CMS-10816 Eligibility Screener Questionnaire

Medicare Part C and Medicare Part D Enrollment Form Interviews (CMS-10816)

Attachment C - Eligibility Screener Questionnaire_Clean

OMB: 0938-1440

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Attachment C: Eligibility Screener Questionnaire


PARTICIPANT NUMERIC IDENTIFIER: ___________________________


  1. Are you ? (read options) You may select more than one answer

    1. MALE

    2. FEMALE

    3. TRANSGENDER, NON-BINARY, OR ANOTHER GENDER


  1. I need to confirm, do you receive health insurance through Medicare?

    1. YES

    2. NO I am sorry, but only people who receive insurance through Medicare are eligible for this study.



  1. How old are you?


_______ years


  • Ok, I am going to conduct the interview and our conversation today will take no more than 30 minutes.



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorAlva Chavez
File Modified0000-00-00
File Created2023-08-28

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