CMS-P-0015A Usual Source of Care

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

USQ-Usual Source of Care

Question Type

Question Text/Description

Code List

Routing

USUAL SOURCE OF CARE QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007
SPALIVE=1
SEASON= WINTER
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after KNQ.

PLACEPAR

US1

yes/no

(01) YES
Is there a particular doctor or other health professional, or a clinic [you/(SP)] usually [go/goes] to when [you are/he (02) NO
is/she is] sick or for advice about [your/his/her] health?
(-8) DON'T KNOW
(-9) REFUSED

BOX USA

routing

IF (INTTYPE=7) AND SP ever reported speaking a language other than English in the home
(SAMPLE_PERSON.WHATLANG EQUALS 1-"SPANISH", 2-"FRENCH", 3-"GERMAN", OR 91-"Other, Specify")
AND P_ENGWELL=1, GO TO LEP6-LANGPROB.
ELSE GO TO US39 – NUSNOTSK.

(01) BOX USB
(02) BOX USB
(03) US3A - CLNAME
(04) US3A - CLNAME
(05) US3A - CLNAME
(06) US3A - CLNAME
(07) US3A - CLNAME
(08) US3A - CLNAME
(09) US3A - CLNAME
(10) US5A - MDNAME
(11) US3A - CLNAME
(12) US3A - CLNAME
(13) US3A - CLNAME
(14) US3A - CLNAME
(91) US2 - PLACEOS
(-8) US3A - CLNAME
(-9) US3A - CLNAME

(01) CONTINUOUS ANSWER

US3A - CLNAME

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

BOX USC

PLACEKND

US2

code one

(01) DOCTOR'S OFFICE OR GROUP PRACTICE
(02) MEDICAL CLINIC
(03) MANAGED CARE PLAN CENTER/HMO
(04) NEIGHBORHOOD/FAMILY HEALTH CENTER
(05) FREESTANDING SURGICAL CENTER
(06) RURAL HEALTH CLINIC
What kind of place [do you/does (SP)] usually go to when [you are/he is/she is] sick or for advice about
(07) COMPANY CLINIC
[your/his/her] health -- is that a managed care plan or HMO center, a clinic, a doctor or other health professional's
(08) OTHER CLINIC
office, a hospital, or some other place?
(09) WALK-IN URGENT CENTER
(10) DOCTOR COMES TO SP'S HOME
IF CLINIC, ASK: Is it a hospital outpatient clinic, or some other kind of clinic?
(11) HOSPITAL EMERGENCY ROOM
IF SOME OTHER PLACE, ASK: Where is this?
(12) HOSPITAL OUTPATIENT DEPARTMENT/CLINIC
(13) VA FACILITY
(14) MENTAL HEALTH CENTER
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

PLACEOS

US2

text

OTHER (SPECIFY)

BOX USB

routing

IF SP WAS COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND, GO TO
US2A - PLACEMCP.
ELSE IF US2 - PLACEKND = 1/DoctorsOffice, GO TO US5A - MDNAME.
ELSE GO TO US3A - CLNAME.

US2A

yes/no

Is this [doctor or other health professional/medical clinic] associated with [your/his/her] [READ MANAGED CARE
PLAN NAME(S) BELOW] plan?

BOX USC

routing

IF US2 - PLACEKND = 1/DoctorsOffice, GO TO US5A - MDNAME.
ELSE GO TO US3A - CLNAME.

PLACEMCP

What is the complete name of the [place/managed care plan or HMO center/(US2 RESPONSE)] that [you go
to/(SP) goes to]?
CLNAME

US3A

verbatim text

(01) US2 - PLACEKND
(02) BOX USA
(-8) BOX USA
(-9) BOX USA

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]

(01) continuous answer
[ENCOURAGE THE RESPONDENT TO REFER TO A BILL, TELEPHONE DIRECTORY, APPOINTMENT CARD, (-8) Don't Know
ETC., FOR COMPLETE INFORMATION.]
(-9) Refused

US4 - USUALDOC

DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02

USUALDOC

US4

yes/no

(01) YES
Is there a particular doctor or other health professional [you usually see/(SP) usually sees] at this [place/managed (02) NO
care plan or HMO center/(US2 RESPONSE)]?
(-8) DON'T KNOW
(-9) REFUSED

(01) US5A - MDNAME
(02) US7-INNOVATE
(-8) US7-INNOVATE
(-9) US7-INNOVATE

Page 1 of 13

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

USQ-Usual Source of Care

Question Type

Question Text/Description

What is the complete name of that doctor or other health professional?
MDNAME

US5A

verbatim text

Code List

Routing

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]

(01) continuous answer
[ENCOURAGE THE RESPONDENT TO REFER TO A BILL, TELEPHONE DIRECTORY, APPOINTMENT CARD,
(-8) Don't Know
ETC., FOR COMPLETE INFORMATION.]
(-9) Refused

MDSEX - US5B

DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02

MDSEX

US5B

code one

Is (US5A PROVIDER NAME) a male or female?

SHOW CARD US1
What is (US5A PROVIDER NAME)'s specialty?
PVSPEC

US6A

code one

[PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE CARD IF THEY MENTION A 'GENERIC'
SPECIALITY LIKE ‘HEART DOCTOR.’ IF RESPONDENT ONLY GIVES A 'GENERIC' SPECIALTY AND THE
GENERIC WORD IS SHOWN IN PARENTHESES FOLLOWING ONE OF THE RESPONSES, SELECT THE
RESPONSE CATEGORY FOR THAT SPECIALTY (E.G., 'CARDIOLOGY'). OTHERWISE SELECT 'OTHER DR
SPECIALTY'.]

(01) MALE
(02) FEMALE
(-8) DON’T KNOW
(-9) REFUSED

US6A - PVSPEC

(01) ALLERGY/IMMUNOLOGY
(02) ANESTHESIOLOGY
(03) CARDIOLOGY (HEART)
(04) DERMATOLOGY (SKIN)
(05) ENDOCRINOLOGY/METABOLISM
(DIABETES,THYROID)
(06) FAMILY PRACTICE
(07) GASTROENTEROLOGY
(08) GENERAL PRACTICE
(09) GENERAL SURGERY
(10) GERIATRICS (ELDERLY)
(11) GYNECOLOGY - OBSTETRICS
(12) HEMATOLOGY (BLOOD)
(13) HOSPITAL RESIDENCE
(14) INTERNAL MEDICINE (INTERNIST)
(15) NEPHROLOGY (KIDNEYS)
(16) NEUROLOGY
(17) NUCLEAR MEDICINE
(18) ONCOLOGY (TUMORS, CANCER)
(19) OPHTHALMOLOGY (EYES)
(20) ORTHOPEDICS
(21) OSTEOPATHY (DO)
(22) OTORHINOLARYNGOLOGY (EAR, NOSE,
THROAT)
(23) PAIN MANAGEMENT SPECIALIST
(24) PATHOLOGY
(25) PHYS MED/REHAB
(26) PHYSICIAN’S ASSISTANT
(27) PLASTIC SURGERY
(28) PODIATRIST
(29) PROCTOLOGY
(30) PSYCHIATRY/PSYCHIATRIST
(31) PULMONARY (LUNGS)
(32) RADIOLOGY
(33) RHEUMATOLOGY (ARTHRITIS)
(34) THORACIC SURGERY (CHEST)
(35) UROLOGY
(36) VASCULAR SURGEON/SPECIALIST
(37) AUDIOLOGIST
(38) CHIROPRACTOR
(39) DENTIST
(40) OPTOMETRIST
(41) PHYSICAL THERAPIST
(42) PSYCHOLOGIST
(43) NURSE PRACTITIONER
(91) OTHER DR SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED

(01)- (43) US7-INNOVATE
(91) US6A - MDSPECOS
(-8) US7-INNOVATE
(-9) US7-INNOVATE

Page 2 of 13

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

USQ-Usual Source of Care

Question Type

Question Text/Description

Code List

Routing

(01) CONTINUOUS ANSWER

US7-INNOVATE

OTHER DR SPECIALTY (SPECIFY)

MDSPECOS

US6A

text

[PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE CARD IF THEY MENTION A 'GENERIC'
SPECIALITY LIKE ‘HEART DOCTOR.’ IF RESPONDENT ONLY GIVES A 'GENERIC' SPECIALTY AND THE
GENERIC WORD IS SHOWN IN PARENTHESES FOLLOWING ONE OF THE RESPONSES, SELECT THE
RESPONSE CATEGORY FOR THAT SPECIALTY (E.G., 'CARDIOLOGY'). OTHERWISE SELECT 'OTHER DR
SPECIALTY'.]

Many health care providers are beginning to participate in innovative health care initiatives, programs, and
payment models. Is (US5A PROVIDER NAME)/(US3A PROVIDER NAME) associated with an innovative health
care initiative such as an accountable care organization or a patient centered medical home?
INNOVATE

US7

yes/no

(01) YES
(02) NO
[IF NEEDED: Innovative health care initiatives are programs that test ways to improve the delivery of health care,
(-8) DON'T KNOW
improve the quality of health care, lower health care costs, and reduce health disparities.]
(-9) REFUSED

BOX USD

IF THE RESPONDENT DOESN'T KNOW WHAT INNOVATIVE HEALTH CARE INITATIVES ARE OR HAS
NEVER HEARD OF INNOVATIVE HEALTH CARE INITIATIVES, SELECT 'DON'T KNOW'.

BOX USD

routing

IF (INTTYPE=7) AND (SAMPLE_PERSON.WHATLANG EQUALS 1-"SPANISH", 2-"FRENCH", 3-"GERMAN", OR
91-"Other, Specify"), GO TO LEP1A-LANGPREF.
ELSE GO TO BOX US1.

LANGPREF

LEP1A

select one

In general, in what language [do you/does (SP)] prefer to receive [your/his/her] medical care?

(01) English
(02) [LANGUAGE SPOKEN AT HOME], or
(03) Both English and [LANGUAGE SPOKEN AT HOME]
equally
(91) OTHER
(-8) Don't Know
(-9) Refused

LANGPFOS

LEP1B

verbatim text

In general, in what language [do you/does (SP)] prefer to receive [your/his/her] medical care?

(01) CONTINUOUS ANSWER

LEP2-LANGPRVD

LANGPRVD

LEP2

select one

[Does (US5A PROVIDER NAME)/Do the providers at (US3A PROVIDER NAME)] speak [LANGUAGE SPOKEN
AT HOME/LEP1B-LANGPFOS]?

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

(01) LEP3-LANGCOMM
(02) LEP4-LANGSYMP
(-8) LEP4-LANGSYMP
(-9) LEP4-LANGSYMP

LEP3

select one

(01) VERY WELL
(02) WELL
(03) NOT WELL
How well can [you/(SP)] and [(US5A PROVIDER NAME)/the providers at (US3A PROVIDER NAME)]
(04) NOT AT ALL
communicate in [LANGUAGE SPOKEN AT HOME/LEP1B-LANGPFOS] about [your/his/her] symptoms? Very well,
(-8) DON’T KNOW
well, not well, or not at all?
(-9) REFUSED

BOX LEP1

routing

IF P_ENGWELL=1, GO TO LEP6-LANGPROB. ELSE GO TO BOX US1.

(01) LEP4-LANGSYMP
(02) LEP2-LANGPRVD
(03) LEP2-LANGPRVD
(91) LEP1B-LANGPFOS
(-8) LEP2-LANGPRVD
(-9) LEP2-LANGPRVD

SHOW CARD US2
LANGCOMM

LEP4

select one

(01) VERY WELL
(02) WELL
(03) NOT WELL
Without the aid of a translator, language assistant, or interpreter, how well can [you/(SP)] and [(US5A PROVIDER
(04) NOT AT ALL
NAME)/the providers at (US3A PROVIDER NAME)] communicate in English about [your/his/her] symptoms? Very
(-8) DON’T KNOW
well, well, not well, or not at all?
(-9) REFUSED

BOX LEP2

routing

IF P_ENGWELL=1, GO TO LEP5-LANGASST. ELSE GO TO BOX US1.

BOX LEP1

SHOW CARD US2
LANGSYMP

(01) PROFESSIONAL INTERPRETER
(02) STAFF PERSON AT MEDICAL PROVIDER’S
OFFICE
(03) FAMILY MEMBER
Who helps [you/(SP)] communicate with [(US5A PROVIDER NAME)/the providers at (US3A PROVIDER NAME)] –
(04) FRIEND
a professional interpreter, a staff person at [your/his/her] provider's office, a family member, a friend, do [you/(SP)]
(05) SOMEONE ELSE
do the best that [you/(SP)] can in English, or does no one help [you/(SP)] becuase [you have/(SP) has] no trouble
(06) DOES BEST THAT CAN IN ENGLISH
communicating in English?
(07) NO ONE HELPS; NO TROUBLE
COMMUNICATING IN ENGLISH
PROBE: Anyone else?
(-8) DON’T KNOW
(-9) REFUSED

BOX LEP2

SHOW CARD US3

LANGASST

LEP5

select all

LEP6-LANGPROB

Page 3 of 13

2021 MCBS Community Questionnaire

USQ-Usual Source of Care

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

LANGPROB

LEP6

select one

Have [you/(SP)] ever had a problem understanding a medical situation because it was not explained in
[LANGAUGE SPOKEN AT HOME/LEP1B-LANGPFOS]?

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

LEP7-LANGHELP

LEP7

select all

(01) PROFESSIONAL INTERPRETER
(02) STAFF PERSON AT MEDICAL PROVIDER’S
OFFICE
Now think about all of [your/(SP)'s] medical providers other than [your/his/her] usual provider.
(03) FAMILY MEMBER
(04) FRIEND
Who helps [you/(SP)] communicate with medical providers who do not speak [LANGUAGE SPOKEN AT
(05) SOMEONE ELSE
HOME/LEP1B-LANGPFOS]– a professional interpreter, a staff person at [your/his/her] provider's office, a family (06) DOES BEST THAT CAN IN ENGLISH
member, a friend, [do you/does (SP)] do the best that [you/(SP)] can in English, or does no one help [you/(SP)]
(07) DOES NOT SEE A MEDICAL PROVIDER
because [you have/(SP) has] no trouble communicating in English?
(08) NO ONE HELPS; HAS NO TROUBLE
COMMUNICATING IN ENGLISH
PROBE: Anyone else?
(-8) DON’T KNOW
(-9) REFUSED

BOX US1

routing

IF US1 - PLACEPAR = NO, DK, or RF, GO TO US39 - NUSNOTSK.
ELSE IF US2 - PLACEKND = 10/AtHome, GO TO PP1A-PROVYR.
ELSE GO TO US8 - GETUSHOW.

SHOW CARD US3

LANGHELP

How [do you/does (SP)] usually get to [(US5A PROVIDER NAME)'S office/(US3A PROVIDER NAME)]?

BOX US1

(01) WALKING
(02) DRIVING
(03) BEING DRIVEN
(04) AMBULANCE OR OTHER SPECIAL VEHICLE
(05) TAXI
(06) OTHER PUBLIC TRANSPORTATION
(07) DR. USUALLY COMES TO HOME
(91) SOME OTHER WAY
(-8) DON'T KNOW
(-9) REFUSED

(01) US9 - GETUSUNT
(02) US9 - GETUSUNT
(03) US9 - GETUSUNT
(04) US9 - GETUSUNT
(05) US9 - GETUSUNT
(06) US9 - GETUSUNT
(07) PP1A-PROVYR
(91) US8 - GETUSOS
(-8) PP1A-PROVYR
(-9) PP1A-PROVYR

GETUSHOW

US8

code one

GETUSOS

US8

verbatim text

SOME OTHER WAY (SPECIFY)

(01) continuous answer

US9 - GETUSUNT

GETUSUNT

US9

code one

About how long does it usually take for [you/(SP)] to get there?

(01) HOURS ONLY
(02) MINUTES ONLY
(03) HOURS AND MINUTES
(-8) DON'T KNOW
(-9) REFUSED

(01) US9 - GETUSHRS
(02) US9 - GETUSMIN
(03) US9 - GETUSHRS
(-8) US10 - ACCOMPUS
(-9) US10 - ACCOMPUS

GETUSHRS

US9

numeric

HOURS:

(01) CONTINUOUS ANSWER

If US9 GETUSUNT=3/HoursAndMinutes go to US9 GETUSMIN.
Else go to US10 - ACCOMPUS.

GETUSMIN

US9

numeric

MINUTES:

(01) CONTINUOUS ANSWER

US10 - ACCOMPUS

ACCOMPUS

US10

yes/no

[Do you/Does (SP)] usually have someone accompany [you/him/her] there?

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

(01) US11 - PERSON_USUALGO
(02) PP1A-PROVYR
(-8) PP1A-PROVYR
(-9) PP1A-PROVYR

[EXPLAIN IF NECESSARY: [Do you/Does (SP)] get there by walking, driving, being driven by someone else, by
ambulance or other special vehicle for disabled people, by taxi, other public transportation, or some other way?]

Who usually goes with [you/(SP)]?
PERSON_USUALGO

US11

roster
SELECT OR ADD ONLY ONE PERSON

ROSTFNAM

US11_NEW

text

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

DISPLAY PERSON ROSTER AS RESPONSE
OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) US11AA-ACCREAS
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS (N+1) US11_NEW-ROSTFNAM
(N+1) ADD ANOTHER
IF EXISTING PERSON SELECTED, GO TO US11AADISPLAY:
ACCREAS.
1 First Name Display ROST.ROSTFNAM.
ELSE IF "ADD ANOTHER" SELECTED, GO TO
2 Last Name Display ROST.ROSTLNAM.
US11_NEW-ROSTFNAM
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/OtherRelative or 92/OtherNonRelative, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
(01) CONTINUOUS ANSWER

US11_NEW - ROSTLNAM

Page 4 of 13

2021 MCBS Community Questionnaire

USQ-Usual Source of Care

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

ROSTLNAM

US11_NEW

text

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

(01) CONTINUOUS ANSWER

US11_NEW - ROSTREL

ROSTREL

US11_NEW

code one

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

ROSTREOS

US11_NEW

verbatim text

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

What are the reasons [you accompany (SP)/this person accompanies you/this person accompanies this person]
do?
ACCREAS

US11AA

code all

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

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

(01) DO NOT DISPLAY
(02) US11AA-ACCREAS
(03) US11AA-ACCREAS
(04) US11AA-ACCREAS
(05) US11AA-ACCREAS
(06) US11AA-ACCREAS
(07) US11AA-ACCREAS
(08) US11AA-ACCREAS
(09) US11AA-ACCREAS
(10) US11AA-ACCREAS
(11) US11AA-ACCREAS
(12) US11AA-ACCREAS
(13) US11AA-ACCREAS
(14) US11AA-ACCREAS
(50) DO NOT DISPLAY
(51) US11AA-ACCREAS
(52) US11AA-ACCREAS
(53) US11AA-ACCREAS
(54) US11AA-ACCREAS
(55) US11AA-ACCREAS
(56) US11AA-ACCREAS
(57) US11AA-ACCREAS
(91) US11_NEW - ROSTREOS
(-8) US11AA-ACCREAS
(-9) US11AA-ACCREAS

US11AA-ACCREAS

(01) WRITES DOWN WHAT DOCTOR
SAYS/RECORDS INSTRUCTIONS/TAKES
NOTES/REMEMBERS
(02) GIVES INFORMATION/EXPLAINS SP'S MEDICAL
CONDITION OR NEEDS TO THE DOCTOR
(03) EXPLAINS DOCTOR’S INSTRUCTIONS TO SP
(04) ASKS QUESTIONS
(05) TRANSLATES LANGUAGE
(06) SCHEDULES APPOINTMENTS
(07) NOTHING/KEEPS SP COMPANY/SITS WITH
SP/MORAL SUPPORT
(08) TRANSPORTATION
(09) SP NEEDS PHYSICAL ASSISTANCE
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01) PP1A-PROVYR
(02) PP1A-PROVYR
(03) PP1A-PROVYR
(04) PP1A-PROVYR
(05) PP1A-PROVYR
(06) PP1A-PROVYR
(07) PP1A-PROVYR
(08)PP1A-PROVYR
(09) PP1A-PROVYR
(91) US11AA - ACCOTHOS
(-8) PP1A-PROVYR
(-9) PP1A-PROVYR

ACCOTHOS

US11AA

verbatim text

OTHER (SPECIFY)

(01) continuous answer

PP1A-PROVYR

PROVYR

PP1A

code one

[Have you/Has (SP)] seen [(US5A PROVIDER NAME)/(US3A PROVIDER NAME)] in the last 12 months?

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

(01) PP1-REMINDAPPT
(02) US27-USCKEVRY
(-8) US27-USCKEVRY
(-9) US27-USCKEVRY

REMINDAPPT

PP1

yes/no

(01) YES
(02) NO
(996) NOT APPLICABLE / R DID NOT HAVE
Some offices remind patients about appointments. Before [your/(SP)'s] most recent visit with [(US5A PROVIDER APPOINTMENT
(-8) DON'T KNOW
NAME)/(US3A PROVIDER NAME) ], did [you/he/she] get a reminder from [(US5A PROVIDER NAME)'S office
(-9) REFUSED
/(US3A PROVIDER NAME)] about the appointment?

PREAPPT

PP2

yes/no

Before [your/(SP)'s] most recent visit with [(US5A PROVIDER NAME)'s office/(US3A PROVIDER NAME)], did
[you/he/she] get instructions telling [you/him/her] what to expect or how to prepare?

The next questions ask about the care [you/(SP)] received from [(US5A PROVIDER NAME)'S office/(US3A
PROVIDER NAME)].

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

(01) PP2- PREAPPT
(02) PP2- PREAPPT
(996) PP4-MISSAPPT
(-8) PP2- PREAPPT
(-9) PP2- PREAPPT

PP4-MISSAPPT

Page 5 of 13

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

USQ-Usual Source of Care

Question Type

Question Text/Description

SHOW CARD US4

MISSAPPT

PP4

code one

Now I’m going to read you questions about the medical providers [you have/SP has] seen in the last twelve
months, that is since {TODAY'S MONTH AND YEAR - 12 MONTHS}.
People have busy lives and miss appointments for many reasons. Since (TODAY'S MONTH AND YEAR-12
MONTHS), how often did [you/(SP)] miss an appointment with [(US5A PROVIDER NAME)/(US3A PROVIDER
NAME)]?

SHOW CARD US4
NEWAPPT

PP5

code one

Since (TODAY'S MONTH AND YEAR-12 MONTHS), when [ you/(SP)] missed an appointment with US5A
PROVIDER NAME/US3A PROVIDER NAME), how often did someone from [(US5A PROVIDER NAME)'S
office/(US3A PROVIDER NAME)] contact [you/him/her] to make a new appointment?

SHOW CARD US4
DOCHLTH

PP8

code one

Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] ask about things in [your/(SP)'s] work or life at home that affect
[your/(SP)'s] health?

SHOW CARD US4
DOCEASY

PP9

code one

Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] explain things in a way that was easy [for (SP)] to understand?

SHOW CARD US4
DOCLSTN

PP10

code one

Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] listen carefully to [you/(SP)]?

SHOW CARD US4
DOCRSPCT

PP11

code one

Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] show respect for what [you/(SP)] had to say?

SHOW CARD US4
ENUFTIME

PP12

code one

Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] spend enough time with [you/(SP)]?

SHOW CARD US4
HLTHIDEA

PP13

code one

Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] ask whether [you/(SP)] had ideas about how to improve [your/his/her]
health?

SHOW CARD US5
STHLTHGL

PP15

code one

Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [(US5A PROVIDER NAME)/the medical providers at
(US3A PROVIDER NAME)] talk with [you/(SP)] about setting goals for [your/his/her] health?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]

Code List

Routing

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

(01) PP8-DOCHLTH
(02) PP5- NEWAPPT
(03) PP5-NEWAPPT
(04) PP5- NEWAPPT
(-8) PP8-DOCHLTH
(-9) PP8-DOCHLTH

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

PP8-DOCHLTH

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

PP9- DOCEASY

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

PP10-DOCLSTN

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

PP11-DOCRSPCT

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

PP12- ENUFTIME

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

PP13- HLTHIDEA

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

PP15-STHLTHGL

(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) PP16- MTHLTHGL
(02) PP16- MTHLTHGL
(03) US27-USCKEVRY
(-8) US27-USCKEVRY
(-9) US27-USCKEVRY

Page 6 of 13

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

USQ-Usual Source of Care

Question Type

Question Text/Description

SHOW CARD US5
MTHLTHGL

PP16

code one

Since (TODAY'S MONTH AND YEAR-12 MONTHS), did the care [you/(SP)] received from [(US5A PROVIDER
NAME)/the medical providers at (US3A PROVIDER NAME)] help [you/(SP)] meet [your/his/her] goals?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]

Code List

Routing

(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED

US27-USCKEVRY

SHOW CARD US6

USCKEVRY

US27

list

(01) STRONGLY AGREE
(02) AGREE
Now I am going to read some statements people have made about their health care. Think about the care [you
(03) DISAGREE
receive/(SP) receives] from (US5A PROVIDER NAME/US3A PROVIDER NAME). For each statement, please tell
(04) STRONGLY DISAGREE
me whether you strongly agree, agree, disagree, or strongly disagree.
(05) NOT APPLICABLE
(-8) Don't Know
[(US5A PROVIDER NAME) is/The doctors or other health professionals at (US3A PROVIDER NAME) are] very
(-9) Refused
careful to check everything when examining [you/him/her].

SHOW CARD US6
USUNWRNG

US27

list

BOX US4

routing

PP17

yes/no

[(US5A PROVIDER NAME) has/The doctors or other health professionals at (US3A PROVIDER NAME) have] a
complete understanding of the things that are wrong with [you/him/her].

Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] get any instructions about your health from
any other staff [in (US5A PROVIDER NAME)'s office/ at (US3A PROVIDER NAME)]?

SHOW CARD US4
OSUPTODT

PP18

code one

(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused

BOX US4

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

(01) PP18- OSUPTODT
(02) PP21- ORDRTEST
(-8) PP21- ORDRTEST
(-9) PP21- ORDRTEST

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

PP19- OSTLKCR

IF PP1A-PROVYR= 01/YES, GO TO PP17 OTHRSTFF.
ELSE GO TO BOX US5.

People often get instructions about their health from more than one person in the same office, such as other
medical providers, nurses, nutritionists, and social workers.
OTHRSTFF

US27-USUNWRNG

Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did these other staff seem up-to-date about the
care [you were/(SP) was] receiving from [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER
NAME)]?

(01) NEVER
(02) SOMETIMES
(03) USUALLY
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did these other staff talk with [you/(SP)] about care
(04) ALWAYS
[you/he/she] [were/was] receiving from [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER
(-8) Don't Know
NAME)]?
(-9) Refused

PP20- OSNOINFO

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

PP21- ORDRTEST

SHOW CARD US4
OSTLKCR

PP19

code one

SHOW CARD US4
OSNOINFO

ORDRTEST

PP20

PP21

code one

yes/no

Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did these other staff seem to know the important
information about [your/(SP)'s] medical history?

The next set of questions ask about the care you received from [(US5A PROVIDER NAME)/the medical providers
at (US3A PROVIDER NAME)] or someone in [his/her/their] office.
(01) YES
(02) NO
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [(US5A PROVIDER NAME)/the medical providers at
(-8) DON'T KNOW
(US3A PROVIDER NAME)] or someone in [his/her/their] office order a blood test, x-ray, or other test for
(-9) REFUSED
[you/(SP)]?

(01) PP22- TSTFLWUP
(02) PP29-HLTHSRVC
(-8) PP29-HLTHSRVC
(-9) PP29-HLTHSRVC

Page 7 of 13

2021 MCBS Community Questionnaire

Variable Name

TSTFLWUP

MR Screen Name

PP22

USQ-Usual Source of Care

Question Type

code one

Question Text/Description

Code List

Routing

SHOW CARD US4

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

PP23-RQSTRSLT

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

PP24- RSLTEASY

PP29-HLTHSRVC

Since (TODAY'S MONTH AND YEAR-12 MONTHS), when [(US5A PROVIDER NAME)/the medical providers at
(US3A PROVIDER NAME)] or someone from [his/her/their] office ordered a blood test, x-ray, or other test for
[you/(SP)], how often did [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)] or
someone from [his/her/their] office follow up to give [you/(SP)] those results?

SHOW CARD US4
RQSTRSLT

PP23

code one

Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [you/(SP)] have to request [your/his/her] test
results before [you/he/she] got them?

RSLTEASY

PP24

code one

(01) NEVER
(02) SOMETIMES
(03) USUALLY
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often were [your/(SP)'s] test results presented in a way (04) ALWAYS
that was easy to understand?
(-8) Don't Know
(-9) Refused

HLTHSRVC

PP29

yes/no

Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] need services at home to help [you/him/her]
take care of [your/his/her] health?

SHOW CARD US4

SHOW CARD US4
SRVCHELP

PP30

code one

GIVEINST

PP31

yes/no

ANYRX

PP35

yes/no

Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office help [you/(SP)] get these services at
home to take care of [your/his/her] health?

[THIS IS DIFFERENT FROM THE PRESCRIPTION DRUG WHERE WE ASK IF THE R HAD ANY
PRESCRIPTIONS FILLED]

SHOW CARD US4
PP36

code one

Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office talk with [you/(SP)] about how [you
were/he was/she was] supposed to take [your/his/her] medicine?

SHOW CARD US4
ASPRSCBD

PP37

code one

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

(01) YES
(02) NO
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [(US5A PROVIDER NAME)/the medical providers at
(-8) DON'T KNOW
(US3A PROVIDER NAME)] or someone in [his/her/their] office give [you/(SP)] instructions about how to take care
(-9) REFUSED
of [your/his/her] health?

Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] take any prescription medicine?

TALKRX

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

There are many reasons why people may not always be able to take their medicines as prescribed.
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often [were you/was (SP)] able to take [your/his/her]
medicine as prescribed?

(01) PP30- SRVCHELP
(02) PP31- GIVEINST
(-8) PP31- GIVEINST
(-9) PP31- GIVEINST

PP31- GIVEINST

PP35-ANYRX

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

(01) PP36- TALKRX
(02) BOX US5
(-8) BOX US5
(-9) BOX US5

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

PP37- ASPRSCBD

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

PP38-BADRCTN

PP38

code one

(01) NEVER
(02) SOMETIMES
(03) USUALLY
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER NAME)/the medical
(04) ALWAYS
providers at (US3A PROVIDER NAME)] or someone in [his/her/their] office talk with [you/(SP)] about what to do if
(-8) Don't Know
[you have/he has/she has] a bad reaction to [your/his/her] medicine?
(-9) Refused

BOX US5

routing

GO TO US37A CARESPCL.

SHOW CARD US4
BADRCTN

BOX US5

Page 8 of 13

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

USQ-Usual Source of Care

Question Type

Question Text/Description

Code List

Routing

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

(01) US37B - DRINFRMD
(02) PP50-HOSADMIT
(-8) PP50-HOSADMIT
(-9) PP50-HOSADMIT

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

US37C - REMINDDR

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

US37D - STPMSPCL

SHOW CARD US1

CARESPCL

US37A

yes/no

Specialists are doctors or other health professionals who specialize in one area of health care. This card lists
some examples of specialists.
Since (TODAY'S MONTH AND YEAR-12 MONTHS) , did [you/(SP)] receive care from any specialists outside the
office of [(US5A PROVIDER NAME)/the doctors or other health professionals at (US3A PROVIDER NAME)]?

SHOW CARD US4
DRINFRMD

US37B

code one

In general, how often [does (US5A PROVIDER NAME)/do the doctors or other health professionals at (US3A
PROVIDER NAME)] seem informed and up-to-date about the care [you get/(SP) gets] from specialists?

SHOW CARD US4
REMINDDR

US37C

code one

STPMSPCL

US37D

yes/no

In general, how often [do you/does(SP)] have to remind [(US5A PROVIDER NAME)/the doctors or other health
professionals at (US3A PROVIDER NAME)] about care [you receive/(SP) receives] from specialists?

(01) YES
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did any specialists outside the office of [(US5A PROVIDER (02) NO
NAME)/the doctors or other health professionals at (US3A PROVIDER NAME)] prescribe medicine for [you/(SP)]? (-8) DON'T KNOW
(-9) REFUSED

SHOW CARD US4
TALKPMS

US37E

code one

In general, how often [does (US5A PROVIDER NAME)/do the doctors or other health professionals at (US3A
PROVIDER NAME)] talk with [you/(SP)] about the medicines prescribed by these specialists?

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

(01) US37E - TALKPMS
(02) US37E1 - NAMESPCL
(-8) US37E1 - NAMESPCL
(-9) US37E1 - NAMESPCL

US37E1 - NAMESPCL

[DISPLAY PROVIDER ROSTER AS RESPONSE
The next four questions ask about care [you/(SP)] received from the specialist [you/he/she] saw most often in the OPTIONS:
last 12 months outside the office of [(US5A PROVIDER NAME)/the doctors or other health professionals at (US3A 1. [PROVIDER 1]
PROVIDER NAME)].
2. [PROVIDER 2]
NAMESPCL

US37E1

verbatim text

First, what is the name of the specialist [you/(SP)] saw most often since (TODAY'S MONTH AND YEAR-12
MONTHS)?

(01) continuous answer
(-8) Don't Know
(-9) Refused

US37E2 - SEXSPCL

[ENCOURAGE THE RESPONDENT TO REFER TO A BILL, TELEPHONE DIRECTORY, APPOINTMENT CARD,
ETC., FOR COMPLETE INFORMATION.]
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02

SEXSPCL

US37E2

code one

Is [(US37E1 PROVIDER NAME)/the specialist you saw most often since (TODAY'S MONTH AND YEAR-12
MONTHS)] a male or female?

(01) MALE
(02) FEMALE
(-8) DON’T KNOW
(-9) REFUSED

US37F - KNOWSPCL

SHOW CARD US5
[IF NEEDED: This question is about the last twelve months, that is since (TODAY'S MONTH AND YEAR - 12
MONTHS).]

KNOWSPCL

US37F

code one

(01) YES, DEFINITELY
The next questions ask about care [you/(SP)] received from the specialist [you/he/she] saw most often in the last (02) YES, SOMEWHAT
twelve months outside the [office of (US5A PROVIDER NAME)/the doctors or other health professionals at (US3A (03) NO
PROVIDER NAME)].
(-8) Don't Know
(-9) Refused
When [you see/(SP) sees] [(US37E1-SPCLNAME)/this specialist], does [he/she/he or she] seem to know enough
information about [your/his/her] medical history?

US37G - RPTINFO

[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]

Page 9 of 13

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

USQ-Usual Source of Care

Question Type

Question Text/Description

SHOW CARD US4
RPTINFO

US37G

code one

When [you see/(SP) sees] [(US37E1-SPCLNAME)/this specialist], how often [do you/does (SP)] have to repeat
information that [you/he/she] [have/has] already given to [(US5A PROVIDER NAME)/the doctors or other health
professionals at (US3A PROVIDER NAME)]?

Code List

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

Routing

KNOWRSLT

SHOW CARD US4

KNOWRSLT

PP49

code one

The next questions ask about care [you/(SP)] received from the specialist [you/he/she] saw most often since
(TODAY'S MONTH AND YEAR-12 MONTHS) outside the [office of (US5A PROVIDER NAME)/the doctors or
other health professionals at (US3A PROVIDER NAME)].
When [you see/(SP) sees] [(US37E1-SPCLNAME)/this specialist], how often does [he/she/he or she] seem to
know [your/(SP)'s] important test results from other providers?

(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused

PP50-HOSADMIT

HOSADMIT

PP50

yes/no

Since (TODAY'S MONTH AND YEAR-12 MONTHS), [were you/was (SP)] admitted to a hospital overnight or
longer?

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

(01) PP51- HOSFLWUP
(02) PP58- MNGCARE
(-8) PP58- MNGCARE
(-9) PP58- MNGCARE

HOSFLWUP

PP51

yes/no

After [your/(SP)'s] most recent hospital stay, did [(US5A PROVIDER NAME)/the medical providers at (US3A
PROVIDER NAME)] or someone in [his/her/their] office contact [you/him/her] to see how [you were/he was/she
was] doing?

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

PP52- HOSMED

HOSMED

PP52

yes/no

After [your/(SP)'S] most recent hospital stay, [were you/was (SP)] prescribed any medicines?

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

(01) PP53- HOSFOLLOWUP
(02) PP54- HOSINSTU
(-8) PP54- HOSINSTU
(-9) PP54- HOSINSTU

HOSFOLLOWUP

PP53

yes/no

After (your/(SP)'s)] most recent hospital stay, did [(US5A PROVIDER NAME)/the medical providers at (US3A
PROVIDER NAME)] or someone in [his/her/their] office contact [you/SP] to check if [you were/he was/she was ]
able to follow instructions about any medicines [you were/he was/she was] prescribed?

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

PP54- HOSINSTU

HOSINSTU

PP54

yes/no

After (your/(SP)'s] most recent hospital stay, (were you/was he/was she] given instructions about caring for
[yourself/himself/herself] at home?

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

(01) PP55- INSTUEASY
(02) PP56- HOSINFO
(-8) PP56- HOSINFO
(-9) PP56- HOSINFO

INSTUEASY

PP55

code one

HOSINFO

PP56

code one

SHOW CARD US5

(01) YES, DEFINITELY
(02) YES, SOMEWHAT
After [your/(SP)'s] most recent hospital stay, were the instructions [you were/(SP) was] given easy to understand? (03) NO
(-8) DON'T KNOW
(-9) REFUSED
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]

SHOW CARD US5
After (your/(SP)'s) most recent hospital stay, did [(US5A PROVIDER NAME)/the medical providers at (US3A
PROVIDER NAME)] seem to know the important information about this hospital stay?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]

(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED

(00) 0 HARD TO MANAGE
(01) 1
(02) 2
People sometimes need to manage their medical care by making appointments with multiple providers, following
(03) 3
their instructions, and taking medicines as prescribed.
(04) 4
(05) 5
Using any number from 0 to 10, where 0 is hard and 10 is easy, what number would you use to rate how easy it
(06) 6
was for [you/(SP)] to manage [your/his/her] medical care since (TODAY'S MONTH AND YEAR-12 MONTHS)?
(07) 7
(08) 8
[IN SITUATIONS WHERE A PROXY OR SOMONE ELSE MANAGES THE RESPONDENT’S MECIAL CARE FOR
(09) 9
OR WITH THEM, ANSWER BASED ON THEIR EXPERIENCE.]
(10) 10 EASY TO MANAGE

PP56- HOSINFO

PP58-MNGCARE

SHOW CARD US7

MNGCARE

PP58

code one

PP58A-DOCCARE

Page 10 of 13

2021 MCBS Community Questionnaire

USQ-Usual Source of Care

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

DOCCARE

PP58A

code one

(01) YES
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] need help from [anyone in (US5A PROVIDER
(02) NO
NAME)'s office/the doctors or other health professionals at (US3A PROVIDER NAME)] to manage [your/his/her]
(-8) DON'T KNOW
care among these different providers and services?
(-9) REFUSED

GETHELP

PP58B

code one

(01) YES, DEFINITELY
(02) YES, SOMEWHAT
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] get the help [you/he/she] needed from [(US5A (03) NO
PROVIDER NAME)'s office/the doctors or other health professionals at (US3A PROVIDER NAME)] to manage
(-8) DON'T KNOW
[your/his/her] care among these different providers and services?
(-9) REFUSED

Routing
(01) PP58B-GETHELP
(02) PP59-ONEDOC
(-8) PP59-ONEDOC
(-9) PP59-ONEDOC

SHOW CARD US5

SHOW CARD US5
ONEDOC

PP59

code one

Since (TODAY'S MONTH AND YEAR-12 MONTHS), was there one provider who knew about all [your/(SP)'s]
medical care needs?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]

SHOW CARD US5
PRVNOMED

PP60

code one

Since (TODAY'S MONTH AND YEAR-12 MONTHS), was there one provider who knew about all the medicines
[you were/(SP) was] taking?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]

NOTAVAIL

COMPUSE

PP60- PRVNOMED

(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX US7

(01) YES
(02) NO
(03) NOT APPLICABLE
(04) NOT SURE
(-9) Refused

BOX EHR1

routing

GO TO US37I- NOTAVAIL

US37I

code one

Since (TODAY'S MONTH AND YEAR-12 MONTHS), when getting care for a medical problem, was there ever a
time when test results, medical records, or reasons for referrals were not available at the time of [your/(SP)’s]
scheduled doctor or other health professional appointment?

BOX EHR1

routing

IF US1-PLACEPAR=1, GO TO EHR2-COMPUSE,
ELSE GO TO BOX USEND.

yes/no

The next few questions will help us understand how [(US5A PROVIDER NAME)/the doctors or other health
professionals at (US3A PROVIDER NAME)] use(s) a computer during [your/(SP)'s] office visit. Please answer the (01) YES
following questions based on where [you go/(SP) goes] for medical care most of the time.
(02) NO
(-8) Don't Know
[Does (US5A PROVIDER NAME)/Do the providers at (US3A PROVIDER NAME)] use a computer during
(-9) Refused
[your/(SP)'s] office visit?

Many health care providers are beginning to use electronic or computer-based medical records instead of using
paper-based records. When [you visit/(SP) visits] [(US5A PROVIDER NAME)/the doctors or other health
professionals at (US3A PROVIDER NAME)] [does he or she/do they] generally enter [your/(SP)'s] health
information into a computer while [you are/(SP) is] present?
EMEDREC

(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX US7

EHR2

US37K

yes/no

[IF SUPPORT STAFF (NURSES, MEDICAL ASSISTANTS) ENTER INFORMATION INTO THE ELECTRONIC
HEALTH RECORD DURING THEIR VISIT, SELECT “YES” AT THIS QUESTION.]

PP59-ONEDOC

(01) US37K - EMEDREC
(02) EHR6-COMPRD
(-8) EHR6-COMPRD
(-9) EHR6-COMPRD

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

(01) EHR3-COMPSHW
(02) EHR6-COMPRD
(-8) EHR6-COMPRD
(-9) EHR6-COMPRD

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

(01) EHR4-COMPINFO
(02) EHR6-COMPRD
(-8) EHR6-COMPRD
(-9) EHR6-COMPRD

[EXPLAIN IF NECESSARY: An “electronic health record” is an electronic version of a patient’s medical history
maintained by a provider over time. It automates the way in which doctors can access patient health information.
"Health Information" includes information such as symptoms, vital signs, test results, or prescribed medicines.]

COMPSHW

EHR3

yes/no

Is the examination room set up so that [(US5A PROVIDER NAME)/the doctors or other health professionals at
(US3A PROVIDER NAME)] can easily show [you/(SP)] information on the computer screen?

Page 11 of 13

2021 MCBS Community Questionnaire

USQ-Usual Source of Care

Variable Name

MR Screen Name

Question Type

Question Text/Description

COMPINFO

EHR4

yes/no

[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A PROVIDER NAME)] use (01) YES
the computer to show [you your/(SP) his/(SP) her] health information during [your/his/her] visit, such as trends in (02) NO
blood pressure reading, height, weight and body mass index, previous lab results, x-rays/images, immunizations or (-8) Don't Know
medications?
(-9) Refused

(01) EHR5-COMPREC
(02) EHR6-COMPRD
(-8) EHR6-COMPRD
(-9) EHR6-COMPRD

COMPREC

EHR5

yes/no

(01) YES
[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A PROVIDER NAME)] use (02) NO
the computer to show [you/(SP)] recommendations for preventive health screenings or other medical services?
(-8) Don't Know
(-9) Refused

EHR6-COMPRD

COMPRD

EHR6

yes/no

(01) YES
[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A PROVIDER NAME)] read
(02) NO
back to [you/(SP)] information that [you have/(SP) has] given during [your/(SP)'s] visit that is being put into
(-8) Don't Know
[your/(SP)'s] medical record?
(-9) Refused

EHR7-COMPINF

COMPINF

EHR7

yes/no

(01) YES
[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A PROVIDER NAME)] send
(02) NO
[you/(SP)] health information electronically, such as information about [your/(SP)'s] medications, exercise plans,
(-8) Don't Know
dietary advice, etc.?
(-9) Refused

EHR8-COMPACC

COMPACC

EHR8

yes/no

[Does (US5A PROVIDER NAME)'s/Do the doctors or other health professionals at (US3A PROVIDER NAME)'s]
office give [you/(SP)] access through [your/(SP)'s] own computer or smart phone to parts or all of [your/(SP)'s]
electronic medical record (such as a list of [your/(SP)'s] medications, lab results, x-ray reports, office notes)
through a “patient portal” or other electronic system?

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

BOX EHR2

BOX EHR2

routing

IF EHR2-COMPUSE=(01) YES, GO TO EHR9-COMPHLP,
ELSE GO TO BOX USEND

(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused

EHR9-COMPDIST

(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused

EHR9-COMPATT

(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused

EHR10-COMPTM

SHOW CARD US6

COMPHLP

EHR9

list

Now I am going to read some statements people have made about how their provider uses a computer. Think
about the care [you receive/(SP) receives] from (US5A PROVIDER NAME/US3A PROVIDER NAME). For each
statement, please tell me whether you strongly agree, agree, disagree, or strongly disagree.
(US5A PROVIDER NAME)'s/The doctors or other health professionals at (US3A PROVIDER NAME) use of the
computer during [my/(SP)'s] visit is helpful to [me/(SP)].

SHOW CARD US6
COMPDIST

EHR9

list

(US5A PROVIDER NAME)'s/The doctors or other health professionals at (US3A PROVIDER NAME) use of the
computer during [my/(SP)'s] visit distracts [him/her/them] from paying attention to [me/(SP)].

SHOW CARD US6
COMPATT

EHR9

list

[(US5A PROVIDER NAME)'s/The doctors or other health professionals at (US3A PROVIDER NAME)] use of the
computer during [my/(SP)'s] visit distracts [me/(SP)] from paying attention to the clinician.

Code List

Routing

SHOW CARD US8

COMPTM

EHR10

code one

(01) Much more than it should be
For the next statement, please tell me if it's much more than it should be, somewhat more than it should be, about (02) Somewhat more than it should be
(03) About what it should be
what it should be, somewhat less than it should be, much less than it should be, or no opinion?
(04) Somewhat less than it should be
(05) Much less than it should be
The amount of time during the visit that (US5A PROVIDER NAME)/the doctors or other health professionals at
(06) No opinion
(US3A PROVIDER NAME) spend(s) on the computer seems:

BOX USEND

Page 12 of 13

2021 MCBS Community Questionnaire

USQ-Usual Source of Care

Variable Name

MR Screen Name

Question Type

NUSNOTSK

US39

list

Question Text/Description
I am going to read some reasons that people have given for not having a usual source of health care. For each
one, please tell me whether or not it is a reason [you do/(SP) does] not have a usual place for health care.
There is no reason to have a usual source of health care because [you/(SP)] seldom or never [get/gets] sick. [Is
that a reason [you do/(SP) does] not have a usual source of health care?]

Code List

Routing

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

US39 - NUSMOVIN

NUSMOVIN

US39

list

[You/(SP)] recently moved into the area. [Is that a reason [you do/(SP) does] not have a usual source of health
care?]

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

US39 - NUSAVAIL

NUSAVAIL

US39

list

[Your/(SP’s)] usual source of health care in this area is no longer available. [Is that a reason [you do/(SP) does]
not have a usual source of health care?]

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

(01) US42 - USWHYNAV
(02) US43 - NUSDIFFP
(-8) US43 - NUSDIFFP
(-9) US43 - NUSDIFFP

(01) US43 - NUSDIFFP
(02) US43 - NUSDIFFP
(03) US43 - NUSDIFFP
(04) US43 - NUSDIFFP
(05) US43 - NUSDIFFP
(91) US42 - USWHYNO1
(-8) US43 - NUSDIFFP
(-9) US43 - NUSDIFFP

USWHYNAV

US42

code one

Why is [your/(SP’s)] usual source of health care no longer available?

(01) PREVIOUS DOCTOR RETIRED
(02) PREVIOUS DOCTOR DIED
(03) PREVIOUS DOCTOR MOVED
(04) SP MOVED
(05) PREVIOUS DR/PLACE TOO FAR AWAY
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

USWHYNO1

US42

verbatim text

OTHER (SPECIFY)

(01) CONTINUOUS ANSWER

US43 - NUSDIFFP

NUSDIFFP

US43

list

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

US43 - NUSTOOFR

Thinking about other possible reasons that people have for not having a usual source of health care, please tell
me if this statement applies to [you/(SP)]:
[You like/(SP) likes] to go to different places for different health care needs. [Is that a reason [you do/(SP) does]
not have a usual source of health care?]

NUSTOOFR

US43

list

The places where [you/(SP)] can receive health care are too far away. [Is that a reason [you do/(SP) does] not
have a usual source of health care?]

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

US43 - NUSTOOEX

NUSTOOEX

US43

list

The cost of health care is too expensive. [Is that a reason [you do/(SP) does] not have a usual source of health
care?]

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

BOX USEND

BOX USEND

routing

GO TO END.

Page 13 of 13