CMS-P-0015A Cognitive Measures

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

CMQ- COGNITIVE MEASURES

Question Text/Description

Code List

Routing

Continue

CNTTM20

(1) CONTINUOUS
(-8) DON'T KNOW
(-9) REFUSED

(1) CNTOTCM1
(-8) TDYMTH
(-9) TDYMTH

(1) CORRECT
(2) INCORRECT
(3) WANTS TO START OVER
(-9) REFUSED

(1) TDYMTH
(2) TDYMTH
(3) CNTTMT2
(-9) TDYMTH

(1) CONTINUOUS
(-8) DON'T KNOW
(-9) REFUSED

CNTOTCM2

(1) CORRECT
(2) INCORRECT
(-9) REFUSED

TDYMTH

(1) MONTH CORRECT
(2) MONTH NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED

TDYDAY

COGNITIVE MEASURES QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C003, C004, C005, C006
SPALIVE=1
SEASON=FALL
SPPROXY=SP
Other: N/A
PLACEMENT
Administer after SCQ.

CNINTRO

CNINTRO

no entry

Now I'd like to ask you some questions having to do with memory. The questions may seem unusual, but they
are routine questions we ask everyone. Some of the questions are very easy and some are difficult, so don’t be
surprised if you have trouble with some of them. Try your best to answer all of the questions without using clues
from around the room. If you wear glasses for reading, please use them.

For the first question, please try to count backward as quickly as you can from the number I will give you. I will
tell you when to stop.
CNTTM20

CNTTM20

numeric

ALLOW R TO START OVER IF S/HE WISHES TO DO SO
Please start with: 20
CORRECT RESPONSES INCLUDE COUNTING DOWN FROM 19 TO 10 OR FROM 20 TO 11

You may stop now. Thank you.
CNTOTCM1

CNTOTCM1

code one

CODE CORRECT IF R COUNTED BACKWARDS FROM 19 TO 10 OR FROM 20 TO 11 WITHOUT ERROR
ALLOW R TO START OVER IF S/HE WISHES TO DO SO

Let's try again.
CNTTMT2

CNTTMT2

numeric
The number to count backward from is: 20

You may stop now. Thank you.
CNTOTCM2

CNTOTCM2

code one
CODE CORRECT IF R COUNTED BACKWARDS FROM 19 TO 10 OR FROM 20 TO 11 WITHOUT ERROR

Please tell me today's date.
TDYMTH

TDYMTH

code one

PROBE MONTH, DAY, YEAR, DAY OF WEEK
THE DATE IS: MONTH/DAY/YEAR

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2020 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

CMQ- COGNITIVE MEASURES

Question Text/Description

Please tell me today's date.
TDYDAY

TDYMTH

code one

PROBE MONTH, DAY, YEAR, DAY OF WEEK
THE DATE IS: MONTH/DAY/YEAR

Please tell me today's date.
TDYYEAR

TDYMTH

code one

PROBE MONTH, DAY, YEAR, DAY OF WEEK
THE DATE IS: MONTH/DAY/YEAR

What is the day of the week?
TDYDOW

TDYDOW

code one
THE DAY OF THE WEEK IS: DAY OF WEEK

Code List

Routing

(1) DAY OF MONTH CORRECT
(2) DAY OF MONTH NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED

TDYYEAR

(1) YEAR CORRECT
(2) YEAR NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED

TDYDOW

(1) DAY CORRECT
(2) DAY NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED

SCISSOR

SCISSOR

SCISSOR

code one

Now I'm going to ask you for the names of some people and things.
What do people usually use to cut paper?

(1) SCISSORS OR SHEARS
(2) NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED

CACTUS

CACTUS

CACTUS

code one

What do you call the kind of prickly plant that grows in the desert?

(1) CACTUS OR NAME OF KIND OF CACTUS
(2) NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED

POTUS

(1) LAST NAME CORRECT
(2) NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED

VPOTUS

(1) LAST NAME CORRECT
(2) NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED

END

Who is the President of the United States right now?
ANSWER IS TRUMP
PROBE FOR LAST NAME
POTUS

POTUS

code one

IF NEEDED: These questions have to do with memory. Assessing memory in the Medicare population is
important to understanding whether the needs of beneficiaries are being met and for measuring the impact on
current and future health care costs.
IF NEEDED: NORC at the University of Chicago is an objective, non-partisan research institution. This survey
will not collect any information about your political affiliation.

Who is the Vice President?
ANSWER IS PENCE
PROBE FOR LAST NAME
VPOTUS

VPOTUS

code one

IF NEEDED: These questions have to do with memory. Assessing memory in the Medicare population is
important to understanding whether the needs of beneficiaries are being met and for measuring the impact on
current and future health care costs.
IF NEEDED: NORC at the University of Chicago is an objective, non-partisan research institution. This survey
will not collect any information about your political affiliation.

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