P-0015A COVID-19 Questionnaire Specifications

2024 MCBS Facility Instrument

Variable Name

MR Screen

CV-COVID-19 Beneficiary

Question Type

Question Text/Description
COVID-19 BENEFICIARY SECTION SPECIFICATIONS

Code List

Routing

(01) CONTINUE

(01) CV2-CVDTEST BOX CV4

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

(00) CVEND-CVENDCT
(01) CV12 - EVRVNUM
(-8) CVEND-CVENDCT
(-9) CVEND-CVENDCT

(01) ONE VACCINE
(02) TWO VACCINES
(03) THREE VACCINES
(04) FOUR OR MORE VACCINES
(-8) DON'T KNOW
(-9) REFUSED

CVEND-CVENDCT

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

CVEND-CVENDCT

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

(00) CV6-VACROST
(01) CV2B-COVRSLT
(-8) CV6-VACROST
(-9) CV6-VACROST

CRITERIA
SAMPLE TYPE= CFR, CFC, FFC, FCF, IPR
RHALIVE= 1/Alive
SEASON
If SAMPLE TYPE= CFR, then SEASON= WINTER
If SAMPLE TYPE in (CFC, FFC, FCF), then SEASON= ALL

CVDINTRO

BOX CVBEG

routing

CV1

CODE ONE

BOX CV4

EVRVAC

PLACEMENT
Administered in flexible order after FQ and RH sections are completed.
IF PVACNUM = 4, GO TO BOX CVEND
ELSE GO TO CV1-CVDINTRO
I am now going to ask you some questions about COVID-19 vaccines services (SP) may have received.
IF SECOND ROUND BASELINE OR CROSSOVER, GO TO CV11 - EVRVAC.
ELSE IF CONTINUING ROUND, GO TO CV13 - YRVAC.
Has (SP) received any COVID-19 vaccines?
[IF NEEDED: Please include booster shots and any additional doses. ]

CV11

[IF NEEDED: This question is asking for the total number of COVID-19 vaccine doses that (SP) has received
since the vaccine first became available in December 2020. ]
How many COVID-19 vaccines has (SP) received in total?
EVRVNUM

[IF NEEDED: Please include booster shots and any additional doses.]

CV12

[IF NEEDED: This question is asking for the total number of COVID-19 vaccine doses that (SP) has received
since the vaccine first became available in December 2020. ]
In (PREVIOUS YEAR), has (SP) received at least one dose of the COVID-19 vaccine?
YRVAC

[IF NEEDED: Please include booster shots and any additional doses. ]

CV13

[IF NEEDED: This question is asking for the total number of COVID-19 vaccine doses that (SP) has received
since the vaccine first became available in December 2020. ]
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?
CVDTEST

CV2

yes/no

[IF NEEDED: For example, the test can be done by swabbing someone’s nose.]
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?

COVRSLT

CV2B

CODE ONE

MCARECV

CV4

yes/no

(01) YES, THE TEST SHOWED R HAD COVID-19
(02) NO, THE TEST SHOWED R DID NOT HAVE
COVID-19
(03) NO RESULTS YET
(-8) DON’T KNOW
DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER SOMEONE HAS EVER BEEN INFECTED
(-9) REFUSED
WITH CORONAVIRUS .
[IF NEEDED: If (SP) had more than one test since (PREVIOUS INTERVIEW DATE/ADMISSION DATE) to
see whether (he/she) was infected with coronavirus or COVID-19, answer yes if any of them were positive.]

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
(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) CONTINUOUS

(01) CV4-MCARECV
(02) CV6-VACROST
(03) CV6-VACROST
(-8) CV6-VACROST
(-9) CV6-VACROST
(00) CV6-VACROST
(01) CV4A-PROVTYP
(-8) CV6-VACROST
(-9) CV6-VACROST
(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) CV6-VACROST

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2024 MCBS Facility Instrument

CV-COVID-19 Beneficiary

Variable Name

MR Screen

Question Type

VACROST

CV6

yes/no

Question Text/Description
[It was previously reported that (SP) received the following COVID-19 vaccines.]

Code List

Routing

DOSE 1: [MONTH] [YEAR] [MANUFACTURER]
DOSE 2: [MONTH] [YEAR] [MANUFACTURER]
...
DOSE 10: [MONTH] [YEAR] [MANUFACTURER]

(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

(01) CONTINUOUS

(01) CV8-VACNME

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]
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]

CV8

code one

(01) PFIZER-BIONTECH/COMIRNATY
(02) MODERNA/SPIKEVAX
(03) JOHNSON & JOHNSON/JANSSEN
[IF NEEDED: Examples include Pfizer-BioNTech/Comirnaty, Moderna/Spikevax, Johnson & Johnson/Janssen,
(04) NOVAVAX
and Novavax.]
(91) OTHER
(-8) DON'T KNOW
ONLY USE THE ‘OTHER’ CATEGORY TO ADD VACCINE MANUFACTURERS APPROVED IN AN FI MEMO
(-9) REFUSED

CV8

verbatim

OTHER (SPECIFY)

(01) CONTINUOUS

(01) CV9-VACSITE

(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
(01) CONTINUOUS

(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

Which COVID-19 vaccine did (SP) get?
VACNME

VACNMEOS

VACSITE

CV9

code one

Where did (SP) go for their COVID-19 vaccine in (VACDATMM) (VACDATYY)?

VACSITOS

CV9

verbatim

OTHER (SPECIFY)
IF LESS THAN TEN DOSES HAVE BEEN REPORTED AND/OR PRELOADED GO TO CV10-VACMOR
ELSE GO TO CVEND-CVENDCT

BOX CV2

(01) CV9-VACSITE
(02) CV9-VACSITE
(03) CV9-VACSITE
(04) CV9-VACSITE
(91) CV8-VACNEMOS
(-8) CV9-VACSITE
(-9) CV9-VACSITE

(01) BOX CV2

Has (SP) had any other COVID-19 vaccine doses?

VACMOR

CV10

yes/no

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]

(00) BOX CV3
(01) BOX CV3
(-8) BOX CV3
(-9) BOX CV3

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2024 MCBS Facility Instrument

Variable Name

MR Screen

CV-COVID-19 Beneficiary

Question Type

BOX CV3
CVENDCT

CVEND

code one

BOX CVEND

routing

Question Text/Description
IF CV10-VACMOR= 1/YES AND LESS THAN TEN DOSES HAVE BEEN REPORTED GO TO CV7VACDATMM
ELSE GO TO CVEND-CVENDCT
YOU HAVE COMPLETED THE COVID-19 BENEFICIARY SECTION FOR THIS SP.
PRESS "1" TO RETURN TO NAVIGATION SCREEN.
GO TO NAVIGATOR

Code List

Routing

(01) Continue

(01) BOX CVEND

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