CMS-P-0015A Introduction

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name

INQ-INTRODUCTION

Question Type

Question Text/Description

Code List

Routing

(01) ENGLISH
(02) SPANISH

INV1- CARIVER

(01) RESPONDENT AGREES TO CONTINUE WITH
RECORDING
(02) RESPONDENT DOES NOT WANT TO BE
RECORDED

(01) IN1AA - ATDOOR
(02) INV2 - NOCARI

INTRODUCTION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=ALL
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
(Start of interview)

QUEXLANG

QUEXLANG

code one

CARIVER

INV1

code one

PLEASE SELECT THE LANGUAGE IN WHICH YOU WOULD LIKE TO CONDUCT THE INTERVIEW.

Some of this interview will be recorded for quality control purposes.
I'd like to continue now, unless you have any questions.

NOCARI

ATDOOR

INV2

IN1AA

no entry

no entry

That's fine. The interview will not be recorded.

IN1AA - ATDOOR

REVIEW WITH THE RESPONDENT THE FOLLOWING IMPORTANT FACTS FROM THE "AT-THE-DOOR"
SHEET:
All survey information will be kept private to the extent permitted by law, as prescribed by the Privacy Act of
1974.

IN2 - VERIFYSP

Medicare benefits will not be affected in any way by survey responses or participation.
REFER TO THE "AT-THE-DOOR" SHEET IF THE RESPONDENT NEEDS ADDITIONAL REASSURANCE.

VERIFYSP

IN2

yes/no

ROSTFNAM

IN3

text

VERIFY THE SP’S NAME. IS THE SP’S NAME CORRECT AND COMPLETE?
FIRST NAME: (SP'S FIRST NAME)
MIDDLE INITIAL: (SP'S MIDDLE INITIAL)
LAST NAME: (SP'S LAST NAME)

(01) YES
(02) NO

(01) INS1- SPAISTATUS
(02) IN3 - ROSTFNAM

MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.
IN3 - ROSTMINI
FIRST NAME:

MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.
ROSTMINI

IN3

text

IN3 - ROSTLNAM
MIDDLE INITIAL:

MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.
ROSTLNAM

IN3

text

INS1- SPAISTATUS
LAST NAME:

Page 1 of 7

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name

INQ-INTRODUCTION

Question Type

Question Text/Description

Code List

Routing

(01) ALIVE AND NOT INSTITUTIONALIZED
(02) ALIVE AND INSTITUTIONALIZED
(03) DECEASED - DIED IN COMMUNITY
(04) DECEASED - DIED IN INSTITUTION/FACILITY

(01) BOX INS1
(02) INS2 - SPINSTMM
(03) INS3 - SPDIEMM
(04) INS2 - SPINSTMM

PLEASE INDICATE THE RESPONDENT'S CURRENT STATUS. IF THE CASE IS A PROXY INTERVIEW AND
YOU HAVEN'T TALKED ABOUT THE RESPONDENT'S VITAL STATUS, PROBE AT THIS TIME ABOUT
WHETHER THE RESPONDENT IS ALIVE OR DECEASED AND WHERE THE RESPONDENT IS LOCATED.

SPAISTATUS

INS1

code one

WHEN WE REFER TO INSTITUTIONALIZED, WE ARE REFERRING TO THE MCBS DEFINITION OF A
FACILITY. FOR THE FULL MCBS DEFINITION OF A FACILITY, CLICK F1. PLEASE REMEMBER THAT
HOSPITALS AND HOSPICE CARE ARE NOT FACILITIES UNDER THE MCBS DEFINITION, SO
RESPONDENTS IN HOSPITALS AND HOSPICE CARE SHOULD NOT BE CONSIDERED TO BE
INSTITUTIONALIZED BELOW.

IS THE RESPONDENT CURRENTLY:

What was the first date [(since [REFERENCE DATE] that [SP])/([that SP])] entered the facility?
SPINSTMM

INS2

date

(01) continuous answer
[EXPLAIN IF NECESSARY: By "facility" we mean a place that provides long term care. By "first date" we mean
(-8) Don't Know
the earliest date that the beneficiary enters any facility and does not enter a hospital or return home.]
(-9) Refused

IN2 - SPINSTDD

IF MORE THAN ONE DATE, ENTER THE EARLIEST.

What was the first date [(since [REFERENCE DATE] that [SP])/([that SP])]entered the facility?
SPINSTDD

INS2

date

(01) continuous answer
[EXPLAIN IF NECESSARY: By "facility" we mean a place that provides long term care. By "first date" we mean
(-8) Don't Know
the earliest date that the beneficiary enters any facility and does not enter a hospital or return home.]
(-9) Refused

SPINSTYY

IF MORE THAN ONE DATE, ENTER THE EARLIEST.

What was the first date [(since [REFERENCE DATE] that [SP])/([that SP])] entered the facility?
SPINSTYY

INS2

date

[EXPLAIN IF NECESSARY: By "facility" we mean a place that provides long term care. By "first date" we mean
(01) continuous answer
the earliest date that the beneficiary enters any facility and does not enter a hospital or return home.]

BOX INSA

IF MORE THAN ONE DATE, ENTER THE EARLIEST.

BOX INSA

routing

IF (INS1 - SPAISTATUS = 4/DeceasedInInstitute) GO TO INS3 - SPDIEMM.
ELSE GO TO BOX INSA1.

SPDIEMM

INS3

date

On what date did (SP) die?

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

(01) INS3 - SPDIEDD
(-8) INS3 - SPDIEDD
(-9) INS3 - SPDIEDD

SPDIEDD

INS3

date

On what date did (SP) die?

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

(01) INS3 - SPDIEYY
(-8) INS3 - SPDIEYY
(-9) INS3 - SPDIEYY

SPDIEYY

INS3

date

On what date did (SP) die?

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

(01) BOX INSA1
(-8) BOX INSA1
(-9) BOX INSA1

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2023 MCBS Community Questionnaire

Variable Name

MR Screen Name

INQ-INTRODUCTION

Question Type

Question Text/Description

BOX INSA1

routing

IF (SPDIEMM or SPINSTMM IN(-8,-9) OR SPDIEYY or SPINSTYY IN(-8,-9) THEN GO TO INS3B-INTHANK.
ELSE IF (INS1 - SPAISTATUS = 3/Deceased) AND (INTTYPE in(3,7,10)) AND
(VIEW_MCBSCOMM_PRELOAD.NEWLY_ELIGIBLE=0) AND (SP'S DATE OF DEATH ENTERED AT INS3 IS
BEFORE JANUARY 1 OF THE CURRENT YEAR), GO TO INS3A - DEASDATE.
ELSE IF (INS1 - SPAISTATUS = 4/DeceasedInInstitute) AND (INTTYPE in(7,10)) AND (SP'S DATE OF
INSTITUTIONALIZATION ENTERED AT INS2 AND SP'S DATE OF DEATH ENTERED AT INS3 ARE BOTH
PRIOR TO JANUARY 1 OF CURRENT YEAR) AND (VIEW_MCBSCOMM_PRELOAD.NEWLY_ELIGIBLE=0),
GO TO INS3A - DEASDATE.
ELSE IF(INS1 - SPAISTATUS = 4/DeceasedInInstitute) AND (INTTYPE in(7,10)) AND (SP'S DATE OF
INSTITUTIONALIZATION ENTERED AT INS2 IS PRIOR TO JANUARY 1 OF CURRENT YEAR) AND (SP'S
DATE OF DEATH ENTERED AT INS3 IS ON OR AFTER JANUARY 1 OF CURRENT YEAR) AND
(VIEW_MCBSCOMM_PRELOAD.NEWLY_ELIGIBLE=0), GO TO INS3A1 - INSTDATE.
ELSE IF (INS1 - SPAISTATUS = 2/AliveAndInstitute) AND (INTTYPE in(7,10)) AND (SP'S DATE OF
INSTITUTIONALIZATION ENTERED AT INS2 IS BEFORE JANUARY 1 OF THE CURRENT YEAR) AND
(VIEW_MCBSCOMM_PRELOAD.NEWLY_ELIGIBLE=0), GO TO INS3A1 - INSTDATE.
ELSE IF(INS1-SPAISTATUS = 2/AliveAndInstitute) AND INTTYPE = 3, GO TO INS3B-INTHANK
ELSE IF (INS1-SPAISTATUS = 3/Deceased) AND INTTYPE = 3 AND SP'S DATE OF DEATH ENTERED AT
INS3 IS PRIOR TO JANUARY 1, GO TO INS3A-DEASDATE
ELSE IF (INS1-SPAISTATUS = 4/DeceasedInInstitute) AND INTTYPE = 3, GO TO INS3B-INTHANK
ELSE GO TO BOX INS1.

INS3A

no entry

Code List

Routing

YOU HAVE ENTERED THAT THE SP, (SP), DIED BEFORE JANUARY 1ST OF [CURRENT YEAR]. IF THIS IS
NOT CORRECT, GO TO THE PREVIOUS PAGE AND ENTER THE CORRECT DATE AT INS3.
DEASDATE

BOX INS1A
IF THIS IS CORRECT, YOU WILL NOT BE CONDUCTING THE COMMUNITY INTERVIEW WITH THE
RESPONDENT. GO TO THE NEXT PAGE TO END THE INTERVIEW.

BOX INS1A

routing

IF SP IS DECEASED, SET RESPONDENT TO PROXY AND GO TO INS3B - INTHANK

YOU HAVE ENTERED THAT THE SP, (SP), WAS INSTITUTIONALIZED BEFORE JANUARY 1ST OF
[CURRENT YEAR]. IF THIS IS NOT CORRECT, GO TO THE PREVIOUS PAGE AND ENTER THE CORRECT
DATE AT INS2.
IF THIS IS CORRECT, YOU WILL NOT BE CONDUCTING THE COMMUNITY INTERVIEW WITH THE
RESPONDENT.
INSTDATE

INS3A1

no entry

INS3B - INTHANK
AFTER CLICKING "NEXT PAGE", YOU WILL RETURN TO CM-FIELD. PLEASE FILL OUT A RECORD OF
CALL AND CODE THIS CASE AS A “NO COM PROXY- GO TO FAC” .
PLEASE COLLECT ANY KNOWN FACILITY CONTACT INFORMATION AND DISCUSS THE CASE WITH
YOUR FIELD MANAGER.

INTHANK

INS3B

no entry

I would like to thank you for your time and cooperation during this interview. We may be contacting you in the
future for further information.

BOX INS1

routing

IF SP IS DECEASED OR INSTITUTIONALIZED, SET RESPONDENT TO PROXY AND GO TO IN4A PERSON_PROXY.
ELSE GO TO IN4 - SPPROXY.

BOX INSB1

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2023 MCBS Community Questionnaire

INQ-INTRODUCTION

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

SPPROXY

IN4

code one

WILL THIS INTERVIEW BE CONDUCTED WITH THE SAMPLE PERSON OR WITH A PROXY?

(01) SAMPLE PERSON
(02) PROXY

(01) BOX INS5
(02) IN4A - PERSON_PROXY

DISPLAY PERSON ROSTER AS RESPONSE
OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
(01-N) BOX INS2AA
…
(N+1) IN4A-ROSTFNAM
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
IF EXISTING PERSON SELECTED, GO TO
BOX INS2AA.
DISPLAY:
ELSE IF "ADD ANOTHER" SELECTED, GO
1 First Name Display ROST.ROSTFNAM.
TO IN4A-ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/OtherRelative or 92/OtherNonRelative, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

PERSON_PROXY

IN4A

roster

SELECT OR ADD THE NAME/RELATIONSHIP OF THE PROXY TO THE SP FOR THIS INTERVIEW.
SELECT OR ADD ONLY ONE PERSON.

ROSTFNAM

IN4A

text

[What is the name of the person and relationship to (SP)?]

(01) continuous answer

IN4A-ROSTLNAM

ROSTLNAM

IN4A

text

[What is the name of the person and relationship to (SP)?]

(01) continuous answer

IN4A-ROSTREL

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

(01) DO NOT DISPLAY
(02) BOX INS2AA
(56) BOX INS2AA
(58) BOX INS2AA
(59) BOX INS2AA
(60) BOX INS2AA
(61) BOX INS2AA
(91) IN4AROSTREOS - ROSTREOS
(-8) BOX INS2AA
(-9) BOX INS2AA

ROSTREL

IN4A

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

IN4AROSTREOS

verbatim text

[What is the name of the person and relationship to (SP)?]

BOX INS2AA

routing

IF PERSON IS ADDED AT IN4A, GO TO BOX INS2A-1.
ELSE GO TO IN5 - VRFYPROX.

(01) continuous reponse
(-8) Don't Know
(-9) Refused

BOX INS2AA

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2023 MCBS Community Questionnaire

Variable Name

MR Screen Name

INQ-INTRODUCTION

Question Type

Question Text/Description

Code List

Routing

(01) YES
(02) NO

(01) BOX INS2A-1
(02) IN6 - ROSTFNAM

I would like to verify your name and relationship to (SP). I have you listed as [READ NAME AND
RELATIONSHIP LISTED BELOW]. Is that correct?
VRFYPROX

IN5

yes/no

IF RELATIONSHIP IS MISSING, SELECT "NO" AND PROBE FOR RELATIONSHIP ON THE NEXT SCREEN.
FIRST NAME: (PROXY'S FIRST NAME)
LAST NAME: (PROXY'S LAST NAME)
RELATIONSHIP: (PROXY'S RELATIONSHIP TO SP)

ROSTFNAM

IN6

text

[What is your correct name and relationship to (SP)?]

(01) continuous answer

IN6 - ROSTLNAM

ROSTLNAM

IN6

text

[What is your correct name and relationship to (SP)?]

(01) continuous answer

IN6 - ROSTREL

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

(01) DO NOT DISPLAY
(02) BOX INS2A-1
(56) BOX INS2A-1
(58) BOX INS2A-1
(59) BOX INS2A-1
(60) BOX INS2A-1
(61) BOX INS2A-1
(91) IN6 - ROSTREOS
(-8) BOX INS2A-1
(-9) BOX INS2A-1

ROSTREL

IN6

code one

[What is your correct name and relationship to (SP)?]

ROSTREOS

IN6

verbatim text

What is your correct name and relationship to (SP)?

BOX INS2A-1

routing

IF SP IS INSTITUTIONALIZED (SPALIVE = 2), SET REASON WHY RESPONDENT IS PROXY TO "SP IS
INSTITUTIONALIZED" (WHYPROXY = 07) AND GO TO BOX INS3.
ELSE IF SP IS DECEASED (SPALIVE = 3), SET REASON WHY RESPONDENT IS PROXY TO "SP IS
DECEASED" (WHYPROXY = 06) AND GO TO BOX INS3.
ELSE GO TO IN6A - WHYPROXY.

WHYPROXY

IN6A

code one

PNSPOS

IN6A

verbatim text

WHAT IS THE MAIN REASON THAT A PROXY RESPONDENT IS NECESSARY?

OTHER (SPECIFY)

(01) continuous reponse
(-8) Don't Know
(-9) Refused

BOX INS2A-1

(01) SP NOT CAPABLE
PHYSICALLY/SICK/BLIND/CAN’T SPEAK/HEAR
(02) SP NOT CAPABLE MENTALLY/POOR
MEMORY/PSYCHIATRIC DISORDER
(03) SP UNABLE TO PROVIDE INFORMATION
REGARDING MEDICAL RECORDS
(04) SP IN HOSPITAL
(05) LANGUAGE PROBLEM
(06) SP IS DECEASED
(07) SP IS INSTITUTIONALIZED
(08) SP NOT AVAILABLE THIS ROUND
(09) AUTHORIZED PROXY MUST ANSWER
QUESTIONS FOR SP (CODE REASON WHY)
(91) OTHER

(01) BOX INS2B
(02) BOX INS2B
(03) BOX INS2B
(04) BOX INS2B
(05) BOX INS2B
(06) BOX INS2B
(07) BOX INS2B
(08) BOX INS2B
(09) BOX INS2B
(91) IN6A - PNSPOS

(01) continuous response

BOX INS3

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2023 MCBS Community Questionnaire

Variable Name

INQ-INTRODUCTION

MR Screen Name

Question Type

Question Text/Description

BOX INS2B

routing

IF RESPONSE TO IN6a - WHYPROXY ONLY INCLUDES 9/CodeReasonWhy, GO TO IN6B - PNSPVB.
ELSE GO TO BOX INS3.

IN6B

verbatim text

BRIEFLY EXPLAIN WHY PROXY MUST ANSWER QUESTIONS.

BOX INS3

routing

IF SP IS IN THE SUPPLEMENTAL SAMPLE AND IN6A - WHYPROXY = 6/SPIsDeceased, GO TO IN6B1 SUPPDIED.
ELSE IF SP IS IN THE SUPPLEMENTAL SAMPLE AND IN6A - WHYPROXY = 7/SPIsInstitute, GO TO IN6B2 SUPPINST.
ELSE GO TO BOX INS5.

SUPPDIED

IN6B1

no entry

YOU HAVE ENTERED THAT THE SP, (SP), IS DECEASED. IF THIS IS NOT CORRECT, GO TO THE
PREVIOUS PAGE AND CORRECT YOUR RESPONSE AT IN6A.

BOX IN6

SUPPINST

IN6B2

no entry

YOU HAVE ENTERED THAT THE SP, (SP), IS INSTITUTIONALIZED. IF THIS IS NOT CORRECT, GO TO
THE PREVIOUS PAGE AND CORRECT YOUR RESPONSE AT IN6A.

BOX IN6

BOX INS5

routing

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW FROM FACILITY), GO TO IN8 - CHEKBRTH.
ELSE IF IT'S A FALL ROUND, GO TO BOX IN6.
ELSE GO TO BOX IN8.

CHEKBRTH

IN8

yes/no

I have [your/(SP’s)] date of birth listed as (CMS BIRTH DATE). Is that correct?

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

(01) IN10 - CHECKAGE
(02) IN9 - HHDOBMM
(-8) BOX IN6
(-9) BOX IN6

HHDOBMM

IN9

date

What is [your/(SP’s)] date of birth?

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

IN9 - HHDOBDD

HHDOBDD

IN9

date

What is [your/(SP’s)] date of birth?

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

IN9 - HHDOBYY

HHDOBYY

IN9

date

What is [your/(SP’s)] date of birth?

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

BOX IN3A

BOX IN3A

routing

IF SP'S DATE OF BIRTH MONTH, DAY OR YEAR COLLECTED AT IN9 = DK OR RF, GO TO BOX IN6.
ELSE GO TO IN10 - CHECKAGE.

PNSPVB

Code List

Routing

BOX INS3

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2023 MCBS Community Questionnaire

INQ-INTRODUCTION

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

CHECKAGE

IN10

yes/no

That makes [you/(SP)] (AGE) today. Is that correct?

(01) YES
(02) NO

(01) BOX IN6
(02) IN9 - HHDOBMM

BOX IN6

routing

IF SP'S AGE IS > 16, DK OR RF, GO TO IN13 - SPMARSTA.
ELSE GO TO BOX IN8.

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

BOX IN7

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

BOX IN8

SPMARSTA

SPCHNLNM

IN13

code one

[Are you/Is (SP)/Was (SP)] married, widowed, divorced, separated, or never married?

BOX IN7

routing

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW FROM FACILITY), GO TO IN14 - SPCHNLNM.
ELSE GO TO BOX IN8.

IN14

numeric

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

BOX IN8

routing

IF INTTYPE in(C001, C002, C003, C004, C005, C006, C007, C010), GO TO ENS.

BOX INSB1

routing

GO TO END1 - INTLANG.

END1 - INTLANG.

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