Download:
pdf |
pdf2022 MCBS Facility Instrument
Variable Name
CV-COVID-19 Beneficiary Supplement
MR Screen Name Question Type
Question Text/Description
Code List
Routing
(01) CONTINUE
(01) CV2-CVDTEST
COVID-19 BENEFICIARY SUPPLEMENT SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= CFR, CFC, FFC, FCF, IPR
RHALIVE= 1/Alive
PLACEMENT
Administered in flexible order after FQ and RH sections are completed.
CVDINTRO
BOX CVBEG
routing
GO TO CV1-CVDINTRO
CV1
CODE ONE
I am now going to ask you some questions about COVID-19 services (SP) may have received.
Since (PREVIOUS INTERVIEW DATE/ADMISSION DATE) has (SP) been tested to see whether (he/she) was
infected with coronavirus or COVID-19 at the time of the test?
[IF NEEDED: For example, the test can be done by swabbing someone’s nose.]
CVDTEST
CV2
yes/no
(00) NO
(01) YES
[IF NEEDED: If (SP) had more than one test to see whether (he/she) was infected with coronavirus or COVID-19 at (-8) DON'T KNOW
the time of the test, refer to their most recent test.]
(-9) REFUSED
(00) CV6-VACROST
(01) CV2A-TESTRES
(-8) CV6-VACROST
(-9) CV6-VACROST
DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER SOMEONE HAS EVER BEEN INFECTED
WITH CORONAVIRUS.
Did the test find that (SP) had Coronavirus or COVID-19?
TESTRES
CV2A
CODE ONE
MCARECV
CV4
yes/no
(01) YES, THE TEST SHOWED R HAD COVID-19
(01) CV4-MCARECV
(02) NO, THE TEST SHOWED R DID NOT HAVE COVID(02) CV6-VACROST
[IF NEEDED: If (SP) had more than one test to see whether (he/she) was infected with coronavirus or COVID-19 at
19
(03) CV6-VACROST
the time of the test, refer to their most recent test.]
(03) NO RESULTS YET
(-8) CV6-VACROST
(-8) DON’T KNOW
(-9) CV6-VACROST
DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER SOMEONE HAS EVER BEEN INFECTED
(-9) REFUSED
WITH CORONAVIRUS.
Since (PREVIOUS INTERVIEW DATE/ADMISSION DATE) has (SP) received medical care (either inside or
outside this (facility/home)) for the coronavirus or COVID-19?
[IF NEEDED: Please include services provided by all health care personnel.]
What kind of provider did (he/she) receive care from for the coronavirus or COVID-19?
PROVTYP
CV4A
code all
SELECT ALL THAT APPLY.
CODE BASED ON THE RESPONSE FACILITY RESPONDENT GIVES.
PROVOTH
CV4A
verbatim
OTHER (SPECIFY)
(00) NO
(01) YES
(-8) DON'T KNOW
(-9) REFUSED
(00) CV6-VACROST
(01) CV4A-PROVTYP
(-8) CV6-VACROST
(-9) CV6-VACROST
(01) EMERGENCY MEDICAL SERVICE PERSONNEL
(02) NURSES
(03) NURSING ASSISTANTS
(04) PHARMACISTS
(05) PHLEBOTOMISTS
(06) PHYSICIANS
(07) TECHNICIANS
(08) THERAPISTS
(91) OTHER
(-8) DON’T KNOW
(-9) REFUSED
(01) CV6-VACROST
(02) CV6-VACROST
(03) CV6-VACROST
(04) CV6-VACROST
(05) CV6-VACROST
(06) CV6-VACROST
(07) CV6-VACROST
(08) CV6-VACROST
(91) CV4A-PROVOTH
(-8) CV6-VACROST
(-9) CV6-VACROST
(01) CONTINUOUS
(01) CV6-VACROST
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
(00) CVEND-CVENDCT
(01) CV7-VACDATMM
(-8) CVEND-CVENDCT
(-9) CVEND-CVENDCT
(01) CONTINUOUS
(01) CV7-VACDATYY
[It was previously reported that (SP) received the following COVID-19 vaccines.]
VACROST
CV6
yes/no
DOSE 1: [MONTH] [YEAR] [MANUFACTURER]
DOSE 2: [MONTH] [YEAR] [MANUFACTURER]
...
DOSE 10: [MONTH] [YEAR] [MANUFACTURER]
Has (SP) received any [additional] COVID-19 vaccines?
When did (SP) receive this dose of the COVID-19 vaccine?
MONTH
VACDATMM
CV7
DATE
PLEASE ENTER COVID-19 VACCINE DOSES IN THE ORDER THEY WERE RECEIVED, STARTING FROM THE
EARLIEST DOSE RECEIVED TO THE MOST RECENT DOSE RECEIVED.
IT WAS PREVIOUSLY REPORTED THAT (SP) RECEIVED THE FOLLOWING COVID-19 VACCINES.
DOSE 1: [MONTH] [YEAR] [MANUFACTURER]
DOSE 2: [MONTH] [YEAR] [MANUFACTURER]
...
DOSE 10: [MONTH] [YEAR] [MANUFACTURER]
Page 1 of 2
2022 MCBS Facility Instrument
Variable Name
CV-COVID-19 Beneficiary Supplement
MR Screen Name Question Type
Question Text/Description
Code List
Routing
(01) CONTINUOUS
(01) CV8-VACNME
(01) PFIZER-BIONTECH/COMIRNATY
(02) MODERNA/SPIKEVAX
(03) JOHNSON & JOHNSON/JANSSEN
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) CV9-VACSITE
(02) CV9-VACSITE
(03) CV9-VACSITE
(91) CV8-VACNEMOS
(-8) CV9-VACSITE
(-9) CV9-VACSITE
OTHER (SPECIFY)
(01) CONTINUOUS
(01) CV9-VACSITE
(01) BOX CV2
(02) BOX CV2
(03) BOX CV2
(04) BOX CV2
(05) BOX CV2
(06) BOX CV2
(07) BOX CV2
(08) BOX CV2
(09) BOX CV2
(10) BOX CV2
(11) BOX CV2
(12) BOX CV2
(91) CV9-VACSITOS
(-8) BOX CV2
(-9) BOX CV2
(01) BOX CV2
When did (SP) receive this dose of the COVID-19 vaccine?
YEAR
VACDATYY
CV7
DATE
PLEASE ENTER COVID-19 VACCINE DOSES IN THE ORDER THEY WERE RECEIVED, STARTING FROM THE
EARLIEST DOSE RECEIVED TO THE MOST RECENT DOSE RECEIVED.
IT WAS PREVIOUSLY REPORTED THAT (SP) RECEIVED THE FOLLOWING COVID-19 VACCINES.
DOSE 1: [MONTH] [YEAR] [MANUFACTURER]
DOSE 2: [MONTH] [YEAR] [MANUFACTURER]
...
DOSE 10: [MONTH] [YEAR] [MANUFACTURER]
VACNME
CV8
code one
Which COVID-19 vaccine did (SP) get? Examples include Pfizer-BioNTech/Comirnaty, Moderna/Spikevax, and
Johnson & Johnson/Janssen.
ONLY USE THE ‘OTHER’ CATEGORY TO ADD VACCINE MANUFACTURERS APPROVED IN AN FI MEMO
VACNMEOS
CV8
verbatim
VACSITE
CV9
code one
Where did (SP) go for their COVID-19 vaccine in (VACDATMM) (VACDATYY)?
(01) (FACILITY)
(02) PHARMACY/DRUG STORE
(03) DOCTORS OFFICE OR GROUP PRACTICE
(04) MASS VACCINATION SITE
(05) MANAGED CARE PLAN CENTER/HMO
(06) NEIGHBORHOOD/FAMILY HEALTH
CENTER/MEDICAL CLINIC
(07) COMPANY CLINIC/WORKPLACE
(08) WALK-IN URGENT CENTER
(09) HOSPITAL
(10) VA FACILITY
(11) HEALTH DEPARTMENT OFFICE
(12) AT HOME
(91) OTHER
(-8) DON’T KNOW
(-9) REFUSED
VACSITOS
CV9
verbatim
OTHER (SPECIFY)
(01) CONTINUOUS
IF LESS THAN TEN DOSES HAVE BEEN REPORTED AND/OR PRELOADED GO TO CV10-VACMOR
ELSE GO TO CVEND-CVENDCT
BOX CV2
Has (SP) had any other COVID-19 vaccine doses?
VACMOR
CV10
yes/no
(00) BOX CV3
(01) BOX CV3
(-8) BOX CV3
(-9) BOX CV3
IF CV10-VACMOR= 1/YES AND LESS THAN TEN DOSES HAVE BEEN REPORTED GO TO CV7-VACDATMM
ELSE GO TO CVEND-CVENDCT
BOX CV3
CVENDCT
PLEASE ENTER COVID-19 VACCINE DOSES IN THE ORDER THEY WERE RECEIVED, STARTING FROM THE
EARLIEST DOSE RECEIVED TO THE MOST RECENT DOSE RECEIVED.
(00) NO
(01) YES
DOSE 1: [MONTH] [YEAR] [MANUFACTURER]
(-8) DON’T KNOW
DOSE 2: [MONTH] [YEAR] [MANUFACTURER]
(-9) REFUSED
DOSE 3: [MONTH] [YEAR] [MANUFACTURER]
...
DOSE 10: [MONTH] [YEAR] [MANUFACTURER]
CVEND
code one
YOU HAVE COMPLETED THE COVID-19 BENEFICIARY SUPPLEMENT SECTION FOR THIS SP.
PRESS "1" TO RETURN TO NAVIGATION SCREEN.
BOX CVEND
routing
GO TO NAVIGATOR
(01) Continue
(01) BOX CVEND
Page 2 of 2
File Type | application/pdf |
Author | Samantha Rosner |
File Modified | 2022-03-25 |
File Created | 2022-03-25 |