CMS-P-0015A Home Health

2022 MCBS Community Questionnaire

Variable Name

MR Screen Name

HHQ-HOME HEALTH UTILIZATION

Question Type

Question Text/Description

Code List

Routing

HOME HEALTH UTILIZATION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
If INTTYPE in (C001, C002, C004, C005, C006, C007, C010) administer after IUQ.

SHOW CARD HH1

HHPRPROF

HH1

yes/no

(At the time of the last interview, [you/(SP)] indicated that [you/(she/he)] had been helped at home by a health or
medical professional.)
(01) YES
(02) NO
[(Since/since) (REFERENCE DATE/UTILDATE)/(Between/between) (REFERENCE DATE) and (DATE OF
(03) INDICATED YES BY DATAPREP. DO NOT
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], [have you been/has (SP) been/was (SP)] helped at
DISPLAY. DATA EDITING ONLY.
home by any (other) health or medical professionals, such as those listed on this card? (This may include health (-8) DON'T KNOW
or medical professionals reported in prior interviews.)
(-9) REFUSED

(01) HH4-PROFWORK
(02) HH18 - HHPRFRND
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) HH18 - HHPRFRND
(-9) HH18 - HHPRFRND

[Health professionals include nurse (visiting nurse, private duty nurse, etc.), doctor, social worker, therapist,
hospice worker, home health aides, and those who provide homemaker services.]

PROFWORK

HH4

PROVIDER_HHPOR
HH5
G

code one

roster

Does this health or medical professional work for a place or organization?
[PROBE: Or does this health or medical professional work for himself/herself?]

(01) WORKS FOR ORGANIZATION
(02) WORKS FOR SELF
(-8) DON'T KNOW
(-9) REFUSED

What is the name of the home health place or organization who helped [you/(SP)] at home [since (REFERENCE
(01) CONTINUOUS ANSWER
DATE/UTILDATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)]?
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
[PROBE: Who would (you/SP) call if the home health provider did not show up?]
1. [PROVIDER 1]
2. [PROVIDER 2]
ADD OR SELECT ONLY ONE PROVIDER.
…
N. [PROVIDER N]
ENTER THE NAME OF THE PLACE OR ORGANIZATION RATHER THAN AN INDIVIDUAL PROVIDER.
N+1. ADD ANOTHER
N+2. NEED TO EDIT SPELLING OF EXISTING
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY ENTERING
PROVIDER
AN EVENT WITH THAT PROVIDER.
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE
[DO NOT ADD A NEW ROSTER ENTRY IF A DIFFERENT PERSON CAME FROM AN ORGANIZATION
PROVNUM>02.
ALREADY LISTED ON THE ROSTER.]

(01) HH5-PROVIDER_HHPORG
(02) HH2-PROVIDER_HHP
(-8) HH2-PROVIDER_HHP
(-9) HH2-PROVIDER_HHP

(01-N) BOX HH1AAA
(N+1) PROVNAME-HH5
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX
HH1AAA.
ELSE IF "ADD ANOTHER" SELECTED, GO TO
PROVNAME-HH5
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPLCHNGSPL.

[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
ENTER THE NAME OF THE PLACE OR ORGANIZATION RATHER THAN AN INDIVIDUAL PROVIDER.
PROVNAME

HH5

verbatim

[DO NOT ADD A NEW ROSTER ENTRY IF A DIFFERENT PERSON CAME FROM AN ORGANIZATION
ALREADY LISTED ON THE ROSTER.]

BOX HH1AAA

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

Page 1 of 7

2022 MCBS Community Questionnaire

Variable Name

MR Screen Name

HHQ-HOME HEALTH UTILIZATION

Question Type

Question Text/Description

WHICH PROVIDER IS MISSPELLED?

CHNGSPL

CHNGSPL

roster

THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."
ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER. IF
YOU ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO
SELECT OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.

CRCTSPL

CRCTSPL

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
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]

Code List
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]

Routing

CRCTSPL-CRCTSPL

DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02.

(01) [Continuous Answer]

BOX HH1AAA

NAME:
(01) CONTINUOUS ANSWER
What is the name of the health professional who helped [you/(SP)] at home [since (REFERENCE
DATE/UTILDATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)]?
PROVIDER_HHP

HH2

roster

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

(01-N) BOX HH1AAA
(N+1) PROVNAME-HH2
(N+2) CHNGSPL-CHNGSPL

IF EXISTING PROVIDER SELECTED, GO TO BOX
HH1AAA
ELSE IF "ADD ANOTHER" SELECTED, GO TO
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY ENTERING
PROVNAME-HH2
AN EVENT WITH THAT PROVIDER.
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
PROVIDER" SELECTED, GO TO CHNGSPLNAME FOR ALL PROVIDERS WHERE
CHNGSPL.
PROVNUM>02.
ENTER NAME OF PERSON WHO HELPED. DO NOT ENTER THE NAME OF PLACE OR ORGANIZATION.

[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
ENTER NAME OF PERSON WHO HELPED. DO NOT ENTER THE NAME OF PLACE OR ORGANIZATION.
PROVNAME

HH2

verbatim

BOX HH1AAA

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

WHICH PROVIDER IS MISSPELLED?

CHNGSPL

CHNGSPL

roster

THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."
ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER. IF
YOU ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO
SELECT OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.

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

CRCTSPL-CRCTSPL

DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02.

WHAT IS THE CORRECT SPELLING OF THIS PROVIDER'S NAME?
CRCTSPL

CRCTSPL

verbatim

THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]

(01) [Continuous Answer]

BOX HH1AAA

NAME:

BOX HH1AAA

routing

IF (HOME HEALTH PROVIDER WAS ADDED AT HH2 OR HH5) OR (AN EXISTING PROVIDER WAS
SELECTED AT HH2 OR HH5 THAT WAS NOT ASSOCIATED WITH A HOME HEALTH EVENT), GO TO HH3 PROVSPEC.
ELSE GO TO BOX HH1BBB.

Page 2 of 7

2022 MCBS Community Questionnaire

Variable Name

MR Screen Name

HHQ-HOME HEALTH UTILIZATION

Question Type

Question Text/Description

What kind of health professional [is (PROVIDER NAME)/did [you/(SP)] see from (PROVIDER NAME)]?
[SELECT THE RESPONSE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT
SPECIFICALLY NAMES THE LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN
PARENTHESES FOLLOWING THAT PROVIDER SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL
SPECIALTY NOT LISTED BELOW, BUT LISTED ON MPQ JOB AID 1, SUCH AS ‘CARDIOLOGY,’ SELECT
'MEDICAL DOCTOR.']

PROVSPEC

HH3

code one

PROVSPOS

HH3

text

OTHER MEDICAL PROVIDER (SPECIFY)

routing

IF HH4 -PROFWORK = 1/Works for Organization, SET HOME HEALTH PROVIDER FOR THIS VISIT TO THE
HOME HEALTH ORGANIZATION SELECTED AT HH5, AND GO TO HH6 - HHPLACE.
ELSE SET HOME HEALTH PROVIDER FOR THIS VISIT TO THE PROVIDER SELECTED AT HH2, HH19,
ST27 OR NS27, AND GO TO BOX HH1BB.

BOX HH1AA

Code List
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR
[LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED

Routing

(01)-(34), (-8), (-9) BOX HH1AA
(91) HH3 - PROVSPOS

BOX HH1AA

HHPLACE

HH6

code one

PROVIDER NAME: (PROVIDER NAME)
What kind of place or organization is (PROVIDER NAME)?

(01) MANAGED CARE PLAN (SUCH AS HMO)
(02) MEAL PROGRAM (SUCH AS MEALS ON
WHEELS)
(03) VISITING NURSE ASSOCIATION
(04) HOME HEALTH AGENCY
(05) HOSPITAL
(06) PRIVATE PHYSICIAN/GROUP PRACTICE
(07) HOSPICE
(08) REHABILITATION OR SPORTS MEDICINE
THERAPY
(09) LOCAL GOVERNMENT ORGANIZATION
(10) CHURCH OR COMMUNITY ORGANIZATION
(11) ASSISTED LIVING/RETIREMENT HOME
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED

HHPLACOS

HH6

text

OTHER (SPECIFY)

(01) CONTINUOUS ANSWER

(01) BOX HH1BB
(02) BOX HH1BBB
(03) BOX HH1BB
(04) BOX HH1BB
(05) BOX HH1BB
(06) BOX HH1BB
(07) BOX HH1BB
(08) BOX HH1BB
(09) BOX HH1BB
(10) BOX HH1BB
(11) BOX HH1BB
(91) HH6 - HHPLACOS
(-8) BOX HH1BB
(-9) BOX HH1BB

Page 3 of 7

2022 MCBS Community Questionnaire

Variable Name

OTHMEALS

MR Screen Name

Question Type

Question Text/Description

BOX HH1BBB

routing

SET HOME HEALTH PROVIDER FOR THIS VISIT TO THE PROVIDER SELECTED AT HH2, HH5, OR HH19.
IF TYPE OF HOME HEALTH PROVIDER ORGANIZATION IS A MEAL PROGRAM, GO TO HH7 - OTHMEALS.
ELSE GO TO BOX HH1BB.

yes/no

[Between (REFERENCE DATE/UTILDATE) and (today/DATE OF DEATH/ DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did (PROVIDER NAME) provide any services to [you/(SP)] other than
delivering meals?

routing

IF TYPE OF HOME HEALTH PROVIDER IS A MEAL PROGRAM THAT DID NOT PROVIDE ANY OTHER
SERVICES BESIDES MEALS, GO TO BOX HH3.
ELSE IF (HOME HEALTH PROVIDER IS A FRIEND OR RELATIVE) OR (TYPE OF HOME HEALTH PROVIDER
IS A LOCAL GOVERNMENT, CHURCH OR COMMUNITY ORGANIZATION), GO TO HH11-EVENT.
ELSE GO TO BOX HH1.

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 HH8 VAPLACE.
ELSE GO TO BOX HH1A.

yes/no

(01) YES
(02) NO
Is [(PROVIDER NAME) associated with/(PROVIDER NAME)] a Department of Veterans Affairs, or V.A., facility?
(-8) DON'T KNOW
(-9) REFUSED

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 HH10A - 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 HH10B - HMOREFER.
ELSE GO TO HH11-EVENT.

HH7

BOX HH1BB

BOX HH1

VAPLACE

HH8

BOX HH1A

HMOASSOC

HMOREFER

HHQ-HOME HEALTH UTILIZATION

HH10A

HH10B

Code List

Routing

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX HH1BB

BOX HH1A

yes/no

Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

yes/no

[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

HH11 -EVENT

(01) [Continuous answer.]

HH12-HPADD

(01) ADD ANOTHER
(02) ALL DONE

(01) HH11 -EVENT
(02) HH13-NEEDNURS

(01) HH11- EVENT
(02) HH10B - HMOREFER
(-8) HH10B - HMOREFER
(-9) HH10B - HMOREFER

When did [you/(SP)] see [(PROVIDER NAME)/(someone from (PROVIDER NAME))]? Please tell me all the
dates [since (REFERENCE DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
EVENT

HH11

roster

[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY
ONCE.]
IF R HAD 5 OR MORE VISITS FROM THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT
"REPEAT VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.

HPADD

HH12

choose one

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

Page 4 of 7

2022 MCBS Community Questionnaire

Variable Name

MR Screen Name

HHQ-HOME HEALTH UTILIZATION

Question Type

Question Text/Description

Code List

Routing

(01) YES, AT LEAST ONE
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

HH14 - NEEDMEAL

(01) YES, AT LEAST ONE
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

HH15 - NEEDCARE

(01) YES, AT LEAST ONE
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX HH2

SHOW CARD HH2

NEEDNURS

HH13

yes/no

(Generally speaking, did/Generally speaking, does)[(PROVIDER NAME)/someone from (PROVIDER NAME)]
help [you/(SP)] by giving any medical or nursing treatment, such as the things shown on this card? ["MEDICAL
OR NURSING TREATMENT" MEANS SUCH THINGS AS APPLYING STERILE BANDAGES OR DRESSINGS,
GIVING MEDICATIONS, TAKING BLOOD PRESSURE, GIVING SHOTS OR INJECTIONS.]
[PROBE: We just need to know in general.]

SHOW CARD HH3
NEEDMEAL

HH14

yes/no

(Generally speaking, did/Generally speaking, does) [(PROVIDER NAME)/someone from (PROVIDER NAME)]
help with [your/(SP’s)] daily needs by doing things, such as the ones shown on this card? [HELP WITH DAILY
NEEDS MEANS HELP IN USING THE TELEPHONE, DOING HOUSEWORK, PREPARING MEALS.]
[PROBE: We just need to know in general.]

SHOW CARD HH4

NEEDCARE

HH15

yes/no

(Generally speaking, did/Generally speaking, does) [(PROVIDER NAME)/someone from (PROVIDER NAME)]
help with [your/(SP’s)] personal care by doing things such as those shown on this card? [HELP WITH
PERSONAL CARE MEANS HELP WITH BATHING, SHOWERING, DRESSING, EATING, WALKING, USING
THE TOILET.]
[PROBE: We just need to know in general.]

BOX HH2

routing

IF EXISTING PROVIDER SELECTED at HH2-PROVIDER_HHP, HH5-PROVIDER_HHPORG, HH19PROVIDER_HHF, or ST13-PROVIDER_STDATE, GO TO BOX HH3.
ELSE IF "ADD ANOTHER" SELECTED at HH2-PROVIDER_HHP, HH5-PROVIDER_HHPORG, HH19PROVIDER_HHF, or or ST13-PROVIDER_STDATE, GO TO HH15A-ATNDPHYS.

To be eligible for Medicare home health services, a beneficiary must be under the care of a physician who
decides home health services are necessary.
What is the complete name of the physician who determined that [you/SP] should receive home health services?
[IF NEEDED: This physician can also be referred to as the attending physician.]
ATNDPHYS

HH15A

text

[IF THE RESPONDENT DOES NOT RECEIVE HOME HEALTH SERVICES THROUGH MEDICARE, SELECT
NOT APPLICABLE. IF THE RESPONDENT DOES NOT KNOW THE NAME OF THE PHYSICIAN, SELECT
DON'T KNOW.]
[ENCOURAGE THE RESPONDENT TO REFER TO A BILL, TELEPHONE DIRECTORY, APPOINTMENT
CARD, ETC., FOR COMPLETE INFORMATION.]

BOX HH3

HHPMORE

HHPOMORE

HH16

HH17

routing

IF CURRENTLY ADMINISTERING ST, GO TO BOX ST23B.
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS33.
ELSE IF CURRENTLY ASKING ABOUT HOME HEALTH FRIENDS OR FAMILY, GO TO HH28-HHFMORE.
ELSE IF HOME HEALTH PROVIDER WORKED FOR SELF, GO TO HH16 - HHPMORE.
ELSE GO TO HH17 - HHPOMORE.

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
(01) continuous answer
(996) NOT APPLICABLE/RESPONDENT DOES NOT
RECEIVE HOME HEALTH SERVICES THROUGH
BOX HH3
MEDICARE
(-8) Don't Know
(-9) Refused
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02.

yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], [have you been/has (SP) been/was (SP)] helped at home by any other
health professionals?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01)HH4 -PROFWORK
(02) HH18 - HHPRFRND
(-8) HH18 - HHPRFRND
(-9) HH18 - HHPRFRND

yes/no

Other than the persons who (have) visited [you/(SP)] from (PROVIDER NAME) [or from the other(s) we’ve talked
about], [have you been/has (SP) been/was (SP)] helped at home by any other health professionals [since
(01) YES
(REFERENCE DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)]?
(-8) DON'T KNOW
(-9) REFUSED
[DON’T INCLUDE ANY OTHER PERSONS COMING FROM THE SAME ORG/ AGENCY LISTED BELOW]

(01) HH4-PROFWORK
(02) HH18 - HHPRFRND
(-8) HH18 - HHPRFRND
(-9) HH18 - HHPRFRND

Page 5 of 7

2022 MCBS Community Questionnaire

Variable Name

MR Screen Name

HHQ-HOME HEALTH UTILIZATION

Question Type

Question Text/Description

Code List

Routing

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP DO NOT
DISPLAY. DATA EDITING ONLY.
(-8) DON'T KNOW
(-9) REFUSED

(01) HH19 - PROVIDER_HHF
(02) BOX HH7
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX HH7
(-9) BOX HH7

SHOW CARD HH5
(At the time of the last interview, [you/(SP)] indicated that, because of health problems, [you/(she/he)] had
received personal care or help at home with daily needs from a person who did not live with [you/(her/him)].)
HHPRFRND

HH18

yes/no

(Besides what you have already talked about, [(Since/since) (REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], because of health problems [have you/has (SP)/did (SP)]
(received/receive) any personal care or help at home with daily needs from (any other) persons who (do/did) not
live with (you/him/her), including friends, neighbors, or relatives? (This may include friends, neighbors, or
relatives reported in prior interviews.)

(01) CONTINUOUS ANSWER
Who helped [you/(SP)]? What is the name of the person who helped (you/him/her)?
ENTER NAME OF PERSON WHO HELPED.
PROVIDER_HHF

HH19

roster

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

(01-N) BOX HH3AA
(N+1) PROVNAME-HH19
(N+2) CHNGSPL-CHNGSPL

IF EXISTING PROVIDER SELECTED, GO TO BOX
HH3AA
ELSE IF "ADD ANOTHER" SELECTED, GO TO
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY ENTERING
PROVNAME-HH19
AN EVENT WITH THAT PROVIDER.
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
PROVIDER" SELECTED, GO TO CHNGSPLNAME FOR ALL PROVIDERS WHERE
CHNGSPL.
PROVNUM>02
[SELECT OR ADD ONLY ONE PERSON. DO NOT ENTER A PERSON WHO LIVES WITH THE SP.]

[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
PROVNAME

HH19

verbatim

ENTER NAME OF PERSON WHO HELPED. DO NOT ENTER THE NAME OF THE PLACE OR
ORGANIZATION.

BOX HH3AA

NAME:

WHICH PROVIDER IS MISSPELLED?

CHNGSPL

CHNGSPL

roster

THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."
ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER. IF
YOU ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO
SELECT OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.

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

CRCTSPL-CRCTSPL

DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02.

WHAT IS THE CORRECT SPELLING OF THIS PROVIDER'S NAME?
CRCTSPL

CRCTSPL

verbatim

THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]

(01) [Continuous Answer]

BOX HH3AA

(01) FRIEND OR NEIGHBOR
(02) RELATIVE
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX HH1AA
(02) HH21 - HHFRELAT
(-8) BOX HH1AA
(-9) BOX HH1AA

NAME:

BOX HH3AA

HHFTYPE

HH20

routing

code one

IF (HOME HEALTH PROVIDER WAS ADDED AT HH19) OR (AN EXISTING PROVIDER WAS SELECTED AT
HH19 THAT WAS NOT ASSOCIATED WITH A HOME HEALTH EVENT), GO TO HH20 - HHFTYPE.
ELSE GO TO BOX HH1BBB.

Is (PROVIDER NAME) a friend, neighbor, or a relative?

Page 6 of 7

2022 MCBS Community Questionnaire

Variable Name

MR Screen Name

HHQ-HOME HEALTH UTILIZATION

Question Type

Question Text/Description

How is (PROVIDER NAME) related to [you/(SP)]?

Code List

Routing

(02) SPOUSE
(56) PARTNER
(58) CHILD
(59) GRANDCHILD
(60) PARENT
(61) SIBLING
(91) OTHER
(-8) Don't Know
(-9) Refused

(02) BOX HH1AA
(56) BOX HH1AA
(58) BOX HH1AA
(59) BOX HH1AA
(60) BOX HH1AA
(61) BOX HH1AA
(91) HH21 - HHFRELOS
(-8) BOX HH1AA
(-9) BOX HH1AA

(01) CONTINUOUS ANSWER

BOX HH1AA

HHFRELAT

HH21

code one

HHFRELOS

HH21

text

OTHER (SPECIFY)

HH28

yes/no

(01) YES
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], [have you/has (SP)/did (SP)] (received/receive) personal care or help at
(-8) DON'T KNOW
home with daily needs from any other persons who (do/did) not live with (you/him/her)?
(-9) REFUSED

BOX HH7

routing

GO TO MPQ.

HHFMORE

(01) HH19 - PROVIDER_HHF
(02) BOX HH7
(-8) BOX HH7
(-9) BOX HH7

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