CMS-P-0015A Cognitive Measures

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

CMQ-Cognitive Measures

Question Text/Description

Code List

Routing

(1) Continue

CNTTM20

COGNITIVE MEASURES QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C003, C004, C005, C006
SPALIVE=1
SEASON=FALL
SPPROXY=SP
Other: N/A
PLACEMENT
Administer after SCQ.

CNINTRO

CNINTRO

no entry

Now I'd like to ask you some questions having to do with memory. The questions may seem unusual, but they are
routine questions we ask everyone. Some of the questions are very easy and some are difficult, so don’t be
surprised if you have trouble with some of them. Try your best to answer all of the questions without using clues
from around the room.
For the first question, please try to count backward as quickly as you can from the number I will give you. I will tell
you when to stop.

CNTTM20

CNTTM20

numeric

ALLOW R TO START OVER IF S/HE WISHES TO DO SO

(1) Continue

(1) CNTOTCM1

Please start with: 20
CORRECT RESPONSES INCLUDE COUNTING DOWN FROM 19 TO 10 OR FROM 20 TO 11
You may stop now. Thank you.
CNTOTCM1

CNTOTCM1

code one

CODE CORRECT IF R COUNTED BACKWARDS FROM 19 TO 10 OR FROM 20 TO 11 WITHOUT ERROR
ALLOW R TO START OVER IF S/HE WISHES TO DO SO

(1) CORRECT
(2) INCORRECT
(3) WANTS TO START OVER
(-8) DON'T KNOW
(-9) REFUSED

(1) TDYMTH
(2) TDYMTH
(3) CNTTMT2
(-8) TDYMTH
(-9) TDYMTH

(1) Continue

CNTOTCM2

(1) CORRECT
(2) INCORRECT
(-9) REFUSED

TDYMTH

(1) MONTH CORRECT
(2) MONTH NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED

TDYDAY

(1) DAY OF MONTH CORRECT
(2) DAY OF MONTH NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED

TDYYEAR

(1) YEAR CORRECT
(2) YEAR NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED

TDYDOW

(1) DAY CORRECT
(2) DAY NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED

SCISSOR

(1) SCISSORS OR SHEARS
(2) NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED

CACTUS

(1) CACTUS OR NAME OF KIND OF CACTUS
(2) NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED

POTUS

Let's try again.
CNTTMT2

CNTTMT2

numeric
The number to count backward from is: 20
You may stop now. Thank you.

CNTOTCM2

CNTOTCM2

code one
CODE CORRECT IF R COUNTED BACKWARDS FROM 19 TO 10 OR FROM 20 TO 11 WITHOUT ERROR
Please tell me today's date.

TDYMTH

TDYMTH

code one

PROBE MONTH, DAY, YEAR, DAY OF WEEK
THE DATE IS: MONTH/DAY/YEAR
Please tell me today's date.

TDYDAY

TDYMTH

code one

PROBE MONTH, DAY, YEAR, DAY OF WEEK
THE DATE IS: MONTH/DAY/YEAR
Please tell me today's date.

TDYYEAR

TDYMTH

code one

PROBE MONTH, DAY, YEAR, DAY OF WEEK
THE DATE IS: MONTH/DAY/YEAR
What is the day of the week?

TDYDOW

TDYDOW

code one
THE DAY OF THE WEEK IS: DAY OF WEEK

Now I'm going to ask you for the names of some people and things.
SCISSOR

SCISSOR

code one
What do people usually use to cut paper?

CACTUS

CACTUS

code one

What do you call the kind of prickly plant that grows in the desert?

Page 1 of 2

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

CMQ-Cognitive Measures

Question Text/Description

Code List

Routing

Who is the President of the United States right now?
ANSWER IS BIDEN
PROBE FOR LAST NAME
POTUS

POTUS

code one

(1) LAST NAME CORRECT
(2) NOT CORRECT
[IF NEEDED: These questions have to do with memory. Assessing memory in the Medicare population is important (-8) DON'T KNOW
to understanding whether the needs of beneficiaries are being met and for measuring the impact on current and
(-9) REFUSED
future health care costs.]

VPOTUS

[IF NEEDED: NORC at the University of Chicago is an objective, non-partisan research institution. This survey will
not collect any information about your political affiliation.]
Who is the Vice President?
ANSWER IS HARRIS
PROBE FOR LAST NAME
VPOTUS

VPOTUS

code one

(1) LAST NAME CORRECT
(2) NOT CORRECT
[IF NEEDED: These questions have to do with memory. Assessing memory in the Medicare population is important (-8) DON'T KNOW
to understanding whether the needs of beneficiaries are being met and for measuring the impact on current and
(-9) REFUSED
future health care costs.]

END

[IF NEEDED: NORC at the University of Chicago is an objective, non-partisan research institution. This survey will
not collect any information about your political affiliation.]

BOX CMEND

routing

IF ROUND = FALL 2023 ROUND 97, GO TO DIQ.
IF INTTYPE in(C001, C002, C004, C005, C006), GO TO DVH.
IF INTTYPE in(C003), GO TO DIQ.

Page 2 of 2