Attachment 26 Attachment 26 HC MEPS Validation Interview

Form Approved

Panel _____

OMB#: 0935-0118
Exp. Date: 12/31/2018

REG

FIID

RUID

MEPS VALIDATION INTERVIEW
The Federal government requires that all persons asked to
respond to one of its surveys be given the following
information:
Public reporting burden for this collection of information is
estimated to average 5 minutes per response, the estimated
time required to complete the survey. An agency may not
conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a currently valid
OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to: AHRQ
Reports Clearance Officer Attention: PRA, Paperwork
Reduction Project (0935-0118) AHRQ, 540 Gaither Road,
Room # 5036, Rockville, MD 20850.

ASSURANCE OF CONFIDENTIALITY
This survey is authorized under 42 U.S.C. 299a. The
confidentiality of your responses to this survey is protected by
Sections 944(c) and 308(d) of the Public Health Service Act [42
U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that
could identify you will not be disclosed unless you have
consented to that disclosure.

BOX A. REVIEW VALIDATION ABSTRACT FORM FOR DETAILS OF THE CASE. ASK FOR THE APPROPRIATE
RESPONDENT. IF THE RESPONDENT IS NOT AVAILABLE, ARRANGE A CALL BACK. IF THE RESPONDENT
WILL NOT BE AVAILABLE IN NEAR FUTURE, TALK TO ANYONE LISTED ON THE RU ROSTER.
INTRODUCTION FOR RESPONDENT OR PROXY: Hello. My name is (NAME) with the Medical Expenditure Panel
Survey being conducted for the Department of Health and Human Services. Recently one of our staff interviewed you.
1.

Do you recall the interview?
YES ..................................................................................................... 1 (5)
NO .................................................................................................. 2

2.

The interviewer asked about (your/your family’s) health care including health care visits and use of prescribed
medicines between (DATES OF REFERENCE PERIOD) and a few other questions. Our records show that
(NAME OF INTERVIEWER) interviewed you on (DATE OF INTERVIEW). (He/she) would have used a small
computer to record the answers. Do you remember that?
YES ..................................................................................................... 1 (5)
NO ....................................................................................................... 2

3.

(VERIFY THAT YOU HAVE REACHED THE CORRECT TELEPHONE NUMBER AND THAT YOU ARE
SPEAKING WITH THE CORRECT RESPONDENT. IF SO CONTINUE.) Perhaps there is some mistake. Is
your telephone number (NUMBER) and you live at (ADDRESS)?
YES ..................................................................................................... 1 (Box B)
NO ....................................................................................................... 2

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4.

Did you live at (ADDRESS) on (DATE OF INTERVIEW)?
YES ..................................................................................................... 1
NO ....................................................................................................... 2 (Box B)

BOX B. PROBE FOR EXPLANATION. (COULD THIS HOUSEHOLD BE A SPLIT? ARE THERE OTHER PEOPLE IN
THE HOUSEHOLD WHO COULD HAVE ANSWERED THE QUESTIONS -- WHAT ABOUT VISITORS?) THANK THE
RESPONDENT. TERMINATE THE INTERVIEW. ADD ANY PERTINENT NOTES IN THE COMMENTS SECTION ON
THE LAST PAGE. REPORT PROBLEM TO THE VALIDATION MANAGER IMMEDIATELY.
5.

First, I would like to thank you very much for participating in this important study. On all of our surveys we
routinely re-contact some people who were interviewed to make sure our interviewers are following procedures
correctly. I have just a few questions to ask about the interview. According to the information I have, on (DATE
OF INTERVIEW) you lived at (ADDRESS). Is that correct?
YES ..................................................................................................... 1 (7)
NO ....................................................................................................... 2

6.

What was your address on (DATE OF INTERVIEW)? ____________________________________________

BOX C. UPDATE ADDRESS ON VALIDATION ABSTRACT AND RECORD IN COMMENTS SECTION ON THIS
FORM.
7.

On (DATE OF INTERVIEW), the following people lived in your household: (READ EACH NAME ON
ABSTRACT FORM). Is that correct?
YES ..................................................................................................... 1 (9)
NO ....................................................................................................... 2

8.

How should this information be changed to make it correct? (MAKE CHANGES ON VALIDATION ABSTRACT.
TRY TO DETERMINE REASON FOR DISCREPANCY AND NOTE IN COMMENTS SECTION ON THIS
FORM.)

9.

Did the interviewer enter your responses into a small computer?
YES ..................................................................................................... 1
NO ....................................................................................................... 2
DONE BY PHONE .............................................................................. 3

BOX D. IF R SAYS INTERVIEWER DID NOT USE A COMPUTER, PROBE FOR REASON AND EXPLAIN IN
COMMENTS SECTION.
10.

Approximately how long did the interview take?
_______ HOURS AND ______ MINUTES

11.

During the interview, the interviewer should have shown you some cards assembled in a notebook/binder that
included the answer categories to some of the survey questions. Did the interviewer use a set of cards like
these?
YES ..................................................................................................... 1
NO ....................................................................................................... 2 (PROBE FOR REASON AND
EXPLAIN IN COMMENTS)

12.

Did the interviewer ask you to refer to records such as a calendar, receipts, or statements during the interview?
YES ..................................................................................................... 1
NO ....................................................................................................... 2

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13.

Did you refer to records such as a calendar, receipts, or statements during the interview?
YES ..................................................................................................... 1
NO ....................................................................................................... 2

14.

Did the interviewer ask about (your/your household’s) purchase(s) of prescribed medicines between
(REFERENCE PERIOD DATES)?
YES ..................................................................................................... 1
NO ....................................................................................................... 2
ASKED, NO PRES MEDS PURCHASED.......................................... 3

BOX E. REVIEW SECTION D OF THE VALIDATION ABSTRACT TO SEE IF ANY AUTHORIZATION FORMS ARE
LISTED. IF NO AUTHORIZATION FORMS ARE LISTED ON ABSTRACT FORM, SKIP TO QUESTION 16;
OTHERWISE GO TO QUESTION 15.
15.

Toward the end of the interview, the interviewer may have prepared authorization forms for medical providers
or pharmacies that you talked about during the interview.
Did the interviewer ask you or anyone in your household to sign any authorization forms?
YES ................................................................................................... 1
NO ..................................................................................................... 2
15A.

Did the interviewer clearly explain the purpose of the form(s)?
YES ..................................................................................................... 1
NO ....................................................................................................... 2
DON’T REMEMBER ........................................................................... 3

15B.

Did the interviewer give you time to read the form(s)?
YES ..................................................................................................... 1
NO ....................................................................................................... 2
DON’T REMEMBER ........................................................................... 3

15C.

Did the interviewer explain who should sign the form(s)?
YES ..................................................................................................... 1
NO ....................................................................................................... 2
DON’T REMEMBER ........................................................................... 3

15D.

Was everyone over the age of 14 asked to sign their own authorization forms at the time of the
interview or did the interviewer leave the form(s) to be signed later? CODE ALL THAT APPLY
SIGNED ON DAY OF INTERVIEW ....................................................
INTERVIEWER LEFT FORM(S) FOR SIGNATURE .........................
DON’T REMEMBER ...........................................................................
IF VOLUNTEERED, REFUSED TO SIGN FORM .............................

16.

1
2
3
4

Did you receive a monetary gift from the interviewer?

16A.

YES ..................................................................................................... 1
NO ....................................................................................................... 2 (PROBE FOR REASON AND
EXPLAIN IN COMMENTS)
How much did you receive?
_______ AMOUNT

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17.

Was the interview conducted in your home or someplace else?
IN RESPONDENT’S HOME .............................................................. 1
SOMEPLACE ELSE .......................................................................... 2
ON THE PHONE ............................................................................... 3

18.

Now I’d like to ask about the interviewer who conducted the MEPS interview with you.
Was the interviewer very courteous, somewhat courteous, or not courteous?
VERY COURTEOUS .......................................................................... 1
SOMEWHAT COURTEOUS .............................................................. 2
NOT COURTEOUS ............................................................................ 3

19.

Are there any comments you would like to make about the interview or the interviewer?
YES ..................................................................................................... 1 (ENTER IN COMMENTS)
NO ....................................................................................................... 2

BOX F. RECORD ANY ADDITIONAL COMMENTS IN THE COMMENTS SECTION. COMPLETE VALIDATION
CONTACT RECORD. REFER TO VALIDATION MANAGER IF PROBLEM OR POTENTIAL PROBLEM.
COMMENTS AND ADDITIONAL QUESTIONS ASKED:

Interviewer Name and ID: _______________________________________________________________
Date Completed: ____________

Letter Sent: (circle) Y or N

Date Sent: _____________

Type of Validation:

Mode of Validation:

SMS Status:

Preselected ................... 1
Additional....................... 2
Less than 30 .................. 3

Telephone .....................1
Field ...............................2
Mail ................................3

Validation Complete ............ 1
Unable to Validate ............... 3
Falsified ............................... 5

Refusal/Breakoff: ...........4
Unable to Contact ..........5
No Attempt Made ..........6

Other (Specify) .................... 7

Validation Outcome:
Acceptable..................... 1
Potential Problem .......... 2
Unacceptable ................ 3
Entered in BFOS:

Initial: ______________

______________________

ID: ________________

Date: ______________

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Westat, 1600 Research Blvd, Rockville, MD 20850