]
FAMILYID
MED
numeric
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
PMKNWNM
PMKNWNM
code one
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?
What condition is this medicine prescribed for or what is its primary use?
PMCOND
PMCOND
code one
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
PMCONDOS
PMCOND
verbatim
GETNUM
GETNUM
numeric
OTHER (SPECIFY)
How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE
OF INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
BOX PM5
routing
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND,
CHECK “ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF
REFILLS.]
Code List
Routing
(01) YES
(02) NO
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND
(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01)-(19) GETNUM-GETNUM
(20) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
BOX PM5
IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
IF SAMEFSAM=1/YES AND PMFORMFN=pills (tablets, capsules), GO TO PM12-TABSADAY;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD
CONTAINS ("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTUNIT.
Page 15 of 30
2021 MCBS Community Questionnaire
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
TABNUM
TABNUM
numeric
HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX PM6
(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6
AMTUNIT
PM16
quantity unit
HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]
(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW
AMTUNOS
PM16
text
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
PM16 - AMTNUM
AMTNUM
PM16
numeric
(01) CONTINUOUS ANSWER
BOX PM6
BOX PM6
routing
IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?
TABSADAY
PM12
numeric
TABSADAY95
PM12
code one
IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX:
HALF A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN (01) CONTINUOUS ANSWER
IN A DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT
"OTHER DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty
PM12 - TABSADAY95
PM13-TABTAKE
How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]
TABTAKE
PM13
numeric
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF
A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS"
TABTAKE96
PM13
code one
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
PM13 - TABTAKE96
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
BOX PM7
Page 16 of 30
2021 MCBS Community Questionnaire
Variable Name
PMSATVA
PMSATHMO
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
MR Screen Name
Question Type
Question Text/Description
BOX PM7
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND
OR ANY PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.
PMSATVA
yes/no
(01) YES
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of (02) NO
Veterans Affairs or V.A.?
(-8) DON'T KNOW
(-9) REFUSED
BOX PM8
routing
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.
PMSATHMO
yes/no
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED
CARE PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE
PLAN NAME(S) BELOW]?
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]
([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE
NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.])
PMMORE
PM17
yes/no
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF
R ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we
haven't talked about?]
VUMORE
BOX VU4
routing
IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO VU7-VUPROCDR.
ELSE GO TO VU14-VUMORE.
VU14
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other eye care visits to this or any other
provider?
Code List
Routing
BOX PM8
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PMMORE-PMMORE
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX PM2
(02) BOX VU4
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) VU2 - PROVIDER_VU
(02) OM1-OMPREYEG
(-8) OM1-OMPREYEG
(-9) OM1-OMPREYEG
Next I’m going to ask you about other medical expenses related to vision care that [you/(SP)] may have had
[between (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
OMPREYEG
OM1
yes/no
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE
(01) YES
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy, replace, or pay for repairs of eyeglasses or contact (03) INDICATED YES BY DATAPREP
lenses?
(-8) Don't Know
(-9) Refused
[Please include the purchases you made during the visit(s) to eye care providers on (EVENT DATES) that you
just told me about.]
(01) OM1B-VUTYPE
(02) BOX VU5
(03) DO NOT DISPLAY.
(-8) BOX VU5
(-9) BOX VU5
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
Page 17 of 30
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
What did [you/(SP)] buy or repair?
VUTYPE
OM1B
code all
FOR EACH DATE, CHECK ALL THAT APPLY. THE DATE WILL BE ENTERED ON THE NEXT SCREEN.
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair glasses or contact lenses?
EVENT_OMEYEG
OM2
roster
Please tell me all the dates [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
OMADD
OM2AA
code one
Code List
Routing
(01) BUY EYEGLASS LENSES
(02) BUY EYEGLASS FRAMES
(03) BUY CONTACT LENSES
(04) REPAIR EYEGLASSES
(-8) DON'T KNOW
(-9) REFUSED
OM2-EVENT_OMEYEG
(01) continuous answer
(-8) Don't Know
(-9) Refused
BOX OM1AA
MM:
DD:
YYYY:
In addition to the medical expenses related to vision care you just told me about, did [you/(SP)] buy, replace, or
pay for repairs for any other eyeglasses or contact lenses [since (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
(01) ADD ANOTHER
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]?
(02) ALL DONE
(01) OM1B - VUTYPE
(02) BOX OM1AA
[DISPLAY ALL EVENTS ENTERED]
BOX OM1AA
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM2A-OMSATHMO.
ELSE GO TO BOX OM1AA2.
On (EVENT DATE), did [you/(SP)] buy or repair the glasses or contact lenses at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?
OMSATHMO
OM2A
yes/no
(01) YES
(02) NO
[PROBE: This could include buying or repairing the glasses or lenses at a plan center; at an optician,
(-8) Don't Know
optometrist or other place that honors [your/(SP’s)] plan card; or through a place or service that the plan referred
(-9) Refused
[you/(SP)] to.]
BOX OM1AA2
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
BOX OM1AA2
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX VU5.
BOX VU5
routing
IF SPALIVE=1 (ALIVE) AND SEASON=WINTER, GO TO VU15-VUNEED.
ELSE GO TO BOX VU6.
Page 18 of 30
2021 MCBS Community Questionnaire
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
VUNEED
VU15
yes/no
Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], was there a time when
{you/SP} needed vision care but could not get it at that time?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) VU16 - VUVNDRS
(02) BOX VU6
(-8) BOX VU6
(-9) BOX VU6
(01) BOX VU6
(02) BOX VU6
(03) BOX VU6
(04) BOX VU6
(05) BOX VU6
(06) BOX VU6
(07) BOX VU6
(08) BOX VU6
(09) BOX VU6
(10) BOX VU6
(91) VU16A - VUVNDRSOS
(-8) BOX VU6
(-9) BOX VU6
BOX VU6
VUVNDRS
VU16
code all
What were the reasons that {you/SP} could not get the vision care {you/she/he} needed?
(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DOCTOR'S OFFICE IS TOO FAR AWAY
(05) DOCTOR'S OFFICE IS NOT OPEN AT CONVENIENT TIMES
(06) ANOTHER DOCTOR RECOMMENDED NOT DOING IT
(07) AFRAID OR DO NOT LIKE DOCTORS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED PROBLEMS TO GO AWAY
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
VUVNDRSOS
VU16A
verbatim text
WHAT OTHER REASON (SPECIFY)
(01) continuous answer
BOX VU6
routing
GO TO HU1-HUPROBE
HU1
yes/no
(01) YES
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to a doctor or any other person for hearing care?
(03) INDICATED YES BY DATAPREP
[Hearing care providers include otorhinolaryngologists (ear nose and throat doctors), otologists, neurotologists,
(-8) Don't Know
audiologists, audiometrists, and hearing instrument specialists.]
(-9) Refused
HUPROBE
(01) [Continuous answer.]
Who did [you/(SP)] see?
PROVIDER_HU
HU2
roster
SELECT OR ADD ONLY ONE PROVIDER.
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY
ENTERING AN EVENT WITH THAT PROVIDER
[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
N+1. ADD ANOTHER
N+2. NEED TO EDIT SPELLING OF EXISTING PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME FOR
ALL PROVIDERS WHERE PROVNUM>02.
(01) HU2 - PROVIDER_HU
(02) HU15--OMHEARAD
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) OM3-OMPRHEAR
(-9) OM3-OMPRHEAR
(01-N) BOX HU1
(N+1) HU2B-PROVNAME
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX
HU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO HU2PROVNAME
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPL.CHNGSPL.
Page 19 of 30
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME BELOW.
YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL
BUT YOU DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION,
ENTER THE GROUP OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD
BLANK.
HPRVNAME
HU2B
verbatim text
HU2B - GRPNAME
YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE
THE PROVIDER NAME IS ENTERED CORRECTLY.
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
NAME:
HGRPNAM
HU2B
verbatim text
GROUP:
PROVSPEC
WHICH PROVIDER IS MISSPELLED?
CHNGSPL
CHNGSPL
roster
[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND 2. [PROVIDER 2]
SELECT "ADD ANOTHER."
…
N. [PROVIDER N]
ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER.
IF YOU ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME FOR
SELECT OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
ALL PROVIDERS WHERE PROVNUM>02.
CRCTSPL
CRCTSPL
verbatim
WHAT IS THE CORRECT SPELLING OF THIS PROVIDER'S NAME?
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
(01) [Continuous Answer]
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]
PROVSPEC
HU2C
code one
What kind of hearing care provider is [PROVNAME]?
(02) MEDICAL DOCTOR, INCLUDING OTOLARYNGOLOGIST
(ENT), OTOLOGIST, NEUROTOLOGIST
(03) AUDIOLOGIST
(44) AUDIOMETRIST
(45) HEARING INSTRUMENT SPECIALIST
(91) OTHER
(-8) Don't Know
(-9) Refused
CRCTSPL-CRCTSPL
BOX HU1
(02) BOX HU1
(03) BOX HU1
(44) BOX HU1
(45) BOX HU1
(91) HU2C1 - PROVSPEC
(-8) BOX HU1
(-9) BOX HU1
Page 20 of 30
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
(01) BOX HU1
(02) DO NOT DISPLAY
(03) DO NOT DISPLAY
(04) BOX HU1
(05) BOX HU1
(06) BOX HU1
(07) BOX HU1
(08) BOX HU1
(09) BOX HU1
(10) BOX HU1
(11) BOX HU1
(12) BOX HU1
(13) BOX HU1
(14) BOX HU1
(15) BOX HU1
(16) BOX HU1
(17) BOX HU1
(18) BOX HU1
(19) BOX HU1
(20) BOX HU1
(21) BOX HU1
(22) BOX HU1
(23) BOX HU1
(24) BOX HU1
(25) BOX HU1
(26) BOX HU1
(27) BOX HU1
(28) BOX HU1
(29) BOX HU1
(30) BOX HU1
(31) BOX HU1
(32) BOX HU1
(33) BOX HU1
(34) BOX HU1
(91) HU2D - PROVSPOS
(-8) BOX HU1
(-9) BOX HU1
PROVSPEC
HU2C1
code one
What kind of hearing care provider is [PROVNAME]?
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST (DO NOT DISPLAY)
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused
PROVSPOS
HU2D
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
BOX HU1
BOX HU1
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND
OR ANY PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO
TO HU3 - VAPLACE.
ELSE GO TO BOX HU2.
HU3
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HU2
routing
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF
THIS PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO HU4 HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND
(THIS PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO HU5 - HMOREFER.
ELSE GO TO HU6 - EVENT_HU.
VAPLACE
BOX HU2
Page 21 of 30
2021 MCBS Community Questionnaire
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
HMOASSC
HU4
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HU6 - EVENT_HU
(02) HU5 - HMOREFER
(-8) HU5 - HMOREFER
(-9) HU5 - HMOREFER
HMOREFR
HU5
yes/no
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S)
BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HU6 - EVENT_HU
EVENT_HU
HU6
roster
When did [you/(SP)] see (PROVIDER NAME)? Please tell me all the dates [since (REFERENCE
DATE/(UTILDATE))/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE
ONLY ONCE.]
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT
"REPEAT VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.
HAVE ALL DATES BEEN ENTERED?
HUADD
HU6B
chose one
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
SHOW CARD DVH3
HUPROCDR
HU7
code all
For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.
EVOSTEXT
HU7A
verbatim text
OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS
HU6B-HUADD
(01) ADD ANOTHER
(02) ALL DONE
(01) HU6 -EVENT_HU
(02) HU7 - DVPROCDR
(01) HEARING AID FITTING/EVALUATION
(02) HEARING AID PURCHASE/REPAIR
(03) HEARING EXAM
(04) EAR WAX REMOVAL
(05) EAR VENTILATION TUBES
(06) TYMPANOPLASTY (RECONSTRUCTION OF EAR DRUM)
(07) COCHLEAR IMPLANT SURGERY
(08) HEARING REHABILITATIVE SERVICES
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) HU9-PRESMDCN
(02) HU9-PRESMDCN
(03) HU9-PRESMDCN
(04) HU9-PRESMDCN
(05) HU9-PRESMDCN
(06) HU9-PRESMDCN
(07) HU9-PRESMDCN
(91) HU7A-EVOSTEXT
(-8) HU9-PRESMDCN
(-9) HU9-PRESMDCN
(01) [CONTINUOUS ANSWER]
HU9 - PRESMDCN
Page 22 of 30
2021 MCBS Community Questionnaire
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
PRESMDCN
HU9
yes/no
Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HU10 - PRESFILL
(02) BOX HU4
(-8) BOX HU4
(-9) BOX HU4
PRESFILL
HU10
yes/no
Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE
RESPONDENT ACTUALLY TOOK THE MEDICINE.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HU3B
(02) BOX HU4
(-8) BOX HU4
(-9) BOX HU4
BOX HU3B
routing
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO HU10A - HUPMMEDS.
ELSE GO TO BOX PM2.
(01) INSTRUCTION WAS READ
BOX PM2
[DISPLAY MEDICINE ROSTER AS RESPONSE OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.
BOX PM3
HUPMMEDS
HU10A
no entry
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can
spell the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)]
(MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same
information on them.]
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since (REFERENCE DATE/UTILDATE), if you’d like to get those bottles, too.
BOX PM2
MEDICINE_PM1
routing
IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS
CASE, GO TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.
MEDICINE_PM1
code one
What is the name of the medicine?
BOX PM3
routing
IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
Page 23 of 30
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM4
(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
The strength was [MEDICINE STRENGTH].
SAMEFSAM
SAMEFSAM
yes/no
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.
PMBOTTLE
BOX PM4
routing
IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.
PMBOTTLE
code one
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS
PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS
ABOUT THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED
MEDICINE LOOKUP BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME
MED
lookup
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND
CORRECT, USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
[MEDICINE NAME SELECTED FROM LOOKUP OR MANUALLY
TYPED]
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
MED
lookup
[PM BRAND NAME]
PMGNNAME
MED
lookup
[PM GENERIC NAME]
PMFORMFD
MED
lookup
Medicine Form [FDB LIST FORM NAME]
Page 24 of 30
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
Medicine Form [MCBS FORM]
(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS, DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
PMFORMMC
MED
code one
PMFORMOS
MED
verbatim
PMFORMFN
MED
verbatim
[FINAL CONCATENATED MEDICINE FORM]
PMSTRNFD
MED
verbatim
Medicine Strength
(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
STRNNUMBB
MED
numeric
Medicine strength number
(01) CONTINUOUS ANSWER
[MEDICINE FORM OTHER SPECIFY]
STRNUNIT
MED
code one
PMSTRNOS
MED
verbatim
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
PMSTRUNI
MED
lookup
[FINAL CONCATENATED MEDICINE STRENGTH]
PMEDID
MED
numeric
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH
THE LOOKUP. IT IS HIDDEN ON SCREEN.]
FAMILYID
MED
numeric
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
Medicine strength unit
(01) CONTINUOUS ANSWER
(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(-8) Don't Know
(-9) Refused
(01)-(08) MED-PMEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID
Page 25 of 30
2021 MCBS Community Questionnaire
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
PMKNWNM
PMKNWNM
code one
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?
(01) YES
(02) NO
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND
(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01)-(19) GETNUM-GETNUM
(20) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM
What condition is this medicine prescribed for or what is its primary use?
PMCOND
PMCOND
code one
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
PMCONDOS
PMCOND
verbatim
OTHER (SPECIFY)
How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE
OF INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
GETNUM
GETNUM
BOX PM5
numeric
routing
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND,
CHECK “ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF
REFILLS.]
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
BOX PM5
IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
IF SAMEFSAM=1/YES AND PMFORMFN=pills (tablets, capsules), GO TO PM12-TABSADAY;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD
CONTAINS ("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTUNIT.
Page 26 of 30
2021 MCBS Community Questionnaire
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
TABNUM
TABNUM
numeric
HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX PM6
(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6
AMTUNIT
PM16
quantity unit
HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]
(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW
AMTUNOS
PM16
text
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
PM16 - AMTNUM
AMTNUM
PM16
numeric
(01) CONTINUOUS ANSWER
BOX PM6
BOX PM6
routing
IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?
TABSADAY
PM12
numeric
TABSADAY95
PM12
code one
IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX:
HALF A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN (01) CONTINUOUS ANSWER
IN A DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT
"OTHER DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty
PM12 - TABSADAY95
PM13-TABTAKE
How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]
TABTAKE
PM13
numeric
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF
A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
PM13 - TABTAKE96
Page 27 of 30
2021 MCBS Community Questionnaire
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Variable Name
MR Screen Name
Question Type
TABTAKE96
PM13
code one
BOX PM7
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND
OR ANY PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.
PMSATVA
yes/no
(01) YES
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of (02) NO
Veterans Affairs or V.A.?
(-8) DON'T KNOW
(-9) REFUSED
BOX PM8
routing
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.
PMSATHMO
yes/no
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.
PMSATVA
PMSATHMO
Question Text/Description
([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE
NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.])
PMMORE
PM17
yes/no
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF
R ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we
haven't talked about?]
HUMORE
BOX HU4
routing
IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO HU7-HUPROCDR.
ELSE GO TO HU14-HUMORE.
HU14
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other hearing care visits to this or any other
provider?
Code List
Routing
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
BOX PM7
BOX PM8
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PMMORE-PMMORE
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX PM2
(02) BOX HU4
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HU2 - PROVIDER_HU
(02) HU15-OMHEARAD
(-8) HU15-OMHEARAD
(-9) HU15-OMHEARAD
Page 28 of 30
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
Question Type
Question Text/Description
Code List
Routing
Next I’m going to ask you about other medical expenses related to hearing care that [you/(SP)] may have had
[between (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
OMHEARAD
HU15
yes/no
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy, replace, or pay for repairs of a hearing aid?
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
[Please include the purchases you made during the visit(s) to hearing care provider on (EVENT DATES) that yo(-9) Refused
just told me about.]
(01) HU16-INTHECANL
(02) BOX HU9
(03) DO NOT DISPLAY.
(-8) BOX HU9
(-9) BOX HU9
[DO NOT INCLUDE HEARING AID BATTERIES AT THIS QUESTION. ENTER HEARING AID BATTERIES IN
THE OMQ AS A HEARING/SPEECH DEVICE.]
SHOW CARD DVH4
What type of hearing aid(s) did [you/(SP)] buy or repair?
INTHCANL
HU16B
list
[IF NEEDED: Were they for [your/(SP’s)] left ear, right ear, or both?]
FOR EACH DATE, CHECK ALL THAT APPLY. THE DATE WILL BE ENTERED ON THE NEXT SCREEN.
(01) LEFT EAR
(02) RIGHT EAR
(-8) Don't Know
(-9) Refued
HU16-INTHEEAR
In the canal hearing aid
INTHEEAR
HU16B
list
In the ear hearing aid
(01) LEFT EAR
(02) RIGHT EAR
(-8) Don't Know
(-9) Refued
HU16-BHNDEAR
BHNDEAR
HU16B
list
Behind the ear hearing aid
(01) LEFT EAR
(02) RIGHT EAR
(-8) Don't Know
(-9) Refued
HU17-EVENT_OMHRAD
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair the (HEARING AID ITEM)?
(01) continuous answer
(-8) Don't Know
(-9) Refused
EVENT_OMHRAD
OMADD
HU17
HU18
roster
code one
Please tell me the dates of each purchase or repair [since (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
MM:
DD:
YYYY:
In addition to the medical expenses related to hearing care you just told me about, did [you/(SP)] buy, replace,
pay for repairs for any other hearing aids? [since (REFERENCE DATE/SURVEY REFERENCE
(01) ADD ANOTHER
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
(02) ALL DONE
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]?
HU18-OMADD
(01) HU16- INTHCANL
(02) BOX HU6
[DISPLAY ALL EVENTS ENTERED]
Page 29 of 30
2021 MCBS Community Questionnaire
Variable Name
OMSATHMO
HVNEED
DVH- DENTAL, VISION, HEARING CARE UTILIZATION
MR Screen Name
Question Type
Question Text/Description
Code List
BOX HU6
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO HU19-OMSATHMO.
ELSE GO TO BOX HU8.
HU19
yes/no
On (EVENT DATE), did [you/(SP)] buy or repair the hearing aid at [READ MANAGED CARE PLAN NAME(S)
(01) YES
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could include buying or repairing the hearing aid at a plan center; from an audiologist, or other
(-9) Refused
provider that honors [your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
BOX HU8
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX HU9.
BOX HU9
routing
IF SPALIVE=1 (ALIVE) AND SEASON=WINTER, GO TO HU20-HVNEED.
ELSE GO TO BOX HU10.
HU20
yes/no
Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], was there a time when
{you/SP} needed hearing care but could not get it at that time?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HU21- HVNDRS
(02) BOX HU10
(-8) BOX HU10
(-9) BOX HU10
(01) BOX HU10
(02) BOX HU10
(03) BOX HU10
(04) BOX HU10
(05) BOX HU10
(06) BOX HU10
(07) BOX HU10
(08) BOX HU10
(09) BOX HU10
(10) BOX HU10
(91) HU16A - HVNDRSOS
(-8) BOX HU10
(-9) BOX HU10
BOX HU10
HVNDRS
HU21
code all
What were the reasons that {you/SP} could not get the hearing care {you/she/he} needed?
(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DOCTOR'S OFFICE IS TOO FAR AWAY
(05) DOCTOR'S OFFICE IS NOT OPEN AT CONVENIENT TIMES
(06) ANOTHER DOCTOR RECOMMENDED NOT DOING IT
(07) AFRAID OR DO NOT LIKE DOCTORS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED PROBLEMS TO GO AWAY
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
HVNDRSOS
HU21A
verbatim text
WHAT OTHER REASON (SPECIFY)
(01) continuous answer
BOX HU10
routing
GO TO EMERGENCY ROOM UTILIZATION (ERQ).
Routing
BOX HU8
Page 30 of 30
| File Type | application/pdf |
| File Title | DVH.xlsx |
| Author | Wishart-Marisa |
| File Modified | 2020-11-10 |
| File Created | 2020-11-10 |