P-0015A MCBS COVID-19 Winter 2021 Facility Supplement

MCBS COVID-19 Winter 2021 Facility Supplement

MCBS COVID-19 Facility Supplement Questionnaire: Winter 2021
Variable Name
Question Text/Description
Facility-Level Questions
Thank you for agreeing to participate in this short survey
about (FACILITYS’ NAME) experiences during the coronavirus
pandemic, also known as COVID-19 or SARS-CoV-2.
SUSINTRO
As of today, are any in-person services currently suspended,
inside or outside of (FACILITY NAME), due to the coronavirus
pandemic?
[IF NEEDED: Please include only in-person services.]

Response Options

Routing

(01) CONTINUE

NEXT QUESTION

(00) NO, NOT SUSPENDED
(01) YES, SUSPENDED
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

(00) TELINTRO
(01) NEXT QUESTION
(02) TELINTRO
(-8) TELINTRO
(-9) TELINTRO

(00) NO, NOT SUSPENDED
(01) YES, SUSPENDED
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

NEXT QUESTION

[IF NEEDED: Suspension of in-person services means these
services are not currently being provided in-person.]
THIS ITEM IS ASKING ABOUT SERVICES CURRENTLY
SUSPENDED INSIDE OR OUTSIDE OF THE FACILITY. “INSIDE”
REFERS TO IN-PERSON SERVICES THAT ARE OFFERED WITHIN
THIS FACILITY. “OUTSIDE” REFERS TO IN-PERSON SERVICES
THAT ARE OFFERED OFF-SITE FROM THIS FACILITY.
OUTDRSUS

[As of today] are in-person primary care visits with a doctor
or other health professional outside this facility currently
suspended due to the coronavirus pandemic?
[IF NEEDED: Primary care visits are for treating common
medical conditions and may be for regular check-ups.]
[IF NEEDED: “Outside” refers to in-person services that are
offered off-site from this facility.]

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MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
OUTSDSUS

Question Text/Description
[As of today] are in-person specialty care visits with a doctor
or other health professional outside this facility currently
suspended due to the coronavirus pandemic?
[IF NEEDED: Specialty care visits may be for more complex
health issues, such as chronic conditions.]

INDRSUS

[IF NEEDED: “Outside” refers to in-person services that are
offered off-site from this facility.]
[As of today] are in-person primary care visits with a doctor
or other health professional inside this facility currently
suspended due to the coronavirus pandemic?
[IF NEEDED: Primary care visits are for treating common
medical conditions and may be for regular check-ups.]

INSDSUS

[IF NEEDED: “Inside” refers to in-person services are offered
within this facility.]
[As of today] are in-person specialty care visits with a doctor
or other health professional inside this facility currently
suspended due to the coronavirus pandemic?
[IF NEEDED: Specialty care visits may be for more complex
health issues, such as chronic conditions.]

Response Options
(00) NO, NOT SUSPENDED
(01) YES, SUSPENDED
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

Routing
NEXT QUESTION

(00) NO, NOT SUSPENDED
(01) YES, SUSPENDED
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

NEXT QUESTION

(00) NO, NOT SUSPENDED
(01) YES, SUSPENDED
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

NEXT QUESTION

[IF NEEDED: “Inside” refers to in-person services that are
offered within this facility.]

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MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
OTHSUSPE

Question Text/Description
[As of today] are any of the following in-person services,
both inside and outside this facility, currently suspended due
to the coronavirus pandemic?
THIS ITEM IS ASKING ABOUT SERVICES CURRENTLY
SUSPENDED INSIDE OR OUTSIDE OF THE FACILITY. “INSIDE”
REFERS TO IN-PERSON SERVICES THAT ARE OFFERED WITHIN
THIS FACILITY. “OUTSIDE” REFERS TO IN-PERSON SERVICES
THAT ARE OFFERED OFF-SITE FROM THIS FACILITY.

OTHSSERV
TELINTRO

Ask YES/NO for each:
• DENTSUS. Dental visits
• MENTHSUS. Psychiatrist or other mental health
professional visits
• PODSUS. Podiatrist visits
• EDHABSUS. Educational or habilitational services
• OTHSUS. Any other types of services
ENTER OTHER TYPES OF SUSPENDED SERVICES
OTHER (SPECIFY)
The next questions ask about telehealth services this facility
offered before the coronavirus pandemic.
Did (FACILITY NAME) offer any services through telehealth
before the coronavirus pandemic?

Response Options
(00) NO, NOT SUSPENDED
(01) YES, SUSPENDED
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

Routing
IF OTHSUS= (01) THEN GO
TO NEXT QUESTION
ELSE GO TO TELINTRO

(01) CONTINUOUS ANSWER

NEXT QUESTION

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

(00) TELCOVID
(01) NEXT QUESTION
(-8) TELCOVID
(-9) TELCOVID

[IF NEEDED: Telehealth visits include visits by telephone or
video.]

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MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
TELOUTDR

Question Text/Description
Were doctor or other health professional visits outside this
facility offered through telehealth before the coronavirus
pandemic? Please include outside visits for both primary and
specialty care.
VISITS SHOULD INCLUDE BOTH PRIMARY AND SPECIALTY
CARE. IF SERVICES WERE OFFERED THROUGH TELEHEALTH
FOR EITHER PRIMARY OR SPECIALITY CARE OUTSIDE THE
FACILITY ANSWER “YES”.

Response Options
(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

Routing
NEXT QUESTION

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

NEXT QUESTION

[IF NEEDED: “Outside” refers to telehealth visits with off-site
primary and specialty care doctors or other health
professionals.]
TELINDR

Were doctor or other health professional visits inside this
facility offered through telehealth before the coronavirus
pandemic?
VISITS SHOULD INCLUDE BOTH PRIMARY AND SPECIALTY
CARE. IF SERVICES WERE OFFERED THROUGH TELEHEALTH
FOR EITHER PRIMARY OR SPECIALITY CARE INSIDE THE
FACILITY ANSWER “YES”.
[IF NEEDED: “Inside” refers to telehealth visits with primary
and specialty care doctors or other health professionals from
this facility.]

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MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
TELMED1

Question Text/Description
Which of the following services, both inside and outside this
facility, were offered through telehealth before the
coronavirus pandemic?
Ask YES/NO for each:
• TELDENT. Dental visits
• TELMH. Psychiatrist or other mental health professional
visits
• TELPOD. Podiatrist visits
• TELEDHAB. Educational or habilitational services
• TELOTH. Any other types of services

OTHSTELE
TELCOVID

[IF NEEDED: Other types of services inside or outside the
facility may include dieticians, nurse practitioners,
physician’s assistants, registered nurses, or social workers.]
ENTER OTHER TYPES OF TELEHEALTH SERVICES OFFERED
BEFORE THE CORONAVIRUS PANDEMIC
OTHER (SPECIFY)
The next questions ask about telehealth services this facility
is currently providing due to the coronavirus pandemic.
As of today, are any services provided through telehealth by
(FACILITY NAME) due to the coronavirus pandemic?

Response Options
(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

Routing
IF TELOTH=(01) THEN GO TO
NEXT QUESTION
ELSE GO TO TELCOVID

(01) CONTINUOUS ANSWER

NEXT QUESTION

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

(00) TELEMDS
(01) NEXT QUESTION
(-8) TELEMDS
(-9) TELEMDS

[IF NEEDED: Telehealth visits include visits by telephone or
video.]

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MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
TLOUTDRC

Question Text/Description
[As of today] are doctor or other health professional visits
outside this facility currently offered through telehealth due
to the coronavirus pandemic? Please include outside visits
for both primary and specialty care.
VISITS SHOULD INCLUDE BOTH PRIMARY AND SPECIALTY
CARE. IF SERVICES ARE OFFERED THROUGH TELEHEALTH
FOR EITHER PRIMARY OR SPECIALITY CARE OUTSIDE THE
FACILITY ANSWER “YES”.

TELINDRC

[IF NEEDED: “Outside” refers to visits with doctors or other
health professionals that would normally see residents offsite from this facility, but are now conducting telehealth
visits due to the coronavirus pandemic.]
[As of today] are doctor or other health professional visits
inside this facility currently offered through telehealth due
to the coronavirus pandemic? Please include inside visits for
both primary and specialty care.
VISITS SHOULD INCLUDE BOTH PRIMARY AND SPECIALTY
CARE. IF SERVICES ARE OFFERED THROUGH TELEHEALTH
FOR EITHER PRIMARY OR SPECIALITY CARE INSIDE THE
FACILITY ANSWER “YES”.

Response Options
(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

Routing
NEXT QUESTION

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

NEXT QUESTION

[IF NEEDED: “Inside” refers to visits with doctors or other
health professionals that would normally see residents
within this facility, but are now conducting telehealth visits
due to the coronavirus pandemic.]

6

MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
TELMED2

Question Text/Description
[As of today] which of the following services, both inside and
outside this facility, are currently offered through telehealth
due to the coronavirus pandemic?
Ask YES/NO for each:
• TELDENTC. Dental visits
• TELMHC. Psychiatrist or other mental health
professional visits
• TELPODC. Podiatrist visits
• TELEDHBC. Educational or habilitational services
• TELOTHC. Any other types of services

OTHCTELE
TELEMDS

ACTINTRO
PREVVIS

[IF NEEDED: Other types of services inside or outside the
facility may include dieticians, nurse practitioners,
physician’s assistants, registered nurses, or social workers.]
ENTER OTHER TYPES OF TELEHEALTH SERVICES CURRENTLY
OFFERED DUE TO THE CORONAVIRUS PANDEMIC
OTHER (SPECIFY)
Due to the coronavirus pandemic, is (FACILITY NAME)
currently conducting any section of the Minimum Data Set
Resident Assessment and Care Screenings, also known as the
MDS, via video calls, voice calls, or conferencing over the
internet, such as with Zoom, Skype, or FaceTime?
Now I would like to ask you about activities this facility may
be using to prevent the spread of COVID-19.
As of today, does (FACILITY NAME) currently allow visitation,
such as by family, friends, or volunteers?
[IF NEEDED: Some examples may include allowing visitation
for end of life situations, making visitation decisions on a
case by case basis, or not restricting visitation at all.]

Response Options
(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

Routing
IF TELOTHC=01 THEN GO TO
NEXT QUESTION
ELSE GO TO TELEMDS

(01) CONTINUOUS ANSWER

NEXT QUESTION

(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED
(01) CONTINUE

NEXT QUESTION

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

(00) PREVVIS4
(01) NEXT QUESTION
(-8) PREVVIS4
(-9) PREVVIS4

NEXT QUESTION

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MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
PREVVIS3

PREVVIS2

PREVHCP1

HCPFLUVC

Question Text/Description
If visitors are permitted inside, are they required to...
Ask YES/NO for each:
• VISMASK. Wear a face mask
• VISRROOM. Restrict their visit to the resident's room
• VISWSHH. Frequently wash hands
Does this facility provide alternative methods for visitation
such as video conferencing for residents?
Does this facility monitor health care personnel adherence
to…
Ask YES/NO for each:
• HCPHH. Hand hygiene
• HCPPPE. Use of Personal Protective Equipment (PPE)
• HCPCDES. Cleaning and disinfecting environmental
surfaces
What is (FACILITY NAME)’s policy about the flu shot for
health care personnel? READ RESPONSE OPTIONS ALOUD:
• Flu shot is required
• Flu shot is recommended
• Neither

Response Options
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

Routing
NEXT QUESTION

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

NEXT QUESTION

(01) VACCINE IS REQUIRED
(02) VACCINE IS
RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED

NEXT QUESTION

NEXT QUESTION

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MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
HCPCOVVC 1

Question Text/Description
What (is/will be) the (FACILITY NAME)’s policy about the
Coronavirus vaccine for health care personnel? READ
RESPONSE OPTIONS ALOUD:
• Vaccine (is/will be) required
• Vaccine (is/will be) recommended
• Neither
• Don’t know

Response Options
(01) VACCINE (IS/WILL BE)
REQUIRED
(02) VACCINE (IS/WILL BE)
RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED

Routing
NEXT QUESTION

PREVRES1

Does this facility educate residents about…

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

NEXT QUESTION

(01) VACCINE IS REQUIRED
(02) VACCINE IS
RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED
(01) VACCINE (IS/WILL BE)
REQUIRED
(02) VACCINE (IS/WILL BE)
RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED

NEXT QUESTION

RESFLUVC

RESCOVVC

Ask YES/NO for each:
• EDSYMTRM. COVID-19 symptoms and transmission
• EDACTRES. Actions they can take to protect themselves
such as hand washing
• EDACTFAC. Actions the facility is taking to keep them
safe
What is (FACILITY NAME)’s policy about the flu shot for
residents? READ RESPONSE OPTIONS ALOUD:
• Flu shot is required
• Flu shot is recommended
• Neither
What (is/will be) the (FACILITY NAME)’s policy about the
Coronavirus vaccine for residents? READ RESPONSE
OPTIONS ALOUD:
• Vaccine (is/will be) required
• Vaccine (is/will be) recommended
• Neither
• Don’t know

NEXT QUESTION

For variables HCPCOVVC and RESCOVVC, interviewers asked about the facility’s future Coronavirus vaccine policy in Fall 2020. Once a Coronavirus vaccine is
available to the public, these items will ask about the Facility’s current Coronavirus vaccine policy.

1

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MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
FACLABCS

Question Text/Description
As of today, is there at least one laboratory-confirmed
COVID-19 case in (FACILITY NAME)? Please include residents
and facility staff.

ALTPROV1

As of today, have additional health care personnel been
recruited in (FACILITY NAME) beyond the usual health care
personnel in this facility in response to the coronavirus
pandemic?

ALTPROV2

[IF NEEDED: Health care personnel may have been recruited
because facility staff have been sick with or exposed to
COVID-19.]
What kind of health care personnel was that? SELECT ALL
THAT APPLY.

CODE BASED ON THE RESPONSE FACILITY RESPONDENT
GIVES:

ALTPROVS
PREMHS

OTHER (SPECIFY)
The next questions are about mental health services.

Response Options
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

Routing
NEXT QUESTION

(01) EMERGENCY MEDICAL
SERVICE PERSONNEL
(02) NURSES
(03) NURSING ASSISTANTS
(04) NURSE PRACTITIONERS
(05) PHARMACISTS
(06) PHLEBOTOMISTS
(07) PHYSICIANS
(08) TECHNICIANS
(09) THERAPISTS
(10) NATIONAL GUARD
(11) OTHER
(-8) DON’T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(01) CONTINUE

(01) PREMHS
(02) PREMHS
(03) PREMHS
(04) PREMHS
(05) PREMHS
(06) PREMHS
(07) PREMHS
(08) PREMHS
(09) PREMHS
(10) PREMHS
(11) NEXT QUESTION
(-8) PREMHS
(-9) PREMHS

(00) MENTHLTH
(01) ALTPROV2
(-8) MENTHLTH
(-9) MENTHLTH

NEXT QUESTION
NEXT QUESTION

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MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
MENTFAC

SUSPCOV

MTELESER

SOCINTRO
ACTINFAC

Question Text/Description
Does this facility usually offer…
Ask YES/NO to each:
• FACMHITS. Individual Therapy Sessions
• FACMHGTS. Group Therapy Sessions
• FACMHSG. Support Groups
• FACMHAT. Art Therapy
• FACMHOTH. Any Other Types of Mental Health Services
Are any of these support services currently suspended due
to the coronavirus pandemic?
SUPPORT SERVICES INCLUDE INDIVIDUAL THERAPY
SESSIONS, GROUP THERAPY SESSIONS, SUPPORT GROUPS,
ART THERAPY OR ANY OTHER TYPE OF MENTAL HEALTH
SERVICES.
Are any of these support services currently shifted to an
online platform, such as Zoom, Skype, or FaceTime due to
the coronavirus pandemic?
SUPPORT SERVICES INCLUDE INDIVIDUAL THERAPY
SESSIONS, GROUP THERAPY SESSIONS, SUPPORT GROUPS,
ART THERAPY OR ANY OTHER TYPE OF MENTAL HEALTH
SERVICES.
The next questions are about social and recreational
activities.
Does this facility usually provide social and recreational
activities within the facility?

Response Options
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

Routing
IF YES TO AT LEAST ONE
SUPPORT SERVICE GO TO
SUSPCOV

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

NEXT QUESTION

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

NEXT QUESTION

ELSE GO TO SOCINTRO

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

NEXT QUESTION

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MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
ACTOUTFAC

BOX 1
ACTSUSP

ACTTELE

Question Text/Description
Does this facility usually provide social and recreational
activities outside the facility?
“OUTSIDE THE FACILITY” REFERS TO ACTIVITES THAT OCCUR
OFF THE FACILITY PREMISES.
IF ACTINFAC or ACTOUTFAC = (01) YES go to ACTSUSP
ELSE go to CVDINTRO
Are any of these activities currently suspended due to the
coronavirus pandemic?
Are any of these activities currently shifted to an online
platform, such as Zoom, Skype, or FaceTime due to the
coronavirus pandemic?

Beneficiary-Level Questions
CVDINTRO
I am now going to ask you some questions about different
types of coronavirus tests (SP) may have had.
CVDTEST
Since (REFERENCE DATE) has (SP) been tested to see
whether (he/she) was infected with coronavirus or COVID19 at the time of the test?
[IF NEEDED: For example, the test can be done by swabbing
someone’s nose.]

Response Options
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

Routing
BOX 1

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

NEXT QUESTION

CONTINUE

NEXT QUESTION

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

(00) ANTICVD
(01) NEXT QUESTION
(-8) ANTICVD
(-9) ANTICVD

NEXT QUESTION

[IF NEEDED: If (SP) had more than one test to see whether
(he/she) was infected with coronavirus or COVID-19 at the
time of the test, refer to their most recent test.]
DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER
SOMEONE HAS EVER BEEN INFECTED WITH CORONAVIRUS.

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MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
TESTRES

Question Text/Description
Did the test find that (SP) had Coronavirus or COVID-19?
[IF NEEDED: If (SP) had more than one test to see whether
(he/she) was infected with coronavirus or COVID-19 at the
time of the test, refer to their most recent test.]

ANTICVD

DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER
SOMEONE HAS EVER BEEN INFECTED WITH CORONAVIRUS.
Since (REFERENCE DATE) has (SP) received an antibody test
to determine if (he/she) had Coronavirus or COVID-19 in the
past?
[IF NEEDED: An antibody test looks at someone’s blood to
see if they have ever been infected with the coronavirus.]

ANTIRES

[IF NEEDED: If (SP) had more than one antibody test to
determine if (he/she) ever had the coronavirus, refer to their
most recent test.]
Did the test find that (SP) had Coronavirus or COVID-19?
[IF NEEDED: An antibody test looks at someone’s blood to
see if they have ever been infected with the coronavirus.]

MEDICARE

[IF NEEDED: If (SP) had more than one antibody test to
determine if (he/she) ever had the coronavirus, refer to their
most recent test.]
Since (REFERENCE DATE) has (SP) received medical care
(either inside or outside this (facility/home)) for the
coronavirus or COVID-19?
[IF NEEDED: Please include services provided by all health
care personnel.]

Response Options
(01) YES, THE TEST SHOWED
R HAD COVID-19
(02) NO, THE TEST SHOWED
R DID NOT HAVE COVID-19
(03) NO RESULTS YET
(-8) DON’T KNOW
(-9) REFUSED

Routing
NEXT QUESTION

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

(00) MEDICARE
(01) NEXT QUESTION
(-8) MEDICARE
(-9) MEDICARE

(01) YES, THE TEST SHOWED
R HAD COVID-19
(02) NO, THE TEST SHOWED
R DID NOT HAVE COVID-19
(03) NO RESULTS YET
(-8) DON’T KNOW
(-9) REFUSED

NEXT QUESTION

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

(00) CDCVAC1
(01) NEXT QUESTION
(-8) CDCVAC1
(-9) CDCVAC1

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MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
PROVTYP

Question Text/Description
What kind of provider did (he/she) receive care from for the
coronavirus or COVID-19? SELECT ALL THAT APPLY.
CODE BASED ON THE RESPONSE FACILITY RESPONDENT
GIVES:

BOX 2
CDCVAC1 2

CVDVACNUM

IF CVVACFLG=1 (VACCINE AVAILABLE) THEN GO TO
CVDVAC1.
ELSE GO TO MDSINTRO.
Since (DATE of COVID-19 vaccine availability) has (SP) had a
coronavirus vaccination?
DO NOT REPORT VACCINES THAT ARE SCHEDULED FOR THE
FUTURE. ONLY REPORT VACCINATIONS THAT HAVE BEEN
RECEIVED BY THE DATE OF THE INTERVIEW.
How many coronavirus vaccination doses has (SP) had?
[IF NEEDED: Some vaccinations require two doses, given on
separate days, in order to work properly.]

Response Options
(01) EMERGENCY MEDICAL
SERVICE PERSONNEL
(02) NURSES
(03) NURSING ASSISTANTS
(04) PHARMACISTS
(05) PHLEBOTOMISTS
(06) PHYSICIANS
(07) TECHNICIANS
(08) THERAPISTS
(09) OTHER
(-8) DON’T KNOW
(-9) REFUSED

Routing
NEXT QUESTION

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

(00) MDSINTRO
(01) NEXT QUESTION
(-8) MDSINTRO
(-9) MDSINTRO

(01) One vaccination dose
(02) Two vaccination doses
(-8) DON’T KNOW
(-9) REFUSED

(01) NEXT QUESTION
(02) NEXT QUESTION
(-8) MDSINTRO
(-9) MDSINTRO

DO NOT REPORT VACCINES THAT ARE SCHEDULED FOR THE
FUTURE. ONLY REPORT VACCINATIONS THAT HAVE BEEN
RECEIVED BY THE DATE OF THE INTERVIEW.

Variables CVDVAC1 through DOSEDAT2 were included in the specifications but were not fielded in Fall 2020. The items will be fielded in a future MCBS
COVID-19 Facility Supplement once a Coronavirus vaccine is available to the public.

2

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MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
DOSEDAT1

DOSEDAT2
MDSINTRO
PHQINTRO

Question Text/Description
Date of first dose of coronavirus vaccination received –
Complete date and skip to the next section if response to
question two was 1; continue to next question if the
response to question two was 2. Month/Year
Date of second coronavirus vaccination received – Complete
date and skip to the next section Month/Year
MOOD
The next section is concerning (SP)’s mood on or around (HS
REF DATE).
MOOD
[3.0, D0100]
On or around (HS REF DATE) was a Resident Mood Interview
conducted for (SP)?

PHQSCORE

[IF NEEDED: This is sometimes referred to as the Patient
Health Questionnaire-9 or PHQ-9©. If an MDS has been
conducted for the resident, it can be found in section
D0100.]
MOOD
[3.0, D0300]
ENTER SYMPTOM FREQUENCY SCORE (00-27) FROM PHQ-9.

Response Options
MONTH (VAC1MM)

MONTH (VAC2MM)

Routing
IF RESPONSE TO
CVDVACNUM =(02) GO TO
DOSEDAT2.
ELSE GO TO MDSINTRO.
NEXT QUESTION

YEAR (VAC2YY)
(01) CONTINUE

NEXT QUESTION

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

(00) PHQSYMPT
(01) PHQSCORE
(-8) PHQSYMPT
(-9) PHQSYMPT

(_ _) CONTINUOUS
RESPONSE
(99) UNABLE TO COMPLETE
INTERVIEW

THANKEND

YEAR (VAC1YY)

ENTER “99” IF THE RESIDENT WAS UNABLE TO COMPLETE
THE INTERVIEW.

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MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
PHQSYMPT

Question Text/Description
MOOD
[3.0, D0500]
Over the last 2 weeks, did the resident have any of the
following problems or behaviors?

Response Options
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

Routing
If (01) YES TO ANY, GO TO
PHQSYMFQ.
ELSE GO TO THANKEND

IF THE FACILITY RESPONDENT IS UNSURE AND THIS
INFORMATION CANNOT BE FOUND IN THE MEDICAL CHART,
BUT THERE IS AN MDS AVAILABLE, YOU CAN REFERENCE THE
MDS ITEM [3.0, D0500].
Ask YES/NO for each:
PHQSYINT. A. Little interest or pleasure in doing things.
PHQSYDEP. B. Feeling or appearing down, depressed, or
hopeless.
PHQSYSLP. C. Trouble falling or staying asleep, or sleeping
too much.
PHQSYTIR. D. Feeling tired or having little energy.
PHQSYAPT. E. Poor appetite or overeating.
PHQSYSES. F. Indicating that s/he feels bad about self, is a
failure, or has let self or family down.
PHQSYCON. G. Trouble concentrating on things, such as
reading the newspaper or watching television.
PHQSYMOV. H. Moving or speaking so slowly that other
people have noticed. Or the opposite - being so fidgety or
restless that s/he has been moving around a lot more than
usual.
PHQSYSUI. I. States that life isn't worth living, wishes for
death, or attempts to harm self.
PHQSYTEM. J. Being short-tempered, easily annoyed.

16

MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
PHQSYMFQ

Question Text/Description
MOOD
[3.0, D0500]
Over the last 2 weeks, would you say [INSERT PROBLEM OR
BEHAVIOR FROM PHQSYMPT] was exhibited never or 1 day,
for 2 to 6 days (several days), for 7 to 11 days (half or more
of the days), or for 12-14 days (nearly every day)?

Response Options
(00) Never or 1 day
(01) 2-6 days (several days)
(02) 7-11 days (half or more
of the days)
(03) 12-14 days (nearly
every day)

Routing
NEXT QUESTION

IF THE FACILITY RESPONDENT IS UNSURE AND THIS
INFORMATION CANNOT BE FOUND IN THE MEDICAL CHART,
BUT THERE IS AN MDS AVAILABLE, YOU CAN REFERENCE THE
MDS ITEM [3.0, D0500].
COLLECT SYMPTOM FREQUENCY FOR EACH
PROBLEM/BEHAVIOR THAT IS REPORTED “YES”
PHQFQIN. Little interest or pleasure in doing things.
PHQSFQDE. Feeling or appearing down, depressed, or
hopeless.
PHQSFQSL. Trouble falling or staying asleep, or sleeping too
much.
PHQSFQTI. Feeling tired or having little energy.
PHQSFQAP. Poor appetite or overeating.
PHQSFQSE. Indicating that s/he feels bad about self, is a
failure, or has let self or family down.
PHQSFQCO. Trouble concentrating on things, such as
reading the newspaper or watching television.
PHQSFQMO. Moving or speaking so slowly that other people
have noticed. Or the opposite - being so fidgety or restless
that s/he has been moving around a lot more than usual.
PHQSFQSU. States that life isn't worth living, wishes for
death, or attempts to harm self.
PHQSFQTE. Being short-tempered, easily annoyed.

17

MCBS COVID-19 Winter 2021 Facility Supplement
Variable Name
THANKEND

Question Text/Description
Thank you for participating in this important survey.

Response Options

Routing

18