CMS-P-0015A Dental, Vision, and Hearing Care Utilization

Medicare Current Beneficiary Survey (MCBS) (CMS-P-0015A)

2023_Den_Vis_Hear_Care_Utl_DVH

OMB: 0938-0568

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Download: pdf | pdf
2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

Code List

Routing

(01) IN-PERSON
(02) PHONE

DUINT- DUINTRO

DENTAL, VISION, & HEARING CARE UTILIZATION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after HIQ.
PHONDVH

PHONDVH

code one

ARE THE UTILIZATION AND COST SECTIONS BEING CONDUCTED IN-PERSON OR OVER THE PHONE?
The next questions are about any medical care [you/(SP)] may have had between (REFERENCE DATE/UTILDATE)
and (today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD).

DUINT

DUINTRO

no entry

(Now would be a good time to get out the planner that [you/(SP)] may have used to record health care visits or other
medical expenses. We will also refer to any statements [you/(SP)] may have received since the last interview.)

DU1 - DUPROBE

First, we’ll talk about dental care.

DUPROBE

DU1

yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to a dentist or any other person for dental care? [Dental
providers include dentists, dental surgeons, endodontists, periodontists, and dental hygienists.]

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

(01) DU2 - PROVIDER_DU
(02) BOX DU5
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX DU5
(-9) BOX DU5

(01) [Continuous answer.]

PROVIDER_DU

DU2

roster

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
Who did [you/(SP)] see?
1. [PROVIDER 1]
2. [PROVIDER 2]
SELECT OR ADD ONLY ONE PROVIDER.
…
N. [PROVIDER N]
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY ENTERING AN
N+1. ADD ANOTHER
EVENT WITH THAT PROVIDER
N+2. NEED TO EDIT SPELLING OF EXISTING
PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.

(01-N) BOX DU1
(N+1) DU2B-PROVNAME
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX DU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO DU2BPROVNAME
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPL-CHNGSPL.

ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME BELOW.
YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT YOU
DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE GROUP
OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.
PROVNAME

DU2B

verbatim text

DU2B - GRPNAME

YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
NAME:

GRPNAME

DU2B

verbatim text

GROUP:
WHICH PROVIDER IS MISSPELLED?

CHNGSPL

CHNGSPL

roster

THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."

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

CRCTSPL-CRCTSPL

ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER. IF YOU
ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO SELECT OR
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.

Page 1 of 25

2023 MCBS Community Questionnaire

Variable Name

CRCTSPL

PROVSPEC

DVH-DENTAL, VISION, AND HEARING

MR Screen Name Question Type

Question Text/Description

Code List

Routing

CRCTSPL

WHAT IS THE CORRECT SPELLING OF THIS PROVIDER'S NAME?
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]

(01) [Continuous Answer]

BOX DU1

What kind of dental provider is [PROVNAME]?

(01) GENERAL DENTIST
(35) DENTAL HYGIENIST
(36) DENTAL TECHNICIAN
(37) DENTAL/ORAL SURGEON
(38) ORTHODONTIST
(39) ENDODONTIST
(40) PERIODONTIST
(41) PROSTHODONTIST
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX DU2
(02) BOX DU2
(03) BOX DU2
(04) BOX DU2
(05) BOX DU2
(06) BOX DU2
(07) BOX DU2
(08) BOX DU2
(91) DU2C1 - PROVSPEC
(-8) BOX DU2
(-9) BOX DU2

(01) DO NOT DISPLAY
(02) BOX DU2
(03) BOX DU2
(04) BOX DU2
(05) BOX DU2
(06) BOX DU2
(07) BOX DU2
(08) BOX DU2
(09) BOX DU2
(10) BOX DU2
(11) BOX DU2
(12) BOX DU2
(13) BOX DU2
(14) BOX DU2
(15) BOX DU2
(16) BOX DU2
(17) BOX DU2
(18) BOX DU2
(19) BOX DU2
(20) BOX DU2
(21) BOX DU2
(22) BOX DU2
(23) BOX DU2
(24) BOX DU2
(25) BOX DU2
(26) BOX DU2
(27) BOX DU2
(28) BOX DU2
(29) BOX DU2
(30) BOX DU2
(31) BOX DU2
(32) BOX DU2
(33) BOX DU2
(34) BOX DU2
(91) DU2D - PROVSPOS
(-8) BOX DU2
(-9) BOX DU2

DU2C

verbatim

code one

PROVSPEC

DU2C1

code one

What kind of dental provider is [PROVNAME]?

(01) DENTIST/DENTAL PROVIDER (DO NOT DISPLAY)
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused

PROVSPOS

DU2D

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

(01) [Continuous answer.]

BOX DU2

routing

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO DU3 VAPLACE.
ELSE GO TO BOX DU2.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

BOX DU2

BOX DU1

VAPLACE

DU3

yes/no

Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?

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2023 MCBS Community Questionnaire

Variable Name

DVH-DENTAL, VISION, AND HEARING

MR Screen Name Question Type

Question Text/Description

BOX DU2

IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO DU4 - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (THIS
PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO DU5 - HMOREFER.
ELSE GO TO DU6 - EVENT_DU.

routing

HMOASSOC

DU4

yes/no

Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

HMOREFER

DU5

yes/no

[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]

EVENT_DU

DU6

roster

When did [you/(SP)] see (PROVIDER NAME)? Please tell me all the dates [since (REFERENCE
DATE/(UTILDATE))/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY
ONCE.]

DU6B

chose one

DU7

code all

PRESMDCN

DU7A

DU9

verbatim text

yes/no

(01) DU6 - EVENT_DU
(02) DU5 - HMOREFER
(-8) DU5 - HMOREFER
(-9) DU5 - HMOREFER
DU6 - EVENT_DU

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

(01) ADD ANOTHER
(02) ALL DONE

(01) DU6 -EVENT_DU
(02) DU7-DVPROCDR

(01) GENERAL EXAM, CHECKUP OR CONSULTATION
(02) CLEANING, PROPHYLAXIS, OR POLISHING
(03) X-RAYS, RADIOGRAPHS, OR BITEWINGS
(04) FLUORIDE TREATMENT
(05) SEALANT (PLASTIC COATINGS ON BACK TEETH)
(06) FILLINGS
(07) INLAYS
(08) CROWNS OR CAPS
(09) ROOT CANAL
(10) PERIODONTAL SCALING, ROOT PLANING, OR
GUM SURGERY
(11) PERIODONTAL RECALL VISIT (PERIODIC OR
REGULAR)
(12) EXTRACTION, TOOTH PULLED
(13) IMPLANTS
(14) ABSCESS OR INFECTION TREATMENT
(15) OTHER ORAL SURGERY
(16) FIXED BRIDGES
(17) DENTURES OR REMOVABLE PARTIAL
DENTURES
(18) RELINING OR REPAIR OF BRIDGES OR
DENTURES
(19) ORTHODONTIA, BRACES, OR RETAINERS
(20) BOND, WHITEN, OR BLEACH
(21) TREATMENT FOR TMD OR TMJ
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED

(01) DU9-PRESMDCN
(02) DU9-PRESMDCN
(03) DU9-PRESMDCN
(04) DU9-PRESMDCN
(05) DU9-PRESMDCN
(06) DU9-PRESMDCN
(07) DU9-PRESMDCN
(08) DU9-PRESMDCN
(09) DU9-PRESMDCN
(10) DU9-PRESMDCN
(11) DU9-PRESMDCN
(12) DU9-PRESMDCN
(13) DU9-PRESMDCN
(14) DU9-PRESMDCN
(15) DU9-PRESMDCN
(16) DU9-PRESMDCN
(17) DU9-PRESMDCN
(18) DU9-PRESMDCN
(19) DU9-PRESMDCN
(20) DU9-PRESMDCN
(21) DU9-PRESMDCN
(91) DU7A-EVOSTEXT
(-8) DU9-PRESMDCN
(-9) DU9-PRESMDCN

OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)

(01) [CONTINUOUS ANSWER]

DU9 - PRESMDCN

Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?

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

(01) DU10 - PRESFILL
(02) BOX DU4
(-8) BOX DU4
(-9) BOX DU4

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.

EVOSTEXT

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

DU6B-DUADD

SHOW CARD DVH1
DVPROCDR

Routing

MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS

IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT "REPEAT
VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.

DUADD

Code List

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2023 MCBS Community Questionnaire

Variable Name

PRESFILL

DUPMMEDS

DVH-DENTAL, VISION, AND HEARING

MR Screen Name Question Type

Question Text/Description

Code List

Routing

DU10

yes/no

Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE RESPONDENT
ACTUALLY TOOK THE MEDICINE.]

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

(01) BOX DU3B
(02) BOX DU4
(-8) BOX DU4
(-9) BOX DU4

BOX DU3B

routing

IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT ROUND,
GO TO DU10A - DUPMMEDS.
ELSE GO TO BOX PM2.

(01) INSTRUCTION WAS READ

BOX PM2

DU10A

no entry

It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can spell
the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)] (MEDICARE
PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same information on them.]
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)] obtained
since (REFERENCE DATE/UTILDATE), if you’d like to get those bottles, too.

BOX PM2

MEDICINE_PM1

routing

IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE, GO
TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.

MEDICINE_PM1

code one

What is the name of the medicine?

BOX PM3

routing

IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2A-SAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.

[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.

BOX PM3

CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
SAMEFSAM

SAMEFSAM

yes/no

The strength was [MEDICINE STRENGTH].
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).

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

BOX PM4

(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED

(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM

Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.

BOX PM4

PMBOTTLE

PMBOTTLE

routing

IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.

code one

CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS ABOUT
THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.

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2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

Code List

Routing

TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED MEDICINE
LOOKUP BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME

MED

lookup

ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT,
USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.

[MEDICINE NAME SELECTED FROM LOOKUP OR
MANUALLY TYPED]

[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
PMFORMFD

MED
MED
MED

lookup
lookup
lookup

[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]

PMFORMMC

MED

code one

PMFORMOS

MED

verbatim

PMFORMFN

MED

verbatim

[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]

PMSTRNFD

MED

verbatim

Medicine Strength

(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW

STRNNUMBB

MED

numeric

Medicine strength number

(01) CONTINUOUS ANSWER

STRNUNIT

MED

code one

PMSTRNOS

MED

verbatim

PMSTRUNI

MED

ookup

PMEDID

MED

numeric

FAMILYID

MED

numeric

PMKNWNM

PMKNWNM

code one

Medicine Form [MCBS FORM]

(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know

Medicine strength unit

(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(-8) MED-PMSTRNFD
(-9) MED-PMSTRNFD

(01) CONTINUOUS ANSWER

(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(-8) Don't Know
(-9) Refused

(01)-(08) MED-PMEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID

[MEDICINE STRENGTH UNIT OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE STRENGTH]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]

DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?

(01) YES
(02) NO
(-9) REFUSED

(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND

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2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

PMCOND

PMCOND

code one

PMCONDOS

PMCOND

verbatim

GETNUM

TABNUM

GETNUM

numeric

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.

OTHER (SPECIFY)

Code List

Routing

(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01)-(19) GETNUM-GETNUM
(91) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?

(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND, CHECK
(-9) Refused
“ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF REFILLS.]

BOX PM5

BOX PM5

routing

IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
IF SAMEFSAM=1/YES AND PMFORMFN=pills (tablets, capsules), GO TO PM12-TABSADAY;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS
("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTUNIT.

TABNUM

numeric

HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

BOX PM6

HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]

(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) PM16 - AMTNUM
(-9) PM16 - AMTNUM

(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER

PM16 - AMTNUM
BOX PM6

AMTUNIT

PM16

quantity unit

AMTUNOS
AMTNUM

PM16
PM16

text
numeric

BOX PM6

routing

OTHER (SPECIFY)
IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.

Page 6 of 25

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

Code List

Routing

HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?

TABSADAY

PM12

numeric

TABSADAY95

PM12

code one

IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF
A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN A (01) CONTINUOUS ANSWER
DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".

(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty

PM12 - TABSADAY95

PM13-TABTAKE

How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often the
medicine is prescribed to be taken.]

TABTAKE

TABTAKE96

PMSATVA

PMSATHMO

PM13

numeric

(01) CONTINUOUS ANSWER
(-7) EMPTY
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
(-8) DON'T KNOW
SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER DOSING
INSTRUCTIONS".

(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY

PM13

code one

BOX PM7

routing

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.

PMSATVA

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
Veterans Affairs or V.A.?

BOX PM8

routing

IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.

PMSATHMO

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors [your/(SP’s)]
plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]

([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE NAMES
OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED BELOW.])
PMMORE

PM17

yes/no

[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R
ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't
talked about?]

PM13 - TABTAKE96

BOX PM7

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

BOX PM8

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

PMMORE-PMMORE

(01) ADD ANOTHER
(02) ALL DONE

(01) BOX PM2
(02) BOX DU4

Page 7 of 25

2023 MCBS Community Questionnaire

Variable Name

DUMORE

DVNEED

DVH-DENTAL, VISION, AND HEARING

MR Screen Name Question Type

Question Text/Description

BOX DU4

routing

IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO DU7-DVPROCDR.
ELSE GO TO DU14-DUMORE.

DU14

yes/no

(01) YES
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other dental care visits to this or any other provider? (-8) Don't Know
(-9) Refused

BOX DU5

routing

IF SPALIVE=1 (ALIVE) AND SEASON=WINTER, GO TO DU15-DVNEED. ELSE GO TO BOX DU6.

yes/no

Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], was there a time when {you/SP}
needed dental care but could not get it at that time?

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

(01) DU16 - DVNDRS
(02) BOX DU6
(-8) BOX DU6
(-9) BOX DU6

(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DENTAL OFFICE IS TOO FAR AWAY
(05) DENTAL OFFICE IS NOT OPEN AT CONVENIENT
TIMES
(06) ANOTHER DENTIST RECOMMENDED NOT
DOING IT
(07) AFRAID OR DO NOT LIKE DENTISTS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED DENTAL PROBLEMS TO GO
AWAY
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX DU6
(02) BOX DU6
(03) BOX DU6
(04) BOX DU6
(05) BOX DU6
(06) BOX DU6
(07) BOX DU6
(08) BOX DU6
(09) BOX DU6
(10) BOX DU6
(91) DU16A - DVNDRSOS
(-8) BOX DU6
(-9) BOX DU6

(01) continuous answer

BOX DU6

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

(01) VU2 - PROVIDER_VU
(02) OM1-OMPREYEG
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) OM1-OMPREYEG
(-9) OM1-OMPREYEG

DU15

DVNDRS

DU16

code all

What were the reasons that {you/SP} could not get the dental care {you/she/he} needed?

DVNDRSOS

DU16A
BOX DU6

verbatim text
routing

WHAT OTHER REASON (SPECIFY)
GO TO VU1-VUPROBE.

yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to an eye doctor or any other person for eye care? [Eye
care providers include ophthalmologists, optometrists, and opticians.]

VUPROBE

VU1

Code List

Routing

(01) DU2 - PROVIDER_DU
(02) BOX DU5
(-8) BOX DU5
(-9) BOX DU5

(01) [Continuous answer.]

PROVIDER_VU

VU2

roster

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
Who did [you/(SP)] see?
1. [PROVIDER 1]
2. [PROVIDER 2]
SELECT OR ADD ONLY ONE PROVIDER.
…
N. [PROVIDER N]
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY ENTERING AN
N+1. ADD ANOTHER
EVENT WITH THAT PROVIDER
N+2. NEED TO EDIT SPELLING OF EXISTING
PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.

(01-N) BOX VU1
(N+1) VU2B-PROVNAME
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX VU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO VU2PROVNAME.
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPL.CHNGSPL..

Page 8 of 25

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

Code List

Routing

ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME BELOW.
YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT YOU
DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE GROUP
OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.
VPRVNAME

VU2B

verbatim text

VU2B - GRPNAME

YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
NAME:

VGRPNAME

VU2B

verbatim text

GROUP:
WHICH PROVIDER IS MISSPELLED?

CHNGSPL

CHNGSPL

roster

THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."

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

CRCTSPL-CRCTSPL

ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER. IF YOU
ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO SELECT OR
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.

CRCTSPL

PROVSPEC

PROVSPEC

CRCTSPL

VU2C

VU2C1

verbatim

code one

code one

WHAT IS THE CORRECT SPELLING OF THIS PROVIDER'S NAME?
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]

(01) [Continuous Answer]

BOX VU1

What kind of eye care provider is [PROVNAME]?

(02) MEDICAL DOCTOR, INCLUDING
OPHTHALMOLOGIST
(16) OPTOMETRIST (OD)
(43) OPTICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED

(02) BOX VU1
(16) BOX VU1
(43) BOX VU1
(91) VU2C1 - PROVSPEC
(-8) BOX VU1
(-9) BOX VU1

What kind of eye care provider is [PROVNAME]?

(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD) (DO NOT DISPLAY)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT

(01) BOX VU1
(02) DO NOT DISPLAY
(03) BOX VU1
(04) BOX VU1
(05) BOX VU1
(06) BOX VU1
(07) BOX VU1
(08) BOX VU1
(09) BOX VU1
(10) BOX VU1
(11) BOX VU1
(12) BOX VU1
(13) BOX VU1
(14) BOX VU1
(15) BOX VU1
(16) DO NOT DISPLAY
(17) BOX VU1
(18) BOX VU1
(19) BOX VU1
(20) BOX VU1

Page 9 of 25

2023 MCBS Community Questionnaire

Variable Name

PROVSPOS

VAPLACE

MR Screen Name Question Type

VU2D

verbatim text

BOX VU1

routing

VU3

BOX VU2

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

yes/no

Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?

routing

IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO VU4 - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (THIS
PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO VU5 - HMOREFER.
ELSE GO TO VU6 - EVENT_VU.

VU4

yes/no

Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

HMOREFR

VU5

yes/no

[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]

VU6

roster

When did [you/(SP)] see (PROVIDER NAME)? Please tell me all the dates [since (REFERENCE
DATE/(UTILDATE))/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY
ONCE.]
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT "REPEAT
VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.

VUADD

VU6B

chose one

Routing

(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused

(21) BOX VU1
(22) BOX VU1
(23) BOX VU1
(24) BOX VU1
(25) BOX VU1
(26) BOX VU1
(27) BOX VU1
(28) BOX VU1
(29) BOX VU1
(30) BOX VU1
(31) BOX VU1
(32) BOX VU1
(33) BOX VU1
(34) BOX VU1
(91) VU2D - PROVSPOS
(-8) BOX VU1
(-9) BOX VU1

OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO VU3 VAPLACE.
ELSE GO TO BOX VU2.

HMOASSC

EVENT_VU

Code List

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

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

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

BOX VU1

BOX VU2

(01) VU6 - EVENT_VU
(02) VU5 - HMOREFER
(-8) VU5 - HMOREFER
(-9) VU5 - HMOREFER
VU6 - EVENT_VU

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS

VU6B-VUADD

(01) ADD ANOTHER
(02) ALL DONE

(01) VU6 -EVENT_VU
(02) VU7-VUPROCDR

Page 10 of 25

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

Code List

Routing

(01) EYE OR VISION EXAM
(02) CONTACT LENS FITTING
(03) CONTACT LENS PURCHASE
(04) EYE GLASS FRAME FITTING OR ADJUSTMENT
(05) EYE GLASS PURCHASE
(06) REFRACTIVE SURGERY (CORRECTIVE VISION
SURGERY)
(07) CATARACT SURGERY
(08) GLAUCOMA SURGERY
(09) CORNEAL SURGERY
(10) VITREO-RETINAL SURGERY
(11) OCULOPLASTIC SURGERY
(12) EYE MUSCLE SURGERY
(13) EYE REMOVAL
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01) VU9-PRESMDCN
(02) VU9-PRESMDCN
(03) VU9-PRESMDCN
(04) VU9-PRESMDCN
(05) VU9-PRESMDCN
(06) VU9-PRESMDCN
(07) VU9-PRESMDCN
(08) VU9-PRESMDCN
(09) VU9-PRESMDCN
(10) VU9-PRESMDCN
(11) VU9-PRESMDCN
(12) VU9-PRESMDCN
(13) VU9-PRESMDCN
(91) VU7A-EVOSTEXT
(-8) VU9-PRESMDCN
(-9) VU9-PRESMDCN

OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)

(01) [CONTINUOUS ANSWER]

VU9 - PRESMDCN

yes/no

Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?

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

(01) VU10 - PRESFILL
(02) BOX VU4
(-8) BOX VU4
(-9) BOX VU4

VU10

yes/no

Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE RESPONDENT
ACTUALLY TOOK THE MEDICINE.]

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

(01) BOX VU3B
(02) BOX VU4
(-8) BOX VU4
(-9) BOX VU4

BOX VU3B

routing

IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT ROUND,
GO TO VU10A - VUPMMEDS.
ELSE GO TO BOX PM2.

(01) INSTRUCTION WAS READ

BOX PM2

[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.

BOX PM3

SHOW CARD DVH2
VUPROCDR

VU7

code all

For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.

EVOSTEXT
PRESMDCN

PRESFILL

VUPMMEDS

VU7A
VU9

VU10A

verbatim text

no entry

It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can spell
the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)] (MEDICARE
PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same information on them.]
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)] obtained
since (REFERENCE DATE/UTILDATE), if you’d like to get those bottles, too.

BOX PM2

MEDICINE_PM1

routing

IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE, GO
TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.

MEDICINE_PM1

code one

What is the name of the medicine?

BOX PM3

routing

IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2A-SAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.

Page 11 of 25

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

Code List

Routing

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

BOX PM4

(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED

(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM

CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
SAMEFSAM

SAMEFSAM

yes/no

The strength was [MEDICINE STRENGTH].
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.

BOX PM4

PMBOTTLE

PMBOTTLE

routing

IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.

code one

CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS ABOUT
THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.

TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED MEDICINE
LOOKUP BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME

MED

lookup

ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT,
USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.

[MEDICINE NAME SELECTED FROM LOOKUP OR
MANUALLY TYPED]

[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
PMFORMFD

MED
MED
MED

lookup
lookup
lookup

[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]

Medicine Form [MCBS FORM]

(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know

PMFORMMC

MED

code one

PMFORMOS

MED

verbatim

PMFORMFN

MED

verbatim

[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]

PMSTRNFD

MED

verbatim

Medicine Strength

(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW

STRNNUMBB

MED

numeric

Medicine strength number

(01) CONTINUOUS ANSWER

(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS

(01) CONTINUOUS ANSWER

Page 12 of 25

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

STRNUNIT

MED

code one

PMSTRNOS

MED

verbatim

PMSTRUNI

MED

ookup

PMEDID

MED

numeric

[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]

FAMILYID

MED

numeric

[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]

PMKNWNM

PMKNWNM

code one

DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?

PMCOND

PMCONDOS

GETNUM

PMCOND

PMCOND

GETNUM

code one

verbatim

numeric

Medicine strength unit

Code List
(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(-8) Don't Know
(-9) Refused

Routing

(01)-(08) MED-PMEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID

[MEDICINE STRENGTH UNIT OTHER SPECIFY]

[FINAL CONCATENATED MEDICINE STRENGTH]

What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.

OTHER (SPECIFY)

How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?

(01) YES
(02) NO
(-9) REFUSED

(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND

(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01)-(19) GETNUM-GETNUM
(91) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND, CHECK
(-9) Refused
“ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF REFILLS.]

BOX PM5

Page 13 of 25

2023 MCBS Community Questionnaire

Variable Name

TABNUM

DVH-DENTAL, VISION, AND HEARING

MR Screen Name Question Type

Question Text/Description

BOX PM5

routing

IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
IF SAMEFSAM=1/YES AND PMFORMFN=pills (tablets, capsules), GO TO PM12-TABSADAY;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS
("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTUNIT.

TABNUM

numeric

AMTUNIT

PM16

quantity unit

AMTUNOS
AMTNUM

PM16
PM16

text
numeric

BOX PM6

routing

Code List

Routing

HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

BOX PM6

HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]

(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) PM16 - AMTNUM
(-9) PM16 - AMTNUM

(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER

PM16 - AMTNUM
BOX PM6

OTHER (SPECIFY)
IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.

HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?

TABSADAY

PM12

numeric

TABSADAY95

PM12

code one

IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF
A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN A (01) CONTINUOUS ANSWER
DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".

(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty

PM12 - TABSADAY95

PM13-TABTAKE

How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often the
medicine is prescribed to be taken.]

TABTAKE

TABTAKE96

PMSATVA

PM13

numeric

(01) CONTINUOUS ANSWER
(-7) EMPTY
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
(-8) DON'T KNOW
SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER DOSING
INSTRUCTIONS".
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY

PM13

code one

BOX PM7

routing

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
Veterans Affairs or V.A.?

PMSATVA

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

PM13 - TABTAKE96

BOX PM7

BOX PM8

Page 14 of 25

2023 MCBS Community Questionnaire

Variable Name

PMSATHMO

DVH-DENTAL, VISION, AND HEARING

MR Screen Name Question Type

Question Text/Description

BOX PM8

IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.

PMSATHMO

routing

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors [your/(SP’s)]
plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]

([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE NAMES
OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED BELOW.])
PMMORE

VUMORE

PM17

yes/no

BOX VU4

routing

IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO VU7-VUPROCDR.
ELSE GO TO VU14-VUMORE.

yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other eye care visits to this or any other provider?

VU14

[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R
ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't
talked about?]

Code List

Routing

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

PMMORE-PMMORE

(01) ADD ANOTHER
(02) ALL DONE

(01) BOX PM2
(02) BOX VU4

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

(01) VU2 - PROVIDER_VU
(02) OM1-OMPREYEG
(-8) OM1-OMPREYEG
(-9) OM1-OMPREYEG

Next I’m going to ask you about other medical expenses related to vision care that [you/(SP)] may have had
[between (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].

OMPREYEG

OM1

yes/no

(01) YES
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
(02) NO
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy,
(03) INDICATED YES BY DATAPREP
replace, or pay for repairs of eyeglasses or contact lenses?
(-8) Don't Know
(-9) Refused
[Please include the purchases you made during the visit(s) to eye care providers on (EVENT DATES) that you just
told me about.]

(01) OM1B-VUTYPE
(02) BOX VU5
(03) DO NOT DISPLAY.
(-8) BOX VU5
(-9) BOX VU5

[INCLUDE NON-PRESCRIPTION READING GLASSES.]

VUTYPE

OM1B

code all

What did [you/(SP)] buy or repair?
FOR EACH DATE, CHECK ALL THAT APPLY. THE DATE WILL BE ENTERED ON THE NEXT SCREEN.

SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair glasses or contact lenses?
EVENT_OMEYEG OM2

roster

Please tell me all the dates [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
[INCLUDE NON-PRESCRIPTION READING GLASSES.]

OMADD

OM2AA

code one

(01) BUY EYEGLASS LENSES
(02) BUY EYEGLASS FRAMES
(03) BUY CONTACT LENSES
(04) REPAIR EYEGLASSES
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:

In addition to the medical expenses related to vision care you just told me about, did [you/(SP)] buy, replace, or pay
for repairs for any other eyeglasses or contact lenses [since (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF (01) ADD ANOTHER
(02) ALL DONE
INSTITUTIONALIZATION/ENDUTILD)]?

OM2-EVENT_OMEYEG

BOX OM1AA

(01) OM1B - VUTYPE
(02) BOX OM1AA

[DISPLAY ALL EVENTS ENTERED]

Page 15 of 25

2023 MCBS Community Questionnaire

Variable Name

DVH-DENTAL, VISION, AND HEARING

MR Screen Name Question Type

Question Text/Description

BOX OM1AA

IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM2A-OMSATHMO.
ELSE GO TO BOX OM1AA2.

routing

Code List

Routing

On (EVENT DATE), did [you/(SP)] buy or repair the glasses or contact lenses at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?
OMSATHMO

OM2A

yes/no

(01) YES
(02) NO
[PROBE: This could include buying or repairing the glasses or lenses at a plan center; at an optician, optometrist or (-8) Don't Know
other place that honors [your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
(-9) Refused

BOX OM1AA2

[INCLUDE NON-PRESCRIPTION READING GLASSES.]

VUNEED

BOX OM1AA2

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX VU5.

BOX VU5

routing

IF SPALIVE=1 (ALIVE) AND SEASON=WINTER, GO TO VU15-VUNEED.
ELSE GO TO BOX VU6.

yes/no

Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], was there a time when {you/SP}
needed vision care but could not get it at that time?

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

(01) VU16 - VUVNDRS
(02) BOX VU6
(-8) BOX VU6
(-9) BOX VU6

(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DOCTOR'S OFFICE IS TOO FAR AWAY
(05) DOCTOR'S OFFICE IS NOT OPEN AT
CONVENIENT TIMES
(06) ANOTHER DOCTOR RECOMMENDED NOT
DOING IT
(07) AFRAID OR DO NOT LIKE DOCTORS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED PROBLEMS TO GO AWAY
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX VU6
(02) BOX VU6
(03) BOX VU6
(04) BOX VU6
(05) BOX VU6
(06) BOX VU6
(07) BOX VU6
(08) BOX VU6
(09) BOX VU6
(10) BOX VU6
(91) VU16A - VUVNDRSOS
(-8) BOX VU6
(-9) BOX VU6

(01) continuous answer

BOX VU6

VU15

VUVNDRS

VU16

code all

What were the reasons that {you/SP} could not get the vision care {you/she/he} needed?

VUVNDRSOS

VU16A
BOX VU6

verbatim text
routing

WHAT OTHER REASON (SPECIFY)
GO TO HU1-HUPROBE

yes/no

(01) YES
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to a doctor or any other person for hearing care? [Hearing
(03) INDICATED YES BY DATAPREP
care providers include otorhinolaryngologists (ear nose and throat doctors), otologists, neurotologists, audiologists,
(-8) Don't Know
audiometrists, and hearing instrument specialists.]
(-9) Refused

HUPROBE

HU1

(01) HU2 - PROVIDER_HU
(02) HU15--OMHEARAD
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) OM3-OMPRHEAR
(-9) OM3-OMPRHEAR

Page 16 of 25

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

Code List

Routing

(01) [Continuous answer.]

PROVIDER_HU

HU2

roster

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
Who did [you/(SP)] see?
1. [PROVIDER 1]
2. [PROVIDER 2]
SELECT OR ADD ONLY ONE PROVIDER.
…
N. [PROVIDER N]
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY ENTERING AN
N+1. ADD ANOTHER
EVENT WITH THAT PROVIDER
N+2. NEED TO EDIT SPELLING OF EXISTING
PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.

(01-N) BOX HU1
(N+1) HU2B-PROVNAME
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX HU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO HU2PROVNAME
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPL.-CHNGSPL.

ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME BELOW.
YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT YOU
DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE GROUP
OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.
HPRVNAME

HU2B

verbatim text

HU2B - GRPNAME

YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
NAME:

HGRPNAM

HU2B

verbatim text

GROUP:
WHICH PROVIDER IS MISSPELLED?

CHNGSPL

CHNGSPL

roster

THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."

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

CRCTSPL-CRCTSPL

ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER. IF YOU
ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO SELECT OR
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.

CRCTSPL

PROVSPEC

CRCTSPL

HU2C

verbatim

code one

WHAT IS THE CORRECT SPELLING OF THIS PROVIDER'S NAME?
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]

(01) [Continuous Answer]

BOX HU1

What kind of hearing care provider is [PROVNAME]?

(02) MEDICAL DOCTOR, INCLUDING
OTOLARYNGOLOGIST (ENT), OTOLOGIST,
NEUROTOLOGIST
(03) AUDIOLOGIST
(44) AUDIOMETRIST
(45) HEARING INSTRUMENT SPECIALIST
(91) OTHER
(-8) Don't Know
(-9) Refused

(02) BOX HU1
(03) BOX HU1
(44) BOX HU1
(45) BOX HU1
(91) HU2C1 - PROVSPEC
(-8) BOX HU1
(-9) BOX HU1

Page 17 of 25

2023 MCBS Community Questionnaire

Variable Name

PROVSPEC

PROVSPOS

MR Screen Name Question Type

HU2C1

HU2D

BOX HU1

VAPLACE

HU3

BOX HU2

HMOASSC

HU4

code one

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

Code List

Routing

What kind of hearing care provider is [PROVNAME]?

(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST (DO NOT DISPLAY)
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT

(01) BOX HU1
(02) DO NOT DISPLAY
(03) DO NOT DISPLAY
(04) BOX HU1
(05) BOX HU1
(06) BOX HU1
(07) BOX HU1
(08) BOX HU1
(09) BOX HU1
(10) BOX HU1
(11) BOX HU1
(12) BOX HU1
(13) BOX HU1
(14) BOX HU1
(15) BOX HU1
(16) BOX HU1
(17) BOX HU1
(18) BOX HU1
(19) BOX HU1
(20) BOX HU1

(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused

(21) BOX HU1
(22) BOX HU1
(23) BOX HU1
(24) BOX HU1
(25) BOX HU1
(26) BOX HU1
(27) BOX HU1
(28) BOX HU1
(29) BOX HU1
(30) BOX HU1
(31) BOX HU1
(32) BOX HU1
(33) BOX HU1
(34) BOX HU1
(91) HU2D - PROVSPOS
(-8) BOX HU1
(-9) BOX HU1

(01) [Continuous answer.]

BOX HU1

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

BOX HU2

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

(01) HU6 - EVENT_HU
(02) HU5 - HMOREFER
(-8) HU5 - HMOREFER
(-9) HU5 - HMOREFER

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

routing

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO HU3 VAPLACE.
ELSE GO TO BOX HU2.

yes/no

Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?

routing

IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO HU4 - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (THIS
PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO HU5 - HMOREFER.
ELSE GO TO HU6 - EVENT_HU.

yes/no

Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

Page 18 of 25

2023 MCBS Community Questionnaire

Variable Name

HMOREFR

EVENT_HU

DVH-DENTAL, VISION, AND HEARING

MR Screen Name Question Type

Question Text/Description

Code List

Routing

HU5

[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]

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

HU6 - EVENT_HU

yes/no

When did [you/(SP)] see (PROVIDER NAME)? Please tell me all the dates [since (REFERENCE
DATE/(UTILDATE))/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY
ONCE.]

MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS

HU6B-HUADD

(01) ADD ANOTHER
(02) ALL DONE

(01) HU6 -EVENT_HU
(02) HU7 - DVPROCDR

(01) HEARING AID FITTING/EVALUATION
(02) HEARING AID PURCHASE/REPAIR
(03) HEARING EXAM
(04) EAR WAX REMOVAL
(05) EAR VENTILATION TUBES
(06) TYMPANOPLASTY (RECONSTRUCTION OF EAR
DRUM)
(07) COCHLEAR IMPLANT SURGERY
(08) HEARING REHABILITATIVE SERVICES
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01) HU9-PRESMDCN
(02) HU9-PRESMDCN
(03) HU9-PRESMDCN
(04) HU9-PRESMDCN
(05) HU9-PRESMDCN
(06) HU9-PRESMDCN
(07) HU9-PRESMDCN
(91) HU7A-EVOSTEXT
(-8) HU9-PRESMDCN
(-9) HU9-PRESMDCN

OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)

(01) [CONTINUOUS ANSWER]

HU9 - PRESMDCN

yes/no

Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?

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

(01) HU10 - PRESFILL
(02) BOX HU4
(-8) BOX HU4
(-9) BOX HU4

HU10

yes/no

Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE RESPONDENT
ACTUALLY TOOK THE MEDICINE.]

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

(01) BOX HU3B
(02) BOX HU4
(-8) BOX HU4
(-9) BOX HU4

BOX HU3B

routing

IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT ROUND,
GO TO HU10A - HUPMMEDS.
ELSE GO TO BOX PM2.

(01) INSTRUCTION WAS READ

BOX PM2

HU6

roster

IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT "REPEAT
VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.
HUADD

HU6B

chose one

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

SHOW CARD DVH3
HUPROCDR

HU7

code all

For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.

EVOSTEXT

PRESMDCN

PRESFILL

HUPMMEDS

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

HU7A

HU9

HU10A

verbatim text

no entry

It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can spell
the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)] (MEDICARE
PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same information on them.]
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)] obtained
since (REFERENCE DATE/UTILDATE), if you’d like to get those bottles, too.

BOX PM2

routing

IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE, GO
TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.

Page 19 of 25

2023 MCBS Community Questionnaire

Variable Name

MEDICINE_PM1

MR Screen Name Question Type

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

MEDICINE_PM1

code one

What is the name of the medicine?

BOX PM3

routing

IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2A-SAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.

Code List
[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.

Routing

BOX PM3

CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
SAMEFSAM

SAMEFSAM

yes/no

The strength was [MEDICINE STRENGTH].
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).

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

BOX PM4

(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED

(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM

Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.

BOX PM4

PMBOTTLE

PMBOTTLE

routing

IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.

code one

CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS ABOUT
THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.

TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED MEDICINE
LOOKUP BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME

MED

lookup

ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT,
USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.

[MEDICINE NAME SELECTED FROM LOOKUP OR
MANUALLY TYPED]

[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
PMFORMFD

MED
MED
MED

lookup
lookup
lookup

[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]

Page 20 of 25

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

Code List

Routing

Medicine Form [MCBS FORM]

(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know

(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS

PMFORMMC

MED

code one

PMFORMOS

MED

verbatim

PMFORMFN

MED

verbatim

[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]

PMSTRNFD

MED

verbatim

Medicine Strength

(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW

STRNNUMBB

MED

numeric

Medicine strength number

(01) CONTINUOUS ANSWER

STRNUNIT

MED

code one

PMSTRNOS

MED

verbatim

PMSTRUNI

MED

lookup

PMEDID

MED

numeric

[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]

FAMILYID

MED

numeric

[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]

PMKNWNM

PMKNWNM

code one

DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?

Medicine strength unit

(01) CONTINUOUS ANSWER

(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(-8) Don't Know
(-9) Refused

(01)-(08) MED-PMEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID

[MEDICINE STRENGTH UNIT OTHER SPECIFY]

[FINAL CONCATENATED MEDICINE STRENGTH]

(01) YES
(02) NO
(-9) REFUSED

(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND

Page 21 of 25

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

PMCOND

PMCOND

code one

PMCONDOS

PMCOND

verbatim

GETNUM

TABNUM

GETNUM

numeric

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.

OTHER (SPECIFY)

Code List

Routing

(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01)-(19) GETNUM-GETNUM
(91) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?

(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND, CHECK
(-9) Refused
“ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF REFILLS.]

BOX PM5

BOX PM5

routing

IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
IF SAMEFSAM=1/YES AND PMFORMFN=pills (tablets, capsules), GO TO PM12-TABSADAY;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS
("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTUNIT.

TABNUM

numeric

HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

BOX PM6

HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]

(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) PM16 - AMTNUM
(-9) PM16 - AMTNUM

(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER

PM16 - AMTNUM
BOX PM6

AMTUNIT

PM16

quantity unit

AMTUNOS
AMTNUM

PM16
PM16

text
numeric

BOX PM6

routing

OTHER (SPECIFY)
IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.

Page 22 of 25

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

Code List

Routing

HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?

TABSADAY

PM12

numeric

TABSADAY95

PM12

code one

IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF
A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN A (01) CONTINUOUS ANSWER
DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".

(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty

PM12 - TABSADAY95

PM13-TABTAKE

How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often the
medicine is prescribed to be taken.]

TABTAKE

TABTAKE96

PMSATVA

PMSATHMO

PM13

numeric

(01) CONTINUOUS ANSWER
(-7) EMPTY
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
(-8) DON'T KNOW
SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER DOSING
INSTRUCTIONS".

(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY

PM13

code one

BOX PM7

routing

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.

PMSATVA

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
Veterans Affairs or V.A.?

BOX PM8

routing

IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.

yes/no

IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.

PMSATHMO

([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE NAMES
OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED BELOW.])
PMMORE

PM17

yes/no

BOX HU4

routing

[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R
ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't
talked about?]

PM13 - TABTAKE96

BOX PM7

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

BOX PM8

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

PMMORE-PMMORE

(01) ADD ANOTHER
(02) ALL DONE

(01) BOX PM2
(02) BOX HU4

IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO HU7-HUPROCDR.
ELSE GO TO HU14-HUMORE.

Page 23 of 25

2023 MCBS Community Questionnaire

Variable Name
HUMORE

DVH-DENTAL, VISION, AND HEARING

MR Screen Name Question Type

Question Text/Description

Code List

Routing

HU14

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other hearing care visits to this or any other
provider?

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

(01) HU2 - PROVIDER_HU
(02) HU15-OMHEARAD
(-8) HU15-OMHEARAD
(-9) HU15-OMHEARAD

yes/no

Next I’m going to ask you about other medical expenses related to hearing care that [you/(SP)] may have had
[between (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].

OMHEARAD

HU15

yes/no

[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
(01) YES
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy, (02) NO
(03) INDICATED YES BY DATAPREP
replace, or pay for repairs of a hearing aid?
(-8) Don't Know
(-9) Refused
[Please include the purchases you made during the visit(s) to hearing care provider on (EVENT DATES) that you
just told me about.]

(01) HU16-INTHECANL
(02) BOX HU9
(03) DO NOT DISPLAY.
(-8) BOX HU9
(-9) BOX HU9

[DO NOT INCLUDE HEARING AID BATTERIES AT THIS QUESTION. ENTER HEARING AID BATTERIES IN THE
OMQ AS A HEARING/SPEECH DEVICE.]

SHOW CARD DVH4
What type of hearing aid(s) did [you/(SP)] buy or repair?
INTHCANL

HU16B

list

(01) LEFT EAR
(02) RIGHT EAR
(-8) Don't Know
(-9) Refued

HU16-INTHEEAR

In the ear hearing aid

(01) LEFT EAR
(02) RIGHT EAR
(-8) Don't Know
(-9) Refued

HU16-BHNDEAR

Behind the ear hearing aid

(01) LEFT EAR
(02) RIGHT EAR
(-8) Don't Know
(-9) Refued

HU17-EVENT_OMHRAD

SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair the (HEARING AID ITEM)?

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

[IF NEEDED: Were they for [your/(SP’s)] left ear, right ear, or both?]
FOR EACH DATE, CHECK ALL THAT APPLY. THE DATE WILL BE ENTERED ON THE NEXT SCREEN.
In the canal hearing aid

INTHEEAR

BHNDEAR

HU16B

HU16B

EVENT_OMHRAD HU17

OMADD

HU18

list

list

roster

code one

Please tell me the dates of each purchase or repair [since (REFERENCE DATE/SURVEY REFERENCE
MM:
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
DD:
INSTITUTIONALIZATION/ENDUTILD)].
YYYY:

In addition to the medical expenses related to hearing care you just told me about, did [you/(SP)] buy, replace, or pay
for repairs for any other hearing aids? [since (REFERENCE DATE/SURVEY REFERENCE
(01) ADD ANOTHER
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) ALL DONE
INSTITUTIONALIZATION/ENDUTILD)]?

HU18-OMADD

(01) HU16- INTHCANL
(02) BOX HU6

[DISPLAY ALL EVENTS ENTERED]

BOX HU6

routing

IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO HU19-OMSATHMO.
ELSE GO TO BOX HU8.

Page 24 of 25

2023 MCBS Community Questionnaire

Variable Name

OMSATHMO

HVNEED

MR Screen Name Question Type

DVH-DENTAL, VISION, AND HEARING

Question Text/Description

On (EVENT DATE), did [you/(SP)] buy or repair the hearing aid at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?

Code List

Routing

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

BOX HU8

HU19

yes/no

BOX HU8

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX HU9.

BOX HU9

routing

IF SPALIVE=1 (ALIVE) AND SEASON=WINTER, GO TO HU20-HVNEED.
ELSE GO TO BOX HU10.

yes/no

Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], was there a time when {you/SP}
needed hearing care but could not get it at that time?

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

(01) HU21- HVNDRS
(02) BOX HU10
(-8) BOX HU10
(-9) BOX HU10

(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DOCTOR'S OFFICE IS TOO FAR AWAY
(05) DOCTOR'S OFFICE IS NOT OPEN AT
CONVENIENT TIMES
(06) ANOTHER DOCTOR RECOMMENDED NOT
DOING IT
(07) AFRAID OR DO NOT LIKE DOCTORS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED PROBLEMS TO GO AWAY
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX HU10
(02) BOX HU10
(03) BOX HU10
(04) BOX HU10
(05) BOX HU10
(06) BOX HU10
(07) BOX HU10
(08) BOX HU10
(09) BOX HU10
(10) BOX HU10
(91) HU16A - HVNDRSOS
(-8) BOX HU10
(-9) BOX HU10

(01) continuous answer

BOX HU10

HU20

[PROBE: This could include buying or repairing the hearing aid at a plan center; from an audiologist, or other
provider that honors [your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]

HVNDRS

HU21

code all

What were the reasons that {you/SP} could not get the hearing care {you/she/he} needed?

HVNDRSOS

HU21A
BOX HU10

verbatim text
routing

WHAT OTHER REASON (SPECIFY)
GO TO EMERGENCY ROOM UTILIZATION (ERQ).

Page 25 of 25


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AuthorMegan Bjorgo
File Modified2021-12-08
File Created2021-12-08

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