CMS-P-0015A Background_Questionnaire

2022 MCBS Facility Instrument

Variable Name

MR Screen Name

BQ-Background Questionnaire

Question Type

Question Text/Description

Code List

Routing

(01) CONSENT OBTAINED (CONTINUE INTERVIEW)
(02) FINAL FINAL CONSENT DENIED
(03) REFUSAL CONVERTED (CONTINUE INTERVIEW)
(04) FINAL REFUSAL

(01) BQ1PRE1 - BQ1PRECT
(02) BQEND - BQENDCT
(03) BQ1PRE1 - BQ1PRECT
(04) BQEND - BQENDCT

BACKGROUND QUESTIONNAIRE SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= CFC, IPR
SEASON
If SAMPLE TYPE= CFC, then SEASON= ALL
If SAMPLE TYPE= IPR, then SEASON= FALL
PLACEMENT
Administered in flexible order after FQ and RH sections are completed.

BOX BQBEG

routing

IF BQDISP = 1/ConsentRequired OR BQDISP = 4/InitialRefusal, GO TO BQCONREF - CONREFFN. ELSE GO
TO BQ1PRE1 - BQ1PRECT.

CONREFFN

BQCONREF

code one

PLEASE INDICATE THE FINAL (CONSENT/REFUAL) STATUS FOR THIS SECTION.

BQ1PRECT

BQ1PRE1

no entry

The following questions are about (SP's) background including (his/her) use of long-term care, demographics,
and (his/her) immediate family. In answering some of these questions, you might find it useful to refer to various (01) CONTINUE
records. Some of these questions refer to specific points in time while others are more general in
(02) CONSENT REQUIRED
nature/background.
(03) INITIAL REFUSAL
IF THERE ARE NO CONSENT OR REFUSAL ISSUES FOR THIS SECTION, PRESS "1" TO CONTINUE.

BEFORADM

BQRH22A

code one

SHOW CARD RH1
Please look at this card and tell me what kind of place (SP) was in just before being admitted here on
(ADMISSION DATE).
PRESS F1 FOR DEFINITIONS.

BEFORAOS

BQRH22A

verbatim text

OTHER (SPECIFY)

BOX BQ3B

routing

IF BQRH22A - BEFORADM = 5/PrivateHomeOrApartment OR 91/Other, GO TO BQRH31A - BLIVEWAL.
ELSE GO TO BQ9PRE - BQ9PRECT.

(01) BQRH22A - BEFORADM
(02) BQEND - BQENDCT
(03) BQEND - BQENDCT

(01) NURSING HOME/REHAB CENTER
(02) PERSONAL CARE HOME/RESIDENTIAL CARE
FACILITY
(03) CCRC/RETIREMENT HOME/CENTER
(04) HOSPITAL
(05) PRIVATE HOME OR APARTMENT
(07) OTHER LTC FACILITY
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX BQ3B
(02) BOX BQ3B
(03) BOX BQ3B
(04) BOX BQ3B
(05) BOX BQ3B
(07) BOX BQ3B
(91) BQRH22A - BEFORAOS
(-8) BOX BQ3B
(-9) BOX BQ3B

(01) Continuous answer

BOX BQ3B

(01) BQRH31B - BLIVENUM
(02) BQRH31B - BLIVENUM
(03) BQRH31B - BLIVENUM
(04) BQ9PRE - BQ9PRECT
(-8) BQ9PRE - BQ9PRECT
(-9) BQ9PRE - BQ9PRECT

BLIVEWAL

BQRH31A

code one

Who lived with (him/her) there?

(01) RELATIVE
(02) NON-RELATIVE
(03) BOTH RELATIVE AND NON-RELATIVE
(04) ALONE
(-8) Don't Know
(-9) Refused

BLIVENUM

BQRH31B

Numeric

How many people, including relatives and non-relatives, lived with (him/her) there?

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

(01) BQ9PRE - BQ9PRECT
(-8) BQ9PRE - BQ9PRECT
(-9) BQ9PRE - BQ9PRECT

BQ9PRECT

BQ9PRE

code one

The next few questions are about (SP's) (level of education,) race, ethnicity, and military service.
PRESS "1" TO CONTINUE.

(01) CONTINUE

(01) BOX BQ4

BOX BQ4

routing

IF HA51-BACK.HEDULEV = DK, RF, EMPTY, OR NULL GO TO BQ9 - EDLEVELF.
ELSE GO TO BQ10A - BHISPORG.

Page 1 of 4

2022 MCBS Facility Instrument

Variable Name

MR Screen Name

BQ-Background Questionnaire

Question Type

Question Text/Description

Code List

Routing

(01) NO FORMAL SCHOOLING
(02) ELEMENTARY (1ST-8TH GRADES)
(03) SOME HIGH SCHOOL (9TH-12TH GRADES)
(04) COMPLETED HIGH SCHOOL, NO COLLEGE
(05) TECHNICAL OR TRADE SCHOOL
(06) SOME COLLEGE
(07) COLLEGE GRADUATE
(08) GRADUATE DEGREE
(-8) Don't Know
(-9) Refused

(01) BQ10A - BHISPORG
(02) BQ10A - BHISPORG
(03) BQ10A - BHISPORG
(04) BQ10A - BHISPORG
(05) BQ10A - BHISPORG
(06) BQ10A - BHISPORG
(07) BQ10A - BHISPORG
(08) BQ10A - BHISPORG
(-8) BQ10A - BHISPORG
(-9) BQ10A - BHISPORG

EDLEVELF

BQ9

code one

As far as you know, what (is/was) the highest level of schooling (SP) completed?
IF DK, USE CATEGORIES AS PROBES.

BHISPORG

BQ10A

yes/no

(Is/Was) (SP) of Hispanic or Latino origin?

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

(00) BQ11A - BQRACE
(01) BQ10B - BHISPORD
(-8) BQ11A - BQRACE
(-9) BQ11A - BQRACE

(01) MEXICAN/MEXICAN AMERICAN/CHICANO(A)
(02) PUERTO RICAN
(03) CUBAN
(91) OTHER HISPANIC, LATINO/A, OR SPANISH ORIGIN
(-8) Don't Know
(-9) Refused

(01) BQ11A - BQRACE
(02) BQ11A - BQRACE
(03) BQ11A - BQRACE
(91) BQ10B - BHISPDOS
(-8) BQ11A - BQRACE
(-9) BQ11A - BQRACE

BHISPORD

BQ10B

code all

SHOW CARD BQ1AA.
Looking at this card, (is/was) (SP) Mexican, Mexican American, or
(Chicano/Chicana), Puerto Rican, Cuban, or of another Hispanic,
(Latino/Latina) or Spanish origin?
CHECK ALL THAT APPLY.

BHISPDOS

BQ10B

verbatim text

OTHER ORIGIN (SPECIFY)

(01) Continuous answer

(01) BQ11A - BQRACE

(01) AMERICAN INDIAN OR ALASKA NATIVE
(02) ASIAN
(03) BLACK OR AFRICAN AMERICAN
(04) NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
(05) WHITE
(91) ANOTHER RACE
(-8) Don't Know
(-9) Refused

(01) BOX BQ4A
(02) BOX BQ4A
(03) BOX BQ4A
(04) BOX BQ4A
(05) BOX BQ4A
(91) BQ11A - BRACEOS
(-8) BOX BQ4A
(-9) BOX BQ4A

(01) Continuous answer

(01) BOX BQ4A

(01) ASIAN INDIAN
(02) CHINESE
(03) FILIPINO
(04) JAPANESE
(05) KOREAN
(06) VIETNAMESE
(91) OTHER ASIAN GROUP
(-8) Don't Know
(-9) Refused

(01) BOX BQ4B
(02) BOX BQ4B
(03) BOX BQ4B
(04) BOX BQ4B
(05) BOX BQ4B
(06) BOX BQ4B
(91) BQ11B - BRACASOS
(-8) BOX BQ4B
(-9) BOX BQ4B

(01) Continuous answer

(01) BOX BQ4B

(01) NATIVE HAWAIIAN
(02) GUAMANIAN OR CHAMORRO
(03) SAMOAN
(91) OTHER PACIFIC ISLANDER GROUP
(-8) Don't Know
(-9) Refused

(01) BOX BQ5
(02) BOX BQ5
(03) BOX BQ5
(91) BQ11C - BRACPIOS
(-8) BOX BQ5
(-9) BOX BQ5

BQRACE

BQ11A

code all

SHOW CARD BQ1A
Please look at this card and tell me what (is/was) (SP's) race.
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

BRACEOS

BQ11A

verbatim text

ANOTHER RACE (SPECIFY)

BOX BQ4A

routing

IF BQ11A-BQRACE INCLUDES 2/Asian, GO TO BQ11B - BRACEASD.
ELSE GO TO BOX BQ4B.

BRACEASD

BQ11B

code all

SHOW CARD BQ1B.
Looking at this card, (is/was) (SP) Asian Indian, Chinese, Filipino,
Japanese, Korean, Vietnamese or some other Asian group?
You can choose more than one group.
CHECK ALL THAT APPLY.

BRACASOS

BRACPIDT

BQ11B

verbatim text

OTHER ASIAN GROUP (SPECIFY)

BOX BQ4B

routing

IF BQ11A-BQRACE INCLUDES 4/NativeHawaiianOrOtherPacificIslander, GO TO BQ11C - BRACPIDT.
ELSE GO TO BOX BQ5.

BQ11C

code all

SHOW CARD BQ1C.
Looking at this card, (is/was) (SP) Native Hawaiian, Guamanian
or Chamorro, Samoan, or some other Pacific Islander group?
You can choose more than one group.
CHECK ALL THAT APPLY.

Page 2 of 4

2022 MCBS Facility Instrument

BQ-Background Questionnaire

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

BRACPIOS

BQ11C

verbatim text

OTHER PACIFIC ISLANDER GROUP (SPECIFY)

(01) Continuous answer

(01) BOX BQ5

BOX BQ5

routing

IF SP IS LESS THAN 15 YEARS OLD, GO TO BQ18PRE - BQ18PRCT.
ELSE GO TO BQ12 - BEVERAF.

BQ12

yes/no

Did (SP) ever serve on active duty in the Armed Forces?

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

(00) BQ12B - BEVERNG
(01) BQ12A - BARMEDF
(-8) BQ12B - BEVERNG
(-9) BQ12B - BEVERNG

(01) IRAQ OR AFGHANISTAN CONFLICT (2001 - Present)
(02) PERSIAN GULF WAR (Aug. 1990 - March 1991)
(03) VIETNAM ERA (Aug. 1964 - May 1975)
(04) KOREAN CONFLICT (June 1950 - Jan. 1955)
(05) WORLD WAR II (Sept. 1940 - July 1947)
(06) WORLD WAR 1 (1917 - 1918)
(07) PEACE TIME ONLY (ALL OTHER TIMES)
(-8) Don't Know

(01) BQ12B - BEVERNG
(02) BQ12B - BEVERNG
(03) BQ12B - BEVERNG
(04) BQ12B - BEVERNG
(05) BQ12B - BEVERNG
(06) DO NOT DISPLAY
(07) BQ12B - BEVERNG
(-8) BQ12B - BEVERNG

BEVERAF

SHOW CARD BQ1
Looking at this card, which time periods best describe when (SP) served in the Armed Forces?
BARMEDF

BQ12A

code all
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

BEVERNG

BQ12B

yes/no

Was (SP) ever an active member of a National Guard or military reserve unit of the United States?

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

(00) BOX BQ5A
(01) BQ12C - BNGDUTY
(-8) BOX BQ5A
(-9) BOX BQ5A

BNGDUTY

BQ12C

yes/no

Was all of (SP's) active duty related to National Guard or military reserve training?

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

(00) BOX BQ5A
(01) BOX BQ5A
(-8) BOX BQ5A
(-9) BOX BQ5A

BOX BQ5A

routing

IF BQ12 - BEVERAF = 1/Yes OR BQ12B - BEVERNG = 1/Yes, GO TO BQ12E - BVARATE.
ELSE GO TO BQ13 - BMRJAN.

BQ12E

Numeric

What (is/was) (SP's) (current/most recent) VA disability rating?
THE VA DISABILITY RATING IS A PERCENTAGE IN MULTIPLES OF 10 (I.E., 10%, 20%, ETC.). ENTER THE
NUMBER AS A WHOLE NUMBER. DO NOT ENTER THE "%" SIGN.

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

(01) BQ13 - BMRJAN
(-8) BQ13 - BMRJAN
(-9) BQ13 - BMRJAN

(Is/Was) (SP) married, widowed, divorced, separated, or never married?

(01)NEVER MARRIED
(02) MARRIED
(03) WIDOWED
(04) DIVORCED
(05) SEPARATED
(-8) Don't Know
(-9) Refused

(01)BQ18PRE - BQ18PRCT
(02) BQ18PRCT BQ15 - BHWLIVES
(03) BQ18PRE - BQ18PRCT
(04) BQ18PRE - BQ18PRCT
(05) BQ18PRE - BQ18PRCT
(-8) BQ18PRE - BQ18PRCT
(-9) BQ18PRE - BQ18PRCT

SHOW CARD BQ2
Please look at this card and tell me where (SP's) spouse lives now.

(01) IN THIS FACILITY
(02) OTHER NURSING HOME/REHAB CENTER
(03) PERSONAL CARE HOME/RESIDENTIAL CARE
FACILITY
(04) CCRC/RETIREMENT HOME/CENTER
(05) HOSPITAL
(06) PRIVATE HOME OR APARTMENT
(07) SPOUSE DECEASED
(08) OTHER LTC FACILITY
(-8) Don't Know
(-9) Refused

(01) BQ18PRE - BQ18PRCT
(02) BQ18PRE - BQ18PRCT
(03) BQ18PRE - BQ18PRCT
(04) BQ18PRE - BQ18PRCT
(05)BQ18PRE - BQ18PRCT
(06) BQ18PRE - BQ18PRCT
(07) BQ18PRE - BQ18PRCT
(08) BQ18PRE - BQ18PRCT
(-8) BQ18PRE - BQ18PRCT
(-9) BQ18PRE - BQ18PRCT

(01) Continue

(01) BOX BQ10

BVARATE

BMRJAN

BQ13

code one

BHWLIVES

BQ15

code one

BQ18PRCT

BQ18PRE

code one

The next few questions are about (SP's) immediate family.
PRESS "1" TO CONTINUE.

BOX BQ10

routing

IF SP IS LESS THAN 15 YEARS OLD, GO TO BQ24 - BINCOAMT.
ELSE GO TO BQ20 - BTOTLCHI.

Page 3 of 4

2022 MCBS Facility Instrument

Variable Name

BTOTLCHI

MR Screen Name

BQ20

BQ-Background Questionnaire

Question Type

Numeric

Question Text/Description

Code List

Routing

Including natural, adopted, and stepchildren, how many living children (does/did) (SP) have?

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

(01) BQ24 - BINCOAMT
(-8) BQ24 - BINCOAMT
(-9) BQ24 - BINCOAMT

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

(01) BQ28 - DIDABBQ
(-8) BQ25 - BLESS25
(-9) BQ25 - BLESS25

(Is/Was) it less than $25,000?

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

(00) BQ27 - BHOWMORE
(01) BQ26 - BHOWLESS
(-8) BQ28 - DIDABBQ
(-9) BQ28 - DIDABBQ

Would you say it (is/was)…

(01) Less than $5,000,
(02) $5,000 - less than $10,000
(03) $10,000 - less than $15,000
(04) $15,000 - less than $20,000
(05) $20,000 - less than $25,000
(-8) Don't Know
(-9) Refused

(01) BQ28 - DIDABBQ
(02) BQ28 - DIDABBQ
(03) BQ28 - DIDABBQ
(04) BQ28 - DIDABBQ
(05) BQ28 - DIDABBQ
(-8) BQ28 - DIDABBQ
(-9) BQ28 - DIDABBQ

Would you say it (is/was)…

(01) $25,000 - less than $30,000
(02) $30,000 - less than $40,000
(03) $40,000 - less than $50,000
(04) $50,000 - less than $66,000
(05) $66,000 - less than $109,000
(06) $109,000 or more
(-8) Don't Know
(-9) Refused

(01) BQ28 - DIDABBQ
(02) BQ28 - DIDABBQ
(03) BQ28 - DIDABBQ
(04) BQ28 - DIDABBQ
(05) BQ28 - DIDABBQ
(06) BQ28 - DIDABBQ
(-8) BQ28 - DIDABBQ
(-9) BQ28 - DIDABBQ

(01) ALL
(02) MAJORITY
(03) HALF
(04) SOME
(05) NONE

(01) BQ29 - WHYABBQ
(02) BQ29 - WHYABBQ
(03) BQ29 - WHYABBQ
(04) BQ29 - WHYABBQ
(05) BQEND - BQENDCT

In studies like this, people are sometimes grouped together according to income.
SHOW CARD BQ3
BINCOAMT

BQ24

Dollar

Looking at this card, please tell me what (is/was) the total yearly income (SP) [and (his/her) spouse] received
from jobs, businesses, interest, Social Security, Railroad Retirement, Supplemental Security Income (SSI),
pensions, and any other sources of income, before taxes or any deductions.
ENTER A WHOLE DOLLAR AMOUNT FOLLOWED BY ".00"

BLESS25

BHOWLESS

BHOWMORE

BQ25

BQ26

BQ27

yes/no

code one

code one

DID YOU ABSTRACT?

DIDABBQ

BQ28

code one

TO ABSTRACT MEANS TO OBTAIN INFORMATION FROM THE BENEFICIARY'S RECORDS FOR ENTRY
INTO THE QUESTIONNAIRE. EXAMPLES OF RECORDS YOU MAY HAVE ABSTRACTED FROM INCLUDE
THE MINIMUM DATA SET (MDS), NURSES NOTES, PHYSICIANS ORDERS, AND/OR OTHER DOCUMENTS
PROVIDED BY THE FACILITY.
USE YOUR BEST JUDGMENT TO DETERMINE WHICH ANSWER IS THE MOST ACCURATE CHOICE FOR
THE AMOUNT YOU ABSTRACTED. IF THERE WAS NO ABSTRACTION AT ALL, PLEASE SELECT "NONE".

WHYABBQ

BQ29

code one

WHY DID YOU ABSTRACT?

(01) NO KNOWLEDGEABLE RESPONDENT AVAILABLE
(02) NO TIME/STAFF BURDEN TOO GREAT
(03) REFUSAL--UNWILLING TO COOPERATE
(91) OTHER

(01) BQEND - BQENDCT
(02) BQEND - BQENDCT
(03) BQEND - BQENDCT
(91) BQ29VB - WHYABBOS

WHYABBOS

BQ29VB

verbatim text

WHY DID YOU ABSTRACT?
OTHER (SPECIFY)

(01) Continuous answer

(01) BQEND - BQENDCT

BQENDCT

BQEND

code one

YOU HAVE COMPLETED THE BACKGROUND SECTION FOR THIS SP.
PRESS "1" TO RETURN TO NAVIGATION SCREEN.

(01) Continue

(1) BOX BQEND

BOX BQEND

routing

GO TO NAVIGATOR

Page 4 of 4