CMS-10816 Eligibility Screener Questionnaire

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

2. 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.

3. How old are you?

_______ years

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