CMS-P-0015A Preventive Care

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

PVQ- PREVENTIVE CARE

Question Type

Question Text/Description

Code List

Routing

PREVENTIVE CARE QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=ALL
SPALIVE=1
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
If INTTYPE in (C001, C002, C003, C004, C005, C006) and SEASON=FALL, administer after MBQ.
If INTTYPE in (C001, C004, C005) and SEASON=WINTER or SUMMER, administer after CPS
If INTTYPE in (C002, C006, C007, C010) and SEASON=SUMMER or WINTER, administer after NSQ

BOX PVBEG

routing

IF RESPONDENT IS DECEASED, GO TO BOX PVEND.
ELSE IF SEASON=FALL, GO TO PV8 - PREVHLTHINTRO.
ELSE IF (SEASON=WINTER), GO TO PVINT-PVINTRO.
ELSE IF (SEASON=SUMMER) AND (WINTER ROUND RESONSE TO PVF1-FLUSHOT^=1/YES), GO TO
PVINT-PVINTRO.
ELSE IF (SEASON=SUMMER) AND (WINTER ROUND RESONSE TO PVF1-FLUSHOT=1/YES), GO TO
BOX PV4.

PVINTRO

PVINT

No entry

IF SEASON=WINTER, FILL "Now I’d like to ask you some questions about the seasonal flu vaccine."
ELSE IF SEASON=SUMMER, FILL "At the time of the last interview, we recorded that [you/(SP)] had not
gotten a flu vaccination for the [CURRENT YEAR MINUS 1] - [CURRENT YEAR] flu season."

FLUSHOT

PVF1

yes/no

Since [July 1st, (CURRENT YEAR MINUS 1)/[MREFDATE]], [have you/has (SP)] had a seasonal flu
vaccination?
IF THE RESPONDENT MENTIONS A SHORT NEEDLE OR NEEDLELESS INJECTOR, CODE AS “YES”.

BOX PV1

routing

PVF1-FLUSHOT

(01) YES
(02) NO
(-8) DON’T KNOW
(-9) REFUSED

(01) FLUSITE-FLUSITE
(02) BOX PV1
(-8) BOX PV4
(-9) BOX PV4

IF SEASON=WINTER OR (IF SEASON=SUMMER AND P_FLUSHOT in (., -7, -8), GO TO PVF2-FLUCODE.
ELSE GO TO BOX PV4.

Page 1 of 7

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

PVQ- PREVENTIVE CARE

Question Type

Question Text/Description

For what reason didn't [you/(SP)] get a seasonal flu vaccination since July 1st?

Code List

Routing

(01) I WAS SICK WITH FLU SO I DON’T’ NEED THE
VACCINE
(02) I DIDN’T KNOW THE VACCINE WAS NEEDED
(03) THE VACCINE COULD GIVE ME FLU
(04) THE VACCINE COULD HAVE SIDE EFFECTS
OR IS NOT SAFE
(05) I DON’T THINK THE VACCINE WILL PREVENT
THE FLU
(06) FLU IS NOT SERIOUS
(07) MY DOCTOR DID NOT TELL ME THAT I
SHOULD GET THE VACCINE
(08) MY DOCTOR TOLD ME NOT TO GET THE
VACCINE
(09) I DON'T LIKE VACCINES OR NEEDLES
(10) I COULDN’T GET TO THE PLACE WHERE THEY
WERE OFFERING THE VACCINE
(11) I COULDN’T FIND A PLACE THAT WAS
OFFERING THE VACCINE
(12) I FORGOT
(13) I COULDN’T AFFORT THE VACCINE
(14) I HAD VACCINE BEFORE AND DON’T NEED TO
GET IT AGAIN
(15) THE VACCINE WAS NOT AVAILABLE
(16) THE VACCINE IS NOT WORTH THE MONEY
(17) I DIDN'T HAVE TIME TO GET THE VACCINE
(18) I’M NOT IN A HIGH RISK/PRIORITY GROUP
(19) I HAVE AN ONGOING HEALTH
CONDITION/ALLERGE/MEDICAL REASON THAT
PREVENT ME FROM GETTING THE VACCINE
(20) I DON'T TRUST WHAT GOVERNMENT SAYS
ABOUT VACCINE
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX PV2
(02) BOX PV2
(03) BOX PV2
(04) BOX PV2
(05) BOX PV2
(06) BOX PV2
(07) BOX PV2
(08) BOX PV2
(09) BOX PV2
(10) BOX PV2
(11) BOX PV2
(12) BOX PV2
(13) BOX PV2
(14) BOX PV2
(15) BOX PV2
(16) BOX PV2
(17) BOX PV2
(18) BOX PV2
(19) BOX PV2
(20) BOX PV2
(91) PVF2 - FLUOTHOS
(-8) BOX PV2
(-9) BOX PV2

FLUCODE

PVF2

code all

FLUOTHOS

PVF2

verbatim text

OTHER (SPECIFY)

BOX PV2

routing

IF MORE THAN ONE RESPONSE SELECTED AS YES AT PVF2-FLUCODE, GO TO PVF3-PVFLU3, ELSE
GO TO BOX PV3

PVF3

code 1

BOX PV3

routing

IF RESPONSE TO PVF2-FLUCODE DOES NOT INCLUDE 15, GO TO PVF5-VACAVAIL..
ELSE GO TO BOX PV4.

(01) VACPAID - VACPAID
(02) VACPAID - VACPAID
(03) VACPAID - VACPAID
(04) VACPAID - VACPAID
(05) VACPAID - VACPAID
(06) VACPAID - VACPAID
(07) VACPAID - VACPAID
(08) VACPAID - VACPAID
(09) VACPAID - VACPAID
(10) VACPAID - VACPAID
(11) VACPAID - VACPAID
(12) VACPAID - VACPAID
(13) VACPAID - VACPAID
(14) VACPAID - VACPAID
(15) VACPAID - VACPAID
(16) VACPAID - VACPAID
(17) VACPAID - VACPAID
(18) VACPAID - VACPAID
(19) VACPAID - VACPAID
(91) FLUSITOS - FLUSITOS
(-8) VACPAID - VACPAID
(-9) VACPAID - VACPAID

VACPAID - VACPAID

[PROBE: Any other reason?]
CHECK ALL THAT APPLY.

Of the reasons you listed, what is the main reason [you/(SP)] did not get a flu vaccination this flu season?
PVFLU3

READ LIST TO RESPONDENT. IF RESPONDENT SELECTS MORE THAN ONE REASON PROBE FOR
MAIN REASON.

BOX PV2

[LIST ALL RESPONSES SELECTED AT PVF2FLUCODE]
_ _ [ENTER MAIN REASON]
(-8) DON’T KNOW
(-9) REFUSED

FLUSITE

FLUSITE

code all

(01) DOCTORS OFFICE OR GROUP PRACTICE
(02) MEDICAL CLINIC
(03) MANAGED CARE PLAN CENTER/HMO
(04) NEIGHBORHOOD/FAMILY HEALTH CENTER
(05) RURAL HEALTH CLINIC
(06) COMPANY CLINIC/WORKPLACE
(07) OTHER CLINIC
(08) WALK-IN URGENT CENTER
(09) HOSPITAL EMERGENCY ROOM
Where did [you/(SP)] go for [your/his/her] most recent seasonal flu shot, was that a managed care plan or HMO
(10) HOSPITAL OUTPATIENT DEPARTMENT/CLINIC
center, a clinic, a doctor’s office, a hospital, a health fair, shopping mall, or some other place?
(11) VA FACILITY
(12) HEALTH FAIR
[IF CLINIC, ASK: Was it a hospital outpatient clinic, or some other kind of clinic? IF SOME OTHER PLACE,
(13) SHOPPING MALL/OTHER STORE
ASK: Where was this?]
(14) SENIOR CENTER
(15) AT HOME
(16) CHURCH/SCHOOL
(17) LIBRARY
(18) HOSPITAL INPATIENT
(19) PHARMACY/DRUG STORE
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

FLUSITOS

FLUSITOS

verbatim text

OTHER (SPECIFY)

BOX PV3

Page 2 of 7

2021 MCBS Community Questionnaire

PVQ- PREVENTIVE CARE

Variable Name

MR Screen Name

Question Type

VACPAID

VACPAID

yes/no

Question Text/Description

Did [you/(SP)] pay some or all of the cost of the flu shot?
Please include any monetary donations that you may have made to cover the cost of the flu shot.

Code List

Routing

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

PVF5-VACAVAIL

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX PV4

BOX PV5

PVF5

yes/no

Did [you/(SP)] have any trouble getting a seasonal flu shot when (you/he/she) wanted to because the vaccine
was in short supply or unavailable?

BOX PV4

routing

IF THIS IS A SUMMER ROUND AND RESPONDENT HAS NOT REPORTED RECEIVING THE SHINGLES
VACCINE (P_SHINGVAC^=1) AND RESPONDENT IS AGE 60 OR ABOVE (AGECALC ≥ 60) OR
RESPONDENT IS AGE=0, GO TO PV6-SHINGVAC.
ELSE GO TO BOX PV5.

PV6

yes/no

Shingles is an illness that results in a rash or blisters on the skin, and is usually painful. There are two vaccines
(01) YES
now available for shingles; Zostavax®, which requires 1 shot, and Shingrix®, a new vaccine which requires 2
(02) NO
shots.
(-8) DON'T KNOW
(-9) REFUSED
[Have you/Has (SP)] had a vaccine for Shingles?

BOX PV5

routing

IF THIS IS A SUMMER ROUND AND RESPONDENT HAS NOT REPORTED RECEIVING THE PNEUMONIA
VACCINE (PNEUSHOT^=1), GO TO PV7-PNEUSHOT.
ELSE GO TO BOX PVEND.

PNEUSHOT

PV7

yes/no

This shot is usually given only once or twice in a person's lifetime and is different from the flu shot. It is also
called the pneumococcal vaccine. There are two types of pneumonia shots: polysaccharide, also known as
Pneumovax®23, and conjugate, also known as Prevnar13®.

PREVHLTHINTRO

PV8

no entry

These next few questions are about preventive health care measures some people take.

yes/no

Within the first 12 months of a beneficiary’s Medicare enrollment, Medicare pays for a one-time “Welcome to
Medicare” visit with their primary care provider to assess their current health. After a beneficiary has been
enrolled in Medicare for 12 months, Medicare pays for “Annual Wellness” visits. These visits are yearly
appointments with the beneficiary’s primary care provider to update their personalized prevention plan.

VACAVAIL

SHINGVAC

[Have you/Has (SP)] EVER had a pneumonia shot?

WELLNESS

PV8A

Since (SAMPLE_PERSON.DATE_FALLRND), [have you/has SP] had either a “Welcome to Medicare” or an
“Annual Wellness” visit?

SHOW CARD PV1
BPTAKEN

PV9

code one

When was the most recent time [you/(SP)] had [your/his/her] blood pressure taken by a doctor or other health
professional?

SHOW CARD PV2
BCTAKEN

PV10

code one
When was the most recent time [you/(SP)] had [your/his/her] cholesterol checked?

BOX PV5A

routing

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX PVEND

(01) CONTINUE
(-7) EMPTY

PV8A- WELLNESS

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

PV9-BPTAKEN

(01) LESS THAN 6 MONTHS AGO
(02) 6 MONTHS TO LESS THAN 1 YEAR AGO
(03) 1 YEAR TO LESS THAN 2 YEARS AGO
(04) 2 YEARS AGO TO LESS THAN 5 YEARS AGO
(05) 5 OR MORE YEARS AGO
(06) NEVER HAD BLOOD PRESSURE TAKEN
(-8) DON'T KNOW
(-9) REFUSED

PV10 - BCTAKEN

(01) LESS THAN 6 MONTHS AGO
(02) 6 MONTHS TO LESS THAN 1 YEAR AGO
(03) 1 YEAR TO LESS THAN 2 YEARS AGO
(04) 2 YEARS AGO TO LESS THAN 5 YEARS AGO
(05) 5 OR MORE YEARS AGO
(06) NEVER HAD CHOLESTEROL CHECKED
(-8) DON'T KNOW
(-9) REFUSED

BOXPV5A

IF ROUND= FALL 2020 ROUND 88, GO TO PV10A-BASKORAL.
ELSE IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3) GO TO PV10A-BASKORAL.
ELSE GO TO PV10B-CASKORAL.

Page 3 of 7

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

PVQ- PREVENTIVE CARE

Question Type

Question Text/Description
[Have you/Has SP] ever had an exam for oral cancer in which the doctor or dentist pulls on [your/his/her]
tongue, sometimes with gauze wrapped around it, and feels under the tongue and inside the cheeks?

Code List

Routing

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) PV10C-OCCEXAM
(02) BOX PV5C
(-8) BOX PV5C
(-9) BOX PV5C

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

BOX PV5C

(01) WITHIN THE PAST YEAR
(02) BETWEEN 1 AND 3 YEARS AGO
(03) OVER 3 YEARS AGO

BOX PV5C

BASKORAL

PV10A

yes/no

CASKORAL

PV10B

yes/no

OCCEXAM

PV10C

code one

BOX PV5C

routing

ELSE IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3) GO TO PV19-BTSTHIV.
ELSE GO TO PV20-CTSTHIV.

PV19

yes/no

The next question is about the test for HIV, the virus that causes AIDS. Except for tests [you/(SP)] may have
had as part of blood donations, [have you/ has he/ has she] ever been tested for HIV?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) PV21-RCNTHIV
(02) BOX PV5D
(-8) BOX PV6
(-9) BOX PV6

When did [you/(SP)] have [your/his/her] most recent HIV test?

(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS
(03) 2 YEARS TO LESS THAN 3 YEARS
(04) 3 YEARS TO LESS THAN 4 YEARS
(05) 4 YEARS TO LESS THAN 5 YEARS
(06) 5 YEARS TO LESS THAN 6 YEARS
(07) 6 YEARS TO LESS THAN 7 YEARS
(08) 7 YEARS TO LESS THAN 8 YEARS
(09) 8 YEARS TO LESS THAN 9 YEARS
(10) 9 YEARS TO LESS THAN 10 YEARS
(11) 10 YEARS AGO OR MORE
(12) 5 YEARS AGO OR MORE
(-8) DON'T KNOW
(-9) REFUSED

BOX PV6

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX PV6
(02) BOX PV5D
(-8) BOX PV6
(-9) BOX PV6

Since (SAMPLE_PERSON.DATE_FALLRND), [have you/has SP] had an exam for oral cancer in which the
doctor or dentist pulls on [your/his/her] tongue, sometimes with gauze wrapped around it, and feels under the
tongue and inside the cheeks?
When did [you/SP] have [your/his/her] most recent oral or mouth cancer exam?

BTSTHIV

code one

Was it within the past year, between 1 and 3 years ago, or over 3 years ago?

RCNTHIV

PV21

CTSTHIV

PV20

The next question is about the test for HIV, the virus that causes AIDS. Except for tests [you/(SP)] may have
had as part of blood donations, since (SAMPLE_PERSON.DATE_FALLRND) [ have you/ has he/ has she]
been tested for HIV?

BOX PV5D

IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3) GO TO PV22-WHYNHIV
ELSE GO TO BOX PV6

SHOW CARD PV1 3
WHYNHIV

PV22

code one

BOX PV6

routing

I am going to show you a list of reasons why some people have not been tested for HIV (the virus that causes
AIDS). Which one of these would you say is the MAIN reason why [you have/(SP) has] not been tested?

(01) IT’S UNLIKELY YOU’VE BEEN EXPOSED TO
HIV
(02) YOU WERE AFRAID TO FIND OUT IF YOU
WERE HIV POSITIVE (THAT YOU HAD HIV)
(03) DR. DID NOT PRESCRIBE OR RECOMMEND IT
(04) YOU DIDN’T WANT TO THINK ABOUT HIV OR
ABOUT BEING HIV POSITIVE
(05) YOU WERE WORRIED YOUR NAME WOULD
BE REPORTED TO THE GOVERNMENT IF YOU
TESTED POSITIVE
BOX PV6
(06) YOU DIDN’T KNOW WHERE TO GET TESTED
(07) YOU DON’T LIKE NEEDLES
(08) YOU WERE AFRAID OF LOSING JOB,
INSURANCE, HOUSING, FRIENDS, FAMILY, IF
PEOPLE KNEW YOU WERE POSITIVE FOR AIDS
INFECTION
(09) SOME OTHER REASON
(10) NO PARTICULAR REASON
(-8) REFUSED
(-9) DON’T KNOW

IF SP IS FEMALE, GO TO PV11 - MAMMOGRM.
ELSE GO TO BOX PV8.

Page 4 of 7

2021 MCBS Community Questionnaire

Variable Name

MAMMOGRM

MR Screen Name

PV11

PVQ- PREVENTIVE CARE

Question Type

yes/no

Question Text/Description

Code List

Routing

[Have you/Has (SP)] had a mammogram or a breast X-ray since (SAMPLE_PERSON.DATE_FALLRND)?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) PV12 - PAPSMEAR
(02) PV11 - MAMCODE
(-8) PV12 - PAPSMEAR
(-9) PV12 - PAPSMEAR

(01) DIDN’T KNOW IT WAS NEEDED/NO
NEED/NOTHING WRONG
(02) NOT RECOMMENDED EVERY YEAR/ON A
DIFFERENT SCREENING SCHEDULE
(03) DIDN’T THINK IT WOULD PREVENT BREAST
CANCER/COULD GET BREAST CANCER
ANYWAY/TEST IS USELESS
(04) NOT AT RISK FOR BREAST CANCER
(05) DOCTOR DID NOT PRESCRIBE OR
RECOMMEND IT
(06) DOCTOR RECOMMENDED AGAINST GETTING
IT
(07) DON’T LIKE MAMMOGRAMS/PAIN, SORENESS,
DISCOMFORT OR REACTIONS
(08) INCONVENIENT/UNABLE TO GET TO
LOCATION/TRANSPORTATION DIFFICULTY
(09) DIDN’T THINK ABOUT IT/FORGOT/MISSED
IT/PROCRASTINATED
(10) COST OF MAMMOGRAM/INSURANCE DOESN’T
COVER COST/NOT WORTH THE MONEY
(11) AFRAID OF RESULTS/DON’T WANT TO KNOW
(12) MAMMOGRAM RADIATION COULD CAUSE
CANCER/ILL EFFECTS
(13) NEVER HEARD OF MAMMOGRAM
(14) APPOINTMENT SCHEDULED FOR FUTURE
DATE
(15) MASTECTOMY/BREASTS REMOVED
(16) TOO ILL, PHYSICALLY/MENTALLY
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01) PV12 - PAPSMEAR
(02) PV12 - PAPSMEAR
(03) PV12 - PAPSMEAR
(04) PV12 - PAPSMEAR
(05) PV12 - PAPSMEAR
(06) PV12 - PAPSMEAR
(07) PV12 - PAPSMEAR
(08) PV12 - PAPSMEAR
(09) PV12 - PAPSMEAR
(10) PV12 - PAPSMEAR
(11) PV12 - PAPSMEAR
(12) PV12 - PAPSMEAR
(13) PV12 - PAPSMEAR
(14) PV12 - PAPSMEAR
(15) PV12 - PAPSMEAR
(16) PV12 - PAPSMEAR
(91) PV11 - MAMNOTHS
(-8) PV12 - PAPSMEAR
(-9) PV12 - PAPSMEAR

MAMCODE

PV11

code all

What is the reason that [you have/(SP) has] not had a mammogram since
(SAMPLE_PERSON.DATE_FALLRND)?
CHECK ALL THAT APPLY.

MAMNOTHS

PV11

verbatim text

OTHER (SPECIFY)

PAPSMEAR

PV12

yes/no

[Have you/Has (SP)] had a Pap smear test since (SAMPLE_PERSON.DATE_FALLRND)?

PV12 - PAPSMEAR
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX PV7
(02) PV13 - PAPCODE
(-8) BOX PV7
(-9) BOX PV7

Page 5 of 7

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

PVQ- PREVENTIVE CARE

Question Type

Question Text/Description

Code List

Routing

(01) DIDN’T KNOW IT WAS NEEDED/NO
NEED/NOTHING WRONG
(02) NOT RECOMMENDED EVERY YEAR/ON A
DIFFERENT SCREENING SCHEDULE
(03) DIDN’T THINK IT WOULD PREVENT
CANCER/COULD GET CANCER ANYWAY/TEST IS
USELESS
(04) NOT AT RISK FOR CANCER
(05) DOCTOR DID NOT PRESCRIBE OR
RECOMMEND IT
(06) DOCTOR RECOMMENDED AGAINST GETTING
IT
(07) DON’T LIKE PAP SMEAR/PAIN, SORENESS,
DISCOMFORT OR REACTIONS
(08) INCONVENIENT/UNABLE TO GET TO
LOCATION/TRANSPORTATION DIFFICULTY
(09) DIDN’T THINK ABOUT IT/FORGOT/MISSED
IT/PROCRASTINATED
(10) COST OF PAP SMEAR/INSURANCE DOESN’T
COVER COST/NOT WORTH THE MONEY
(11) AFRAID OF RESULTS/DON’T WANT TO KNOW
(12) NEVER HEARD OF PAP SMEAR
(13) APPOINTMENT SCHEDULED FOR FUTURE
DATE
(14) HAD HYSTERECTOMY/NO UTERUS, OVARIES
(15) TOO ILL, PHYSICALLY/MENTALLY
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX PV7
(02) BOX PV7
(03) BOX PV7
(04) BOX PV7
(05) BOX PV7
(06) BOX PV7
(07) BOX PV7
(08) BOX PV7
(09) BOX PV7
(10) BOX PV7
(11) BOX PV7
(12) BOX PV7
(13) BOX PV7
(14) BOX PV7
(15) BOX PV7
(91) PV13 - PAPNOTHS
(-8) BOX PV7
(-9) BOX PV7

PAPCODE

PV13

code all

What is the reason that [you have/(SP) has] not had a Pap smear test since
(SAMPLE_PERSON.DATE_FALLRND)?
CHECK ALL THAT APPLY.

PAPNOTHS

PV13

verbatim text

OTHER (SPECIFY)

BOX PV7

routing

IF RESPONDENT HAS NOT PREVIOUSLY REPORTED HYSTERECTOMY
(SAMPLE_PERSON.P_HYSTEREC^=1) AND RESPONSE TO PV13 – PAPCODE DOES NOT INCLUDE
14/HadHysterectomy, GO TO PV14 - HYSTEREC.
ELSE GO TO BOX PVEND.

PV14

yes/no

[Have you/Has (SP)] ever had a hysterectomy?

BOX PV8

routing

IF SP HAS EVER REPORTED HAVING PROSTATE SURGERY IN A PREVIOUS ROUND
(sample_person.P_PROSSURG=1), GO TO PV16 - DIGTEXAM.
ELSE GO TO PV15 - PROSSURG.

PV15

yes/no

HYSTEREC

BOX PV7

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX PVEND

[Since (SAMPLE_PERSON.DATE_FALLRND), [have you/has (SP)/[Have you/has (SP)] ever] had surgery on
(your/his) prostate?
PROSSURG

(01) YES
(02) NO
(-8) DON'T KNOW
[EXPLAIN IF NECESSARY: Surgery on the prostate gland is typically used as a treatment for prostate cancer
(-9) REFUSED
or to correct urinary problems. Surgery can include complete or partial removal of the prostate.]

PV16 - DIGTEXAM

[These next few questions are about follow-up care sometimes prescribed after prostate surgery].

DIGTEXAM

PV16

yes/no

[Have you/Has (SP)] had a digital rectal examination (of the prostate) since
(SAMPLE_PERSON.DATE_FALLRND)?
[EXPLAIN IF NECESSARY: The exam may be used to detect prostate cancer, to determine whether cancer
has spread beyond the prostate, and as part of follow-up care after prostate surgery.]

[Have you/Has (SP)] had a blood test for detection of prostate cancer, known as a PSA, since
(SAMPLE_PERSON.DATE_FALLRND)?
BLOODTST

PV17

yes/no

PSA = PROSTATE-SPECIFIC ANTIGEN
[EXPLAIN IF NECESSARY: The test may be used to detect prostate cancer, to determine whether cancer has
spread beyond the prostate, and as part of follow-up care after prostate surgery.]

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

PV17 - BLOODTST

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX PVEND
(02) PV18 - PRONCODE
(-8) BOX PVEND
(-9) BOX PVEND

Page 6 of 7

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

PVQ- PREVENTIVE CARE

Question Type

Question Text/Description

Code List

Routing

(01) DIDN’T KNOW IT WAS NEEDED/NO
NEED/NOTHING WRONG
(02) NOT RECOMMENDED EVERY YEAR/ON A
DIFFERENT SCREENING SCHEDULE
(03) DIDN’T THINK IT WOULD PREVENT
CANCER/COULD GET CANCER ANYWAY/TEST IS
USELESS
(04) NOT AT RISK FOR CANCER
(05) DOCTOR DID NOT PRESCRIBE OR
RECOMMEND IT
(06) DOCTOR RECOMMENDED AGAINST GETTING
IT
(07) DON’T LIKE BLOOD TESTS/PAIN, SORENESS,
DISCOMFORT OR REACTIONS
(08) INCONVENIENT/UNABLE TO GET TO
LOCATION/TRANSPORTATION DIFFICULTY
(09) DIDN’T THINK ABOUT IT/FORGOT/MISSED
IT/PROCRASTINATED
(10) COST OF TEST/INSURANCE DOESN’T COVER
COST/NOT WORTH THE MONEY
(11) AFRAID OF RESULTS/DON’T WANT TO KNOW
(12) NEVER HEARD OF PSA
(13) APPOINTMENT SCHEDULED FOR FUTURE
DATE
(14) PROSTATECTOMY/PROSTATE REMOVED
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX PVEND
(02) BOX PVEND
(03) BOX PVEND
(04) BOX PVEND
(05) BOX PVEND
(06) BOX PVEND
(07) BOX PVEND
(08) BOX PVEND
(09) BOX PVEND
(10) BOX PVEND
(11) BOX PVEND
(12) BOX PVEND
(13) BOX PVEND
(14) BOX PVEND
(91) PV18 - PRONOTHS
(-8) BOX PVEND
(-9) BOX PVEND

PRONCODE

PV18

code all

What is the reason that [you have/(SP) has] not had a prostate blood test or PSA since
(SAMPLE_PERSON.DATE_FALLRND)?
CHECK ALL THAT APPLY.

PRONOTHS

PV18

verbatim text

OTHER (SPECIFY)

BOX PVEND

routing

IF SEASON=FALL AND INTTYPE in(C001, C002, C003, C004, C005, C006), GO TO HFQ.
IF SEASON=WINTER, GO TO KNQ.
IF SEASON=SUMMER, GO TO CPQ

BOX PVEND

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