CMS-P-0015A Facility Screener

2019 MCBS Facility Screener

Variable Name

FSINTRO

MR Screen Name

FSI01

Question Type

no entry

Question Text/Description

Code List

Hello, my name is (FI NAME). I am from NORC at the Unversity of Chicago and we are conducting the Medicare
Current Beneficiary Survey for the Centers for Medicare and Medicaid Services, also known as CMS, part of the
United States Department of Health and Human Services. We are studying a sample of people eligible for
Medicare who live in community and facility settings.

Routing

FS01 -SPRESIDENOW

I am contacting you to confirm information that a person in our sample lives or has lived in (FACILITY NAME).
Does (SP) currently live at (FACILITY NAME)?
SPRESIDENOW

FS01

yes/no

IF RESPONDENT DOES NOT KNOW, ASK TO SPEAK TO SOMEONE WHO WOULD KNOW ADMISSION
INFORMATION.
Since (LAST INTERVIEW DATE), has (SP) lived [here/there]?

SPRESIDE

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

(01) BOX INSTR2
(02) FS02 - SPRESIDE

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

(01) BOX INSTR1
(02) FS08-FSWHERE

FS02

yes/no

BOX INSTR1

routing

IF SUPPLEMENTAL SAMPLE, GO TO FS08 - FSWHERE.
ELSE CONTINUE to BOX INSTR2.

BOX INSTR2

routing

IF ADDRESS PRELOADED GO TO FS03 - FSVERIFY.
IF ADDRESS NOT PRELOADED GO TO FS3a - FSTADDR1.

FSVERIFY

FS03

verbatim text

I need to verify the name and contact information I have for (FACILITY NAME). I have…READ INFORMATION
BELOW

(01) ADDRESS CORRECT
(02) ADDRESS INCORRECT

(01) FS04-FSFACILITY
(02) FS03a-FACNAME

FACNAME

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

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

FS03a- FSTADDR1

FSTADDR1

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

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

FS03a-FSTADDR2

FSTADDR2

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

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

FS03a-FCITY

FCITY

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

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

FS03a-FSTATE

FSTATE

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

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

FS03a-FZIPCODE

FZIPCODE

FS03a

verbatim text

CORRECT OR ENTER THE INFORMATION BELOW

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

FS03a-FPHONE

FS03a-FFAX

FS04- FSFACILITY

IF RESPONDENT DOES NOT KNOW OR , ASK TO SPEAK TO SOMEONE WHO WOULD KNOW ADMISSION
INFORMATION.

FPHONE

FS03a

verbatim text

CORRECT THE PORTIONS OF THE PHONE LISTED BELOW

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

FFAX

FSO3a

verbatim text

CORRECT THE PORTIONS OF THE FAX NUMBER LISTED BELOW

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

Page 1 of 3

2019 MCBS Facility Screener

Variable Name

MR Screen Name

Question Type

Question Text/Description

What type of facility or place is (FACILITY NAME)? (Is this a…)

Code List

Routing

(01)CONTINUING CARE RETIREMENT COMMUNITY
(CCRC)
(02) RETIREMENT COMMUNITY
(03) ADULT/GROUP HOME
(04) NURSING HOME/UNIT WITHIN A CCRC OR
RETIREMENT CENTER
(05)HOSPITAL-BASED SNF UNIT
(06) ASSISTED LIVING FACILITY
(07) BOARD AND CARE HOME
(08) DOMICILIARY CARE HOME
(09) PERSONAL CARE HOME
(010) REST HOME/RETIREMENT HOME
(11) MENTAL HEALTH CENTER/PSYCHIATRIC
SETTING
(12) INSTITUTION FOR THE INTELLECTUALLY
DISABLED/DEVELOPMENTALLY DISABLED
(13) REHABILITATION FACILITY
(14) OTHER LONG-TERM CARE FACILITY (SPECIFY)
(15) PRIVATE RESIDENCE
(-8) Don't Know
(-9) Refused

(01) FS05-FSNAME
(02) FS05 -FSNAME
(03) FS06-FSRES
(04) FS07-FSADMIN
(05) FS07-FSADMIN
(06) FS07-FSADMIN
(07) FS07 -FSADMIN
(08) FS07 -FSADMIN
(09)FS07-FSADMIN
(10) FS07 -FSADMIN
(11) FS07-FSADMIN
(12) FS07-FSADMIN
(13) FS07-FSADMIN
(14) FS04a- FSFACILITYOTH
(15) CLOSING1

FSFACILITY

FS04

code one

FSFACILITYOTH

FS04a

verbatim text

What type of facility is (FACILITY NAME)?

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

FS07-FSADMIN

FSNAME

FS05

verbatim text

What is the name of the specific place within (FACILITY NAME) where (SP) was residing on or around since
[LAST INTERVIEW DATE]?

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

FS07-FSADMIN

USE CATEGORIES AS PROBES IF NECESSARY

FSRES

FS06

yes/no

Are residents placed in this facility by an agency of state, county, or local government?

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

FSSPCARENAME

FS06a

verbatim text

Please give me the information of the person who is responsible for the oversight of (SP's) care.

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

FS06a- FSTADDR1

FS06a-FSTADDR2

(01) FS06a-FSSPCARENAME
(02) FS07- FSADMIN

FPADDR1

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FPADDR2

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS06a -FCITY

FPCITY

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS06a-FSTATE

FPSTATE

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS06a-FZIPCODE

FPZIPCODE

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS06a-FPHONE

FPPHONE

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FS06a-FFAX

FS07 - FSADMIN

FPFAX

FS06a

verbatim text

ENTER THE NAME, ADDRESS, AND PHONE NUMBER BELOW

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

FSADMIN

FS07

verbatim text

What is the name of the facility administrator at (FACILITY NAME)?

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

BOX INSTR3

BOX INSTR3

routing

IF FS01 - SPRESIDENOW = 01 GO TO CLOSING 2
ELSE GO TO CLOSING 2
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) FS08a-FACNAME
(02) BOX INSTR4
(03) FS09 - FSDODMM
(04) BOX INSTR4
(05) BOX INSTR4

FSWHERE

FS08

code one

Do you know where (SP) went after living at (FACILITY NAME)?

Page 2 of 3

2019 MCBS Facility Screener

Variable Name

FACNNAME

FNADDR1

FNADDR2

FNCITY

FNSTATE

FNZIPCODE

FNPHONE

FNFAX

FSDODMM

FSDODDD

FSDODYY

MR Screen Name

FS08a

FS08a

FS08a

FS08a

FS08a

FS08a

FS08a

FS08a

FS09

FS09

Question Type

Question Text/Description

Code List

Routing

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

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

FS08a- FSTADDR1

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

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

FS08a -FSTADDR2

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

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

FS08a-FCITY

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

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

FS08a-FSTATE

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

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

FS08a-FZIPCODE

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

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

FS08a-FPHONE

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

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

FS08a-FFAX

verbatim text

Please give me (SP)'s new address:
ENTER THE INFORMATION BELOW

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

What was the date of death?

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

FS08a-FSDODDD

What was the date of death?

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

FS08a-FSDODYY

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

FSFACILITY

date

date

FS09

date

What was the date of death?

BOX INSTR4

routing

IF FS02 - SPRESIDE = 01 (YES) THEN GO TO CLOSING1
ELSE GO TO CLOSING2

CLOSING1

no entry

That is all of the information I need at this time. Thank you very much for your time. We will contact (you/SP) to
arrange an interview.

CLOSING2

no entry

Thank you very much for your time.
We will contact you if there are additional questions.

Page 3 of 3