CMS-P-0015A Emergency Utilization

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

ERQ-EMERGENCY ROOM UTILIZATION

Question Type

Question Text/Description

Code List

Routing

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

(01) ER2 - PROVIDER_ER
(02)BOX ER6
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX ER6
(-9) BOX ER6

EMERGENCY ROOM 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 DUQ.

ERPROBE

ER1

yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], [have you gone/has (SP) gone/did (SP) go] to a hospital emergency
room for medical care?

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

PROVIDER_ER

ER2

roster

Where did [you/(SP)] go (to which hospital)?
SELECT OR ADD ONLY ONE HOSPITAL.
[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE HOSPITAL.]

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

ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY
ENTERING AN EVENT WITH THAT PROVIDER

N. [PROVIDER N]
N+1. ADD ANOTHER
N+2. NEED TO EDIT SPELLING OF EXISTING
PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02.

(01-N) BOX ER1
(N+1) ER2-PROVNAME
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX
ER1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO ER2PROVNAME
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPLCHNGSPL.

[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
ENTER THE NAME OF THE PROVIDER AND THE BILLING/GROUP OR PRACTICE NAME BELOW.
[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE HOSPITAL]
PROVNAME

ER2

verbatim

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.

BOX ER1

YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
NAME:

GROUPNAM

ER2

verbatim

GROUP:

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND 2. [PROVIDER 2]
…
SELECT "ADD ANOTHER."
N. [PROVIDER N]
ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER. IF
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
YOU ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO
NAME FOR ALL PROVIDERS WHERE
SELECT OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
PROVNUM>02.
WHICH PROVIDER IS MISSPELLED?

CHNGSPL

CHNGSPL

roster

CRCTSPL-CRCTSPL

Page 1 of 7

2021 MCBS Community Questionnaire

Variable Name

CRCTSPL

MR Screen Name

CRCTSPL

BOX ER1

VAPLACE

ER3

BOX ER1B

HMOASSOC

HMOREFER

ER3A

ER3B

ERQ-EMERGENCY ROOM UTILIZATION

Question Type

Question Text/Description

verbatim

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
(01) [Continuous Answer]
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]

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
ER3 - VAPLACE.
ELSE GO TO BOX ER1B.

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 ER3A - 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 ER3B - HMOREFER.
ELSE GO TO ER4 - EVENT_ER.

yes/no

(01) YES
(02) NO
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
(-8) Don't Know
(-9) Refused

(01) ER4 - EVENT_ER
(02) ER3B - HMOREFER
(-8) ER3B - HMOREFER
(-9) ER3B - HMOREFER

yes/no

(01) YES
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]? (02) NO
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]
(-8) Don't Know
(-9) Refused

ER4 - EVENT_ER

ER4

roster

ERADD

ER4B

choose one

PRESMDCN

PRESFILL

ER7

ER8

BOX ER1

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

EVENT_ER

ER6

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

Routing

yes/no

When did [you/(SP)] go to the emergency room at (PROVIDER NAME)?

ERADMIT

Code List

Please tell me all the dates [since REFERENCE DATE/UTILDATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
[IF THE SAMPLE PERSON SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE
ONLY ONCE.]
HAVE ALL DATES BEEN ENTERED?

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:

BOX ER1B

ER4B-ERADD

(01) ADD ANOTHER
(02) ALL DONE

(01) ER6 -EVENT_ER
(02) ER6-ERADMIT

[Were you/Was (SP)] admitted to (PROVIDER NAME) from the emergency room?

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

(01) BOX ER4
(02) ER7 - PRESMDCN
(-8) ER7 - PRESMDCN
(-9) ER7 - PRESMDCN

yes/no

During [your/(SP’s)] visit to the emergency room, were any medicines prescribed for [you/(SP)]?

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

(01) ER8 - PRESFILL
(02) BOX ER4
(-8) BOX ER4
(-9) BOX ER4

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 ER3A
(02) BOX ER4
(-8) BOX ER4
(-9) BOX ER4

yes/no

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

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2021 MCBS Community Questionnaire

Variable Name

ERPMMEDS

ERQ-EMERGENCY ROOM UTILIZATION

MR Screen Name

Question Type

Question Text/Description

BOX ER3A

routing

IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO ER8A - ERPMMEDS.
ELSE GO TO BOX PM2.

ER8A

no entry

Code List

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.]

Routing

BOX PM 2

[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

MEDICINE_PM1

BOX PM3

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.

code one

What is the name of the medicine?

routing

IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2ASAMEFSAM.
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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2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

ERQ-EMERGENCY ROOM UTILIZATION

Question Type

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

MED

lookup

[PM BRAND NAME]

PMGNNAME

MED

lookup

[PM GENERIC NAME]

PMFORMFD

MED

lookup

Medicine Form [FDB LIST FORM NAME]

PMFORMMC

MED

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
(-9) Refused

PMFORMOS

MED

verbatim

[MEDICINE FORM OTHER SPECIFY]

(01) CONTINUOUS ANSWER

PMFORMFN

MED

verbatim

[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

Medicine strength unit

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

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

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2021 MCBS Community Questionnaire

ERQ-EMERGENCY ROOM UTILIZATION

Variable Name

MR Screen Name

Question Type

Question Text/Description

PMSTRNOS

MED

verbatim

[MEDICINE STRENGTH UNIT OTHER SPECIFY]

PMSTRUNI

MED

ookup

[FINAL CONCATENATED MEDICINE STRENGTH]

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

PMCOND

PMCOND

code one

PMCONDOS

PMCOND

verbatim

DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?

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)]]?
GETNUM

TABNUM

GETNUM

numeric

[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND,
CHECK “ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF
REFILLS.]

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?

Code List

Routing

(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
(-9) Refused

BOX PM5

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

BOX PM6

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2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

ERQ-EMERGENCY ROOM UTILIZATION

Question Type

Question Text/Description

Code List

Routing
(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) BOX PM6

AMTUNIT

PM16

quantity unit

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

AMTUNOS

PM16

text

OTHER (SPECIFY)

(01) CONTINUOUS ANSWER

PM16 - AMTNUM

AMTNUM

PM16

numeric

(01) CONTINUOUS ANSWER

BOX PM6

BOX PM6

routing

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

TABSADAY95

PM12

PM12

numeric

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 (01) CONTINUOUS ANSWER
IN A 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".

code one

PM12 - TABSADAY95

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

PM13-TABTAKE

(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW

PM13 - TABTAKE96

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

BOX PM7

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

PM13

numeric
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A
PILL 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".

TABTAKE96

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.

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2021 MCBS Community Questionnaire

Variable Name

PMSATVA

PMSATHMO

MR Screen Name

ERQ-EMERGENCY ROOM UTILIZATION

Question Type

Question Text/Description

PMSATVA

yes/no

(01) YES
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of (02) NO
Veterans Affairs or V.A.?
(-8) DON'T KNOW
(-9) REFUSED

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.]

PMMORE

ERMORE

([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.])

PM17

yes/no

BOX ER4

Routing

IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO ER6-ERADMIT.
ELSE GO TO ER10-ERMORE.

ER10

yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other visits to the emergency room at this or
any other hospital?

BOX ER5

routing

IF WINTER ROUND AND ((SP REPORTED AN EMERGENCY ROOM VISIT AT ER2) AND (SP IS ALIVE
AND NOT INSTITUTIONALIZED)), GO TO AC6A - EWAITUNT.
ELSE GO TO BOX ER6.

BOX ER6

routing

GO TO IPQ.

[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

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 ER4

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

(01) ER2 - PROVIDER_ER
(02) BOX ER5
(-8) BOX ER5
(-9) BOX ER5

Page 7 of 7