CMS-P-0015A CV-COVID-19 Beneficiary Supplement

2022 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]

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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

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